Gender equality and global health: intersecting political challenges.

BACKGROUND: Women's and men's health outcomes are different. Some differences are biological, related to male and female sex, while others are related to their gender. Sex- and gender-related issues require different solutions, but policy makers lack straightforward heuristic strategies to identify gender-related health inequities. METHODS: Using 169 causes of disability-adjusted life years (DALYs) from the 2017 Global Burden of Disease, we calculated the female-to-male (f:m) and male-to-female (m:f) ratios of global DALYs, rank-ordered the ratios by size and calculated the proportion of all-cause DALYs that each cause explained, separately for males and females 15-49 years old. Gender-related vs sex-related causes were categorised using literature on the drivers for the 15 causes with highest f:m and m:f ratios. RESULTS: Causes of DALYs with high m:f ratios appear to be gendered and include: road injuries, interpersonal violence, and drowning - totaling 12.4% of men's (15-49 years) all-cause DALYs. However, causes of DALYs with high f:m ratios are more likely a mix of sex-related and gender-related factors - including headache disorders, depressive disorders, and dietary iron deficiency - totaling 13.4% of women's (15-49 years) all-cause DALYs. Ratios vary by age, geography and Socio-demographic Index. CONCLUSIONS: Gender-related vs sex-related causes were categorised using available literature on the drivers for selected causes, illustrating that sex-disaggregated data represents a mix of social and biological influences. This analysis offers a model that policy makers can use to uncover potential gender inequalities in health, including intersections with other social factors. From it, new challenges emerge for global health policy makers and practitioners willing to address them. Global health actors will need to achieve a balance between the two agendas of global health and gender equality

'If she gets married when she is young, she will give birth to many kids': a qualitative study of child marriage practices amongst nomadic pastoralist communities in Kenya

Child marriage is associated with adverse health and social outcomes for women and girls. Among pastoralists in Kenya, child marriage is believed to be higher compared to the national average. This paper explores how social norms and contextual factors sustain child marriage in communities living in conflict-affected North Eastern Kenya. In-depth interviews were carried out with nomadic and semi-nomadic women and men of reproductive age in Wajir and Mandera counties. Participants were purposively sampled across a range of age groups and community types. Interviews were analysed thematically and guided by a social norms approach. We found changes in the way young couples meet and evidence for negative perceptions of child marriage due to its impact on the girls’ reproductive health and gender inequality. Despite this, child marriage was common amongst nomadic and semi-nomadic women. Two overarching themes explained child marriage practices: 1) gender norms, and 2) desire for large family size. Our findings complement the global literature, while contributing perspectives of pastoralist groups. Contextual factors of poverty, traditional pastoral lifestyles and limited formal education opportunities for girls, supported large family norms and gender norms that encouraged and sustained child marriage

Perpetration of intimate partner violence and mental health outcomes: sex- and gender-disaggregated associations among adolescents and young adults in Nigeria.

BACKGROUND: The association between intimate partner violence (IPV) victimisation and poor mental health outcomes is well established. Less is known about the correlation between IPV perpetration and mental health, particularly among adolescents and young adults. Using data from the nationally representative Violence Against Children Survey, this analysis examines the association between IPV perpetration and mental health for male and female adolescents and young adults in Nigeria. METHODS: Multivariate logistic regression models were used to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol use. Models were sex-disaggregated, controlled for age, marital status, and schooling, and tested with and without past exposure to violence. Standard errors were adjusted for sampling stratification and clustering. Observations were weighted to be representative of 13-24 year-olds in Nigeria. RESULTS: Males were nearly twice as likely as females to perpetrate IPV (9% v. 5%, respectively; P < 0.001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio (aOR) = 4.60 for males; aOR = 2.71 for females). Female perpetrators had 2.73 higher odds of reporting severe sadness (95% confidence interval CI = 1.44, 5.17; P = 0.002) and 2.72 times greater odds of reporting suicide ideation (1.28, 5.79; P = 0.010) than non-perpetrating females, even when controlling for past-year violence victimisation. In contrast, male perpetrators had 2.65 times greater odds of feeling worthless (1.09, 6.43; P = 0.031), and 2.36 times greater odds of reporting alcohol use in the last 30 days (1.50, 3.73; P < 0.001), as compared to non-perpetrating males. CONCLUSIONS: Among adolescents and young adults in Nigeria, IPV perpetration and negative mental health outcomes are associated but differ for males and females. Mindful of the cross-sectional nature of the data, it is possible that socially determined gender norms may shape the ways in which distress from IPV perpetration is understood and expressed. Additional research is needed to clarify these associations and inform violence prevention efforts

The story of the “now-women”: changing gender norms in rural West Africa

This article offers a qualitative investigation of how human rights education sessions, embedded in a multi-faceted intervention, helped members of a rural community in West Africa challenge inequitable gender norms that hindered women’s political participation. Results show a change in women’s political participation and community members’ descriptions of women’s potential. Three features of the intervention contributed to this change: (1) its pedagogical approach; (2) its substantive content; and (3) the engagement of men and women together. The article calls for interventions that facilitate sustained dialogue between men and women to achieve greater gender equity

Gender-related data missingness, imbalance and bias in global health surveys

Global surveys have built-in gender-related biases associated with data missingness across the gender dimensions of people’s lives, imbalanced or incomplete representation of population groups, and biased ways in which gender information is elicited and used. While increasing focus is being placed on the integration of sex-disaggregated statistics into national programmes and on understanding effects of gender-based disparities on the health of all people, the data necessary for elucidating underlying causes of gender disparities and designing effective intervention programmes continue to be lacking. Approaches exist, however, that can reasonably address some shortcomings, such as separating questions of gender identification from biological sex. Qualitative research can elucidate ways to rephrase questions and translate gendered terms to avoid perpetuating historical gender biases and prompting biased responses. Non-health disciplines may offer lessons in collecting gender-related data. Ultimately, multidisciplinary global collaborations are needed to advance this evolving field and to set standards for how we measure gender in all its forms