Open Access Research article

Is gender policy related to the gender gap in external cause and circulatory disease mortality? A mixed effects model of 22 OECD countries 1973–2008

Mona Backhans1*, Bo Burström1, Antonio Ponce de Leon12 and Staffan Marklund3

Author Affiliations

1 Department of Public Health Sciences, Karolinska Institutet, Stockholm, 171 76, SWEDEN

2 Department of Epidemiology, Instituto de Medicina Social, Rio de Janeiro State University, Rio De Janeiro, BR-20550011, Brazil

3 Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, 171 76, SWEDEN

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BMC Public Health 2012, 12:969  doi:10.1186/1471-2458-12-969

Published: 12 November 2012



Gender differences in mortality vary widely between countries and over time, but few studies have examined predictors of these variations, apart from smoking. The aim of this study is to investigate the link between gender policy and the gender gap in cause-specific mortality, adjusted for economic factors and health behaviours.


22 OECD countries were followed 1973–2008 and the outcomes were gender gaps in external cause and circulatory disease mortality. A previously found country cluster solution was used, which includes indicators on taxes, parental leave, pensions, social insurances and social services in kind. Male breadwinner countries were made reference group and compared to earner-carer, compensatory breadwinner, and universal citizen countries. Specific policies were also analysed. Mixed effect models were used, where years were the level 1-units, and countries were the level 2-units.


Both the earner-carer cluster (ns after adjustment for GDP) and policies characteristic of that cluster are associated with smaller gender differences in external causes, particularly due to an association with increased female mortality. Cluster differences in the gender gap in circulatory disease mortality are the result of a larger relative decrease of male mortality in the compensatory breadwinner cluster and the earner-carer cluster. Policies characteristic of those clusters were however generally related to increased mortality.


Results for external cause mortality are in concordance with the hypothesis that women become more exposed to risks of accident and violence when they are economically more active. For circulatory disease mortality, results differ depending on approach – cluster or indicator. Whether cluster differences not explained by specific policies reflect other welfare policies or unrelated societal trends is an open question. Recommendations for further studies are made.

Gender policy; Gender equality; Mortality gaps; Country comparison; Time series data