Gender equality, empowerment and health: From measurement to impact

Abstract

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