Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data

The influence of gender-equitable attitudes on sexual behaviour among unmarried adolescents in rural Tanzania: a longitudinal study

PLAIN LANGUAGE STATEMENT

Gender norms that centre men and disadvantage women create gender inequality, which can lead to risky sexual behaviour. This study examined how both community and individual attitudes toward gender norms influenced risky sexual behaviour in adolescents, and whether that influence was different between males and females. We found that higher gender-equitable attitudes were linked to increased odds of HIV testing in the last 12 months, and decreased odds of engaging in a sexual relationship with a much older partner. Individual high gender-equitable attitudes among girls were also linked to higher odds of them using condoms and contraceptives. Gender-equitable attitudes did not seem to influence early sexual debut, engagement in transactional sex, having multiple sexual partners at the same time, or the number of sexual partners a participant had in the last 12 months. Based on these findings, programming designed to increase gender-equitable attitudes might be helpful in increasing HIV testing and condom and contraceptive use, but it needs to involve the entire community, not just individual boys and girls.

Gender-aware Parkinson's care: a design-based study of patient perspectives on gender norms and gender-sensitive care

Background

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.

Methods

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.

Findings

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.

Interpretation

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.

Funding

The Gatsby Foundation and co-funded by the PPP Allowance by Health∼Holland. Travel reimbursements for participants were made available through a Parkinson's Foundation grant (PF-FBS-2026).

Gender norms, contraceptive use, and intimate partner violence: A six-country analysis

BACKGROUND

While considerable research has explored associations between gender norms and various sexual and reproductive health behaviors (SRH) with the aim of informing programs, no studies have examined whether couple concordance on specific gender norms is associated with both contraceptive use and reduced intimate partner violence (IPV) experience.

METHODS

This study relies on analysis of Demographic and Health Survey (DHS) couples' datasets from Mali, Nigeria, Nepal, Pakistan, Tanzania, and Zambia that were collected in/after 2015 and include the DHS Domestic Violence Module for female respondents. To examine the associations between couple concordance regarding household decision-making or justification of violence (wife beating) and women's use of modern contraceptives or experience of violence, bivariate and multivariate logistic regression models were fit using Stata15.

RESULTS

Joint decision-making about large household purchases was significantly positively associated with modern contraceptive use in all study countries as well as with reduced odds of IPV experience in adjusted models in Tanzania and Zambia. In Nigeria, women's justification for violence was negatively associated with contraceptive use. Across settings, women in couples where both justified violence had significantly increased odds of reporting IPV experience.

CONCLUSIONS

The evidence suggests that family planning programs should support joint decision-making as it was positively associated with contraceptive use across the six countries and is a proxy for shared economic power within the household. IPV reduction and prevention programs should also consider encouraging joint decision-making given the correlations found in two settings. Programs should enable participants to interrogate attitudes regarding justifying violence against female partners and propose approaches to avoid IPV. Finally, husbands' alcohol consumption, a strong predictor of IPV experience, has too long been overlooked.

Lysmeral Exposure in Children and Adolescences Participating in the German Environmental Survey (2012-2015): Integrating Sex/Gender into Analysis

Comprehensive consideration of the biological and social diversities of sex and gender as well as their interdependencies is mostly missing in human biomonitoring (HBM) studies. Using the INGER sex/gender concept as theoretical background, we analyzed differences in exposure to lysmeral, a compound commonly found as a fragrance in cosmetics, personal care, and household products, in 2294 children and adolescents in Germany using decision tree, regression, and mediation analysis. The variables "sex assigned at birth" and "age", as well as well as use of personal care products and fabric conditioner proved to have the highest explanatory value. Mediating effects of behaviour associated with societal gender expectations were observed, as the use of cosmetics correlated highly with lysmeral metabolites concentrations in girls between 6 and 17 years, with the strongest effect in adolescents between 14 and 17 years old. In the youngest age group (3-5 years) boys showed higher concentration of the metabolite tert-butylbenzoic acid (TBBA) compared to girls of the same age but only if TBBA urine concentrations were normalized on creatinine. Our study offers the first retrospective sex/gender assessment of HBM data. It demonstrates the possibilities to rethink and broaden sex/gender analysis in existing HBM-studies and highlights the need for inclusion of new sex/gender concepts in the design of new studies.

Eating Disorders in Children and Adolescent Males: A Peculiar Psychopathological Profile

(1) Background: Eating Disorders (EDs) are severe psychiatric disorders with high rates of mortality, multiple medical and psychiatric comorbidities associated, and often chronic illness. Historically, EDs are among the most gendered of psychiatric illnesses, and male presentations have been perceived as rare and unusual. This perception resulted in the systematic underrepresentation of males in research on Eds, and as consequence, in a scarcity of research investigating clinical and psychological features in this population. (2) Methods: The present study aims to evaluate clinical and psychopathological features in a sample of 287 children and adolescents, 27 males and 260 females with EDs, in order to identify similarities and differences. (3) Results: Males were younger than females, with similar medical and clinical conditions, but a different distribution of typology of EDs in middle childhood and middle adolescents. The Eating Disorders Inventory-3, TAS-20 for alexithymia and CDI for depressive symptoms' profiles are similar, while males showed higher scores at the global indexes of Symptom Checklist 90-Revised test in early adolescence. (4) Conclusions: Results suggest gender-specific similarities and differences in clinical and psychological features in children and adolescent males, which may require specific diagnosis and treatment.

Effect of imbalanced sampling and missing data on associations between gender norms and risk of adolescent HIV

BACKGROUND

Despite strides towards gender equality, inequalities persist or remain unstudied, due potentially to data gaps. Although mapped, the effects of key data gaps remain unknown. This study provides a framework to measure effects of gender- and age-imbalanced and missing covariate data on gender-health research. The framework is demonstrated using a previously studied pathway for effects of pre-marital sex norms among adults on adolescent HIV risk.

METHODS

After identifying gender-age-imbalanced Demographic and Health Survey (DHS) datasets, we resampled responses and restricted covariate data from a relatively complete, balanced dataset derived from the 2007 Zambian DHS to replicate imbalanced gender-age sampling and covariate missingness. Differences in model outcomes due to sampling were measured using tests for interaction. Missing covariate effects were measured by comparing fully-adjusted and reduced model fitness.

FINDINGS

We simulated data from 25 DHS surveys across 20 countries from 2005-2014 on four sex-stratified models for pathways of adult attitude-behaviour discordance regarding pre-marital sex and adolescent risk of HIV. On average, across gender-age-imbalanced surveys, males comprised 29.6% of responses compared to 45.3% in the gender-balanced dataset. Gender-age-imbalanced sampling significantly affected regression coefficients in 40% of model-scenarios (N = 40 of 100) and biased relative-risk estimates away from gender-age-balanced sampling outcomes in 46% (N = 46) of model-scenarios. Model fitness was robust to covariate removal with minor effects on male HIV models. No consistent trends were observed between sampling distribution and risk of biased outcomes.

INTERPRETATION

Gender-health model outcomes may be affected by sampling gender-age-imbalanced data and less-so by missing covariates. Although occasionally attenuated, the effect magnitude of gender-age-imbalanced sampling is variable and may mask true associations, thus misinforming policy dialogue. We recommend future surveys improve balanced gender-age sampling to promote research reliability.

FUNDING

Bill & Melinda Gates Foundation grant OPP1140262 to Stanford University.