An analysis of 40 low-income and middle-income countries in the Asia-Pacific region: it is during early adolescence where marked gender inequalities in health and wellbeing consistently emerged

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region. Elissa Kennedy et al. The Lancet Global Health, October 19, 2020. https://doi.org/10.1016/S2214-109X(20)30354-5

Summary

Background: By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life.

Methods: We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks.

Findings: Although son preference is evident in some settings—as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations—it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20–24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15–24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking.

Interpretation: These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded.

Discussion

Son preference remains evident in some settings, signified by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (which might indicate prenatal sex determination and sex-selective abortion), and a higher than expected mortality among female children in some South Asian and Pacific nations. Gender inequalities in other indicators of wellbeing across early childhood were otherwise not observed; gains made in child mortality, undernutrition, and primary education have been, for the most part, equally shared by boys and girls in this region. Progress, however, has not continued through the second decade of life, with gender inequalities in wellbeing emerging most markedly and increasing during adolescence.

Adolescent girls continue to face considerable disadvantage in relation to sexual and reproductive health and rights, including protection from child marriage and intimate partner violence. Despite near universal commitments to end child marriage, a substantial proportion of girls in the Asia-Pacific region were married by age 18 years, and rates of adolescent childbearing remain high in many countries. Girls have poor access to modern contraception and experienced high rates of intimate partner and sexual violence. Discrimination and disadvantage affecting girls was most notable in South Asia, reflected in the highest rates of child marriage, adolescent births, intimate partner violence, and suicide mortality, and lower education participation and completion. Despite having achieved educational parity in many countries, girls are not transitioning to further training or employment at the same rate as boys. Unpaid domestic work, early parenthood, and care-giving responsibilities are likely to be important contributors to girls' unemployment, suggesting that despite improved education participation, girls commonly remain in traditional gender roles following school completion and experience profound gendered barriers to participation in paid employment.

26

Adolescent boys have greater all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, and alcohol and other drugs, and higher prevalence of harmful drinking and tobacco smoking. In all but some South Asian countries (Bangladesh, India, and Pakistan), boys also had substantially higher rates of suicide mortality than their female counterparts. Although rates of upper secondary school participation and completion were similar for boys and girls in most countries, boys were more likely to be out of school in several East and Southeast Asian and Pacific countries, and were more likely to be engaged in child labour and hazardous work.

Puberty is transformative in the health and development trajectories of girls and boys. While physical, hormonal, and neurodevelopmental pubertal processes contribute to biological sex differences in some health outcomes and risks, puberty is also characterised by an intensification of gender socialisation, during which gender identity, roles, and norms sharply diverge and take on increasing prominence.

27

 These norms are consolidated during adolescence and profoundly shape the lives of adolescents, with consequences for health that extend into adulthood and for the next generation.

11

 Gender norms vary across sociocultural contexts; however, common gender stereotypes underpin disadvantage for both girls and boys across the Asia-Pacific region. Underlying patriarchal systems that reinforce gender norms assigning higher status and power to boys over girls, and reward hegemonic (dominant) constructs of masculinity, contribute to boys' risk taking, use of and exposure to violence, and poor care seeking. These same systems police restrictive feminine norms that limit girls' opportunities and agency, and increase vulnerability to harmful practices (such as child marriage), intimate partner violence, and poor sexual and reproductive health.

3

,  

28

 Non-conformity with rigid norms can lead to sanctions and punishment, which also have negative health and wellbeing outcomes.

3

These findings substantially extend our understanding of gender inequality during childhood and adolescence. They challenge the narrow focus on women in existing gender indicators, policies, and programmes, and draw attention to the need to prioritise adolescents, an age group where few investments have been made to date. This analysis also highlights the substantial regional and national variation in the impacts of gender inequality, emphasising the need for context-specific programming and policy. Such a response will require investments across many sectors. Action is required to prevent child marriage and adolescent pregnancy; remove policy, financial, and regulatory barriers limiting adolescents' access to sexuality education and sexual and reproductive health services; and reform workplaces to address gendered barriers that limit opportunities for girls to enter and remain in employment.

5

 Greater attention is also needed to understand and address harmful norms and constructs of masculinity, as these not only contribute to adverse health outcomes and risks for boys into adulthood, but also have profound impacts on girls' health and wellbeing.

29

 By early adolescence, girls and boys have attitudes that support gender inequality, and these norms are strongly influenced, and enforced, by family, peers, and societal structures.

27

 They are therefore amenable to intervention, with some evidence that gender-transformative approaches combining strategies at the individual, social, and structural level might promote equitable gender attitudes and related behaviours during adolescence.

30

Measuring and monitoring gender inequality during these key formative years is crucial. Of the 54 gender-sensitive SDG indicators (defined by UN Women),

2

 only 13 relate specifically to childhood and adolescence and are focused largely on education, harmful practices affecting girls (child marriage, female genital mutilation), intimate partner and sexual violence, and child labour. A further 16 indicators related to poverty, employment, harassment, trafficking, homicide, and conflict call for disaggregation by sex and age. However, the extent to which these will be reported by both age and sex to allow for gender inequalities in this age group to be identified is unclear. Some key gender differences identified by this analysis (ie, suicide, injury, child mortality, alcohol use, and tobacco smoking) are not currently tracked as gender-sensitive indicators, nor do these SDG indicators explicitly require disaggregation by sex or age. Additionally, current summary measures of societal gender inequality, such as the GII and SIGI, primarily reflect disadvantage and discrimination against adult women. A small number of studies have shown that increasing societal gender inequality is associated with poor child health outcomes.

31

,  

32

,  

33

 Although this analysis did not specifically explore the relationship between these indices and gender inequalities in first two decades of life, there was a suggestion that existing gender indices correspond to inequalities in sexual and reproductive health and rights and some indicators of education, but less so to health risk behaviour or injury that predominantly affect males. An index of gender inequality that is specific to children and adolescents represents an important research agenda.

This study has some limitations. We used modelled data to populate some indicators relating to health to improve data coverage, consistent with analyses in the Lancet Series;

34

,  

35

 however, wide uncertainty estimates for some indicators suggest poor-quality primary data and a heavy reliance on modelling, which might affect our estimated gender inequalities. Nonetheless, it is reassuring that the findings of figure 2 (based on modelled data) are consistent with figure 3 (based largely on primary data). Even with the inclusion of modelled data, some potentially relevant aspects of health and wellbeing were not able to be examined due to the lack of internationally agreed and defined indicators, or lack of data disaggregated by age and sex. These include individual-level measures of poverty, food security, menstrual health, conflict, freedom of movement and share of public spaces, harassment and discrimination, and feeling of safety. There were also fewer indicators available for children than adolescents, and fewer indicators for the domains of protection and safe environment than those of health and education. These gaps, and the limitations of quantitative data to describe gender inequality and its effects, have also been noted by other authors.

2

,  

3

 The reporting of national data did not allow for important gender inequalities at a subnational level to be identified, or for analysis of intersecting inequalities related to ethnicity, poverty, disability, migrant status, or sexual orientation. Additionally, because of the lack of indicators and national-level comparable data, estimates for individuals with non-cisgender or non-binary identity could not be included, despite the substantial discrimination experienced by young people with diverse gender identity.

3

This analysis has identified some important gender inequalities and trends emerging in the first two decades of life and further research is required to examine the drivers of gender inequality and gender socialisation, and the sociocultural context of gender norms and impacts in this diverse region. In the immediate term, the alignment of the reporting framework to UNICEF's strategic plan helps to inform gender-responsive programming for children and adolescents. Although the developed framework was specific to the Asia-Pacific region, the heterogeneity of this region in terms of development and societal gender inequality (appendix p 3), coupled with this region being home to more than half of the world's young people, underscores its global relevance.

The SDGs have brought attention to gender equality as a global human right and health and development priority. The current focus on girls' sexual and reproductive health and elimination of harmful practices is well justified, as data from the Asia-Pacific region show that much remains to be achieved. However, there is a need to broaden the measurement and response to gender inequality arising during the first two decades of life, with much greater attention to adolescence as well as the effects of harmful gender norms on boys. The indicators included in this analysis are harmonised with available data collection efforts and might therefore serve as a foundation to this task. Action is clearly required to address the gender norms and structural determinants that not only drive poor sexual and reproductive health for girls, but also contribute to girls' poor outcomes across other domains of health and wellbeing, and underpin the excess mortality and health risks experienced by adolescent boys. Gender inequality remains one of the most pervasive challenges in global health and development. Early adolescence, when gender socialisation intensifies and key gender inequalities emerge, presents a crucial opportunity to address harmful gender norms before they are crystallised, and to advance gender equality for all.