Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms

doi:10.1016/S0140-6736(19)30656-7

The Lancet

Volume 393, Issue 10190, 22–28 June 2019, Pages 2522-2534

https://doi.org/10.1016/S0140-6736(19)30656-7 Get rights and content

Summary

Evidence that gender inequalities and restrictive norms adversely affect health is extensive; however, far less research has focused on testing solutions. We first comprehensively reviewed the peer-reviewed and grey literature for rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. We identified four mutually reinforcing factors underpinning change: (1) multisectoral action, (2) multilevel, multistakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. Following this review, because little research has investigated the effects of national-level law and policy reforms, we conducted original quasi-experimental studies on laws and policies related to education, work, and income, all social determinants of health in which deep gender inequalities exist. We examined whether the laws and policies significantly affected health outcomes and gender norms, and whether law-induced and policy-induced changes in gender norms mediated the health effects, in areas for which longitudinal data existed. Laws and policies that made primary education tuition-free (13 intervention countries with the law and/or policy and ten control countries without) and that provided paid maternity and parental leave (seven intervention and 15 control countries) significantly improved women's and their children's health (odds ratios [OR] of 1·16–2·10, depending on health outcome) and gender equality in household decision making (OR 1·46 for tuition-free and 1·45 for paid maternity and parental leave) as a proxy indicator of gender norms. Increased equality partially mediated the positive effects on health outcomes. We conclude by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

Introduction

Adverse social circumstances—including educational disadvantage, poverty, and poor working conditions—raise morbidity and mortality, as shown conclusively by the vast published literature, well summarised by the WHO Commission on Social Determinants of Health.1, 2 Extensive evidence shows that gender inequalities leave women and girls worse off in each of these areas.³ For example, an estimated 5 million more girls of primary-school age are out of school than boys.⁴ Women earn only 77% of their male counterparts' wages, and their overall labour-force participation, 48·5%, trails 26·5 percentage points behind men's.⁵ Governance structures shaping education, work, and income are also grossly unequal. Women constitute only a minority of private-sector chief executive officers,⁶ and women's representation in national parliaments still stands at only 23·7%.⁷

Gender inequalities and power imbalances also markedly affect interpersonal relationships and individual agency. A 2018 analysis of surveys from 54 countries found that four in five women did not have agency in critical aspects of family relationships.⁸ Furthermore, women and girls disproportionately carry caregiving and household responsibilities globally. According to data from 83 countries and areas, women allocate 2·6 times as much of their day to unpaid care and domestic work as men.⁷

When women receive lower wages, pensions, or social protections than men, they are personally disadvantaged, their households have fewer resources, and less money is spent on the health and education of all children.9, 10 Although gender inequalities disproportionately disadvantage women and girls, both gender inequalities and restrictive gender norms negatively affect the health of people of all sexes. Papers 1 and 3 of this Series11, 12 on gender equality, norms, and health provide numerous examples of pathways whereby restrictive gender norms affect the health of men and boys13, 14, 15 and gender and sex minorities, as well as women and girls.16, 17, 18, 19

Key messages

•
High-quality gender-transformative programmes shared several features: multisectoral action, multilevel and multistakeholder involvement, diversified programming, and social participation and empowerment
•
Tuition-free primary education and paid maternity and parental leave policies improved gender equality in decision making and improved health outcomes; these policies had both direct positive health effects and a positive impact on health mediated by more gender equality in decision making
•
More broadly, policies and programmes that lead to greater equality in education and at work are promising for increasing life expectancy as an increase in educational parity was significantly associated with improvements in both female and male life expectancy, and an increase in parity at work with improvement in female life expectancy
•
Increasing gender equality in governance matters for the passage and implementation of transformative programmes, laws, and policies; many countries provide promising approaches to increasing gender equality in leadership positions and monitoring equity of budgets and human resource allocations
•
For both policy and programmatic interventions, long-term follow-up of their passage, support, and implementation across settings is needed

There is a vast breadth of settings important to human health—including interpersonal relationships, schools, workplaces, and governments—in which restrictive gender norms, as well as gender inequalities, prevail. Restrictive gender norms help to perpetuate, reinforce, and propagate inequalities and shape how people live, grow, interact, learn, and work.11, 12 Addressing gender inequalities and restrictive gender norms is essential for respecting everyone's human rights, and, beyond this intrinsic importance, can lead to substantial potential health gains for all.

This paper, the third in this Series, focuses on approaches that aim to decrease gender inequalities and restrictive gender norms and improve health. Particularly, we investigate what works in societal, community, and household settings that dramatically influence health outcomes but do not deliver medical care. In paper 4 of this Series,²⁰ the effects of gender inequalities and restrictive gender norms in health systems are detailed.

Because these approaches have prompted varying quantities of research, this paper adopts differing methods of examining how programmes and how laws and policies might affect gender inequalities, restrictive gender norms, and health outcomes. Other promising vehicles of change, including social movements and governance, are addressed in paper 5 of this Series.²¹

We begin by presenting a comprehensive review of existing research on the effectiveness of programmes at improving health and addressing restrictive gender norms.²² We then present original research on an understudied topic: the potential of laws and policies to change both gender norms and health outcomes at scale. Both possible pathways of impact—programmes, and laws and policies—are shown in our conceptual model (appendix), which builds on the framework presented in paper 1 of this Series.¹¹ In our discussion, we examine promising reforms in governance, which can affect the success of laws, policies, and programmes at improving gender equality. We conclude by discussing our findings' implications for ongoing efforts to improve health.

Section snippets

Improving health and transforming gender norms through programme implementation

We comprehensively researched the peer-reviewed and grey literature to identify rigorously evaluated programmes that fit criteria for gender-transformative programming²² (panel 1) and sought to change health outcomes in any area. By searching for and including any rigorously evaluated programme, provided it fit the parameters of our gender-transformative definition and evaluated changes in a health-related outcome (at minimum) or health-related and gender-related outcomes (at best), we expanded

Descriptive analysis of findings

We identified 87 evaluations of 85 programmes that met evaluation criteria by using quantitative methods that can assess causality (appendix): 52 (60%) used exclusively quantitative approaches and the remaining used mixed methods. 40 (46%) used a randomised experimental design and 47 (54%) were quasi-experimental. Geographically, the 85 programmes were heavily concentrated in sub-Saharan Africa (n=39, 46%), south Asia (n=20, 24%), and North America (n=14, 16%). Although the search strategy

Analysis of what works to transform gender norms and health-related outcomes

We did an additional level of analysis to reflect programmatic evidence of, or potential for, broader norm change: multiplicity, sustainability, spreadability, and scalability (panel 1). From the 85 programmes identified in our search, 41 (48%) measured multiple outcomes, 34 (40%) showed sustainability, 41 (48%) showed evidence of spread, and 32 (38%) were taken to scale or showed the intent to do so. Only 16 programmes met all four criteria and were deemed to have the highest quality (appendix

Can laws and policies improve gender norms and health at national scale?

Many strong community-level approaches were apparent in our analyses of programmes that work to transform gender norms and health-related outcomes, but relatively few approaches were available at the national level. Additionally, although the best programmes we assessed effectively moved gender norms, thus changing a key social determinant of health, few programmes addressed other key drivers of gender inequality and restrictive gender norms at a national level, including disparities in

New longitudinal analyses

We selected laws and policies, subject to data availability, that have the potential to improve gender equality in education and work for our analyses. We then evaluated whether these law and policy reforms affected health outcomes by reducing gender disparities in household roles. Taking an example in the area of work and income, we examine the impact of paid maternity and parental leave on gender equality in decision making and health outcomes. Evidence has shown that paid maternity and

Data

For each country under study, we retrieved data on the availability of tuition-free primary education from a database compiled by the WORLD Policy Analysis Center (known as WORLD) at the University of California, Los Angeles, CA, USA.⁶⁶ The information in WORLD's database was largely derived from original legislation and policy documents available through the UN Educational, Scientific, and Cultural Organization's Observatory on the Right to Education.⁶⁷ The Policy Relevant Observational

Results of longitudinal law and/or policy analyses: impact on gender roles in decision making and on health outcomes

Exposure to an additional 10 weeks of paid maternity and parental leave substantially increased the odds of better women's and children's health outcomes, particularly use of modern contraception methods, relative to women with no exposure (OR 1·34–2·10; table 1). Exposure to tuition-free primary education laws and/or policies substantially increased women's likelihood of completing primary school (appendix), and substantially increased women's and their children's likelihood of having better

Health impact augmented by more gender-equitable roles

We also investigated whether these law-induced and/or policy-induced changes in the proxy for gender norms helped account for the reforms' health benefits. For each health outcome, we report both the direct and the indirect (ie, mediated by the norm proxy) effects of law and/or policy exposure (table 2).

Exposure to both laws and/or policies had not only significant and positive direct effects on health outcomes, but also significant and positive indirect effects, showing that gender norm change

Examining global adoption of educational and labour laws and policies

Given the effectiveness of these educational and labour laws and/or policies at improving gender equality and multiple health outcomes, their global adoption should be examined. Our analysis of their current state of adoption in all 193 UN countries revealed important progress and concerning gaps for both laws and/or policies. Seven countries worldwide have not adopted tuition-free primary education laws and/or policies, and 32 have not committed to providing tuition-free secondary education

Examining potential for health improvements from a broader array of laws and policies increasing gender equality in education and work

Although our quasi-experimental studies focused on legislated guarantees of tuition-free primary education and paid maternity and parental leave, other initiatives that change restrictive gender norms and promote gender equality in education and work are also likely to affect health. For example, many laws and policies affecting advancement in, and the quality of, education and work might dramatically affect gender equality. Although data were not available to examine these laws and policies in

Gaps and limitations

Several important limitations of these studies should be noted. Our review of programme evaluations was not restricted by health outcome, age, or geographic area. Therefore, feasibility required limiting the review to quantitative and mixed-methods studies with experimental and quasi-experimental designs, which are suitable for examining causal effect. Potentially high-quality programmes that were evaluated solely with qualitative or other non-experimental methods were not included. Also, the

Discussion

Our findings make clear that well designed and implemented laws, policies, and programmes can both transform norms and improve health. The effective interventions include those explicitly focused on transforming restrictive gender norms and those known to increase equal opportunities across sex and gender, whether or not that is the stated objective. Successful examples of increasing equal opportunities include lowering cost barriers to education for everyone, which disproportionately benefits

References (82)

C Yu et al.
Marching to a different drummer: a cross-cultural comparison of young adolescents who challenge gender norms
J Adolesc Health
(2017)
E Maticka-Tyndale et al.
Quasi-experimental evaluation of a national primary school HIV intervention in Kenya
Eval Program Plann
(2007)
PM Pronyk et al.
Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial
Lancet
(2006)
D Swendeman et al.
Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases
Soc Sci Med
(2009)
K Deininger
Does cost of schooling affect enrollment by the poor? Universal primary education in Uganda
Econ Educ Rev
(2003)
M Daku et al.
Maternal leave policies and vaccination coverage: a global analysis
Soc Sci Med
(2012)
M Hajizadeh et al.
Paid maternity leave and childhood vaccination uptake: longitudinal evidence from 20 low- and-middle-income countries
Soc Sci Med
(2015)
A Quamruzzaman et al.
Are tuition-free primary education policies associated with lower infant and neonatal mortality in low- and middle-income countries?
Soc Sci Med
(2014)
P Kalsi
Seeing is believing: can increasing the number of female leaders reduce sex selection in rural India?
J Dev Econ
(2017)
Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health
(2008)

J Benach et al.

Employment conditions and health inequalities. Final report to the WHO Commission on Social Determinants of Health

G Sen et al.

Unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it. Final report to the WHO Commission on Social Determinants of Health

Global education monitoring report gender review 2018: meeting our commitments to gender equality in education

(2018)

World employment social outlook: trends for women 2018—global snapshot

(2018)

The global gender gap report 2017

(2017)

Turning promises into action: gender equality in the 2030 Agenda for Sustainable Development

(2018)

J Klugman et al.

Voice and agency: empowering women and girls for shared prosperity

(2014)

D Thomas

The distribution of income and expenditure within the household

Ann Econ Stat

(1993)

AR Quisumbing et al.

Resources at marriage and intrahousehold allocation: evidence from Bangladesh, Ethiopia, Indonesia, and South Africa

Oxf Bull Econ Stat

(2003)

L Heise et al.

Gender inequality and restrictive gender norms: framing the challenges to health

Lancet

(2019)

A Weber et al.

Gender norms and health: insights from global survey data

Lancet

(2019)

J Campos-Serna et al.

Gender inequalities in occupational health related to the unequal distribution of working and employment conditions: a systematic review

Int J Equity Health

(2013)

A Eng et al.

Gender differences in occupational exposure patterns

Occup Environ Med

(2011)

M Stergiou-Kita et al.

What's gender got to do with it? Examining masculinities, health and safety and return to work in male dominated skilled trades

Work

(2016)

H Fay et al.

Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana

AIDS Behav

(2011)

T Sandfort et al.

Histories of forced sex and health outcomes among southern African lesbian and bisexual women: a cross-sectional study

BMC Womens Health

(2015)

Y Zaikman et al.

Gender role violations and the sexual double standard

J Homosex

(2016)

K Hay et al.

Disrupting gender norms in health systems: making the case for change

Lancet

(2019)

G Rao Gupta et al.

Gender equality and gender norms: framing the opportunities for health

Lancet

(2019)

The Gender Integration Continuum training session user's guide

(2017)

A Muralidharan et al.

Transforming gender norms, roles, and power dynamics for better health: evidence from a systematic review of gender-integrated health programs in low- and middle-income countries

(2015)

E Rottach et al.

Gender perspectives improve reproductive health outcomes: new evidence

(2009)

RP Pande et al.

‘If your husband calls, you have to go’: understanding sexual agency among young married women in urban South India

Sex Health

(2011)

NA Constantine et al.

Short-term effects of a rights-based sexuality education curriculum for high-school students: a cluster-randomized trial

BMC Public Health

(2015)

EE Daniel et al.

The effect of reproductive health communication interventions on age at marriage and first birth in rural Bihar, India: a retrospective study

(2012)

N Diop et al.

The TOSTAN program: evaluation of a community based education program in Senegal

(2004)

MS Dunbar et al.

The SHAZ! project: results from a pilot randomized trial of a structural intervention to prevent HIV among adolescent women in Zimbabwe

PLoS One

(2014)

A Kanesathasan et al.

Catalyzing change: improving youth sexual and reproductive health through Disha, an integrated program in India

(2008)

N Kyegombe et al.

The impact of SASA!, a community mobilization intervention, on reported HIV-related risk behaviours and relationship dynamics in Kampala, Uganda

J Int AIDS Soc

(2014)

F Midhet et al.

Impact of community-based interventions on maternal and neonatal health indicators: results from a community randomized trial in rural Balochistan, Pakistan

Reprod Health

(2010)

K Paine et al.

‘Before we were sleeping, now we are awake’: preliminary evaluation of the Stepping Stones sexual health programme in The Gambia

Afr J AIDS Res

(2002)

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Previous literature suggests that men reporting more gender-equitable attitudes are more likely to use condoms, but there is a paucity of data evaluating whether these attitudes are associated with contraceptive communication and use. The objective of this study is to test the hypothesis that men reporting more gender-equitable attitudes will be more likely to (a) engage in contraceptive communication with their wives and (b) that they and/or their wives will be more likely to use all forms of family planning, compared to men with less equitable attitudes.
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Men with more gender-equitable attitudes were more likely to discuss family planning with their wives (AOR = 1·05, 95%CI 1·03-1·07, p < 0·001) and to use condoms (ARRR = 1·03, 95%CI 1·00-1·06, p = 0·07). There was no association between gender-equitable attitudes and use of other types of contraception.
While gender-equitable attitudes among men may facilitate condom use and family planning communication in marriage, they do not appear to be linked with greater likelihood of use of more effective types of contraceptive use. This suggests that males supportive of gender equity may take greater responsibility for family planning vis a vis a less effective contraceptive, condoms, in the absence of more effective short-acting contraceptives for men.
The National Institutes of Health [Grant number 5R01HD084453-01A1] and the Bill & Melinda Gates Foundation, Seattle, WA [grant number INV-002967].
Parental gender attitudes and children's mental health: Evidence from the UK household longitudinal study
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Gender role attitudes have been found to be associated with the mental health of adults and adolescents, but little is known about whether parents' gender attitudes are associated with their children's mental health. Using data from Understanding Society, the UK Household Longitudinal Study (UKHLS), a large-population representative sample, we examine the links between parental gender role attitudes and child mental health outcomes as measured by the total and five components of the strengths and difficulties questionnaire (SDQ). We construct structural equation models, separately for mothers and for fathers and for children aged 5 and 8, and adjust for key sociodemographic variables. We find that children aged 5 years exhibit fewer emotional and peer relationship problems and are more prosocial when their mothers have more egalitarian (compared to traditionalist) gender role attitudes. We also find that children are more prosocial at age 8 when their mothers have more egalitarian gender role attitudes. No statistically significant mediation effect is observed via maternal parenting behaviour. Fathers' more egalitarian gender role attitudes were associated with higher hyperactivity at age 5 and more prosocial behaviour at age 8. Further, engaging in less negative parenting behaviour completely mediates the association of fathers' more egalitarian gender attitudes with children's mental health across the majority of the SDQ scales. This suggests that parental gender attitudes may be a possible target for the prevention of mental health difficulties among children; however, future research will be required to examine the extent to which the associations we identified reflect causality.
Effects of education on adult mortality: a global systematic review and meta-analysis
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The positive effect of education on reducing all-cause adult mortality is known; however, the relative magnitude of this effect has not been systematically quantified. The aim of our study was to estimate the reduction in all-cause adult mortality associated with each year of schooling at a global level.
In this systematic review and meta-analysis, we assessed the effect of education on all-cause adult mortality. We searched PubMed, Web of Science, Scopus, Embase, Global Health (CAB), EconLit, and Sociology Source Ultimate databases from Jan 1, 1980, to May 31, 2023. Reviewers (LD, TM, HDV, CW, IG, AG, CD, DS, KB, KE, and AA) assessed each record for individual-level data on educational attainment and mortality. Data were extracted by a single reviewer into a standard template from the Global Burden of Diseases, Injuries, and Risk Factors Study. We excluded studies that relied on case-crossover or ecological study designs to reduce the risk of bias from unlinked data and studies that did not report key measures of interest (all-cause adult mortality). Mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among studies and to adjust for study-level covariates. This study was registered with PROSPERO (CRD42020183923).
17 094 unique records were identified, 603 of which were eligible for analysis and included data from 70 locations in 59 countries, producing a final dataset of 10 355 observations. Education showed a dose–response relationship with all-cause adult mortality, with an average reduction in mortality risk of 1·9% (95% uncertainty interval 1·8–2·0) per additional year of education. The effect was greater in younger age groups than in older age groups, with an average reduction in mortality risk of 2·9% (2·8–3·0) associated with each additional year of education for adults aged 18–49 years, compared with a 0·8% (0·6–1·0) reduction for adults older than 70 years. We found no differential effect of education on all-cause mortality by sex or Socio-demographic Index level. We identified publication bias (p<0·0001) and identified and reported estimates of between-study heterogeneity.
To our knowledge, this is the first systematic review and meta-analysis to quantify the importance of years of schooling in reducing adult mortality, the benefits of which extend into older age and are substantial across sexes and economic contexts. This work provides compelling evidence of the importance of education in improving life expectancy and supports calls for increased investment in education as a crucial pathway for reducing global inequities in mortality.
Research Council of Norway and the Bill & Melinda Gates Foundation.
Exploring barriers and strategies for improving sexual and reproductive health access for young men in Sweden: Insights from healthcare providers in youth clinics
2024, Sexual and Reproductive Healthcare
Youth clinics in Sweden are not reaching young men to the same extent as young women. We conducted a qualitative study to explore healthcare providers’ (HCPs) perspectives on the barriers to young men’s access to sexual and reproductive health (SRH) services and how youth clinics can better accommodate the needs of young men. We used thematic analysis to analyze eight interviews with nine HCPs (three men and six women).
We developed three themes: 1) It’s about the youth clinics and those working in them—the clinics suffered from low organizational support, which affected their ability to accommodate young men’s needs and were perceived as “girls’ clinics”. Midwifery, which is the main profession of HCPs working with SRH in the clinics, was perceived as a women’s profession for women’s SRH; 2) It’s not all about the youth clinics—young men were perceived as lacking essential knowledge about SRH and gender norms were preventing young men from visiting youth clinics; 3) Organizational strategies for improving access—the participants discussed strategies to attract young men, including separate reception for young men, hiring more male staff, having higher age limits for young men, and digital solutions to address privacy concerns.
There is a need for societal efforts to increase young men’s knowledge about SRH and improve their access to SRH services. Several strategies can be adapted by youth clinics to attract more young men but there is need for further research to design and evaluate such interventions.
Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019
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Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality.
Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10–24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index.
One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (−28.9% vs. −12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings.
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Gender dimensions are progressively recognised as a relevant social determinant of health in people with Parkinson’s disease (PD). However, little is known about the impact of gender norms and stereotypes on illness experiences of men and women with PD and what they consider important focal points for gender-sensitive PD care.
We conducted two equity-centred design (ECD) sessions on December 7, 2022 and December 8, 2022, at the Radboud University Medical Centre in the Netherlands. This participatory multi-method approach includes patients in the research and design process and was used to explore the impact of gender norms and stereotypes in illness experiences and generate patient-driven recommendations for gender-aware Parkinson’s care. Quantitative survey data and design-based data were descriptively analysed, and qualitative focus group discussions were thematically analysed.
This study included thirteen men and fifteen women with PD in the Netherlands. All participants were of Dutch descent, with a median age of 65.5 years and a median clinical disease duration of 4.2 years. The gendered stereotype that “people with PD are old men” affected both men’s and women’s perception of living with the disease and the perceptions of their social environment. Men described masculine stereotypes related to physical strength and provider roles, while women expressed those related to feminine physical appearance and caregiver roles, influencing their illness experiences. For some, these norms influenced personal behaviours, while for others, they affected experiences through societal attitudes.
Our findings suggested that several gender norms and stereotypes influence the illness experiences of men and women with PD, manifesting at ideological, interpersonal, and internalised levels. Some participants internalised these norms, affecting their coping behaviours, while others encountered them in broader ideological contexts that shaped societal attitudes and interpersonal relationships. To advance gender sensitive PD care, it's essential to explore the impact of gender roles and norms, especially regarding how they might impede coping strategies, care access and utilisation for individuals of diverse gender identities.
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View all citing articles on Scopus

^†: Members of the Steering Committee are listed at the end of this Series paper

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SeriesImproving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms

Summary

Introduction

Section snippets

Improving health and transforming gender norms through programme implementation

Descriptive analysis of findings

Analysis of what works to transform gender norms and health-related outcomes

Can laws and policies improve gender norms and health at national scale?

New longitudinal analyses

Data

Results of longitudinal law and/or policy analyses: impact on gender roles in decision making and on health outcomes

Health impact augmented by more gender-equitable roles

Examining global adoption of educational and labour laws and policies

Examining potential for health improvements from a broader array of laws and policies increasing gender equality in education and work

Gaps and limitations

Discussion

J Adolesc Health

Eval Program Plann

Lancet

Soc Sci Med

Econ Educ Rev

Soc Sci Med

Soc Sci Med

Soc Sci Med

J Dev Econ

Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health

Employment conditions and health inequalities. Final report to the WHO Commission on Social Determinants of Health

Unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it. Final report to the WHO Commission on Social Determinants of Health

Global education monitoring report gender review 2018: meeting our commitments to gender equality in education

World employment social outlook: trends for women 2018—global snapshot

The global gender gap report 2017

Turning promises into action: gender equality in the 2030 Agenda for Sustainable Development

Voice and agency: empowering women and girls for shared prosperity

The distribution of income and expenditure within the household

Ann Econ Stat

Resources at marriage and intrahousehold allocation: evidence from Bangladesh, Ethiopia, Indonesia, and South Africa

Oxf Bull Econ Stat

Gender inequality and restrictive gender norms: framing the challenges to health

Lancet

Gender norms and health: insights from global survey data

Lancet

Gender inequalities in occupational health related to the unequal distribution of working and employment conditions: a systematic review

Int J Equity Health

Gender differences in occupational exposure patterns

Occup Environ Med

What's gender got to do with it? Examining masculinities, health and safety and return to work in male dominated skilled trades

Work

Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana

AIDS Behav

Histories of forced sex and health outcomes among southern African lesbian and bisexual women: a cross-sectional study

BMC Womens Health

Gender role violations and the sexual double standard

J Homosex

Disrupting gender norms in health systems: making the case for change

Lancet

Gender equality and gender norms: framing the opportunities for health

Lancet

The Gender Integration Continuum training session user's guide

Transforming gender norms, roles, and power dynamics for better health: evidence from a systematic review of gender-integrated health programs in low- and middle-income countries

Gender perspectives improve reproductive health outcomes: new evidence

‘If your husband calls, you have to go’: understanding sexual agency among young married women in urban South India

Sex Health

Short-term effects of a rights-based sexuality education curriculum for high-school students: a cluster-randomized trial

BMC Public Health

The effect of reproductive health communication interventions on age at marriage and first birth in rural Bihar, India: a retrospective study

The TOSTAN program: evaluation of a community based education program in Senegal

The SHAZ! project: results from a pilot randomized trial of a structural intervention to prevent HIV among adolescent women in Zimbabwe

PLoS One

Catalyzing change: improving youth sexual and reproductive health through Disha, an integrated program in India

The impact of SASA!, a community mobilization intervention, on reported HIV-related risk behaviours and relationship dynamics in Kampala, Uganda

J Int AIDS Soc

Impact of community-based interventions on maternal and neonatal health indicators: results from a community randomized trial in rural Balochistan, Pakistan

Reprod Health

‘Before we were sleeping, now we are awake’: preliminary evaluation of the Stepping Stones sexual health programme in The Gambia

Afr J AIDS Res

Series
Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms