Gender-patterned associations of exposure, coping, and health outcomes of perceived unfairness stress in urban China

Abstract

Background

Perceived unfairness stress (PUS) is recognized as a chronic social stressor affecting wellbeing globally. In China, rapid socioeconomic change and persistent gender norms make the pathways from unfairness to health outcomes especially complex, yet underexplored.

Objectives

This research examines gender-patterned associations among perceived unfairness stress, coping strategies in response to unfairness, and unfairness-related health outcomes among urban Chinese adults.

Methods

A sample of 2,843 adults aged 18–85 from four provincial capitals was collected using multistage stratified sampling in 2021. PUS was measured across seven life domains. Coping responses to unfairness-related stress were assessed using a self-reported measure of primary coping strategy. Unfairness-related health outcomes were operationalized as experiencing at least one of three stress-related symptoms attributed to unfair treatment. Logistic regression models were estimated separately for male and female participants, controlling for socio-demographic covariates.

Results

Overall, 33.6% of respondents reported severe perceived unfairness stress and 38.5% reported unfairness-related health outcomes. Education and promotion were the most frequently reported domains of unfairness for both genders; healthcare-related unfairness ranked third among women, whereas men more frequently reported other domains. Stratified analyses revealed gender-patterned associations. After adjustment for life stress and other covariates, severe PUS remained associated with higher odds of unfairness-related health outcomes among men, whereas this association was not observed in women. In contrast, life stress was the only stress indicator consistently associated with unfairness-related health outcomes in the female models. Regarding coping strategies, active coping was associated with a lower likelihood of unfairness-related health outcomes compared with avoidant coping among men, while no comparable pattern was observed among women.

Conclusions

Perceived unfairness stress and unfairness-related health outcomes were common among urban adults in China. The findings suggest that coping responses and gendered social contexts may shape how individuals experience and respond to unfairness-related stress. Interventions aimed at reducing perceived unfairness in domains such as education and promotion, together with gender-sensitive stress-management strategies, may help mitigate stress-related health symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27727-0.

Introduction

Although a robust link between stress and a wide range of mental and physical health outcomes has been well established [1], scholars emphasize the necessity of refining stress classifications, as stressors differ in both desirability and controllability [2, 3]. Life stress typically refers to routine stressors or daily hassles—such as substandard living conditions or interpersonal conflicts—which tend to be more immediate and, to some extent, manageable on an individual level [4]. However, not all stressors are equivalent.

Perceived Unfairness Stress (PUS) is conceptualized as a chronic, structural form of stress stemming from systemic inequities beyond individual control [5]. It encompasses perceived violations of rights and psychological harms related to group identity or personal experience [6]. According to the Perceived Unfairness Model, experiences of injustice trigger harmful stress responses, fostering anxiety and insecurity that, over time, can severely erode social functioning and overall well-being [7, 8].

In recent years, empirical studies support the health toll of perceived unfairness, particularly in Western contexts. A large multiethnic survey found that higher unfairness scores were significantly associated with self-reported histories of depression and hypertension [9]. In the Whitehall II cohort, employees in the highest quartile of perceived injustice had much higher odds of developing metabolic syndrome (and its components like obesity and dyslipidemia) compared to those reporting low unfairness [10]. In sum, chronic perceptions of unfairness carry concrete risks for both psychological and physiological illness.

Importantly, cultural factors shape perceptions of unfairness. Among these, the cultural value of power distance has a particularly strong influence on how individuals perceive and respond to unfairness. In high power-distance cultures, hierarchical inequality is generally accepted as a social norm, and China ranks among the highest globally on Hofstede’s power distance index [11, 12]. Correspondingly, survey research shows that Chinese citizens often regard inequality as a legitimate outcome of market competition and individual effort, attributing success to hard work or talent rather than systemic bias [13, 14].

Cross-cultural studies have found that, when faced with organizational inequity, American workers exhibit stronger turnover intentions than their Chinese (or Korean/Japanese) counterparts [15]. In East Asian collectivist societies, individuals may be more inclined to tolerate or internalize unfair treatment rather than react openly [16]. These cultural patterns suggest that many Chinese may perceive and respond to institutional unfairness differently than Westerners. For instance, studies in Western nations have shown that people with lower socioeconomic status are more likely to experience dissatisfaction and perceived unfairness due to relative deprivation [17]. In contrast, research in China indicates that people with greater social and educational resources (urban, educated individuals) are more likely to recognize and question unfair distributions than lower-status groups [18]. Despite these insights, little is known about whether and how perceived unfairness stress operates within this sociocultural context.

In addition to cultural variation, gender represents another fundamental axis of variation in stress exposure, appraisal, and coping. Women generally have higher prevalence of stress-related mental health conditions (depression, anxiety), whereas men exhibit higher rates of stress-linked physical disorders (e.g., cardiovascular disease) [19]. This divergence has a physiological basis: estrogen and oxytocin systems are thought to mediate stress in women, contributing to mood and anxiety vulnerabilities, while men’s stronger sympathoadrenal responses make them more prone to hypertension and heart disease [20]. Epidemiological surveys in Europe and Canada consistently report that women have higher perceived stress and psychological distress [21, 22]. By contrast, men’s stress is often expressed physiologically. Supporting this, a study of Chinese physicians found that high job strain predicted worse physical functioning in men, whereas for women, perceived aspects of the work environment (effort-reward imbalance) were more predictive of mental health outcomes [23]. China’s traditional gender norms likely intersect with these patterns: gender role expectations may shape both exposure to unfairness and coping strategies. To date, little research has examined how PUS operates in China or how it interacts with gender. The present study therefore investigates PUS and its health-related outcomes in a Chinese sample, with special attention to gender differences in stress exposure and coping.

Differential exposure to stress by gender

Although gender influences many elements in the stress process, the initial appraisal -- whether a situation is perceived as stressful, forms the foundation for understanding the health implications of stress [24]. Social role theory posits that sex-differentiated role expectations channel behavior and opportunities, thereby producing systematic differences in stress exposure and meaning-making [25]. Women often report higher perceived stress levels overall (e.g., due to greater domestic and caretaking demands) [21, 26], and they frequently encounter interpersonal stressors such as marital dissolution, elder care, or childrearing conflicts [22, 24]. Men, by contrast, are disproportionately exposed to more occupational or financial stressors (job instability, promotion competition and legal/financial problems) [27].

These differences are rooted in gendered divisions of labor and enduring societal norms that allocate economic provision to men and caregiving to women [28]. Importantly, such patterns extend beyond life stress to more structural and chronic stressors. Studies examining perceived injustice and discrimination reveal that women are particularly vulnerable to gender-based unfairness, with perceived gender discrimination negatively impacting mental wellbeing over time [29, 30]. However, interestingly, research on workplace incivility toward women found that male observers actually reported greater perceptions of injustice than female observers when witnessing unfair treatment of women [31]. This suggests that while women may experience more direct unfairness stress, men may be more sensitized to recognizing structural injustices. Such evidence underscores that gender differences in stress exposure are not merely individual-level phenomena but are embedded within broader structural inequalities, making the examination of unfairness stress through a gender lens particularly salient in the Chinese context.

Gender differences in PUS effects on health

Turning to specific stressors, PUS has been linked to adverse physical and mental health in both genders. In the Whitehall II cohort, De Vogli et al. (2007) reported that participants perceiving high unfairness had a 55% higher risk of future coronary events (even controlling for conventional risk factors) and significantly worse physical and mental health functioning. In the same cohort, high perceived unfairness predicted obesity, hypertension, dyslipidemia, and insulin resistance; individuals in the highest unfairness quartile had substantially higher odds of developing metabolic syndrome [10]. However, research on gender differences in these associations is limited and sometimes inconsistent. For example, in the Chinese context, perceived income inequality was found to negatively affect self-rated and mental health, with a markedly stronger effect for women than for men [32]. By contrast, Chen et al. (2025) found that severe PUS was associated with higher prevalence of noncommunicable chronic diseases but not with self-rated health and reported no gender differences in this association which highlights the need for further investigation.

Mechanisms of gender variation: coping styles

Depending on the Stress Appraisal and Coping Model (1984) [1], coping responses significantly influence the physiological consequences of stress exposure [33]. Adaptive coping strategies (problem-solving, seeking social support) are generally more effective in resolving stress-related issues and promoting emotional well-being, self-esteem and quality of life [34, 35]. Conversely, maladaptive strategies (avoidance, substance use) can lead to emotional issues such as anxiety and depression, as well as behavioral problems like suicide and substance abuse [36, 37].

From the vantage of gender socialization and social role theory, lifelong learning of “appropriate” masculine and feminine roles shapes both exposure to different stressors and the coping strategy. Research consistently finds that women are more likely to adopt emotion-focused or social support–seeking strategies, while men favor problem-focused or rational strategies [38, 39]. For instance, meta-analyses show women more frequently employ a range of emotion regulation tactics across contexts, though men may increase avoidance or problem-solving depending on the nature of the stressor [40]. The “tend-and‐befriend” framework further illuminates gendered coping: women often manage stress by nurturing and seeking social ties, an evolutionarily adaptive behavior mediated by oxytocin, whereas men are more inclined toward problem-focused or avoidant strategies [41].Importantly, these gendered coping tendencies reflect differences in strategy selection shaped by social role expectations rather than inherent contradictions in coping effectiveness. Within the stress-process framework [33], coping is conceptualized as a conditioning factor that shapes how stress exposure translates into subsequent health outcomes. Thus, the health consequences of perceived unfairness may depend not only on exposure itself but also on the type of coping strategy deployed in response. Because gender norms influence coping preferences, the effectiveness of coping strategies under conditions of perceived unfairness may differ between men and women. Accordingly, coping strategies are expected to moderate the relationship between perceived unfairness stress (PUS) and unfairness-related health outcomes, potentially amplifying or attenuating its effects.

Current study

In sum, cultural and gender norms in China create a unique context for understanding unfairness stress. Because China’s high power distance and predominant attribution of outcomes to individual effort can normalize systemic unfairness [42], PUS may be internalized or underreported in certain social groups. Given sparse and mixed evidence on gendered health effects of PUS in China, this study examines how perceived unfairness stress is associated with unfairness-related health outcomes among Chinese adults, with particular attention to gender-patterned associations in stress exposure and coping patterns. Unfairness-related health outcomes refer to functional and physiological responses that individuals attribute to experiences of perceived unfairness stress. We test the hypotheses that (H1) higher levels of PUS are associated with increased odds of unfairness-related health outcomes; (H2) the pattern of associations differs by gender; and (H3) coping strategies moderate the relationship between PUS and unfairness-related health outcomes. By illuminating these gendered stress processes, the study aims to inform more targeted stress-reduction interventions and policy responses in Chinese health, workplace, and educational settings.

Method

Participants and data collection

This cross-sectional study was conducted from July to December 2021 and approved by the Ethics Committee of Zhejiang Chinese Medical University (Approval No. 20210622-3). A multistage stratified sampling design was applied. First, four provincial capitals representing different geographic regions and levels of socioeconomic development were selected: Hangzhou (East), Guangzhou (South), Guiyang (West), and Xi’an (Northwest). In each city, two administrative districts were randomly selected, followed by two residential communities within each district. Within selected communities, we applied quota-based proportional recruitment to approximate the age–sex distribution of the permanent urban population according to the most recent local statistical yearbooks (2020 census-based demographic structure [43]). Specifically, age groups (< 25, 25–34, 35–44, 45–54, ≥ 55 years) and sex strata were used as benchmarks. Recruitment continued within each community until the predefined proportional quotas were reached. Eligible participants were permanent residents aged ≥ 18 years who had lived locally for at least one year.

Participants were approached through community outreach in residential compounds and public service centers. A total of 2,851 questionnaires were collected. Data cleaning followed a predefined protocol that included verification of data completeness and consistency checks for scale ranges. Eight cases were excluded due to missing data on the primary outcome; 2,843 valid responses were included in the final analytic sample. As composite scale variables (PUS and life stress scores) were bounded within predefined theoretical ranges, all observed values fell within permissible limits and no additional exclusions were made for extreme values. The excluded cases accounted for 0.28% of the total sample (8/2,851). Given the very small proportion of exclusions, no imputation procedures were performed. Participants who provided verbally informed consent and completed the survey received a small appreciation gift valued at three yuan.

Measures

Dependent and independent variables

Perceived Unfairness Stress (PUS)

Perceived unfairness stress (PUS) was measured through standard questionnaires designed by Jiang and colleagues [44], comprising of seven dimensions:1) income unfairness 2) educational unfairness 3) promotion unfairness 4) medical unfairness 5) work unfairness 6) pension unfairness and, 7) others unfairness. In the binary logistic regression analysis, all items pertaining to the perceived stress measures were rated on a five-point, Likert type scale ranging from 1 (“feeling no stress”) to 5 (“excessive stress”). For inferential analyses, the seven items were summed to create a total PUS score ranging from 7 to 35. Consistent with prior validation studies, a cutoff score of ≥ 21 was used to classify severe unfairness stress (coded as 1), with scores below 21 coded as 0. This scale demonstrated high internal consistency in the present study (Cronbach’s α = 0.918). For domain-specific descriptive analyses (Table 2), severity was operationalized at the item level to illustrate high-intensity stress endorsement within each unfairness domain. Specifically, responses of “considerable stress” and “excessive stress” were coded as 1 (severe), whereas “feeling no stress,” “little stress,” and “some stress” were coded as 0. These item-level dichotomizations were used solely for descriptive reporting and were not included in regression modeling.

Table 2.

Gender differences in unfairness stress of the study sample. (N = 2843)

Variable	Male		Female		χ²(p)
	n	%	n	%
Unfairness-related health outcomes					8.273, p = 0.004
Yes	580	41.2	515	35.9
No	829	58.8	919	64.1
Unfairness stress coping					38.700, p < 0.001
Avoidant coping	297	21.1	233	16.2
Active coping	550	39.0	526	36.7
Social support–seeking coping	417	29.6	558	38.9
Confrontive coping	46	3.3	20	1.4
Other coping strategies	99	7.0	97	6.8
Income unfairness a					11.300, p = 0.001
Yes	222	15.8	164	11.4
No	1187	84.2	1270	88.6
Educational unfairness a					6.614, p = 0.010
Yes	233	16.5	188	13.1
No	1176	83.5	1246	86.9
Promotion unfairness a					6.471, p = 0.011
Yes	240	17.0	195	13.6
No	1169	83.0	1239	86.4
Medical unfairness a					6.355, p = 0.012
Yes	232	16.5	188	13.1
No	1177	83.5	1246	86.9
Work unfairness a					6.070, p = 0.014
Yes	219	15.5	177	12.3
No	1190	84.5	1257	87.7
Pension unfairness a					6.028, p = 0.014
Yes	208	14.8	167	11.6
No	1201	85.2	1267	88.4
Others unfairness a					10.768, p = 0.001
Yes	234	16.6	176	12.3
No	1175	83.4	1257	87.7
Life stress					4.614, p = 0.032
Severe stress	625	44.4	579	40.4
No severe stress	784	55.6	855	59.6

Abbreviations:

^a A variable corresponds to a single item from the seven-item unfair stress scale and reflects perceived stress within that specific domain

Bold values indicate statistically significant results (p < 0.05)

Coping responses to perceived unfairness

Coping responses to perceived unfairness were assessed using the question: “How do you respond to stressful events that are unfair to you?” Respondents were asked to select the option that best reflected their primary coping response when facing unfairness-related stress. The coping categories were conceptually informed by established coping frameworks, including the COPE inventory and the stress appraisal and coping model (1984) [1], but the present study did not employ the Brief-COPE scale or its scoring system. Instead, the survey captured respondents’ dominant coping tendency through predefined response options. Based on prior research on coping in stress contexts, responses were classified into five coping strategies: (1) social support–seeking coping (e.g., talking with family or friends), (2) active coping (taking action to address the situation), (3) avoidant coping (enduring or withdrawing), (4) confrontive coping (e.g., aggressive or confrontational responses), and (5) other coping strategies. Because the specific behaviors underlying the “other” category were not directly measured in this survey, it was retained as a separate category in the analysis rather than merged with other coping domains.

Unfairness stress related to health outcomes

Unfairness-related health outcomes (USO) were assessed using the question: “Have you experienced any of the following symptoms in the last five years as a result of unfair treatment?” The item asked respondents to indicate the main consequence they experienced following unfairness-related stress events. Three response options captured different manifestations of stress-related consequences: (1) inability to persist in school or work for more than one day, (2) reduced food intake for more than three consecutive days (reduced by more than one third), and (3) short sleep duration (less than five hours per day for more than three consecutive days) [44, 45]. Because these responses represent distinct functional or physiological manifestations of stress, rather than items of a unidimensional symptom scale, they were treated as mutually exclusive categories. The five-year recall period was used to capture relatively infrequent but salient unfairness-related stress experiences that may occur during major life events such as education, employment, or promotion processes. For the purposes of analysis, USO was operationalized as a binary indicator reflecting whether respondents reported any unfairness-related health consequence. Participants who endorsed at least one of the three outcomes were coded as having USO (1), while those reporting none of these consequences were coded as 0.

Covariates

Life stress and mental health variables were included as potential confounders to account for broader stress exposures and baseline psychological vulnerability that may be associated with both perceived unfairness stress and health outcomes.

Life stress

Life stress was measured through standard questionnaires designed by Yang and colleagues [46]. Life stress questions were measured by six items of stressors from having:1) Employment and income instability 2) Excessive job demands and time pressure 3) Strained workplace relationships 4) Family conflict 5) Children’s educational or employment difficulties and 6) Poor personal or family health. All items were rated on a five-point scale: feeling no stress (0); little stress (1); some stress (2); considerable stress (3); and excessive stress (4).The total score ranged from 0 to 24, with scores ≥ 18 classified as severe life stress (coded as 1; otherwise 0). The scale demonstrated acceptable reliability in this study (Cronbach’s α = 0.88).

Mental health

The mental health status among participants was measured by the 12-item Chinese Health Questionnaire (CHQ), derived from the General Health Questionnaire (GHQ) (1989) [47], and has been widely used to assess mental health status in the community and primary care setting across China [48]. The CHQ version was the Mandarin version which was revised and adapted by Yang and colleagues according to Chinese mainland culture, designed to screen for mental disorders in community settings [49]. All items were rated on a four-point scale: not at all (0), same as usual (0), rather more than usual (1), or much more than usual (1). The twelve items of mental health were combined into a range of 0–12, prior research utilizing the CHQ has employed a threshold score of three or higher to denote psychological distress [47, 49].

Demographic characteristics

Demographic data including the place of residence, age, gender, ethnicity, marital status, educational attainment, occupation, and income were collected.

Statistical analysis

All data were entered into a database using Microsoft Excel. The dataset was then imported into IBM SPSS Statistics version 26 for statistical analyses. Descriptive statistics were calculated to determine the prevalence of unfairness-related health outcomes and to examine gender-patterned associations in PUS of the study sample. Logistic models were utilized to assess associations between the dependent and independent variables among different genders separately. We estimated a sequence of nested models to assess the robustness of associations: (1) a base model including demographic covariates (place of residence, age, ethnicity, marital status, education and occupation); (2) a stress-process model that added PUS and coping responses to perceived unfairness to the base model; and (3) a full model that further adjusted for life stress and mental health. For each model, we report adjusted odds ratios (aORs) with 95% confidence intervals (CIs) and statistical significance was set at p < 0.05.

In addition, pooled logistic regression models including interaction terms were estimated to formally test potential effect modification. Specifically, interaction terms for sex * PUS, sex * coping strategies, and coping strategies * PUS were introduced in the fully adjusted model. These analyses were conducted to assess whether the associations between perceived unfairness stress, coping strategies, and unfairness-related health outcomes differed by gender or coping responses. Because interaction tests typically have lower statistical power than stratified analyses, the interaction models were used as complementary analyses to aid interpretation of gender-specific patterns.

Result

Table 1 presents the descriptive statistics for all participants. The study analyzed a sample of 2843 people (1434 women and 1409 men) between 18 and 85 years old. Most participants (85.5%) were Han ethnicity and over half (52.4%) had attained education beyond the university level. Unfairness-related health outcomes were reported by 38.5% of the sample, while 33.6% experienced PUS. Notably, 47.3% of those who reported avoidant coping and 54.5% of those who reported confrontive coping as their coping response to perceived unfairness also experienced unfairness-related health outcomes.

Table 1.

Sociodemographic characteristics of the study sample. (N = 2843)

Variable	N	%	Unfairness related health outcomes (n)	% with unfairness-related health outcomes	χ2 /t	p
City					19.942	< 0.001
Xi’an	770	27.1	279	36.2
Hangzhou	699	24.6	243	34.8
Guangzhou	835	29.4	323	38.7
Guiyang	539	19.0	250	46.4
Sex					8.273	0.004
Male	1409	49.6	580	41.2
Female	1434	50.4	515	35.9
Age					75.274	< 0.001
< 25	769	27.0	237	30.8
25–34	443	15.6	176	39.7
35–44	578	20.3	293	50.7
45–54	485	17.1	213	43.9
> 55	568	20.0	176	31.0
Ethnicity					4.662	0.031
Han	2432	85.5	917	37.7
Minority	411	14.5	178	43.3
Marital status					44.616	< 0.001
Married	1616	56.8	637	39.4
Never married	998	35.1	344	34.5
Divorced	126	4.4	81	64.3
Widowed	103	3.6	33	32.0
Education					13.623	0.003
Junior high school and below	673	23.7	253	37.6
Senior high school	680	23.9	301	44.3
University	1331	46.8	478	35.9
Postgraduate or above	159	5.6	63	39.6
Occupation					83.323	< 0.001
Government agencies/public institutions/ state-owned enterprises	466	16.4	179	38.4
Private enterprise	467	16.4	205	43.9
Self-employed people	402	14.1	208	51.7
Freelance work	516	18.1	222	43.0
Unemployed/student/retired	992	34.9	281	28.3
Income					7.901	0.095
< 50,000	791	27.8	281	35.5
50,000 -100,000	865	30.4	344	39.8
100,000 -150,000	603	21.2	245	40.6
150,000-200,000	279	9.8	118	42.3
> 200,000	305	10.7	107	35.1
Perceived Unfairness Stress a					56.572	< 0.001
Severe stress	955	33.6	460	48.2
No Severe stress	1888	66.4	635	33.6
Life stress					86.545	< 0.001
Severe stress	1204	42.3	583	48.4
No Severe stress	1639	57.7	512	31.2
Mental health					202.177	< 0.001
Mental disorder	714	25.1	435	60.9
No Mental disorder	2129	74.9	660	31.0
Unfairness Stress Coping					47.687	< 0.001
Avoidant coping	528	18.6	250	47.3
Active coping	1075	37.8	370	34.4
Social support–seeking coping	968	34.0	386	39.9
Confrontive coping	66	2.3	36	54.5
Other coping strategies	195	6.9	49	25.1

Abbreviations:

^a Perceived Unfairness Stress was operationalized as a dichotomous composite indicator derived from the summed score of the seven-item unfair

Bold values indicate statistically significant results (p < 0.05)

Table 2 presents the analysis of gender differences in PUS conditions using a series of chi-square tests. Significant gender differences were found in coping responses to perceived unfairness, unfairness-related health outcomes, and domains of unfairness stress. Overall, men reported slightly higher levels of perceived unfairness stress than women, with differences ranging from 3.2 to 4.4% points across domains. Although these differences were modest, the largest gap was observed for income-related unfairness, reported by 15.8% of men and 11.4% of women. Men were more likely to report unfairness-related health outcomes (χ²=8.273, p = 0.004). Additionally, coping strategies differed significantly between men and women (χ²=38.700, p < 0.001). Men were more likely to adopt active coping strategies, whereas women were more likely to seek social support.

Table 3 presents the results of multiple regression analyses on unfairness-related health outcomes by genders. Stress Process Model indicated that, among individuals experiencing PUS, males (OR = 2.135; 95% CI = 1.673,2.726; p < 0.001) were more likely to have unfairness-related health outcomes than females (OR = 1.833; 95% CI = 1.421,2.365; p < 0.001). Compared with avoidant coping, males’ active coping (OR = 0.499; 95% CI = 0.366,0.679; p < 0.01), and other coping (OR = 0.373; 95% CI = 0.219,0.634; p < 0.001) were protective factor for unfairness-related health outcomes, while active coping (OR = 0.674; 95% CI = 0.476,0.954; p < 0.05) and other coping (OR = 0.422; 95% CI = 0.238,0.747; p < 0.01) were also protective for females. After controlling for other variables, Full Model showed that among male participants, PUS was significantly associated with a higher likelihood of unfairness-related health outcomes (OR = 1.574; 95%CI = 1.190,2.081; p < 0.01) whereas this association was not significant among females. Both active coping (OR = 0.540; 95% CI = 0.392,0.744; p < 0.001) and other coping (OR = 0.399; 95% CI = 0.230,0.690; p < 0.01) remained protective factors for males, similarly other coping (OR = 0.393; 95% CI = 0.217,0.711; p < 0.01) remained protective for females. Mental health was significantly associated with unfairness-related health outcomes in both males (OR = 3.299; 95%CI = 2.483,4.383; p < 0.001) and females (OR = 2.970; 95%CI = 2.231,3.953; p < 0.001). Life stress was only significantly associated with unfairness-related health outcomes in females (OR = 1.593; 95%CI = 1.216,2.086; p < 0.01).

Table 3.

Logistic Regression Analyses on unfairness-related health outcomes of the study sample. (N = 2843)

Group	Base Model		Stress Process Model		Full Model
	Male	Female	Male	Female	Male	Female
City
Xi’an	1.00	1.00	1.00	1.00	1.00	1.00
Hangzhou	0.613(0.447,0.841) b	1.103(0.794,1.532)	0.661(0.475,0.920) c	1.136(0.809,1.594)	0.817(0.580,1.151)	1.335(0.938,1.899)
Guangzhou	0.815(0.593,1.121)	1.063(0.775,1.458)	0.766(0.549,1.067)	0.966(0.698,1.336)	0.759(0.538,1.072)	0.923(0.659,1.293)
Guiyang	1.064(0.728,1.556)	1.629(1.095,2.424) c	1.433(0.961,2.135)	1.976(1.309,2.985) b	1.403(0.928,2.122)	1.776(1.159,2.723) b
Age
< 25	1.00	1.00	1.00	1.00	1.00	1.00
25–34	1.049(0.677,1.624)	1.631(1.025,2.596) c	1.065(0.678,1.672)	1.443(0.901,2.312)	1.023(0.640,1.636)	1.363(0.839,2.215)
35–44	1.513(0.943,2.428)	2.828(1.723,4.642) a	1.451(0.893,2.359)	2.439(1.474,4.035) b	1.592(0.960,2.641)	2.624(1.563,4.405) a
45–54	0.854(0.516,1.415)	3.043(1.807,5.124) a	0.903(0.537,1.517)	2.658(1.563,4.523) a	0.984(0.574,1.686)	2.792(1.613,4.835) a
> 55	0.669(0.405,1.106)	1.599(0.941,2.717)	0.690(0.412,1.157)	1.330(0.774,2.284)	0.727(0.424,1.247)	1.616(0.923,2.829)
Ethnicity
Han	1.00	1.00	1.00	1.00	1.00	1.00
Minority	0.954(0.651,1.398)	0.950(0.650,1.389)	0.922(0.623,1.365)	0.903(0.613,1.329)	0.735(0.487,1.109)	0.759(0.507,1.136)
Marital status
Married	1.00	1.00	1.00	1.00	1.00	1.00
Never married	1.074(0.734,1.572)	1.858(1.223,2.822) b	1.191(0.804,1.765)	1.731(1.132,2.649) c	1.289(0.857,1.940)	1.696(1.095,2.625) c
Divorced	1.727(0.988,3.019)	3.177(1.810,5.574)	1.622(0.918,2.867)	2.898(1.637,5.129) a	1.377(0.764,2.484)	2.544(1.418,4.565) b
Widowed	1.284(0.710,2.322)	0.729(0.338,1.574) c	1.297(0.703,2.393)	0.689(0.317,1.498)	1.207(0.634,2.296)	0.586(0.261,1.314)
Education
Junior high school and below	1.00	1.00	1.00	1.00	1.00	1.00
Senior high school	0.801(0.575,1.116)	1.253(0.879,1.788)	0.872(0.619,1.228)	1.330(0.925,1.912)	0.894(0.629,1.272)	1.568(1.076,2.284) c
University	0.679(0.488,0.945) c	1.180(0.814,1.710)	0.725(0.514,1.021) c	1.185(0.809,1.735)	0.693(0.487,0.988) c	1.339(0.903,1.985)
Postgraduate or above	0.781(0.462,1.321)	1.132(0.589,2.176)	0.919(0.531,1.589)	1.164(0.596,2.273)	0.915(0.519,1.612)	1.243(0.620,2.490)
Occupation
Government agencies/public institutions/ state-owned enterprises	1.00	1.00	1.00	1.00	1.00	1.00
Private enterprise	1.168(0.814,1.676)	1.293(0.826,2.024)	1.434(0.985,2.087)	1.373(0.871,2.166)	1.434(0.976,2.107)	1.333(0.833,2.133)
Self-employed people	1.175(0.797,1.732)	2.321(1.476,3.648) a	1.351(0.904,2.020)	2.463(1.556,3.900) a	1.355(0.895,2.051)	2.264(1.412,3.632) b
Freelance work	1.013(0.703,1.462)	1.285(0.835,1.978)	1.077(0.738,1.571)	1.311(0.845,2.032)	1.098(0.744,1.619)	1.266(0.806,1.987)
Unemployed/student/retired	0.474(0.326,0.690) a	1.222(0.792,1.887)	0.504(0.342,0.740) a	1.190(0.767,1.848)	0.480(0.322,0.714) a	1.077(0.683,1.699)
Perceived Unfairness Stress d
No severe stress			1.00	1.00	1.00	1.00
Severe stress			2.135(1.673,2.726) a	1.833(1.421,2.365) a	1.574(1.190,2.081) b	1.277(0.962,1.695)
Unfair Stress Coping
Avoidant coping			1.00	1.00	1.00	1.00
Active coping			0.499(0.366,0.679) b	0.674(0.476,0.954) c	0.540(0.392,0.744) a	0.832(0.579,1.194)
Social support–seeking coping			0.734(0.532,1.012)	0.944(0.670,1.330)	0.778(0.558,1.084)	1.062(0.744,1.516)
Confrontive coping			1.380(0.704,2.705)	0.670(0.246,1.824)	1.378(0.685,2.769)	1.040(0.376,2.872)
Other coping strategies			0.373(0.219,0.634) a	0.422(0.238,0.747) b	0.399(0.230,0.690) b	0.393(0.217,0.711) b
Life stress
No severe stress					1.00	1.00
Severe stress					1.256(0.955,1.651)	1.593(1.216,2.086) b
Mental health
No Mental disorder					1.00	1.00
Mental disorder					3.299(2.483,4.383) a	2.970(2.231,3.953) a
Fixed parameters	1.178	0.138a	1.044	0.158a	0.696	0.091a

Abbreviations:

^ap<0.001

^bp<0.01

^cp<0.05

^d Perceived Unfairness Stress was operationalized as a dichotomous composite indicator derived from the summed score of the seven-item unfair stress scale

Interaction tests using pooled logistic regression models indicated that neither the interaction between sex and coping strategies (p = 0.265) nor between sex and perceived unfairness stress (p = 0.341) reached statistical significance. The interaction between coping strategies and PUS approached statistical significance (p = 0.047). Detailed results of the pooled interaction models are provided in Supplementary Table S1.

Discussion

The present findings suggest that perceived unfairness is a relatively common source of stress and is associated with unfairness-related health outcomes in China. In our sample, 38.5% reported unfairness-related health outcomes, highlighting how pervasive and harmful injustice can be, even when many Chinese may tacitly accept inequity [14]. Perceived unfairness may trigger stress responses that can “compound and compromise physical health” over time [7]. This is consistent with previous studies showing that unfair treatment or social inequity is linked to anxiety, depression, hypertension and other poor outcomes [5]. Although broad life stress also undermines health, our results suggest that PUS is a distinctive stress dimension deserving attention. In China’s rapidly changing society, widening gaps and contested resources may mean that even if many are accustomed to unfairness, it may still be associated with a health burden.

Domains of unfairness and gender differences: education, career, healthcare

The highest domain of PUS reported in our sample was education and promotion for both men and women. This pattern aligns with well-documented features of contemporary China: a highly competitive, high-stakes college-entrance system (the gaokao), pronounced educational stratification, and rigid occupational hierarchies that make access to educational credentials and promotion pivotal life-course events. While previous research has largely focused on unfair promotion within specific groups, such as nurses and police officers, the broader social and cultural context influencing these perceptions has been relatively overlooked [50, 51]. However, influenced by collectivist values, obedience to authority, and a desire to maintain harmonious relationships within organizations, Chinese individuals may sometimes suppress their dissatisfaction or remain silent in the face of unfair promotion [52]. Similarly, educational access or selection is perceived as compromised—by corruption or preferential treatment—the psychological consequences may arise. For example, a nationally representative study found that corrupt admissions (e.g., bribery or preferential placement) are associated with worse mental health among Chinese adolescents, consistent with a cognitive-dissonance and fairness-violation mechanism [53].

Men reported slightly higher unfairness than women across domains, which broadly aligns with the idea that in a male-dominated society, men may hold systems to higher “fairness standards” [54]. Interestingly, gender differences emerged in which domains provoked strong unfairness: healthcare ranks third for women (after education and promotion), whereas men more often report “other” domains (e.g., housing) as their third concern. This gendered pattern likely reflects the persistent gendered division of care in Chinese families: women disproportionately shoulder childcare and eldercare responsibilities, and therefore are more attuned to perceived inequities in access to medical services or the quality of care received by family members [55, 56]. Consequently, perceived unfairness in healthcare settings may register as a particularly important stressor for women precisely because it directly threatens their caregiving role and the wellbeing of dependents.

The male–female gap in unfairness perception may also appear to be shaped by socialization and power relations. Patriarchal norms confer men with relatively greater status and voice in public and occupational spheres, which may make deviations from presumed procedural or distributive justice more conspicuous—and hence more likely to be labeled and reported as “unfair” by men [31, 57]. Women, by contrast, may be socialized into expectations of accommodation and relational maintenance; repeated exposure to structural disadvantage can foster normalization or resignation—processes conceptualized in the learned-helplessness and system-justification literatures—so that many experiences of structural unfairness are absorbed into a general pattern of life hardship rather than being appraised primarily as discrete injustices [58]. In short, men may be more likely to notice and overtly resent violations of fairness that threaten status, whereas women may be more likely to internalize pervasive structural constraints as part of ordinary life stress.

Gendered pattern in unfairness stress coping and health outcomes

Although formal interaction tests did not demonstrate statistically significant gender modification, stratified analyses suggested that active coping was associated with a lower likelihood of unfairness-related health outcomes among men compared with avoidant coping, whereas this pattern was not observed among women. This pattern may reflect the extent to which the effectiveness of coping strategies depends on their alignment with prevailing gender norms. In many social contexts, traditional masculine role expectations encourage problem-oriented responses when fairness or status is challenged, potentially making active coping more socially supported and psychologically reinforcing for men.

By contrast, women are more often socialized toward relational and emotion-focused coping strategies [25, 59, 60]. While these approaches may provide important emotional support, they may be less effective when stressors involve structural or institutional unfairness that cannot easily be resolved through interpersonal discussion. Supporting this interpretation, research on co-rumination has shown that repeated discussion of stress without resolution can, in some cases, intensify emotional distress and even elevate physiological stress markers, particularly among women [61, 62]. Taken together, these findings suggest that differences in coping efficacy may arise not only from the strategy itself but also from the broader social context in which coping behaviors are enacted.

In addition, we observed that divorce or widowhood among women was associated with fewer unfairness-related health consequences. Although this finding may appear counterintuitive, it is consistent with previous research suggesting that married women often shoulder multiple social roles, including employment, childcare, and elder care, which may amplify stress exposure [63, 64]. While earlier studies emphasize the importance of marital satisfaction and marital adjustment in shaping stress experiences, our findings suggest that marriage itself may also represent an important context in which women encounter perceived unfairness [63, 65]. Women who are no longer embedded in these role expectations may experience fewer situations that they interpret as unfair. In contrast, no comparable pattern was observed among men, suggesting that marital roles may operate differently across genders in shaping exposure to and interpretation of unfairness-related stress.

Although the specific behaviors constituting the “other coping” category were not directly measured in this survey, the consistency of its protective association across both genders warrants theoretical reflection. One plausible interpretation is that this category may capture coping responses that fall outside the four strategies operationally defined in this study—responses that are nonetheless meaningful in the Chinese sociocultural context. Perceived unfairness stress, by its structural and systemic nature, is largely chronic and resistant to individual-level resolution. Under such conditions, problem-focused coping is likely to prove ineffective, as perceived injustice in domains such as blocked promotion or unequal educational access cannot typically be altered through individual action alone. Emotion-focused strategies may offer temporary relief but are insufficient for sustained adaptation under chronic, irresolvable stress [66].

Within Folkman’s revised stress-coping framework, meaning-focused coping emerges precisely under these circumstances—activated when prior coping efforts have been exhausted, it operates by drawing on beliefs, values, and existential goals to reframe the significance of the stressor, revise goals that are no longer attainable, or reorder life priorities in ways that reduce the salience of blocked domains [66]. Such meaning-oriented responses may be particularly congruent with Chinese cultural traditions rooted in Taoist and Buddhist philosophy, which emphasize acceptance of adversity, self-transcendence, and the principle of Wu Wei [67, 68]. Cross-cultural evidence further suggests that, compared with Euro-Canadians, Chinese individuals are significantly more likely to perceive meaning in stressful experiences and to adopt acceptance-based and positive reframing coping strategies in response [69]. It is therefore speculative but theoretically plausible that the “other coping” category may partly reflect such culturally embedded, meaning-oriented practices. This interpretation cannot be verified with the present data, and qualitative research is needed to identify the actual behavioral content of these responses before any conclusions about mechanisms or practical implications can be drawn.

Gendered patterns in associations with unfairness-related health outcomes: life stress versus perceived unfairness stress

Finally, our gender-stratified models suggest a pattern of differentiation: among men, perceived unfairness stress was associated with unfairness-related health outcomes, whereas among women, general life stress appeared more consistently associated with these outcomes. Although formal interaction tests did not confirm statistically significant gender modification (p = 0.341), these stratified patterns may nonetheless point to theoretically meaningful differences worthy of further investigation. One possible interpretation is that gendered socialization and structural exposure shape both the salience of stressors and the labeling process by which individuals translate stressful experience into attributions of “unfairness.” Socialization theory holds that men are normatively oriented toward instrumental, status-related domains (work, promotion, public competence) [25], so discrete violations of procedural or distributive justice in those arenas are more likely to be recognized, encoded as unfair, and experienced as acute threats to valued resources [27]; consequently such events show a direct association with health outcomes [23]. Women, socialized toward relational and caregiving roles, routinely experience a confluence of family- and care-related strains [28]; these chronic, diffuse burdens may be experienced as general life stress rather than discrete injustice events, so life stress better predicts their somatic/functional responses in multivariate models.

Two further theoretical mechanisms may help to contextualize and deepen this interpretation. The first draws on Conservation of Resources (COR) theory—pending replication with longitudinal data—which suggests that stress and ill-health arise most when valued resources are threatened or lost [70]. For men whose social resources and status are concentrated in occupational domains, a specific unfair event (e.g., blocked promotion) constitutes a salient resource loss and therefore precipitates measurable health effects. For women who routinely expend and are constrained in multiple resource domains (time, caregiving capacity, emotional labor), the accumulation of broadly defined life stress better captures the resource depletion process that leads to unfairness-related health outcomes. A second speculative interpretation draws on structural role-strain perspectives (including status inconsistency and intersectionality), which suggest that women’s multiple, overlapping roles can blur the boundary between “unfairness” and “ordinary hardship” — leading to a pattern in which systemic unfairness is normalized or subsumed within general life strain and hence shows a weaker direct association with unfairness-related health outcomes once life stress and other controls are included. These mechanisms, however, remain hypothetical in the absence of formal interaction evidence and should be tested in future prospective studies.

These patterns should also be interpreted within China’s broader social structure. Despite rapid modernization and rising female education and labor participation, China remains a structurally male-dominant society in which power, economic resources, and public voice are still disproportionately concentrated among men [71]. Our findings suggest, however, that even men—traditionally viewed as beneficiaries of this social order—are not immune to the health costs of structural unfairness, experiencing tangible stress-related impairments when fairness norms are violated in status-related domains. By contrast, women’s unfairness-related stress may be substantially underestimated. They often face higher baseline life stress from unpaid care and role overload yet have limited opportunity or social legitimacy to frame structural disadvantages as “unfairness.” Instead, these experiences are more likely to be internalized as personal responsibility or ordinary life pressure. Continued attention to perceived unfairness stress (PUS) is therefore essential—not only for elucidating gendered pathways linking unfairness to stress and health, but also for informing more equitable workplace policies, social support systems, and public-health interventions aimed at mitigating unfairness-related health disparities.

Statement of limitations

Several limitations should be considered when interpreting the findings of this study. First, although the sample included four representative cities from different regions of China, these were all provincial capitals with relatively higher levels of economic and social development, and rural populations were not included. In addition, the cross-sectional design limits causal inference. These factors may affect the representativeness and generalizability of the results. Second, unfairness-related health outcomes were assessed through self-reported symptoms following major stress events. Although three key stress-related health manifestations were selected based on previous research, the self-report nature of these measures may introduce recall bias. Because unfairness-related stress events often occur during important life stages and relatively infrequently, a longer recall window was used to capture such experiences; however, retrospective reporting may still be subject to memory limitations. Third, coping was assessed by asking respondents to report their primary coping response to unfairness-related stress. While identifying the predominant coping strategy is a commonly used approach, the measure does not capture the use of multiple coping strategies. In addition, the study did not collect detailed information on the specific strategies included in the “other” category, which may contain diverse coping behaviors and warrants further exploration in future research. Finally, although several demographic variables were controlled for, unfairness-related health outcomes are influenced by a wide range of factors beyond those examined in this study. Psychological characteristics such as resilience, as well as broader social and political contexts, may shape how individuals perceive and respond to unfairness. These factors remain insufficiently explored in the present analysis and should be examined in future research, particularly regarding how they may interact with gender in shaping stress perceptions and health outcomes.

Conclusion and implication

In conclusion, our study suggests that perceived unfairness stress (PUS) is a noteworthy public health concern in contemporary urban China, with nearly 40% of adults reporting unfairness-attributed symptoms such as sleep disturbance, reduced food intake, or difficulty maintaining work or school activities. Coping strategies appear to yield unequal health consequences depending on the broader social context in which they are enacted. Gender-patterned differences were observed in both stress exposure and associated outcomes. In stratified analyses, health outcomes among men were more closely linked to specific perceptions of unfairness, whereas among women general life stress appeared to play a more prominent role even when unfairness stress was present. These patterns suggest that gender socialization and structural constraints may shape not only the types of stressors individuals encounter but also how these stressors are interpreted and managed.

The policy implications are twofold. First, efforts to address perceived unfairness in commonly cited domains—such as education and promotion—may help reduce stress-related symptoms among adults. Second, stress-management interventions may benefit from gender-sensitive approaches. For men, strengthening grievance channels and fairness-related institutional mechanisms may help address perceived injustice, whereas for women policies that alleviate cumulative life stress and strengthen coping resources may be particularly relevant. It is further noted that the coping strategy associated with the strongest protective effect in this study remains behaviorally uncharacterized; future qualitative research is warranted to inform more precise intervention design.

Authors’ contributions

Conceptualization: [Shuhan Jiang] [Weifang Zhang]; Data curation: [Shuhan Jiang] [Mingyuan Sheng] [Jiayao Ye] [Zhaoqing Liao] [Qi Lu]; Formal analysis: [Mingyuan Sheng] [Shuhan Jiang]; Funding acquisition: [Shuhan Jiang]; Methodology: [Shuhan Jiang] [Mingyuan Sheng]; Project administration: [Shuhan Jiang]; Resources: [Shuhan Jiang]; Supervision: [Shuhan Jiang]; Validation: [Shuhan Jiang]; Writing – original draft: [Shuhan Jiang] [Mingyuan Sheng] [Jiayao Ye] [Zhaoqing Liao] [Qi Lu]; Writing – review & editing: [Shuhan Jiang] [Mingyuan Sheng] [Weifang Zhang]. All authors have read and approved the final manuscript.

Funding

This study was funded by the Young Scientists Fund of the National Natural Science Foundation of China (No. 72504257), the Social Science Foundation of the Ministry of Education of China (No. 23YJCZH090), and the Provincial “Top Soldier” and “Leading Wild Goose” Program (No. 2023C03072).

Data availability

The data sets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study was approved by the Ethics Committee at Zhejiang Chinese Medical University (approval number:20210622-3) and verbal consent was obtained from all participants prior to data collection.

Consent for publication

Not applicable. The manuscript does not contain any individual person’s identifiable data; therefore, consent for publication is not required.

Competing interests

The authors declare no competing interests.