EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

9. MAIN HEALTH ISSUES AND TRENDS FOR DIFFERENT AGE AND GENDER POPULATION GROUPS

9.5. Special gender-related issues

9.5.3. Data description and analysis

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9.5.3. Data description and analysis

 

Health inequalities

 

Lifestyle, as well as familial predisposition, can influence the risk of contracting diseases such as cancers. Restricted lifestyles, with less advantageous work conditions, lower education and other stresses that affect lifestyle choices and access to screening and treatment, may adversely influence health risk behaviours.

 

Figure 9.5.1. Percentage of deaths in the 15-44 age group compared to total deaths for men and women for selected EUGLOREH countries

 

Economic inequalities mean that in many countries women have difficulty in acquiring the basic necessities for a healthy life. It is notable that women with children have lower employment rates than those without (European Commission, 2006).

 

Figure 9.5.2. Unemployed persons as a percentage of the labour force, 2003

 

In most countries, the overwhelming majority (80% or over) of single parents are women (Council of Europe: OECD). Women also appear more affected by the tension of combining participation in the labour market with private responsibilities. This manifests itself as back pain (30%), stress (28%), muscular pains in the arms or legs (17%), skin diseases, infectious diseases, asthma and allergies (European Commission, 2003). By contrast, males suffer more from accidents, back pain and hearing loss (EU Agency for Health & Safety at Work, 2004). Unshared domestic work can be exhausting and debilitating, especially when combined with inadequate resources and/or pregnancy. Mental health can be damaged when the work is given little recognition and is carried out in isolation (Doyal, 1998).

 

Table 9.5.1. Sex differences in the prevalence of mental disorders across the life-cycle    

Source: WHO (2004)

 

Life-cycle stage

Mental disorder

Male: female difference

Childhood

Pervasive developmental disorder

Males > > Females

Attention deficient hyperactivity disorder (ADHD)

Males > > Females

Conduct disorders

Males > > Females

Learning disability

Males > > Females

Adolescence

Depression

Females > > Males

Deliberate self-harm

Females >    Males

Eating disorders

Females > > Males

Substance abuse

Males > > Females

Adulthood

Depression and anxiety

Females >    Males

Schizophrenia

Males   =  Females

Bipolar disorder

Males   =  Females

Substance abuse

Males > > Females

Old agea

Dementias

Females >    Males

Depression

Females >    Males

Psychoses

Females > > Males

>    prevalence is approximately two- to threefold greater;

>>  greater than a threefold difference in prevalence

a    The difference in old age is likely to be due to the greater longevity of women

 

 

Table 9.5.. Prevalence of depression in European epidemiological studies

 

Table 9.5.3. Suicide Rates

 

Gender differences are apparent in the patterns of help sought for psychological disorder. Women are more likely to seek help from their primary care physician and disclose mental health problems to him/her. Men are more likely to seek specialist mental healthcare, and are the main users of inpatient care. Gender bias can also occur in the treatment of psychological disorders. Doctors are more likely to diagnose depression in women compared to men, even when they have similar scores on standardised measures of depression, or present identical symptoms. There may also be differences in access to specific treatments such as psychotherapy or anti-depressants, and in the response to treatments and their outcomes. Female gender is a significant predictor of being prescribed mood altering psychotropic drugs. The disability associated to mental illness falls most heavily on those who experience three or more co-morbid disorders; this occurs mainly with women (Austbury et al, 2002; Hällström et al, 2001).

 

Biological factors in the way women develop can put them at social disadvantage and thereby influence health. Girls who reached menarche by the age of 11 are more likely to say they are too fat than girls who mature later. Thus, these girls are more likely to engage in dieting/weight control behaviour and can also be more prone to risk behaviours, e.g. as they are perceived as older and more mature than other girls of the same age, they may begin to socialise with older peers. Consequently, they may come under more social pressure to indulge in risk behaviours. Being younger, they may also be more malleable in conforming to the ideas of peers (WHO/HBSC, 2004).

 

Education

 

Numerous studies demonstrate that life expectancy and ‘positive health experiencesincrease for those with higher levels of education.. The prevalence of ill-health is seen to increase steadily with decreasing educational level (EP/EIWH, 2007).

 

 

Individuals of either gender with low levels of education are more likely to suffer chronic from health problems and resulting disability than the more educated. Studies have shown that children of mothers educated only to primary school level have a higher risk of health problems than children of more educated mothers (European Commission, 2003). Education is also significantly associated to health risk behaviours: the more advanced the smoking epidemic curve in a country, the more smoking is concentrated among the least educated of that country.

 

Poor education, poverty, bad lifestyle choices and bad working conditions can negatively affect functional capacity in later life. Some countries have noted that people with poor functional ability are more likely to become institutionalised, which in itself can lead to dependence. In most countries, older people have a lower average standard of education than that of younger people. This lack of education will influence the income, social role, expectations and the aspirations a person has during his/her life (WHO, 1999).

 

In the EU25, more women than men aged 20 to 24 had completed at least upper secondary education in 2005: 80% of women compared to 75% of men. Only in the Czech Republic and the United Kingdom the proportions are similar (Eurostat, 2006).

 

Table 9.5.4. Percentage of 25-64 year old females with at least upper secondary education (2003)

 

Poverty in old age

 

Although reduced, poverty amongst the elderly in Europe has not been eliminated. The United Kingdom continues to show relatively high poverty rates; Finland and Sweden now register in the lower scale of overall elder poverty levels. Poverty rates rise with both age and changes in living arrangements. The rate of poverty directly affects a greater number of women 75 years old or older who are living alone compared to men. Poverty is highest amongst the divorced, widowed and never-married. (Smeeding and Sandström, 2005).

 

Pensions: The elderly invariably receive lower average incomes than the non-elderly, though there are large variations across countries. Pensions represent the main source of an older person’s income. An adequate standard of living for an older person can be measured by the inequality reduction potential of old age pensions rather than their generosity (Heinrich, 2000). While the life quality of all older people may be affected by lower income, women are particularly affected due to their biological potential to live longer than men.

 

Carers: In the UK, nearly one in four women in their 50s are likely to be providing care (Age Concern, 2007a), although statistics show that over the age of 65, unpaid care is more likely to be provided by men (UK National Statistics On-line, 2007). (See Figure 9.5.3) Carers can often be penalised financially by employersinflexibility and rigid state pension rules if taking time out of work to care for sick, older and disabled partners, relatives and friends (Age Concern, 2007b).

 

Figure 9.5.3. Percentage of people in households providing unpaid care in England and Wales, by sex and age, April 2001

 

Violence

 

Violence episodes take place every day, although precise national and international statistics are lacking. Violence can take the form of physical, sexual or psychological abuse. Violence against women is perpetrated for reasons connected with discriminatory cultural policies, practices which deny gender equality, or which tolerate this form of violence (Council of Europe, 2004). Domestic violence does not distinguish between geographical boundaries, age or race, and occurs in every kind of family relationship and in every social milieu. Estimates on violence against women, published by various sources, are reported in Table 9.5.5.

 

Table 9.5.5. Violence against women

 

 

 

A. information of Sexual Violence in various Countries

Francea

·          25,000 raped per year

Irelanda (2002 study)

·          20.4% of women have reported a sexual assault as adults

·          6.4% reported rape as adults

Latviab (1998 study)

·          5.2% women reported being sexually assaulted in last 5  years

Lithuania

·          26.5% of women reported sexual abuse by a stranger after age 16

·          18.2% of women reported sexual abuse by a stranger after age 16

Hungaryb (1999 data)

·          2.2% of women over 16 reported being raped

·          9.4% reported almost being raped

·          7.4% raped by their partner

United Kingdom (England & Wales)b (2000 data)

·          4.9% of women have reported rape or sexual assault on at least one occasion since the age of 16

 a European Women’s Lobby, 2001

b London Metropolitan University, 2003  

 

 

 

B. Information of domestic violence in various Countries

Spaina,b

·          1.88 million women assaulted – only 43,000 reported it to the police

·          One woman every 5 days killed by her partner

Lithuaniac

·          42.4% of all married/cohabiting women  victims of physical/sexual violence by present partner

·          10.6% women reported most serious incident to police

Hungaryd

·          13% in/have been in a relationship reported being beaten by husband/partner

·          18% afraid of being beaten by partner

·          22% said partner had threatened to beat them

Netherlandse

·          21% of all women aged between 20 and 60 reported an act of physical abuse

·          11% reported an act of severe physical assault

Polandf,g

·          60% of divorced women reported being hit at least once by their ex-husbands

·          an additional 25% reported repeated violence

·          58.31% of cases police called to at home concerned women being attacked by intimate members of the family

United Kingdomb,f

·          25% women had been punched or slapped by partner or ex-partner in their lifetime

·          Approximately 2 women per week killed by their partners

a Women’s Institute of Spain, 2002; b Joni Sager, 2003; c Women’s issues Information Centre, “Women in LithuaniaVilnius, 1999; d TARKI Research Institute national survey, 1999; e WHO 2002; f UNICEF 2000; g Police data 2002.

 

 

 

Most reported intimate partner violence is perpetrated by men towards women. However, violence is also committed by women towards men, and within same sex relationships. One in 4 women and 1 in 6 men will experience domestic violence over their lifetimes (Council of Europe, 2002). In England and Wales in the year preceding interview, there were an estimated 12.9 million incidents of domestic violence acts against women, and 2.5 million against men (Women’s Aid, 2004).

 

The cost of domestic violence to the health services appears to be high. Victims are found to have more operative surgery, more doctor visits, hospital stays, visits to pharmacies and mental health consultations over their lifetime than the non-victimised. Wider costs include those to judicial systems, refuge provision, lost earnings and emotional costs to the victim. In England & Wales in 2004, the cost of intimate partner violence was estimated at £5.7 billion (Euro 8.4 billion), with an extra £17 billion (Euro 25 billion) for emotional costs to the victim (WHO, 2007). In Finland, it has been established that one act of violence in a family may cost society 185 000 Finnish marks (about Euro 30 000). In comparison, treatment for the perpetrator costs as little as Euro 1 000 (FIDH, 2006).

 

There is wide variation in the legislative means used to address intimate partner violence. Several Member States, normally regarded as advanced (e.g. Holland), have no specific legislation on domestic violence, while others have legislation which is underused. In Greece, marital rape does not expressly constitute an offence; in Italy it is considered a crime (though the law is rarely applied). In France, marital rape is recognised as an offence and therefore punished. In some countries (e.g. Portugal), laws were adopted under international pressure rather than through increased awareness of the issues, and there are no means for implementing the law (FIDH, 2006).

 

 

Alcohol misuse

 

Alcohol related problems represent about 9% of the disease burden in Europe, perhaps as high as 10.7% in Eastern Europe. Men are generally heavier drinkers than women; women may be at a higher risk due to lower body weight and their different metabolisms as related to alcohol dehydrogenase activity. A recent study has shown that in the UK young females are most likely to drink at or above ‘high risk levels (WHO/GENACIS, 2005). Levels of consumption or genetic difference alone do not explain cross-cultural variation in behaviour when people drink. Drinking behaviour is related to cultural beliefs about alcohol, expectancies regarding the effects of alcohol and social norms regarding drunken comportment. This is not to detract from the fact that alcohol exacerbates financial difficulties, childcare problems, infidelity or other family stressors, and creates tension and conflict between partners (WHO, 2007). Socio-economic grouping is a significant factor in the causes of mortality associated with alcohol (European Commission, 2002).

 

Fourteen per cent of men and 4 per cent of women report lifetime experience of alcohol misuse or dependence. Some 42 million Europeans experience alcohol problems at some time in their lives and it is estimated that there are 84 million people in Europe either suffering from alcohol problems or afflicted by another one's drinking. One third of problem drinkers receiving treatment cite marital conflict as one of the main problems caused by drinking. There is much evidence to show that there is a correlation between domestic violence and alcohol. High proportions of perpetrators of domestic violence are either problem drinkers or under the influence of alcohol at the time of the assault. Equally, high proportions of victims of violence are also under the influence of alcohol at the time of the assault (EUROCARE, 1998). Socio-economic grouping is a significant factor in the causes of mortality associated with alcohol (European Commission, 2002). More complete and reliable information is needed on the contribution of alcohol to divorce, family break-up, child neglect and abuse.

 

Risk factors for breast cancer in women may include regular use of alcohol (especially if combined with hormone replacement therapy (Beral, 2003), and higher body mass index (BMI) in early adulthood (Michels, 2006)

 

In adolescence, the number of girls who drink alcohol weekly rises sharply between 11 and 15 years of age. A survey among 15-16 year-olds found that 26% of boys and 22% of girls in Sweden had been drunk at the age of 13 or earlier. In Greece the rate was 11% and 6% respectively (Jernigan, 2001).

 

Table 9.5.6 below illustrates drinking patterns for men and women in selected EU countries. While a high percentage of Italian and French women drink every day, the highest percentage of female binge drinkers are in the UK and Ireland.

 

Table 9.5.6. Drinking patterns among men and women in selected European countries

 

Figure 9.5.4. Girls who drink any alcoholic drink weekly (%)

 

Tobacco smoking

 

Women are more likely than men to take up smoking as a means of weight control, and to continue smoking, rather than risk putting on weight. Moreover, many women smoke in order to relax and relieve stress. Australian research has suggested that women smoke more in situations of difficulty and negative emotion and are more likely to begin smoking again while feeling sad or depressed.

 

In 2002, the rates of regular daily smokers were slightly higher in the ten Accession Countries than EU-15 (32% vs 29%) with the highest prevalence in the Netherlands (33.5 per 100 000) and Latvia (33.2) (WHO, 2002a). Overall, rates appear to have been on a slight decrease since accession, though data to support this statement are patchy. A marginal increase was seen in Belgium, Estonia, Ireland and Italy. The highest prevalence in 2004 was in Poland (32.0) and the Netherlands (30.8 per 100.000). (WHO HFA-DB, 2006). Across the EU, more men are seen to smoke than women, with the only exception being Sweden (EUROSTAT, 2007) with correspondingly higher levels of smoking related health problems.

 

Table 9.5.7. Percentage of Female Adults Smoking in 1985 and 2002-2003

 

The issues around quitting smoking are complex. Evaluations need to take account of variables such as socio-economic status and educational level as well as gender roles and expectations. There is evidence to suggest that pharmacologically-based aids to cessation are not equally effective for both sexes (Borland, 1990), though this may be influenced by social experience and available support.

 

There are some important gender differences in smoking behaviour. About nine out of 10 tobacco users start before they are 18 years old. Smoking is driven predominantly by psychosocial reasons such as wanting to look older, needing to relax, feeling rebellious, or even as a result of boredom. Girls especially are attracted by the idea that it might control weight gain. It has been noticed that children who smoke frequently have low self esteem, impaired psychological wellbeing, or are poor achievers at school, and tend not to be succeeding according to their own or society's terms (Jarvis, 2004). While boys are more likely to start smoking earlier than girls, smoking rates for girls are overtaking those for boys in many northern and western European countries.

 

Women who continue to smoke, and those who fail at attempts to stop smoking, tend to have lower education and employment levels than women who quit smoking. They smoke a higher number of cigarettes per day and tend, therefore, to be more addicted to cigarettes. They have less social support to stop smoking, are less confident in resisting temptations to smoke, and are thus cognitively less ready to stop smoking (CDC, 2001). There is some evidence that pharmacologically-based aids to cessation are not equally effective for both sexes (Borland, 1990), but this may be due to social experience and available support rather than the treatment per se. Women are more likely to participate in cessation programmes but rarely show better results than for men. Extraordinary circumstances of poverty, violence, severe depression, chronic stress, oppressive racial or sexual discrimination and other immobilising forces preclude cessation (Christen et al, 1998).

 

The WHO/HBSC report Health Behaviour in School-aged Children recommends gender-specific intervention programmes to control adolescent smoking, in particular for adolescent girls, as their smoking behaviour may influence future health. The interaction between smoking and oral contraceptives is thought to increase the risk of cardiovascular disease and affect reproductive health. Smoking in young women may therefore have a significant impact on the developmental and growth environment of the next generation (WHO/HBSC, 2004).

 

Nutrition

 

A Eurobarometer survey has found that in 11 out of 15 Member States the weight of citizens has increased, with the most striking increases in Luxembourg (2.7 kg), Denmark (1.7 kg) and Ireland (1.6 kg) (Eurobarometer, 2006). In April 2007 the European Commission launched their Strategy for Europe on Nutrition, Overweight and Obesity related health issues.

 

Current EU environments favour obesity. There is an abundance of food in Europe that, while energy-rich, is often poor in nutrients. Food portion sizes are growing, though people with sedentary lifestyles actually need less energy. Social and economic pressures can mean that both work and leisure hours offer decreasing opportunities for physical activity. There are distinct differences in the northern and southern (Mediterranean) food cultures. Nevertheless, it has been seen that across all Member States it is the least educated who consume fewer fresh vegetables, and are on average shorter and more obese than the most educated, though the dimension of these differences can vary between men and women and in accordance with the drinking and diet culture (European Commission, 2003).

 

It is more commonly women who provide food, health and care to their families. They choose which foods to purchase and decide which way they will feed the family. Men attach less importance to health when selecting their diet compared to women, but the pressures affecting their different lifestyle choices have not yet been fully understood.

 

Figure 9.5.5. Adults (15+) selectingtrying to eat healthily’ as an important influence on food choice, divided per sex and age, 1996 (%)

 

Women’s personal food choices, however, may have a shortage of nutrients. Poor nutrition in females can reduce learning and employment potential (Hammarström and Janlert, 2005) and increase reproductive and health risks. In addition, women’s reduced economic and empowerment opportunities may have an impact on patterns of behaviour and access to resources, leading ultimately to poorer health in older age. Poverty can increase with age, and leave some elderly women and men at risk of vitamin or mineral deficiency (Volkert, 2005).

 

Physical activity

 

Levels of physical activity vary across the member states of EU-15, but in general southern countries of the EU-15 have lower levels of physical activity than northern and western countries. Physical inactivity is defined as less than 2.5 hours per week of moderate exercise or 1 hour per week of vigorous exercise. The World Health Report 2002 estimates that over 3% of all disease burden, over 20% of CHD, and 10% of stroke in developed countries is caused by physical inactivity.

 

The data on the levels of physical inactivity across Europe are poor. There have been only two multinational surveys, both of which were carried out only in member states of the EU-15. The most recent was the 2002 Eurobarometer survey on physical activity, which asked a series of questions on the frequency and duration of vigorous activity, moderate activity and walking. The results of the survey are regarded as difficult to interpret. However, it is clear that the proportion of adults who regularly undertake physical activity is low. In 2002, over 40% of adults in EU-15 countries reported no moderate level physical activity in the past week, 17% no episodes of walking for 10 minutes or more, while 49% spent in excess of 4.5 hours each day sitting. Only 15% reported daily moderate level physical activity. Investigations into work-related physical activity showed that 49% of the EU population get little or no physical activity at work.

 

Table 9.5.8. Days of vigorous physical activity in the last 7 days per gender

 

Table 9.5.9. Time spent on vigorous physical activity in the last 7 days per gender

 

Current evidence suggests that the immediate social environment of children and youth - including parents, peers and teachers - has an influence on their physical activity habits. The impact of social modelling appears to be more significant for girls. The absence of active role models may negatively influence girlslong-term decision to participate in physical activity and sport (New South Wales Department of Education and Training, 2007).

 

Girls are less active than boys across all countries and regions and all age groups and the gender gap increases with age. Reduced physical activity may stem from cultural factors or learned behaviour. Clear activity preferences are apparent from the time of puberty (Bedward and Williams, 2000). It has been observed that while boys tend to use most of the playground space for active games, girls tend to prefer natural areas over manufactured equipment (Brodin and Lindstrand, 2006: Lindholm, 1995). Access to school sports facilities may be unequal, and resourcing of extracurricular activities can have a male-sport bias. Activities are often targeted at elite performers and not at students wanting to participate in non-competitive or non-traditional activities. To demonstrate their masculinity, many boys want to be seen as assertive, if not aggressive. Some girls demonstrate femininity by being passive and submissive. Young people need guidance in discovering how dominant masculinities and femininities can limit the way they see themselves as male and female (Paechter, 2003).

 

Feelings of dissatisfaction with body shape, low self-esteem and lack of confidence cause anxiety and lack of interest and are a major deterrent to girls’ and some boysparticipation in physical activity and sport. The display of the body has the potential to embarrass the individual (Probyn, 2000).

 

Caring duties

 

Women continue to meet the majority of society’s caring needs. Among those who were employed, women working in the public sector were more likely than those in the private sector to be carers. Women who had worked in a caring profession were more likely to become unpaid carers (Rowntree, Foundation, 2006). In Germany it is calculated that 80% of carers are women (Schneekloth and Müller, 2000). Due to the higher life expectancy of women and their lower average age at marriage, older men in need of care are more likely to be cared for by their spouses than vice versa (Stiehr, 2004). In addition, family membersdisproportionately daughters and daughters-in-law – are an important source of support and care for older women all over Europe (EIWH, 2006).

 

Reviews of caring responsibilities conducted in North America reveal diversity in the type of duties women and men carers engage in, and in the differential effect these duties have on their lives (Women’s Health Council 2005: Navaie-Waliser, Spriggs and Feldman, 2000; Morris, 2001; Armstrong and Kits, 2004). More women than men provide demanding and intensive forms of daily caring: bathing and dressing, care with incontinence and walking, dressing changes, assistance with medical equipment and the administration of multiple prescription medication. Women also more often have responsibility for more than one care recipient than men. Men are more likely to concentrate on care management or household maintenance, shopping or transportation, and are more likely than women to get formal help. Women are more likely to provide daily, inflexible care, while men provide care that can be more easily planned and organised around paid work.

 

A study conducted in 2001 by the Joseph Rowntree Foundation in Britain found that care giving was associated with disadvantage. The proportion of the population providing unpaid care was higher in deprived areas and areas with higher levels of poor health. Carers were also relatively disadvantaged and more likely than others of the same age to be in poor health themselves. Caregivers were less likely than others of the same age to be employed (Rowntree Foundation, 2006).

 

Workforce and Family Responsibilities

 

The inactivity rate of women aged between 25 and 54 was 23.6% in 2006 in the EU27, compared to 8.1% for men. This period is the main working age, and also the age when families are founded and children are raised. The main single reason for prime-aged women to be outside the labour force is therefore family responsibilities. Among prime-aged women, the percentage inactive due to family responsibilities varied greatly between Member States: the United Kingdom (1.9%) had the lowest percentage, followed by Sweden (2.1%) and Denmark (2.3%). At the other end of the scale, Malta (45.9%), followed by Ireland (23.1%) and Luxembourg (21.7%) had the highest rates. Education and retirement explain the higher inactivity rates observed at either end of the age scale.

(Eurostat, 2007)

 

In the Member States for which data is available, the total number of hours spent in gainful work/study and domestic work is generally higher for women than for men: over an hour more in Italy, Slovenia, Estonia, Lithuania, Spain and Hungary. Women work the longest hours in Lithuania and Slovenia (around 8 hours a day) and the least in Germany and Belgium (around 6h:30 a day). In the United Kingdom and Sweden the number of hours are almost equal, perhaps reflecting the statistics on the number of prime aged women in the workforce. Women spend more time than men on domestic work, while the reverse is true for gainful work and study.

 

In the Member States for which data is available, women have less free time than men. The difference ranged from 20 minutes in Sweden to 1h:05 in Slovenia. Women have the most free time in Finland (5h:30) and Germany (5h:24), and the least in Lithuania (3h:49). The main domestic tasks carried out by women are food preparation and cleaning and other upkeep. In general, men tend to spend a higher proportion of time on gardening, shopping and services, construction and repairs. Women and men spend almost equal amounts of time on eating meals and personal care, ranging from 2 to 3 hours a day depending on the Member State (Eurostat, 2006).

 

Patients

 

With increasing life expectancies, chronic disease prevalence and incidence, and a changing demographic and economic profile, individuals with disabling health conditions are likely to spend a longer period of time needing managed care. EURODEM research found that people with dementia are over 30 times more likely to die in an institution than people who do not have dementia. This has serious implications for healthcare systems, as it is currently estimated that European countries need to provide one year of dementia care per person over the age of 65. Characteristics associated to increased chances of moving into institutional care included older age, being unmarried, poorer health, being a tenant rather than an owner occupier and, among women, having no children (Joseph Rowntree Foundation, 2006).

 

Gender differences have been observed in care receiving, with women receiving fewer hours of care than men (Morris, 2004). There is an implicit presumption that women are better able to look after themselves, leading to the needs of women being unmet. On average, 10% of EU women report having had one or more (non-birth) hospitalisations in the past year, with a total of about 10 days of stay. Older women are about twice as likely as younger women to have been hospitalised, and tend to stay longer (See: http://ec.europa.eu/health/index_en.htm).