Gender bias in health care underlies health disparities (Hamberg, 2008, Humphries et al. 2017, Morais et al. 2020). There is a broad empirical basis in epidemiological data for evaluating health from a gender perspective: the same diseases that affect men and women differ in frequency, symptoms, prognosis, and response to treatment. Gender also affects medical communication (Dielissen et al. 2012): how patients present symptoms (Gattino et al. 2019, Danielsson et al. 2009, Hall and Roter 2002) and how physicians interpret complaints and signs of illness (Andersson et al. 2012, Chiaramonte and Friend 2006, Hamberg et al. 2002).
The world’s leading health organizations have set the goal of improving gender equality in health by various initiatives, statements, and policies. The World Health Organization (WHO) has defined gender as part of its 2014-2019 programming. An aim of Sex Gender Equity in Research (Heidari et al. 2016) is to include information about the sex and gender of medical trial participants in all study phases. In addition, gender is a key issue in the formulation of the 2030 Agenda and its Sustainable Development Goals (SDGs), with the inclusion of a stand-alone global goal (SDG5) to achieve gender equality and women’s rights.
Despite these advances, male bias in medicine still holds sway. Knowledge about health and disease predominantly refers to men and men’s health, with the result that men and women are systematically and erroneously viewed as either the same or different (Risberg et al. 2009, Ruiz-Cantero et al. 2007), with repercussions for the health of women and men alike.
Gender awareness in health care
In general terms, taking gender into account in health care means aiming for appropriateness, i.e., more effective and efficient interventions in prevention, diagnosis, treatment, and rehabilitation (Andersson et al. 2012). To achieve this goal, health care workers need to be aware of gender-related aspects of health and how to tailor medical attention and promote greater gender equality in health care. Gender awareness in health care means that physicians know how to recognize gender and incorporate it into their daily practice as a determinant of health and disease. Previous studies (Verdonk et al. 2008, Verdonk et al. 2007) investigating gender awareness among medical students found that the female students generally took a more patient-centered approach, which correlated with less adherence to conventional stereotypes about men and women and greater gender sensitivity (Verdonk et al. 2007). The professional role models to which medical students aspired also varied: the ideal physician for male students was primarily associated with hierarchical authority, decision making, rationality, competitiveness, and objectivity, whereas female students associated the ideal physician with caring, concern for others, and understanding. In a more recent study involving students in medicine and health care, Siller and colleagues (2017) underlined the importance of gender medicine in the course curriculum. Gender sensitivity, also among laboratory staff, was positively associated with gender teaching. Furthermore, male students were noted to benefit more than female students from taking courses in gender medicine.
A review of the scientific literature published between 1967 and 2001 reported that, compared to their male counterparts, female physicians provide more information, are more attentive, and show more interest in patients’ emotions, lifestyle, and family ties (Roter et al. 2002). A recent study by Gattino and colleagues (2020) investigating awareness of the gender dimension among family physicians and postgraduate medical students found that the women were more sensitive to gender issues than their male colleagues and that the professional role contributed to gender awareness: male and female postgraduate medical students were more sensitive to addressing gender differences in their practice.
Miller and colleagues first defined the concept of gender awareness in health care in 1999. The various instruments to operationalize this construct differ in what they measure and what they describe. These differences reflect the debate surrounding the concept of gender awareness (Miller et al. 1999, Khoury and Weisman 2002, Verdonk et al. 2009). Two validated instruments to assess gender awareness on a theoretical basis in health care workers are the Gender Awareness Inventory – Veterans Administration (GAI-VA, Salgado et al. 2002) and the Nijmegen Gender Awareness in Medicine Scale (N-GAMS, Verdonk et al. 2008). The GAI-VA scale is based on the model of gender awareness proposed by Miller and colleagues (1999) and was developed and validated for a population of U.S. military veterans, i.e., a social group composed mainly of men. The GAI-VA assesses three dimensions of gender awareness among health care workers: gender sensitivity, gender ideology, and knowledge. Gender sensitivity indicates the extent to which health care workers are aware of and understand the needs of women patients. Gender ideology indicates the attitude of medical staff toward these veterans, while knowledge refers to the accuracy of information about patients and their needs. The scale has demonstrated good psychometric properties, but its focus on this patient category precludes its extension to other health care contexts.
Differently, the N-GAMS assesses gender awareness among medical students towards their patients in general and extends it to male and female physicians, thus overcoming one of the limitations of the GAI-VA. The N-GAMS also assesses three dimensions: gender sensitivity (GS), gender role ideology toward patient (GRIP), and gender role ideology toward doctors (GRID). GS refers to the extent to which medical students are able to perceive gender differences and the impact of gender on medical practice, GRIP refers to stereotypes about how male and female patients communicate and cope with health and illness, and GRID refers to gender stereotypes of physicians. The three subscales have shown good reliability and the scale has shown good criterion validity as a whole, indicating that the N-GAMS is a useful tool to measure gender awareness among health care workers.
Given the relevance of the gender dimension in health care, developing valid instruments that can reliably measure physician gender awareness is a critical step in supporting the claim that increased physician gender awareness helps minimize gender bias in health care. In addition, such instruments can be advantageously employed to evaluate the effectiveness of intervention programs for increasing gender awareness among health care workers. Drawing on these assumptions, the main aim of the current study was to work toward this goal by adapting and validating the Nijmegen Gender Awareness Scale (Verdonk et al. 2008) to the Italian context. Already validated in other European contexts (see Morais et al. 2020), the N-GAMS is currently one of the most important tools developed so far to assess the level of gender awareness among health care workers. We tested its validity and reliability on a sample of physicians in service and medical students in postgraduate specialization.
Aims and Hypotheses
With the present study we evaluated the psychometric properties of the N-GAMS in a sample of Italian general practitioners and postgraduate medical students specializing in general medicine. To the best of our knowledge, there are no validated instruments to assess gender awareness among Italian health care workers. Our study had three aims. The first was to test the dimensions of the scale by confirmatory factor analysis. We wanted to understand whether the answers to the 32 items were governed by a single latent dimension (unidimensional model), by two dimensions – one referring to Gender Sensitivity and the other to Gender-Role Ideology (bidimensional model) or by the 3-factor structure originally proposed by Verdonk et al. (2008), one referring to Gender Sensitivity, and the other two measuring Gender-Role Ideology towards Patients and Gender-Role Ideology towards Doctors (tridimensional model). Our hypothesis was that the tridimensional model would show a better fit to the data than either the unidimensional or the bidimensional model (Hypothesis 1).
The second study aim was to determine using a multigroup the invariance of the confirmatory factor model between men and women and between practicing physicians and medical students in postgraduate specialization. Our hypothesis was that the model is invariant (Hypothesis 2) in relation to these variables and allows for an appropriate and meaningful comparison of N-GAMS values related to gender and professional role (Meredith 1993, Meredith and Horn, 2001).
Following Morais et al. (2020), our third aim was to extend the study to criterion-related validity of the measure, since in the original study it was tested only against the three criteria: student, gender, and patient-centeredness. We wanted to assess the relationship between gender awareness and physician empathy and sexism. Empathy has cognitive and affective/emotional dimensions (Hojat et al. 2001). The cognitive dimension involves the ability to understand another person’s experiences and feelings, to see the external world from the other person’s perspective, and to communicate that understanding. The affective/emotional dimension involves the ability to relate to or connect another person’s experiences and feelings to one’s own. Empathy is an important aspect in medical practice. Though it eludes commonly used performance measures it can improve clinical outcomes. Consistent with previous studies (Gattino et al. 2019, Morais et al. 2020), and since empathy explicitly concerns the doctor/patient relationship, we hypothesized:
H3a) the empathy of physicians participating in the study correlates positively with their gender sensitivity, H3b) physicians with more empathy have a less stereotypical view of patients and physicians, and thus there is a negative correlation between empathy and Gender Role Ideology towards Patients and Gender Role Ideology towards Doctors.
Sexism, as an expression of an ideology that attributes stereotypical characteristics to male and female roles, may be associated with gender ideology toward both patients and physicians. Accordingly, we expected:
H3c) higher levels of sexism (according to the model of Glick and Fiske, 1996, 1999) are associated with higher levels of Gender Ideology toward both Patients and Doctors, H3d) higher levels of sexism are negatively associated with Gender Sensitivity.