Table 3.

Illustrated checklist of practical steps of sex/gender sensitivity in the stages of the research process

Stage of research process - Practical steps	Example from [81]: Sex Differences in Neonatal Mortality in Sarlahi, Nepal: The Role of Biology and Environment
1. Background/Research question
1.1. Review of existing sex/gender-based knowledge - Are there differences/similarities between and within sex/gender groups? - What are the biological and social causes? - Are there different results across time, space or cultures?	- Differences were found in the literature, e.g. between boys and girls in neonatal mortality in high-income countries (boys are at greater risk) and South Asia (sometimes girls experience more neonatal mortality), and in the early (days 1–7) and late (days 8–28) neonatal period - Biological explanations favouring survival of girls (height/weight, maturity of the lungs, sex steroid influences of the immune system), more relevant in high-income countries - Sociocultural explanations for girls’ risk of neonatal mortality in South Asia: gender preference, differential care-seeking behaviours, birth order and family composition, perceptions of illnesses
1.2. Evaluation of the knowledge base. What is the sex/gender-related gap?	“Unanswered questions remain regarding the impact that biological (immutable factors specific to the newborn or his/her mother) and environmental factors (mutable external factors) have on sex specific trends in neonatal mortality” [81]
1.3. Formulation of sex/gender-related study aim and research question to address the knowledge gap	“… biological and environmental factors that might explain sex differences in neonatal mortality…” [81]
2. Study design
2.1 Definition of sex/gender-related biological and social factors based on a theoretical model	- Biological factors typically indicating a higher risk for neonatal mortality in males: birth outcomes such as weight, gestational age, respiratory depression, malformations - Social/environmental factors which may indicate a gender preference: peri- and postnatal care such as feeding practices, hygiene and skin care practices, warming practices and care-seeking behaviours
2.2 Selection of sex/gender sensitive outcome and exposure measures	- Sex/gender-based justification of the outcome measure early/late neonatal mortality
2.3 Sample size calculation is justified with respect to sex/gender-related study aims, e.g. to detect differences between or within sex/gender groups	- Secondary analysis of a population-based randomised trial, 23,662 newborns were included in the analysis
3. Statistical analysis
3.1 Analytic strategy, statistical modelling is justified with respect to the sex/gender-related aims of the study	- Stratified analysis by sex/gender and ethnicity, explorative examination of sociodemographic, newborn and maternal characteristics; model building strategy reflected the four conditions: biological vs. social/environmental factors, early vs. late neonatal period
3.2 The analysis is conducted stratified by sex/gender (if appropriate) but avoids overemphasis of sex/gender	- Differentiation by ethnic groups (Pahadi and Madeshi)
3.3 Sex/gender stratified presentation of sample characteristics	- Sociodemographic characteristics are reported to not be meaningfully different between boys and girls
3.4 Sex/gender differences and similarities are reported	- Biological factor, care practices and crude mortality rates were presented by sex/gender and differed significantly - Multivariate models analysing biological and social/environmental factors in the early and the late neonatal period showed no influence of care related factors - Further exploration showed social factors in one ethnic group to be related with excess mortality in the late neonatal period
4. Discussion
4.1 Findings are discussed in the context of existing literature; unexpected results, strength and weaknesses of the study with regard to sex/gender aspects are interpreted	- Main results are discussed with regard to: • Expectations concerning early vs. late neonatal period • Seasonal influences on food availability for pregnant women • Newborn care services favoured boys, providing evidence of gender preference • Differences within the group of girls depending on ethnic group (Pahadi, Madeshi) and prior sex composition of siblings - Missing values on birth weight are discussed as a limitation, but did not affect sex/gender-related factors
4.2 Implications for research and practice of the main sex/gender-related findings are discussed	- Important issues are highlighted: (1) neonatal analysis must be stratified by early and late period, (2) biology has a greater impact on early, environmental factors on late neonatal mortality, (3) the explanation model ‘gender preferences’ is oversimplified as it applies only to a certain group