Gender Parity at Scale: Examining Correlations of Country-Level Female Participation in Education and Work with Measures of Men’S and Women’S Survival
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ARTICLE IN PRESS JID: ECLINM [m5G;March 4, 2020;0:13] EClinicalMedicine 000 (2020) 100299 Contents lists available at ScienceDirect EClinicalMedicine journal homepage: https://www.journals.elsevier.com/eclinicalmedicine Research Paper Gender parity at scale: Examining correlations of country-level female participation in education and work with measures of men’s and women’s survival Adva Gadoth*, Jody Heymann WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, 621 Charles E Young Drive South, Los Angeles, CA 90095 ARTICLE INFO ABSTRACT Article History: Background: Past research has demonstrated the relationship between women’s educational levels and other Received 6 December 2019 measures of social development with maternal and child health outcomes. This study examines the relation- Revised 12 February 2020 ship between gender parity in education and work, achieved through greater female participation in both Accepted 14 February 2020 spheres, with survival in both women and men. Available online xxx Methods: Utilizing cross-sectional indicators from United Nations agencies, we constructed global indices of gen- der parity in education and work for international comparison. Multivariable regression was performed to assess relationships between gender parity index scores and national mortality rates or life expectancy indicators. Findings: Gender parity in both arenas was significantly associated with improved health outcomes after con- trolling for country health expenditures and other characteristics. A 10% higher country educational parity index score was associated with 59¢5 fewer maternal deaths per 100 000 live births, a 2¢1-year increase in female life expectancy, and almost a 1-year increase in male life expectancy at birth. Similarly, a 10% higher work parity index score was significantly associated with 14¢6 fewer maternal deaths per 100 000 live births and a 0¢9-year increase in female life expectancy at birth, with no deleterious relationship to male life expectancy. Interpretation: This study extends past research by examining actionable areas of gender equality and their impact on both male and female survival. While longitudinal research is needed to examine both causality and mechanisms, our findings suggest longevity gains for both women and men, and for all children through reduced maternal mortality, where greater parity in school and work is exhibited. Funding: No funding source directly supported the work in this manuscript. We are deeply indebted to the Conrad N Hilton Foundation for its support of Adva Gadoth as a Hilton Scholar. © 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/) 1. Introduction of school compared with their male peers, and only three in four girls complete their lower secondary education [7,8]. Women are also far ’ While extensive and far-reaching, the impacts of gender on health less represented in the formal labour market, trailing men s participa- can be summarised as operating through two major pathways: directly tion rate by more than 25% [9]. Amongst those able to secure formal to and from the health care system, and indirectly mediated by other employment, women are consistently compensated less for their social, economic, and political determinants of health [1].Examplesof work than men, and frequently relegated to jobs with low potential À direct impacts include influencing health-seeking behaviours and health for promotional growth [10 14]. care received [2]. Indirect impacts may include differential work experi- These figures are concerning considering a large body of literature À ences, with implications for personal income, occupational exposures, linking poor education and work outcomes to poor health [6,15 17]. and other factors affecting health and health care [3À5]. Important research exploring the relationship between various ’ Three of the central social determinants of health—education, measures of women s empowerment and health has shown that work, and income—are shaped by marked gender disparities [6]. higher female educational attainment and improved gender equality Globally, an excess of 5 million girls of primary school age remain out are associated with reduced maternal and infant mortality, as well as increased health service utilisation [18À24]. However, these findings * Corresponding author. have been restricted almost exclusively to low and middle income E-mail address: [email protected] (A. Gadoth). countries (LMIC), and focus heavily on reproductive and child health, https://doi.org/10.1016/j.eclinm.2020.100299 2589-5370/© 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article as: A. Gadoth and J. Heymann, Gender parity at scale: Examining correlations of country-level female participation in education and work with measures of men’s and women’s survival, EClinicalMedicine (2020), https://doi.org/10.1016/j.eclinm.2020.100299 ARTICLE IN PRESS JID: ECLINM [m5G;March 4, 2020;0:13] 2 A. Gadoth and J. Heymann / EClinicalMedicine 00 (2020) 100299 from all geographic regions and income levels. Implications for future Research in Context research and for population health policy are discussed. Evidence before this study 2. Methods Using the final report of the Women and Gender Equity Knowl- edge Network to the WHO Commission on Social Determinants of 2.1. Measures of gender parity Health as a launching point (published Sept. 2007), we conducted targeted searches of the World Bank, ILO, UN agencies, and WHO Our goal for each parity index was to describe concisely both the websites to collect reports on gender equality and its relationship overall proportion of girls or women participating in each social with health, education, and labour. Additionally, we searched sphere out of a total age-eligible population of female participants at PubMed for quantitative analytic articles published between Octo- the national level (absolute participation), and how that proportion ber 2007 and October 2018 with Boolean search terms (‘gender of participants compares with the same measure for boys or men equity’ OR ‘gender inequity’ OR ‘gender equality’ OR ‘gender (relative participation). Absolute measures of participation were inequality’ OR ‘gender parity’)AND(‘index’ OR ‘indices’)AND included to identify distinctions between countries with poor partici- (‘health’ OR ‘mortality’ OR ‘survival’ OR ‘life expectancy’). pation rates for both men and women and countries with high partic- Gender inequality has been consistently linked with poor ipation rates for both, which would otherwise be masked. education and work outcomes, especially for women, and with Participation at higher levels of education and occupation, as well as sex-based health disparities. Empirical studies of gender equal- overall participation, is incorporated into each index. ity have primarily reported negative associations between gen- der equality and maternal mortality in low- and middle- 2.2. Gender parity in education income countries, with a few studies extending this relation- ship to child and infant mortality. However, links between gen- Our measure of gender parity in education captures three aspects der equality and the long-term health and survival of both of women’s and girls’ educational attainment: (1) overall enrolment sexes remains uncertain. rates for girls, (2) how enrolment for girls compares to boys, and (3) whether women and girls are advancing in their education by exam- Added value of this study ining enrolment in primary, secondary, and tertiary education. For To our knowledge, this is the first study to investigate the quanti- each level of education (primary, secondary, and tertiary), we multi- tative relationship between country-level gender parity in educa- ply the gross female enrolment rate by the ratio of female-to-male tion or work and broad measures of longevity for people of both (F:M) enrolment. All female-to-male ratios were capped at a maxi- sexes. We constructed novel, segregated gender parity indices for mum value of 1, the benchmark of equality, to avoid penalisation of school and work that measured the inclusion and advancement countries where female participation rates surpass those of men (the of women in each social sphere. Compiling an international sam- same approach taken by the World Economic Forum’s Gender Gap ple of 97 countries from every region and income level, we found Index) [25]. We then sum these ratios and divide by 3 to create an that gender parity in education was significantly associated with educational parity index score that can be interpreted as the average female and male life expectancy at birth (p<0¢0001 and p =0¢04, product of a country’s F:M enrolment ratios and gross enrolment respectively) and with maternal mortality ratios (p<0¢0001), fol- rates for girls across all three levels of schooling, as follows: lowing control for several national covariates. Furthermore, gen- P 3 ðÞGross girls0 school enrolment à F : M enrolment ratio der parity in work was significantly associated with maternal n¼1 n n ; mortality (p =0¢002) and female life expectancy (p<0¢0001). 3 While occupational gender parity was positively correlated with where n represents the education level (1=primary school, 2=secondary men’s life expectancy in crude analysis (p =0¢04), this relation- school, 3=tertiary school).