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

Sex and gender bias in chronic coronary syndromes research: analysis of studies used to inform the 2019 European Society of Cardiology guidelines

Background

Sex and gender inequalities in ischemic heart diseases persist. Although ischemic heart disease is less common in women, they experience worse clinical outcomes and are less likely to receive guideline-recommended treatments. The primary scientific literature from which clinical guideline recommendations are derived may not have considered potential sex- and gender biases. This study aims to determine whether the literature cited in recent cardiovascular guidelines' clinical recommendations contain sex and gender biases.

Methods

We analysed publications cited in the 2019 European Society of Cardiology (ESC) guideline recommendations on chronic coronary syndromes, using a checklist to guide data extraction and evaluate the individual studies for sex- and gender-related aspects, such as inclusion/exclusion criteria, outcome measures, and demographic data reporting. To assess representation over time, the proportion of women participants in each study was computed and analysed using a beta regression model. We also examined the associations between women's representation, journal impact factor and author gender.

Findings

Among the 20 ESC recommendations on chronic coronary syndromes, four contained sex-related statements; we did not identify any gender-specific suggestions. The referenced literature upon which these recommendations were based consisted of 108 articles published between 1991 and 2019, encompassing more than 1.6 million study participants (26.8%; 432,284 women). Only three studies incorporated sex-sensitive designs; none were gender-specific. The term "gender" did not occur in 84% (n = 91/108) of the publications; when used, it was exclusively to denote biological sex. The proportion of women (assumed by investigators) among study participants fluctuated over time. Having a woman as first (odds ratio (OR) = 1.68, 95% CI: 1.19-2.39) or last author (OR = 2.28, 95% CI: 1.31-3.97), was significantly associated with having more women participants in the study.

Interpretation

The data underlying ESC guideline recommendations largely lack reporting of possible sex- and gender-specific aspects, and women are distinctly underrepresented. To what extent these recommendations apply to members of specific population groups who are not well-represented in the underlying evidence base remains unknown.

Funding

This study is part of the Gender and Health Inequalities (GENDHI) project, ERC-2019-SyG. This project has received funding from the European Research Council (ERC).

Interactions among neighborhood conditions, sleep quality, and episodic memory across the adult lifespan

OBJECTIVES

On average, adults racialized as non-Hispanic Black and Hispanic sleep more poorly than adults racialized as non-Hispanic White (hereafter, Black, Hispanic, White), but associations between factors that may moderate sleep-memory associations in these groups, such as neighborhood conditions, are unclear. Poorer neighborhood conditions (e.g. lower neighborhood cohesion) may be negatively associated with sleep quality and multiplicatively influence sleep-memory associations. We hypothesized lower ratings of neighborhood conditions would be associated with poorer sleep quality and moderate the association between sleep quality and episodic memory, especially in Black and Hispanic adults, who are disproportionately situated in poor neighborhood conditions.

DESIGN

Seven-hundred-thirty-six adults across the adult lifespan (27-89 years) were recruited from the northern Manhattan community as a part of the Offspring Study of Racial and Ethnic Disparities in Alzheimer's disease. Sleep quality was assessed using a modified version of the Pittsburgh Sleep Quality Index, and episodic memory was evaluated with the Buschke Selective Reminding Test. With multiple regression models, we measured associations between perceived neighborhood conditions and sleep quality and the interaction between sleep quality and neighborhood conditions on episodic memory stratified by racial/ethnic and gender identity groups.

RESULTS

Overall, poorer neighborhood conditions were associated with poorer sleep quality. In Black and Hispanic women, the sleep-memory association was moderated by neighborhood conditions. With more favorable neighborhood conditions, Black women showed an association between higher sleep quality and higher memory performance, and Hispanic women showed a protective effect of neighborhood (higher memory even when sleep quality was poor).

CONCLUSION

Poorer neighborhood experiences may contribute to poorer sleep quality across groups. In Black and Hispanic women, the association between sleep quality and episodic memory performance was dependent upon neighborhood conditions. These findings may inform tailored, structural level sleep interventions, aimed to improve neighborhood experiences and thereby sleep quality and episodic memory.

Is Social Support Associated With Clinical Outcomes in Adults With Nonspecific Chronic Low Back Pain? A Systematic Review

OBJECTIVES

Nonspecific chronic low back pain (NSCLBP) is associated with psychological and social factors such as social support. However, little research has focused on the latter. This article aimed to review the literature on the association between social support and clinical outcomes of patients with NSCLBP, particularly regarding differences in sex, gender, and types of social support.

METHODS

MEDLINE, EMBASE, Web of Science, PsycINFO, and CENTRAL were searched until April 19, 2024, without restrictions of time or language. Eligible articles were observational studies reporting measures of association between social support and clinical outcomes among adults with NSCLBP. Risk of bias was assessed using the QUIPS tool, and findings were analyzed qualitatively. This systematic review was registered on PROSPERO (CRD42022363210).

RESULTS

Of the 3528 identified studies, 11 were included in the review (1290 patients), showing a moderate to high risk of bias. Of the 5 studies showing a significant finding for pain, 4 reported a negative correlation (r=-0.18, -0.32, -0.35, -0.36) and 1 did not report any association index. Of the 6 studies showing a significant finding for disability, 2 reported a negative correlation (r=-0.29, -0.42), 2 reported a positive association (r=0.322; β=0.29), and 2 did not report any association index. No data was available for the investigated subgroups or secondary clinical outcomes.

DISCUSSION

Small associations were found between social support and clinical outcomes of individuals with NSCLBP. Further research is needed to establish its clinical relevance according to types of social support, sex, and gender.

Gender-Transformative Interventions for Young Adolescents: What Have We Learned and Where Should We Go?

PURPOSE

To identify the key facilitators and barriers to implementing gender-transformative interventions among young adolescents (ages 10-14 years) in low- and middle-income countries and provide recommendations for guiding the next generation of intervention approaches.

METHODS

A scoping review of the literature was first conducted to identify articles that contained the following inclusion criteria: (1) included 10- to 14-year-olds as a target population; (2) addressed gender inequality as a pathway to improved health; (3) implemented in a low- and middle-income country context; and (4) published between 2010 and 2023. Two databases, Scopus and PubMed, were searched as well as the gray literature. Additionally, to collect critical reflections on gender-transformative interventions, two expert meetings and four key informant interviews were conducted.

RESULTS

Among the 59 articles which were retrieved and reviewed, 30 were evaluations of specific gender-transformative interventions and the remaining 29 included literature reviews or critical reflections of gender-transformative interventions. Three key themes emerged from our analysis: (1) tailoring approaches for both boys and girls; (2) incorporating multilevel approaches; and (3) engaging multiple sectors, such as health, education, and sports. In each theme, we highlight the primary challenges as well as promising practices for implementation.

DISCUSSION

Efforts should continue unpacking the characteristics of intervention approaches where positive results are found among boys and girls in both implementation and impact. In terms of both multilevel and multisectoral programming, more evidence is needed to help identify which intervention activities should target which populations at what levels and how much to achieve positive impacts among young adolescents.

Mapping resilience: a scoping review on mediators and moderators of childhood adversity with a focus on gender patterns

BACKGROUND

Childhood adversity is associated with a host of negative health and socioeconomic outcomes far into adulthood. The process of avoiding such outcomes is often referred to as resilience. Mapping resilience comprehensively and across contexts is highly relevant to public health, as it is a step towards understanding environments and interventions that contribute to preventing or reversing negative outcomes after early adverse experiences.

OBJECTIVES

This review scoped out the literature on resilience factors in relation to adulthood outcomes as diverse as mental health and educational attainment. Our aim was to understand where there is untapped research potential, by examining the current evidence base on resilience factors in terms of (a) resources that can buffer the impact of childhood adversity and (b) the pathways linking adversity to long-term outcomes. Furthermore, we aimed to identify gender patterns in these resources and pathways, which has not been a primary interest of reviews on resilience to date, and which can add to our understanding of the different ways in which resilience may unfold.

ELIGIBILITY CRITERIA

Studies had to include an adversity experienced in childhood, an outcome considered indicative of resilience in adulthood, and at least one putative resilience factor, which had to be approached via mediation or moderation analysis. We considered cohort, case-control and cross-sectional studies.

SOURCES OF EVIDENCE

We searched PubMed, Scopus and PsycINFO and included original, peer-reviewed articles published before 20 July 2023 in English, German, French, Spanish, Dutch and Swedish.

CHARTING METHODS

All three authors collaborated on the extraction of information relevant to answering the research questions. The results were visually and narratively summarised.

RESULTS

We included 102 studies. Traditionally anchored in the field of psychology, the resilience literature focuses heavily on individual-level resilience factors. Gender was considered in approximately 22% of included studies and was always limited to comparisons between men and women. There is no evidence that childhood adversity impacts men and women differently in the long term, but there is some evidence for gender differences in resilience factors.

CONCLUSIONS

There is untapped potential in resilience research. By considering structural-level factors simultaneously with individual-level factors, and including gender as one of the elements that shape resilience, we can map resilience as a heterogeneous, multilevel process from a public health perspective. This would complement the extensive existing literature on individual-level factors and help reframe resilience as a concept that can be intervened on at a structural level, and that is subject to societal norms and forces, such as gender. There is a lack of quantitative studies including transgender and gender-non-conforming persons.

Do Attitudes towards Gender Equality Influence the Internalization of Ambivalent Sexism in Adolescence?

Sexism during adolescence may hinder the attainment of gender equality and the eradication of violence against women. The aim of this research was to analyze the relationship between an individual's view on gender equality and the internalization of ambivalent sexism, as well as to study the impact of different types of egalitarian attitudes (sociocultural, relational, and personal) on the levels of hostile and benevolent sexism among the adolescent population. A quantitative approach with a cross-sectional design was employed in this research. The sample group consisted of 1840 students (50.1% female and 49.9% male) in Compulsory Secondary Education in Castilla-La Mancha, Spain. The results show that adolescents who endorse pro-gender-inequality attitudes exhibit greater levels of hostile and benevolent sexism than their counterparts. Conversely, adolescents adopting pro-equality attitudes leads to lower levels of ambivalent sexism. In both male and female adolescents, egalitarian attitudes at the sociocultural, relational, and individual levels have a negative impact on the internalization of sexism. It is therefore crucial for both schools and families to prioritize the instruction of egalitarian values from early childhood, as this will aid in advancing a fairer and more equal society whilst eradicating sexist biases and violence against women.

The global macroeconomic burden of Alzheimer's disease and other dementias: estimates and projections for 152 countries or territories

BACKGROUND

Alzheimer's disease and other dementias (ADODs) severely threaten the wellbeing of older people, their families, and communities, especially with projected exponential growth. Understanding the macroeconomic implications of ADODs for policy making is essential but under-researched.

METHODS

We used a health-augmented macroeconomic model to calculate the macroeconomic burden of ADODs for 152 countries or territories, accounting for: the effect on labour supply of reduced working hours of informal caregivers; the effect on labour supply of ADODs-related mortality and morbidity; age-sex-specific differences in education, work experience, labour market participations, and informal caregivers; and treatment and formal care costs diverting from savings and investments.

FINDINGS

ADODs will cost the world economy 14 513 billion international dollars (INT$, measured in the base year 2020; 95% uncertainty interval [UI] 12 106-17 778) from 2020 to 2050, equivalent to 0·421% (95% UI 0·351-0·515) of annual global GDP. Japan incurs the largest annual GDP loss at 1·463% (1·225-1·790). China (INT$2961 billion [2507-3564]), the USA (INT$2331 billion [1989-2829]), and Japan (INT$1758 billion [1471-2150]) face the largest absolute economic burdens. The economic burden of informal care ranges from 60·97% in high-income countries to 85·45% in lower-middle-income countries, and treatment and formal care costs range from 10·50% in lower-middle-income countries to 30·80% in high-income countries.

INTERPRETATION

The macroeconomic burden of ADODs is substantial and unequally distributed across countries and regions. Global efforts to reduce the burden, especially with regard to informal care, are urgently needed.

FUNDING

National Institute on Aging, National Institutes of Health; Chinese Academy of Engineering; Chinese Academy of Medical Sciences; Bill & Melinda Gates Foundation; Davos Alzheimer's Collaborative through Data for Decisions.

Reproductive health service access and utilisation among migrant women in Dhaka's urban slums: a qualitative study

This study explores the impact of migration on the access and utilisation of sexual and reproductive health services by women living in an informal settlement in Dhaka, Bangladesh. A total of 16 in-depth interviews were conducted in March and April of 2019 with women (18-49 years old) who had migrated from rural areas to Dhaka. They reported continued economic insecurity while receiving minimal support from the state. All women reported financial and infrastructural barriers to accessing formal sexual and reproductive health services and tended to seek resources and support through social networks within the slum and from informal health services. Compared with more recent migrants, women who had migrated and resided in the slums for longer found it easier to utilise social networks and resources for sexual and reproductive health. Women had more agency in experimenting with contraceptives but had less power in making decisions during pregnancy and when seeking health care. Menstrual health was a neglected aspect of public health. The study indicates that public health policy targeting the urban poor needs to address the unique challenges faced by migrant women in informal settlements to rectify inequities in health services that leave significant portions of the urban poor population behind.

Development of a multidomain gender norm attitude scale for youth in Bangladesh

Objective

Gender norms shape individuals' perceptions and behaviours, particularly concerning health outcomes. However, the lack of comprehensive gender norm attitude measures in low- and middle-income countries, including Bangladesh, impedes gender-transformative efforts. This study introduces the Multidomain Gender Norm Attitude Scale (M-GNAS) to evaluate gender norm attitudes among Bangladeshi youths.

Method

Three sequential studies were conducted in Bangladesh in 2022 to develop the M-GNAS. Study 1 engaged 124 participants in focus group discussions, generating a 40-item pool reflecting prevalent gender norms. Study 2 involved 1374 youths (mean age 26.82, SD 5.50) to finalise the M-GNAS items and explore its latent structure through exploratory factor analysis (EFA). Study 3, with 1416 participants of similar age, used confirmatory factor analysis (CFA) to assess structural validity and structural equation modelling to evaluate measurement invariance (MI) across genders.

Results

EFA identified a four-domain solution with 13 items: gender-appropriate behaviour, family financial decisions, family responsibility, and career choice. CFA supported this four-domain solution (CFI=0.96, TLI=0.95; RMSEA=0.07; SRMR=0.04). MI across gender was well established (CFI & TLI>0.95, RMSEA≤0.06, SRMR<0.6). Higher education was associated with more egalitarian attitudes (F (5, 1408) = 7.25, p < 0.001), supporting the scale's construct validity.

Conclusion

The M-GNAS is a psychometrically robust tool for assessing youths' attitudes toward prevalent gender norm domains in Bangladesh. It holds the potential for contributing to gender-transformative programmes and could be applied in similar initiatives across developing nations, contingent upon appropriate validation.

Cross-sectional associations of gender identity and sexual orientation, with co-occurrence and clustering of health-related behaviours among British adolescents: Millennium cohort study

PURPOSE

We examined whether gender identity and sexual orientation were associated with seven health-related behaviours, and with co-occurrence and clustering of these behaviours among British adolescents.

METHODS

Millennium Cohort Study (age 17 wave) provided data on the exposures, gender identity (male, female, genderqueer) and sexual orientation (heterosexual, bisexual, gay or lesbian, or other), and seven self-reported health-related behaviours (binge drinking, drug use, no consumption of breakfast, no consumption of fruits or vegetables, physical inactivity, poor sleep, and smoking or vaping). Poisson regressions examined associations between the exposures and single behaviours (reporting prevalence ratios (PRs)); and multinomial logistic regressions were used for behavioural cumulative co-occurrence score (reporting PRs). Cluster patterns were identified using Ward's agglomerative hierarchical cluster analysis while associations with cluster membership were performed using logistic regressions (reporting odds ratios (ORs)).

RESULTS

Our sample included 6022 adolescents (55.4% female, 1.5% genderqueer, 11.6% non-heterosexual). Adolescents who identified as genderqueer had the highest prevalence of not eating breakfast (PR: 60.5% [95%CI 48.4-71.4]) and poor sleep (68.7% [95%CI 55.6-79.3]). Those who identified as bisexual had a higher PR of co-occurring behaviours (2.46 [95%CI 1.39-4.27]). Among the three clusters identified (1: Multiple risk behaviours; 2: Physical inactivity and binge drinking; 3: Poor diet and physical inactivity), adolescents who identified as genderqueer or other sexual orientation showed the highest prevalence in cluster 3.

CONCLUSION

Gender and sexual minority British adolescents showed a higher prevalence of risky health-related behaviours, and higher risk of co-occurring behaviours. Physical inactivity and poor diet behaviours commonly clustered together for these groups.

[DIVERGesTOOL-development of a toolbox for the assessment of sex/gender diversity]

In health research, there is a need for comprehensive survey instruments capable of assessing the multidimensionality and variability of sex/gender. The research project DIVERGesTOOL was conducted in response to this need, which has become increasingly evident in recent years. The aim was to develop an application-oriented toolbox for the assessment of sex/gender diversity in quantitative health-related research in Germany.The development process followed a participatory design, as representatives of large epidemiological studies in Germany were directly involved. During four collaborative workshops, a toolbox was developed that contains several different elements. The basic items are a generally usable set of three different questionnaire items based on the two-step approach. They are recommended as a replacement for the binary sex or gender item that are currently routinely used in health-related research. In addition, the toolbox contains further exemplary questionnaire items for specific research questions or study populations. The developed items were supplemented with detailed instructions for their application and additional information. The toolbox is an open online resource accessible to any user ( https://www.uni-bremen.de/divergestool-projekt/divergestool-toolbox ).In the long term, the DIVERGesTOOL is intended to support researchers in integrating sex/gender diversity into their own research and thus to contribute to more sex/gender sensitivity in health-related research and valid findings.

A Grounded Theory Approach to Understanding Men Confronting Infertility

Purpose: This study aims to delve into the process of men confronting infertility. Design: This research employed the Straussian grounded theory approach. Methods: The study encompassed interviews with 16 participants from a private fertility center in Isfahan, Iran, between March 2023 and March 2024. The interviews were semistructured. Data analysis was carried out concurrently using constant comparative methods and standard grounded theory techniques. the participants' main concerns were identified, culminating in developing a substantive theory centered around a core category. Findings: The primary category for men struggling with infertility was "forced concealment." This was exhibited through the suppression of emotions, maintaining secrecy about infertility, hiding treatment, and attributing infertility to their wives to counteract threats to their masculinity. Factors such as partners, family, societal surroundings, care providers, and beliefs influenced the adopting of the "forced concealment" strategy. Conclusions: The "forced concealment" theory offers insights into the experiences of men struggling with infertility. The study highlights the necessity of formulating culturally sensitive strategies that enable healthcare providers, nurses, and health system managers to effectively fulfill their roles and address the challenges and needs of couples confronting male infertility. This can be realized through a comprehensive approach that integrates nursing skills and competencies.

Addressing mental illness stigma in German higher education: study protocol for a mixed-methods evaluation of a psychosocial setting-based intervention

INTRODUCTION

Mental illness stigma is associated with a range of negative consequences, such as reduced help-seeking for mental health problems. Since stigma affects individual, social, and structural aspects, multilevel interventions such as the Canadian programme The Working Mind have been proven to be the most effective. Given the solid evidence base for The Working Mind, it is our aim to implement and evaluate culturally adapted versions of the programme in German higher education, targeting students, employees and managers.

METHODS AND ANALYSIS

We will evaluate the programme with regard to its effect on mental illness stigma, openness to mental health problems, willingness to seek help, and positive mental health outcomes. Further, we will investigate the programme's effectiveness dependent on gender and personal values, various mechanisms of change, and factors facilitating and hindering implementation. The study uses a sequential explanatory mixed-methods evaluation design (QUAN → qual) that consists of three steps: (1) quasi-experimental online survey with programme participants, (2) focus groups with programme participants, and (3) qualitative interviews with programme stakeholders. The quantitative data collected in step 1 will be analysed using 2×3 analysis of variances and a parallel multiple mediation analysis. The results will inform the qualitative data to be collected in steps 2 and 3, which will be analysed using qualitative content analysis.

ETHICS AND DISSEMINATION

The study was approved by the local Ethics Committee (Ethics Committee of University Medicine Greifswald; BB 098/23). Participants have to provide written consent before taking part in a focus group or interview. As for the online survey, participants have to give their consent by agreeing to an online data protection form before they can start completing the survey. We will publish central results and the anonymised data in an Open Access Journal. Further, the statistical code will be included as a supplement to the paper(s) documenting the results of the study.

TRIAL REGISTRATION NUMBER

DRKS00033523.

2023 Global Survey of Optometry: Defining Variations of Practice, Regulation and Human Resources Between Countries

Purpose

To provide information on the demographics of optometrists and regulation of the optometry profession in countries who were members of the World Council of Optometry (WCO) during the period 2022-2023.

Methods

A non-random, purposive sampling and a key informant strategy was employed to conduct a survey-based cross-sectional study on the professional landscape and distribution of optometrists; educational landscape; legislative aspects of the profession; and the scope of optometry practice in countries who were members of WCO during the period 2022-2023. Key informants were identified by WCO country members' leadership.

Results

In the 39 countries surveyed, one optometrist serves 23,200 persons on average. Only 46.2% of the countries met the internationally suggested 1:10,000 optometrist-to-population ratio. The average male-to-female ratio was 45% males/55% females, with a division of average age as follows: under 45 years of age 46% as compared to above 45 years of age 54%. It was reported that optometry is not regulated in France, Portugal, India, Kenya and Cameron. Thirteen countries (33%) do not require a Bachelor's degree as a minimum to practice optometry. Use of diagnostic drugs is prohibited in 20% of the countries, with 25% of the countries limiting the use of therapeutic pharmaceutical agents.

Conclusion

Many countries where optometry is recognized struggle to have an adequate number of optometrists; this hinders access to eye care. This is compounded by unregulated minimum levels of education for entry-level optometric practitioners. In addition, several countries limit or prohibit many optometric procedures that restrict the ability of optometrists to provide eye care and vision health services at the primary care level.

Gender-responsive monitoring and evaluation for health systems

Gender-responsive monitoring and evaluation (M&E) for health and health systems interventions and programs is vital to improve health, health systems, and gender equality outcomes. It can be used to identify and address gender disparities in program participation, outcomes, and benefits, as well as ensure that programs are designed and implemented in a way that is inclusive and accessible for all. While gender-responsive M&E is most effective when interventions and programs intentionally integrate a gender lens, it is relevant for all health systems programs and interventions. Within the literature, gender-responsive M&E is defined in different and diverse ways, making it difficult to operationalize. This is compounded by the complexity and multi-faceted nature of gender. Within this methodological musing, we present our evolving approach to gender-responsive M&E which we are operationalizing within the Monitoring for Gender and Equity (MAGE) project. We define gender-responsive M&E as intentionally integrating the needs, rights, preferences, and power relations among women and girls, men and boys, and gender minority individuals, as well as across social, political, economic, and health systems, in M&E processes. This is done through the integration of different types of gender data and indicators, including: sex or gender specific, sex or gender disaggregated, sex or gender specific/disaggregated which incorporate needs, rights and preferences, and gender power relations and systems indicators. Examples of each of these are included within the paper. Active approaches can also enhance the gender-responsiveness of any M&E activities, including incorporating an intersectional lens and tailoring the types of data and indicators included and processes used to the specific context. Incorporating gender into the programmatic cycle, including M&E, can lead to more fit-for-purpose, effective, and equitable programs and interventions. The framework presented in this paper provides an outline of how to do this, enabling the uptake of gender-responsive M&E.

Changes in social inequalities in excess body weight and body dissatisfaction among adolescents in Barcelona, Spain, 2016-2021

OBJECTIVES

Adolescence is a crucial life stage that can lead to excess weight and body dissatisfaction. Social inequalities in these issues may have been exacerbated by the COVID-19 pandemic. We aimed to analyze the presence of socioeconomic inequalities and their changes in these inequalities stratified by sex in 13- to 19-year-olds in a large Mediterranean city (Barcelona, Spain).

STUDY DESIGN

Cross-sectional population-based study.

METHODS

We used data from the 2016 and 2021 editions of the FRESC survey, which is a representative citywide survey that captures various aspects of adolescent health. Excess weight was determined by objective body mass index measurements. Body dissatisfaction was defined as the discrepancy between perceived and desired body shape. Socioeconomic status was divided into five pseudo-quintiles by using the Family Affluence Scale. We calculated the corresponding prevalence estimates and fitted robust Poisson regression models to estimate both simple and complex measures of inequality, including relative and absolute differences between the two survey years.

RESULTS

The overall prevalence of excess weight increased from 25.3% [23.9-26.6] to 29.8% [28.2-31.4] between 2016 and 2021. Similarly, body dissatisfaction increased from 44.2% [42.6-45.8] to 60.4% [58.7-62]. Socioeconomic inequalities in excess weight significantly increased in girls (adjusted ratio of the relative index of inequalities = 1.72 [1.08; 2.74] but not in boys. No significant changes were detected in body dissatisfaction in either girls or boys.

CONCLUSIONS

Our findings highlight the presence of a sex-specific change in socioeconomic inequalities in adolescent well-being regarding excess weight and body dissatisfaction. These results underscore the need for local public policies to improve social equity in adolescent health.

Women's health and well-being in five birth cohorts from low- and middle-income countries: Domains and their associations with early-life conditions

Background

Women's health and well-being (WHW) have been receiving growing attention, but limited progress has been made on how to measure its different domains in low- and middle-income countries (LMICs). We used data from five long-term birth cohorts in Brazil, Guatemala, the Philippines and South Africa to explore different domains of adult WHW, and how these domains relate to early life exposures.

Methods

Based upon an a priori conceptualisation of eight postulated WHW outcomes available in the data, we grouped them as follows: human capital (intelligence quotient, schooling, height, and teenage childbearing), metabolic health (body mass index and metabolic syndrome score), and psychological (happiness and Self-Reported Questionnaire (SRQ) scores). Correlation analyses confirmed the variables theoretically belonging to the same dimension of WHW were statistically related. We then applied principal component analysis to each group of variables separately and used the first principal component as a summary quantitative measure of the corresponding WHW dimension. Finally, we assessed the association of each domain with a range of early-life factors: wealth, maternal education, maternal height, water, and sanitation, birthweight, length at two years and development quotient in mid-childhood.

Results

The three domains were largely uncorrelated. Early determinants were positively associated with human capital, while birth order was negatively associated. Fewer associations were found for the metabolic or psychological components. Birthweight and weight at age two years were inversely associated with metabolic health. Maternal education was associated with better psychological health.

Conclusions

Our findings indicate that WHW is multidimensional, with most women in the cohorts being compromised in one or more domains while few women scored highly in all three domains. Our analyses are limited by lack of data on adolescent exposures and on other relevant WHW dimensions such as safety, agency, empowerment, and violence. Further research is needed in LMICs for identifying and measuring the multiple domains of WHW.

A deeper consideration of sex/gender in quantitative health research: a checklist for incorporating multidimensionality, variety, embodiment, and intersectionality throughout the whole research process

BACKGROUND

There is a growing awareness of the need to adequately integrate sex and gender into health-related research. Although it is widely known that the entangled dimensions sex/gender are not comprehensively considered in most studies to date, current publications of conceptual considerations and guidelines often only give recommendations for certain stages of the research process and - to the best of our knowledge - there is a lack of a detailed guidance that accompanies each step of the entire research process. The interdisciplinary project "Integrating gender into environmental health research" (INGER) aimed to fill this gap by developing a comprehensive checklist that encourages sex/gender transformative research at all stages of the research process of quantitative health research. In the long term this contributes to a more sex/gender-equitable research.

METHODS

The checklist builds on current guidelines on sex/gender in health-related research. Starting from important key documents, publications from disciplines involved in INGER were collected. Furthermore, we used a snowball method to include further relevant titles. The identification of relevant publications was continued until saturation was reached. 55 relevant publications published between 2000 and 2021 were identified, assessed, summarised and included in the developed checklist. After noticing that most publications did not cover every step of the research process and often considered sex/gender in a binary way, the recommendations were modified and enriched based on the authors' expertise to cover every research step and to add further categories to the binary sex/gender categories.

RESULTS

The checklist comprises 67 items in 15 sections for integrating sex/gender in quantitative health-related research and addresses aspects of the whole research process of planning, implementing and analysing quantitative health studies as well as aspects of appropriate language, communication of results to the scientific community and the public, and research team composition.

CONCLUSION

The developed comprehensive checklist goes beyond a binary consideration of sex/gender and thus enables sex/gender-transformative research. Although the project INGER focused on environmental health research, no aspects that were specific to this research area were identified in the checklist. The resulting comprehensive checklist can therefore be used in different quantitative health-related research fields.

Sex-related differences in oncological surgery and postoperative outcomes: comprehensive, nationwide study in France

BACKGROUND

The main objective of this study was to undertake an exhaustive investigation of sex-related differences in cancer surgery.

METHODS

This observational study used data from the French national health insurance system database covering 98.8% of the population. Patients diagnosed with non-sex-specific solid invasive cancers between January 2018 and December 2019 were included. The main outcomes were likelihood of undergoing cancer surgery, type of oncological surgery performed, and associated 30-, 60-, and 90-day postoperative reoperation and mortality rates, by sex.

RESULTS

For the 367 887 patients included, women were 44% more likely than men to undergo cancer surgery (OR 1.44, 95% c.i. 1.31 to 1.59; P < 0.001). However, the likelihood of surgery decreased with advancing age (OR 0.98, 0.98 to 0.98; P < 0.001), and with increasing number of co-morbid conditions (OR 0.95, 0.95 to 0.96; P < 0.001), especially in women. Men had higher 90-day reoperation (21.2 versus 18.8%; P < 0.001) and mortality (1.2 versus 0.9%; P < 0.001) rates than women, overall, and for most cancer types, with the exception of bladder cancer, for which the 90-day mortality rate was higher among women (1.8 versus 1.4%; P < 0.001). After adjustment for age, number of co-morbid conditions, and surgical procedure, 90-day mortality remained higher in men (OR 1.16, 1.07 to 1.26; P < 0.001), and men were 21% more likely than women to undergo reoperation within 90 days (OR 1.21, 1.18 to 1.23; P < 0.001).

CONCLUSION

Women were much more likely than men to undergo cancer surgery than men, but the likelihood of surgery decreased with advancing age and with increasing number of co-morbid conditions, especially in women. These findings highlight a need for both increased awareness and strategies to ensure gender equality in access to oncological surgical treatment and improved outcomes.

Delay of Gratification, Gender Role Attitudes, and Death Reflections Predict Death Anxiety

Previous work has established that gender, age, and self-control can predict Death Anxiety (DA), the distress that centers around thoughts of one's mortality. However, it has not been determined if DA is associated with Delay of Gratification (DG; a tendency to forgo immediate rewards to receive a more favorable outcome in the future), attitudes toward gender roles (as compared to gender identity itself), and Death Reflections (DR; positive goals that occur when contemplating death). To examine these relations, 131 adults (45% women; aged 23-67 years) completed questionnaires that assess these constructs. We found that greater DG, egalitarian gender role attitudes, and engagement with DR were all associated with reduced DA. Gender identity was not associated with any variable, including DA. Age correlated independently with DA, but not when included in the regression models. These results demonstrate that elements of self-regulation and prosocial attitudes may predict baseline DA.

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Trend in prevalence, associated risk factors, and longitudinal outcomes of sarcopenia in China: A national cohort study

AIMS

To estimate the contemporary trend in the prevalence of sarcopenia and evaluate its risk factors and the longitudinal associations with multiple chronic conditions and mortality among Chinese middle-aged and older adults.

METHODS

This was a nationwide, prospective cohort study using data from the China Health and Retirement Longitudinal Study. The definition of sarcopenia was based on the Asian Working Group for Sarcopenia 2019 algorithm. In the cross-sectional analysis, we estimated the trend in the weighted prevalence of sarcopenia from 2011 to 2015 and examined the associated risk factors for sarcopenia severity in 2011. In the longitudinal analysis, we assessed the longitudinal associations between sarcopenia and 14 chronic conditions and mortality during a 9-year follow-up.

RESULTS

The weighted prevalence of sarcopenia remained consistently high in the overall population from 2011 (15.9%, 95% confidence intervals [CI]: 15.1, 16.6) to 2015 (15.0%, 95% CI: 14.3, 15.6; p for trend = 0.075). A range of risk factors were independently associated with the severity of sarcopenia, including older age, female sex, lower socioeconomic status, smoking status, malnutrition, and several chronic conditions. Possible sarcopenic and sarcopenic individuals had higher odds of several chronic conditions (i.e., heart disease, chronic lung disease, and memory-related disease) and increased risks of mortality (possible sarcopenia: odds ratios (OR): 1.66, 95% CI: 1.37, 2.00; sarcopenia: OR: 1.69, 95% CI: 1.36, 2.11) in 9 years of follow-up.

CONCLUSIONS

The prevalence of sarcopenia remained consistently high in the investigated population. Various risk factors were significantly associated with a higher prevalence of sarcopenia. Sarcopenic individuals had higher odds of several chronic conditions and increased risks of mortality, highlighting that the urgent need for dedicated efforts to improve the management of sarcopenic patients.

Functional limitation among middle age and older adults: Exploring cross-national gender disparities

OBJECTIVE

Functional limitations are prevalent among aging demographics, especially women. Structural and health factors, which vary worldwide, influence rates of functional limitations. Yet, gender disparities in functional limitation remain unclear in a global context.

METHODS

We use 2018 data from the Health and Retirement Study (HRS) international family of studies with respondents ages 50-64 and (n = 87,479) and 65-89 (n = 92,145) to investigate gender disparities in large muscle functional limitation (LMFL) across 10 countries/regions using mixed effects logistic regression, with special attention to structural indicators of inequality and health.

RESULTS

Among both women and men, LMFL was generally higher in China, India, Mexico, United States, and Baltic States than in England, Scandinavia, Southern Europe, Eastern Europe, and Western Europe. The gender disparity in LMFL gradually declined at older ages in India, China, Mexico, and United States, while this disparity gradually increased at older ages throughout Europe. Among middle age respondents, the greater risk of LMFL for women in countries/regions with a high GII was no longer observed after accounting for comorbidities. Among older respondents, a lower risk of LMFL for women in countries/regions with a high GII was not observed until accounting for comorbidities.

DISCUSSION

Our findings suggest that rates of LMFL are higher in middle-income countries than high-income countries, especially among women, and in countries with a higher GII. In addition, consideration of comorbidities was integral to these relationships. Thus, national/regional contexts inform differential rates of functional limitation, particularly as it relates to gender.

Gender differences in participation one year after stroke: exploring biopsychosocial predictors for women and men

BACKGROUND

Women appear to have a higher risk for long term restrictions in participation than men. This gender difference is poorly understood, as solely biomedical factors have been examined to date.

OBJECTIVES

The aims of this study are (1) to map gender differences in participation outcome one year after stroke, and (2) to identify demographic, stroke-related, or psychological predictors of participation for women and men separately.

METHODS

A total of 326 patients (mean age 66.5 ± 12.4y, 35.0% women) completed the restriction and satisfaction subscales of the Utrecht Scale of Evaluation of Rehabilitation-Participation (USER-P) at one year after stroke. Bivariate and multiple linear regression analyses were performed.

RESULTS

Women reported worse scores for restrictions in participation compared to men (median 75.4 versus 87.9 respectively, p = 0.001), especially in physical activities such as daytrips and going out. Satisfaction with participation was similar between women and men. Worse cognitive functioning (β = 0.17) was associated with more restrictions in participation in men only, other predictors of restrictions in participation were similar between women and men. The presence of depressive symptoms (β = -0.49) was associated with worse satisfaction with participation in men, whereas an increased stroke severity (β = -0.29) and the presence of maladaptive psychological factors (β = -0.36) were associated with worse satisfaction with participation in women.

CONCLUSIONS

Women experience more restrictions in participation compared to men one year after stroke. Taking into account gender-specific predictors of participation in stroke aftercare is important, as different biopsychosocial factors contribute to problems in participation across women and men.

Age of migration and common mental disorders among migrants in early adulthood: a Norwegian registry study

BACKGROUND

Younger age of migration is associated with higher risk of psychotic disorders but the relationship between age of migration and common mental disorders is less clear. This study investigates the association between age of migration and diagnosed common mental disorders among migrants living in Norway.

METHODS

Using national Norwegian register data from 2008 to 2019, we compared the odds of a common mental disorder diagnosis in healthcare services during early adulthood among non-migrants, descendants and migrants with different ages of migration and lengths of stay. We also investigated differences in the relationship for different migrant groups and for men and women.

RESULTS

Descendants and childhood migrants with ≥ 19 years in Norway had higher odds of common mental disorders than non-migrants, while those migrating during adolescence with ≥ 19 years in Norway had similar odds. Those migrating during emerging and early adulthood had lower odds. Overall among migrants, the relationship between age of migration and common mental disorders was more pronounced for migrants < 19 years in Norway than ≥ 19 years and for non-refugees compared with refugees, especially men.

CONCLUSIONS

Descendants and childhood migrants with long stays may have higher odds of common mental disorders due to the associated stress of growing up in a bicultural context compared with non-migrants. Age of migration has a negative association with diagnosed common mental disorders but much of this effect may attenuate over time. The effect appears weaker for refugees, and particularly refugee men, which may reflect higher levels of pre-migration trauma and stress associated with the asylum-seeking period for those arriving as adults. At the same time, migrants, especially those arriving as adults, experience barriers to care. This could also explain the particularly low odds of diagnosed common mental disorders among adult migrants, especially those with shorter stays.

Effects of human inequality and urbanization on ecological well-being performance: A System-GMM analysis

Enhancing the efficiency with which ecological consumption is transformed into human well-being is a necessary condition for achieving sustainable development. However, the current literature lacks systematic methods and applications for scientifically assessing Ecological Well-being Performance (EWP). How to value and index EWP is crucial to improve EWP. This study combines the Human Development Index (HDI), Life Satisfaction (LS), and Ecological Footprint (EF) to construct a new Index of Ecological Well-being Performance (IEWP). Meanwhile, human inequality and urbanization are two common and profound socio-economic phenomena with potential impacts on EWP. Therefore, this study uses panel data for 129 countries from 2010 to 2021 and applies the System-GMM approach to explore the impact of human inequality, urbanization, and the interaction between these two factors on EWP. Our results show that EWP has a cumulative effect in the long run. Human inequality has a negative effect on EWP, while the effect of urbanization is positive. Compared to developed countries, the negative impact of human inequality and the positive impact of urbanization are more pronounced in emerging and developing countries. This paper further reveals that the interaction term inhibits EWP, which indicates that urbanization exacerbates the negative effect of human inequality and that human inequality weakens the positive effect of urbanization. This paper contributes to understanding how human inequality and urbanization affect sustainable development from the perspective of EWP.

Gender and stigma in antiretroviral treatment adherence in Mozambique: A qualitative study

Both gender and HIV stigma are known to contribute to poor retention to antiretroviral therapy (ART), but little is known how they interact in decisions about adherence or default by people living with HIV (PLWH). This qualitative study explored HIV stigma and gender interaction in PLWH's care decisions in Mozambique. Transcribed data from semi-structured interviews of 68 men and 71 women living with HIV, were coded and analyzed for themes of HIV stigma, gender norms and treatment continuation and interruption pathways, using both deductive and inductive coding approaches. Stigma experiences were found to be influenced by gender roles. Anticipation of stigma was common across the narratives of PLWH, while women had more experiences of enacted stigma, particularly by their intimate partners. Women's treatment interruptions were influenced by fear of partner's negative reaction. Men's narratives showed internalized stigma and delayed treatment due to anticipated stigma and masculine norm of strength. Severe internalized stigma was found among single mothers, who without economic or moral support defaulted treatment. Women's pathway to adherence was facilitated by their caregiver role and support from partner or kin family. Men's adherence was facilitated by experience of severe symptoms, provider role and by support from their mother or partner. Results indicate that linkage of stigma to gender roles interact in treatment decisions in three main ways. First, HIV stigma and unequal gender norms can work jointly as a barrier to adherence. Secondly, those resisting restrictive gender norms found it easier to manage HIV stigma for the benefit of treatment adherence. Thirdly, some gender norms also facilitated adherence and stigma management. Programs targeted at HIV stigma reduction and improving ART adherence among heterosexual populations should be built on an understanding of the local gender norms and include socially and culturally relevant gender sensitive and transformative activities.

Exploring the Interplay of problematic pornography use, sexism, and rape myth acceptance: An Italian cross-sectional study

The relationships among pornography use, sexist ideology and false or stereotypical ideas about rape are controversial. This study specifically examines the associations of problematic pornography use (PPU) with sexism and rape myth acceptance among both male and female participants within the Italian context utilizing a cross-sectional methodology. Based on data from 815 participants collected through an online questionnaire, the study identifies significant gender-based differences, with men typically exhibiting higher scores on sexism, rape myth acceptance, and token resistance beliefs. Correlation analysis revealed that in men, there was a positive relationship between pornography cravings and sexist beliefs but not between pornography cravings and minimizing rape or accusations of lying (rape myth). Women showed significant positive correlations across all problematic pornography use dimensions with sexist ideology, although the relationship with rape myth acceptance varied. These findings underscore the critical need for acknowledging these relationships to enhance strategies for preventing gender-based violence.

Inclusion of Sex and Gender to Improve the State of the Science in Women's Health

ABSTRACT

The influence of sex and gender-related factors on health and disease at all levels of scale, across all health conditions, and throughout the entire life course is increasingly clear. A series of policies instituted by the National Institutes of Health (NIH) that require researchers to include appropriate populations and to analyze the data accordingly have strengthened the evidence base around the health of women. Translating these advances to the entire research ecosystem can catalyze rigorous biomedical discovery that can improve health. We encourage journals, publishers, and funders to align their policies and expectations regarding sex and gender considerations in research with those of the NIH and other international funding agencies.

Contraception Requirements in Clinical Research Consent Forms: Assessing and Supporting Gender Inclusive Practices

Gender-diverse individuals are underserved in clinical research settings. Reliance on gendered language throughout the consent process for clinical research contributes to the marginalization of these populations. The research objective was to assess use of gender-inclusive language used to describe the contraception requirement in consent forms. We categorized and analyzed contraception language in 289 clinical trial consent forms using a deductive and summative content analysis approach. We found that 79% (n = 227) of consent forms contained gender-inclusive language, 80% (n = 231) used terms that fell under the biological sex language, and 91% (n = 264) used gendered language. No consent forms used exclusively gender-inclusive language and the majority 63% (n = 182) featuring a combination of all three language types. There were many consent forms which would have been entirely gender-inclusive language if section headings with references to biological-sex-specific contraceptives were excluded, suggesting that gender-inclusive language may be attainable with minor revisions.

Sexual and Reproductive Health Among Cisgender Women With HIV Aged 18-44 Years

INTRODUCTION

The sexual and reproductive health of cisgender women with HIV is essential for overall health and well-being. Nationally representative estimates of sexual and reproductive health outcomes among women with HIV were assessed in this study.

METHODS

Data from the Centers for Disease Control and Prevention's Medical Monitoring Project-including data on sexual and reproductive health-were collected during June 2018-May 2021 through interviews and medical record abstraction among women with HIV and analyzed in 2023. Among women with HIV aged 18-44 years (n=855), weighted percentages were reported, and absolute differences were assessed between groups, highlighting differences ≥|5%| with CIs that did not cross the null.

RESULTS

Overall, 86.4% of women with HIV reported receiving a cervical Pap smear in the past 3 years; 38.5% of sexually active women with HIV had documented gonorrhea, chlamydia, and syphilis testing in the past year; 88.9% of women with HIV who had vaginal sex used ≥1 form of contraception in the past year; and 53.4% had ≥1 pregnancy since their HIV diagnosis-of whom 81.5% had ≥1 unintended pregnancy, 24.6% had ≥1 miscarriage or stillbirth, and 9.8% had ≥1 induced abortion. Some sexual and reproductive health outcomes were worse among women with certain social determinants of health, including women with HIV living in households <100% of the federal poverty level compared with women with HIV in households ≥139% of the federal poverty level.

CONCLUSIONS

Many women with HIV did not receive important sexual and reproductive health services, and many experienced unintended pregnancies, miscarriages/stillbirths, or induced abortions. Disparities in some sexual and reproductive health outcomes were observed by certain social determinants of health. Improving sexual and reproductive health outcomes and reducing disparities among women with HIV could be addressed through a multipronged approach that includes expansion of safety net programs that provide sexual and reproductive health service coverage.

Reflexivity and positionality applied to medical practice: a study on implicit gender bias with medical students in a Swiss university

BACKGROUND

An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students' reflection on the way in which social position modulates their relationship to patients.

METHODS

As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students' assignments (n=76), applying a thematic analysis framework.

RESULTS

Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias.

CONCLUSION

Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

Intersectionality, gender norms, and young adolescents in context: a review of longitudinal multicountry research programmes to shape future action

Discriminatory gender norms can intersect and interact with other dimensions of discrimination-such as age, race, ethnicity, disability, education status, and sexual orientation-to shape individuals' experiences and impact their health and wellbeing. This interaction is referred to as intersectionality. Although the theory has been in circulation since the late 1980s, only recently has it gained traction in low-income and middle-income settings, and it has yet to fully penetrate global research on adolescence. The social and structural intersectional drivers of adolescent health and wellbeing, particularly during early adolescence (age 10-14 years), are poorly understood. The evidence base for designing effective interventions for this formative period of life is therefore relatively small. In this Review, we examine how gender intersects with other forms of disadvantage in the early stages of adolescence. Analysing data from hybrid observation-intervention longitudinal studies with young adolescents in 16 countries, our aim is to inform the health and wellbeing of girls and boys from a range of social contexts, including in conflict settings. Adolescents' perceptions about gender norms vary by context, depend on individual opinion, and are shaped by socioecological drivers of gender inequalities in health. Shifting those perceptions is therefore challenging. We argue for the importance of applying an intersectionality lens to improve health and wellbeing outcomes for young adolescents and conclude with five practical recommendations for programme design and research.

Sex and gender differences in adverse events following influenza and COVID-19 vaccination

INTRODUCTION

Active and passive surveillance studies have found that a greater proportion of females report adverse events (AE) following receipt of either the COVID-19 or seasonal influenza vaccine compared to males. In a predominately young adult female population of healthcare workers, we sought to determine the intersection of biological sex and sociocultural gender differences in prospective active reporting of vaccine outcomes, which remains poorly characterized.

METHODS

This cohort study enrolled Johns Hopkins Health System healthcare workers (HCWs) who were recruited from the mandatory annual fall 2019-2022 influenza vaccine and the fall 2022 COVID-19 bivalent vaccine campaigns. Vaccine recipients were enrolled the day of vaccination and AE surveys were administered two days post-vaccination for bivalent COVID-19 and influenza vaccine recipients. Data were collected regarding the presence of a series of solicited local and systemic AEs. Open-ended answers about participants' experiences with AEs also were collected for the COVID-19 vaccine recipients.

RESULTS

Females were more likely to report local AEs after either influenza (OR = 2.28, p = 0.001) or COVID-19 (OR = 2.57, p = 0.008) vaccination compared to males, regardless of age or race. Males and females had comparable probabilities of reporting systemic AEs after either influenza (OR = 1.18, p = 0.552) or COVID-19 (OR = 0.96, p = 0.907) vaccination. Hormonal birth control use did not impact the rates of reported AEs following influenza vaccination among reproductive-aged female HCWs. Women reported more interruptions in their daily routine following COVID-19 vaccination than men and were more likely to seek out self-treatment. More women than men scheduled their COVID-19 vaccination before their days off in anticipation of AEs.

CONCLUSIONS

Our findings highlight the need for sex- and gender-inclusive policies to inform more effective mandatory occupational health vaccination strategies. Further research is needed to evaluate the potential disruption of AEs on occupational responsibilities following mandated vaccination for healthcare workers, a predominately female population, and to more fully characterize the post-vaccination behavioral differences between men and women.

Active listening, shared decision-making and participation in care among older women and primary care nurses: a critical discourse analysis approach from a gender perspective

BACKGROUND

Nursing care for older women represent a challenge worldwide due to its characteristics. When communication is impaired between primary care nurses and older women living alone, an imbalance in power relations occurs. The main objective of this study is to analyse the power relations between older women and primary care nurses in situations of active listening, shared decision-making and participation in care.

METHODS

We developed a qualitative study in southern Spain using a discursive and gender approach. We used purposeful sampling to interview older women who lived alone and received home nursing care. Simultaneously, we conducted focus groups with primary care nurses who provided home care to older women. A linguistic analysis of the transcripts was carried out.

RESULTS

Nine semi-structured face-to-face interviews were conducted with older women who lived alone and two face-to-face focus groups with four primary care nurses in each. The discourse of the participants demonstrated an imbalance in power relations. Influenced by work overload, active listening was considered a privilege in primary care nurses´ discourse. Regarding shared decision-making, older women´s discourses revealed "mirages" of real situations where they thought they were deciding. Participation in care was difficult since older women saw themselves as a nuisance in nurses´ presence, and primary care nurses did not facilitate older women's engagement. Older women weren´t considered when organising home visits and had interiorised a subordinated feeling. Similarly, a strict sense of identity made primary care nurses feel powerful in their relationships with older women.

CONCLUSIONS

The discourse of older women represented them as victims of a hostile panorama whilst they were sometimes satisfied with the deficient care received. The discourse of primary care nurses used more discursive strategies to represent themselves as professionals committed to caring. However, it also revealed deficiencies in care, discriminatory elements, and feelings of being limited by their working conditions. Active listening to older women and engagement in decision-making readjust empower the older women. Attending to the needs and concerns of primary care nurses could recalibrate the power imbalance between them and healthcare organisations.

Family Factors and Gender Norms as Protective Factors Against Sexual Risk-Taking Behaviors Among Adolescent Girls in Southern Uganda

Adolescent girls and young women are at a higher risk for HIV infection stemming from barriers to accessing comprehensive sexual health education, unequal cultural, social, and economic statuses, limited access to education and health care services, and gender-based violence. This makes adolescent girls susceptible to high-risk sexual behaviors. This study examines the protective role of family, social support factors and gender norms against sexual risk-taking behaviors among secondary school adolescent girls in Uganda. Baseline data from the National Institute of Mental Health-funded Suubi4Her study were analyzed. A total of 1260 girls aged 14-17 years and enrolled in the first or second year of secondary school were recruited across 47 secondary schools. Hierarchical linear regression models were conducted to determine the role of family, social support factors and gender norms on sexual risk-taking behaviors. Results indicate that traditional gender norms, family care and relationships, and social support were all associated with lower levels of sexual risk-taking intentions-a proxy for engaging in sexual risk behaviors. Findings point to the need to develop family level support interventions to equip adolescent girls with adequate sexual health-related knowledge and skills to facilitate safer sexual practices and reduce high-risk sexual-taking behaviors, as they develop and transition into young adulthood.

Gender(ed) science: How the institutionalization of gender continues to shape the conduct and content of women's health research

Gender refers to the socially constructed roles, behaviors, and attributes that a particular society considers appropriate for men and women based on assumptions about biological sex. It also operates as a major social organizing principle that confers unequal power, status, and resources to men and women, with direct consequences for health. Historic patriarchal and misogynistic beliefs and values are reinforced through social institutions, including health science, which reify gender inequities. This commentary examines two key domains in which the social organization and institutionalization of gender in scientific research affect the conduct of women's health research and, by extension, women's health outcomes. These domains are: 1) decisions about which topics are prioritized, researched, and funded and 2) the dissemination of research findings. Using the National Institutes of Health (NIH) as a case study to illustrate broader patterns in scientific research, we present evidence of gender-based inequities in what is prioritized, deemed fundable, and disseminated, and how this affects knowledge production and attention to women's health. We highlight efforts and progress made by the NIH and call for additional attention to further address gender-based inequities and their impact on women's health research. We conclude with a call for critical social science analyses-ideally supported by the NIH-of the social organization of health science research to identify points of intervention for redressing deep-seated obstacles to advancing research on women's health.

Stigma, social support, and spirituality: associations with symptoms among Black, Latina, and Chinese American cervical cancer survivors

PURPOSE

Few studies have examined experiences of stigma and factors associated with symptoms among cervical cancer survivors from diverse racial and ethnic backgrounds. We investigated survivorship experiences and patient-reported outcomes in the SPADE symptom cluster (sleep disturbance, pain interference, anxiety, depression, and energy/fatigue) among Black, Latina, and Chinese American women diagnosed with cervical cancer.

METHODS

In two phases of research with cervical cancer survivors, we collected qualitative data through individual interviews (N=12; recruited through community referrals) and quantitative data from an observational cohort study (N=91; recruited through 4 national cancer registries). We coded interview transcripts to describe the survivors' experiences. We then evaluated associations between social support, spirituality, and SPADE symptom cluster domains using linear regression models.

RESULTS

Qualitative analysis yielded four themes: perceptions of stigma, empowerment, physical and psychological effects, and social support. These concepts revolved around internal and external stigmas, emotional responses, strengthened faith, and different social support types. Quantitative analyses indicated that greater spirituality was associated with lower symptom burden on all five SPADE domains (p<0.01). We observed nuanced associations between specific types of social support and SPADE domains.

CONCLUSIONS

The survivorship experiences of Black, Latina, and Chinese American women with cervical cancer are negatively influenced by perceptions of stigma. Higher scores on spirituality and varied types of social support were significantly associated with fewer symptoms in the SPADE symptom cluster.

IMPLICATIONS FOR CANCER SURVIVORS

Results suggest targets for future interventions to reduce symptom burden among women diagnosed with cervical cancer by leveraging spirituality and social support.

Workshop summary: National Institutes of Health (NIH) 2022 scientific workshop on gender and health

In this manuscript, we summarize the goals, content, and impact of the Gender and Health: Impacts of Structural Sexism, Gender Norms, Relational Power Dynamics, and Gender Inequities workshop held by the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) in collaboration with 10 NIH Institutes, Centers, and Offices. Specifically, we outline the key points emerging from the workshop presentations, which are the focus of the collection of articles in this supplement. The overarching goals of the workshop were to convene NIH staff, the external scientific community, and the public to discuss methods, measurement, modifiable factors, interventions, and best practices in health research on gender as a social and cultural variable and to identify opportunities to advance research and foster collaborations on these key topics. Themes emerging from the workshop include the need for intersectional measures in research on gender and health, the role of multilevel interventions and analyses, and the importance of considering gender as a social and structural determinant of health. Careful, nuanced, and rigorous integration of gender in health research can contribute to knowledge about and interventions to change the social and structural forces that lead to disparate health outcomes and perpetuate inequities.

"Women's work": Gender and the physician workforce

Historically, the physician professional identity and the organizational structure of Western medicine have been defined by masculine norms such as authority and assertiveness. The past five decades have seen a rapid shift in the demographics of attendees as medical schools, with equal numbers of women and men matriculants for nearly twenty years. Gender as a social, cultural, and structural variable continues to influence the physician workforce. The entry of women into medicine, has had far reaching effects on the expectations of patients, the interactions of physicians with other members of the healthcare team, and the delivery of care. Redefining the culture of medicine to accommodate the diversity of the modern workforce may benefit all physician and improve the delivery of healthcare.

Paediatric melioidosis

Melioidosis is a tropical infectious disease caused by the saprophytic gram-negative bacterium Burkholderia pseudomallei. Despite the infection being endemic in southeast Asia and northern Australia, the broad clinical presentations and diagnostic difficulties limit its early detection, particularly in children. Melioidosis more commonly affects the immunocompromised and adults. Melioidosis is increasingly being diagnosed around the world and whole-genome sequencing indicates that these cases are not linked with travel to endemic areas. Research has concentrated on the adult population with limited experience reported in the care of this uncommon, but potentially fatal condition in children presenting with bacteraemia and pneumonia.

Advancing gender transformative intersectional science for health justice: An ecosocial analysis

At a time when health-oriented institutions both globally and nationally are increasingly recognizing the need to support research, interventions and training that engage with analysis of how gendered social systems shape population health, independent of and in conjunction with sex-linked biology, it is essential that this work reject biological essentialism and instead embrace embodied integration. In this essay, guided by the ecosocial theory of disease distribution, I clarify connections and distinctions between biological versus social reproduction and inheritance, underscore the non-equivalence of the categories "sex" and "race," and offer a set of examples analyzing the production of gendered health inequities and who needs to do what to address them. The examples concern the worlds of work (sexual harassment; breastfeeding; sex work), ecologic environments (water access; fracking, sexually transmitted infections, & sexual violence); sexual reproduction and reproductive justice (gender stereotyping of reproductive biology; sterilization abuse and abortion bans); and (4) gender transformative initiatives (violence; health interventions). To advance gender transformative intersectional science for health justice, I offer recommendations regarding requirements for justifying data conceptualization, analysis and governance that can be implemented by institutions with the power to shape the funding, translation, and publication of science involving gender, sex-linked biology, and the people's health.

Stigmatizing deferrals disproportionally reduce donor return rates: Evidence from Brazil

BACKGROUND AND OBJECTIVES

Prior research has shown that temporary deferrals negatively influence donor return rates, but it remains unknown the extent to which these effects vary across reasons for deferral. We investigate whether deferrals differ in their degree of perceived stigmatization and, if so, how being deferred for stigmatizing (vs. non-stigmatizing) reasons affects subsequent donation behaviour.

MATERIALS AND METHODS

We examined whether reasons for deferral vary on their perceived level of stigmatization through an online survey (n = 400). Furthermore, we used a dataset encompassing 25 years of donation records from the state-run blood collection agency (BCA) from Rio de Janeiro, Brazil, to investigate how stigmatizing (vs. non-stigmatizing) reasons for deferral affected return rates of 82,648 donors over a 60-month follow-up period.

RESULTS

Being deferred for sex- and drug-related reasons was perceived as much more stigmatizing than other reasons for deferral (odds ratio = 3.14, 95% confidence interval [CI]: 2.33-4.25). Controlling for multiple observables, prospective donors were less likely to return to the BCA when deferred for stigmatizing (vs. non-stigmatizing) reasons (adjusted hazard ratio = 0.87, 95% CI: 0.83-0.93).

CONCLUSION

Donors perceive deferrals motivated by sex- and drug-related reasons as particularly stigmatizing, which is negatively associated with donor return rates. BCAs may want to pay special attention when communicating stigmatizing reasons for deferral to prospective donors.

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Gender/Sex Disparities in the COVID-19 Cascade From Testing to Mortality: An Intersectional Analysis of Swiss Surveillance Data

Objectives

This study investigates gender and sex disparities in COVID-19 epidemiology in the Canton of Vaud, Switzerland, focusing on the interplay with socioeconomic position (SEP) and age.

Methods

We analyzed COVID-19 surveillance data from March 2020 to June 2021, using an intersectional approach. Negative binomial regression models assessed disparities between women and men, across SEP quintiles and age groups, in testing, positivity, hospitalizations, ICU admissions, and mortality (Incidence Rate Ratios [IRR], with 95% Confidence Intervals [CI]).

Results

Women had higher testing and positivity rates than men, while men experienced more hospitalizations, ICU admissions, and deaths. The higher positivity in women under 50 was mitigated when accounting for their higher testing rates. Within SEP quintiles, gender/sex differences in testing and positivity were not significant. In the lowest quintile, women's mortality risk was 68% lower (Q1: IRR 0.32, CI 0.20-0.52), with decreasing disparities with increasing SEP quintiles (Q5: IRR 0.66, CI 0.41-1.06).

Conclusion

Our findings underscore the complex epidemiological patterns of COVID-19, shaped by the interactions of gender/sex, SEP, and age, highlighting the need for intersectional perspectives in both epidemiological research and public health strategy development.

Gender-transformative programmes: a framework for demonstrating evidence of social impact

Ample evidence has demonstrated that gender inequality and restrictive gender norms wield significant influence over health outcomes. While gender-transformative programmes have grown with the aim of challenging these norms and promoting gender equality, their effectiveness in driving sustainable norm change remains a subject of debate. This paper introduces a comprehensive analytical framework designed to assess the impact of these programmes.Drawing from extensive literature reviews of rigorously evaluated health programmes, this framework identifies four key dimensions that are instrumental in determining a programme's potential for transformative change. These dimensions are multiplicative effect, sustainability, spread and scalability. Multiplicative effect emphasises the interconnected nature of societal systems, positing that altering one element can trigger cascading effects throughout the entire system. Sustainability recognises that change within a system is less likely to revert once the structure has shifted. Programmes that facilitate norm change are more likely to sustain the changes brought about by their interventions. Spread acknowledges the importance of engaging entire networks that share the targeted norms. Successful programmes should demonstrate evidence of gender-related outcomes extending beyond the immediate beneficiaries, progressively diffusing through the broader population. Finally, scalability emphasises the need to bring gender-transformative initiatives to a larger scale to effect broader norm change.By aligning programme design and evaluation with these four dimensions, the proposed framework provides a standardised approach for assessing gender-transformative programmes. It shifts the focus from individual-level change to systemic transformation, bridging the gap between programmatic aspirations and the ability to measure genuine progress.