Introduction
As we approach 5 years since the ratification of the United Nations Sustainable Development Goals (SDG), including SDG 5: Gender Equality and Empowerment of all Women and Girls, and 25 years since the 4th World Conference on Women in Beijing, which set the first Declaration and Platform for Action toward Women's Equality, we must take stock of our progress and advancements on these key issues for global health and development. Monitoring of progress requires clear measurement of targets, but while global development is advancing insight into potential targets for change, the science of measurement of gender equality and empowerment remains a nascent field.
In 2016, shortly after SDG ratification and the launching of the Bill and Melinda Gates Foundations' initiative to support Women and Girls at the Center of Development, the EMERGE [Evidence-based Measures of Empowerment for Research on Gender Equality] Project was launched as global platform for building the use and recognition of scientific rigor in the development and testing of gender equality and empowerment measures [see emerge.ucsd.edu]. However, the value of this platform is only as useful as the availability of best evidence measures allow. To that end, we developed this Special Issue of Social Science & Medicine - Population Health to profile innovations and advancements in measurement of gender equality and empowerment, focusing on measures that can improve health at scale. Via a process of an open call for papers and rigorous peer review, we selected 14 papers for this Special Issue that highlight the value of understanding gender equality and empowerment across health issues and across national populations. This body of work documents gender equality and empowerment measures that influence women and girls’ health throughout the lifespan and on diverse emotional, physical, and mental health outcomes, and establishes a standard for the science of measurement regarding how these can be developed and adapted for diverse cultural contexts.
Across a number of papers in this issue, we see agency as a key area of focus; this is particularly seen in the papers on reproductive autonomy and gender-based violence (GBV). Silverman et al.’s (2019) study highlights ways husbands and families control reproductive behaviors, and showcases how this reproductive coercion, first measured in the United States on the basis of partner control, must be adapted and expanded in the context of India to include consideration of in-laws, where there is cultural acceptability of in-law involvement in reproductive decision-making. Hinson, Edmeades, Murithi, and Puri (2019) illuminate in their research on reproductive decision-making in Nepal the need for more nuanced examination of women's involvement, as joint decision making has value for whether to use contraception, but women's greater control over decision-making regarding the form of contraceptive is more indicative of agency and use. Samari's (2019) study of decision-making and the mediating role of gender attitudes in the association between education and fertility in Egypt yields similar findings, with joint decision-making among spouses regarding family planning seen to suppress the association between low education and high fertility in Egypt. Studies on GBV included in this Special Issue further emphasize the role of control, but in this case on violence and safety for women and girls, both in and outside of the household. Analyses by Heise, Pallitto, Garcia Moreno, and Clark (2019) of the WHO Multicountry Study on Domestic Violence and Women's Health expand on prior research demonstrating the public health impact of physical and sexual intimate partner violence (IPV) by demonstrating that psychological violence (e.g., verbal abuse, humiliation or degradation), a more common form of IPV, is also associated with negative health outcomes, and further, is linked to men's controlling behaviors (e.g., restricting movement or social contact), demonstrating the centrality of male entitlement to IPV. Clark et al.’s (2019) research from Nepal further reinforces the interconnection of these forms of partner abuse and control and their association with poor mental health outcomes, with greater effects seen under conditions of greater diversity and severity of abuses from a male partner. Reed et al.’s (2019) work adds to this perspective by profiling the high levels of exposure to sexual harassment faced by adolescent girls in public spaces in the context of an urban and low-resourced border community in the United States, and that these everyday experiences of harassment are associated with increased risk for substance use, depression, and anxiety, as girls must either face harassment as a normative experience or restrict their freedom of movement. Overall, these papers offer important insight into women and girls' agency in households and public spaces and the potential consequences, and even harms, of their expressing their autonomy. These constructs related to decision-making, partner control, and freedom of movement offer important targets for change that are neither sufficiently nor consistently seen in our global indicators of gender equality and empowerment.
Gender attitudes and norms were also recognized in a number of papers in this issue as affecting both health and health behavior, across national contexts. Baird et al.’s (2019) research with male and female adolescents offers a more comprehensive measure of individual gender attitudes and perceived community norms than that seen in prior studies, by including items on education, domestic time use, financial inclusion and economic empowerment, relationships and marriage, and sexual and reproductive health; notably, reliability on community norms was stronger than that seen for gender attitudes, possibly because of more rapidly shifting gendered beliefs among youth. Nonetheless, this study demonstrates that more restrictive gender attitudes and norms are associated with worse health and well-being for both male and female youth. Shakya, Weeks, and Christakis’s (2019) study on village norms related to acceptability of adolescent fertility similarly demonstrates that community norms are associated with higher adolescent fertility rates, with stronger effects seen in more cohesive villages. Taken together, these studies demonstrate that restrictive gender norms at the community or village level maintain greater restrictions on girls than boys, enforce prioritization of domestic labor and fertility for girls, and detrimentally affect adolescent health outcomes. An additional study from India assessing health expenditure related to hospitalization in India, finds that women, particularly older women, are less likely than same age men to be hospitalized when needed, and less likely to be prioritized for scarce resource financing (e.g., reliance on borrowing money or selling of assets to ensure payment of expenditures) when hospitalized (Moradhvaj & Saikia, 2019).Though this work does not directly assess norms, findings clearly reveal normative perceptions of women's lesser value and potential return on investment relative to men, particularly as women age. Overall, these findings illustrate the fundamental devaluation of women and girls relative to men perceived by communities, families, and even women and girls themselves, and that these norms affect the health of women and girls afrom early to late in life.
While much of the research presented in this issue utilizes new measures to provide insight into how we can advance concepts to better understand and provide empirical data regarding gender equality and empowerment indicators and their effects on health, there is also need to ensure we are adequately utilizing existing data to provide greater clarity on benchmarks of progress. To that end, two papers in this Special Issue utilize existing data sets and indicators to help elevate the standards by which we are measuring gender equality and empowerment for health and development. Klugman, Li, Barker, Parsons, and Dale (2019) has established a new Women, Peace and Security (WPS) Index able to be operationalized for 131 nations, capturing norms and attitudes, as well as decision-making control and autonomy indicators. Findings from this research demonstrate that this index, created as a combination of these indicators, is associated with poorer maternal and child health outcomes. The WPS Index is now in its second year of implementation and offers a report card on progress that accounts for contexts of conflict, safety, and justice for women and girls in its analysis. Jones et al. (2019) similarly provides a measure developed from Demographic and Health Survey data available for over 90 countries; while their analyses are limited to a smaller number of African nations, their measure extends beyond attitudes and agency indicators to also include assets and resources, often posited as required for agency to shift from autonomy to action. This more comprehensive index is associated with better child nutrition outcomes, but importantly, the assets element of the index is important for the poorest but not the richest quintile. Green, Wang, Ballakrishnen, Brueckner, and Bearman’s (2019) study also examines assets in the form of male partner remittances (funds sent from migrant husbands to wives at home), and finds that stable receipt of remittance even more than level of remittance is associated with greater health care decision-making control and freedom of movement to acquire health care among wives of migrants in Kerala, India. Again, these findings demonstrate the importance of stable assets and women's control over these assets as being important elements of gender empowerment, but they also showcase the importance of contextually specific development of measurement and intersectional analyses as part of our evaluation of new measures even while we strive for comparable national level indicators.
The value of contextual insights in this work is, again, supported in our final two studies, both of which engaged in elicitation processes to guide understanding of empowerment based on local inputs. Bisung and Dickin’s (2019) work in Ghana and Burkina Faso involved a community mapping approach that demonstrated that empowerment as relates to water, sanitation and hygiene (WaSH) includes knowledge, norms and attitudes, and access (which may also be viewed as assets, such as access to latrines), but also social participation and engagement, an issue well-documented as a means for participatory action and health system accountability (Hay et al., 2019 Jun 22). Schuster et al. (2019) engaged in a cultural consensus analyses to understand women's empowerment and gender-based violence in the West Bank, but here there was no single cultural understanding of these issues. Both studies highlight the importance of cultural inputs, but also the still-emerging understanding of these constructs that will continue to require more qualitative as well as quantitative work for clarity and insight. Nonetheless, across both studies, community and health system members, leaders, and stakeholders affirm the need for focus on gender equality and empowerment to support health, reinforcing the value of this approach.
In summary, the research in this Special Issue provides novel measurement and advances rigorous methodologies demonstrating the strong science underlying the development of new indicators of gender equality and empowerment for health and development. The work also highlights three major areas of focus in newly forming research: 1) Agency as indicated by control over one's own actions, and safety from violence as recourse against agency; 2) Gender attitudes and norms related to the treatment, opportunities and value of women and girls relative to men and boys; and 3) Distribution of and control over assets and resources that can facilitate or impede shifts from agency to action. How we define and measure these focal areas will certainly need considerations of context and intersectionality to best reflect the needs of diverse populations, and more work is clearly needed to assess these issues for sexual and gender minorities as well as for men and boys. As part of the Special Issue call for papers, we received almost no manuscripts focused on these latter populations. Nonetheless, the work presented in this Issue offers important insights as well as a strong standard for the science of our field, while simultaneously bringing us closer to defining and achieving targets and benchmarks for SDG5, particularly for its application to health. The necessary next step is to now apply this work to achieve action and change across program and policy.
Ethics statement
This introduction does not use data but only literature review, requiring no ethical approvals.
References
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