Economic Benefits of Investing in Women’s Health: A Systematic Review

Background

Globally, the status of women’s health falls short of its potential. In addition to the deleterious ethical and human rights implications of this deficit, the negative economic impact may also be consequential, but these mechanisms are poorly understood. Building on the literature that highlights health as a driver of economic growth and poverty alleviation, we aim to systematically investigate the broader economic benefits of investing in women’s health.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed health, gender, and economic literature to identify studies that investigate the impact of women’s health on micro- and macroeconomic outcomes. We developed an extensive search algorithm and conducted searches using 10 unique databases spanning the timeframe 01/01/1970 to 01/04/2013. Articles were included if they reported on economic impacts stemming from changes in women’s health (table of outcome measures included in full review,

Effect of Women’s Perceptions and Household Practices on Children’s Waterborne Illness in a Low Income Community

An ecosystem approach to human health was adopted in a community-based study carried out in Bebnine, an underserved town in Lebanon. The objective of the study is to examine the association between women’s household practices and diarrhea among children in a setting where contaminated drinking water and intestinal diseases are common. A total of 280 women were randomly selected and interviewed using a structured questionnaire. Data were collected on 712 children between the ages of 6 and 14. The study instrument included determinants of diarrhea such as sociodemographic characteristics, water, sanitation, hygiene practices, gender variables, and behavioral risk factors. Multivariate regression analysis was employed to examine the association between water handling practices and diarrhea. The prevalence of diarrhea is 5%. Female children are more likely to suffer from diarrhea than male children (OR = 2.58; 95% CI: 1.19–5.62). Treatment of drinking water at the household level and the use of drinking water for cooking and the preparation of hot beverages are protective against diarrhea (OR = 0.15; 95% CI: 0.03–0.65). Female caretakers’ behaviors such as daily bathing and seeking medical care at times of illness are protective against diarrhea in children. The findings suggest that diarrhea is a gendered health problem. Female children, who are generally more involved in household activities than male children, are at higher risk of suffering from diarrhea. Female caretakers’ personal hygiene, household practices, and perceptions of diarrhea are additional risk factors. Intervention activities would be more effective if based on a better understanding of gender roles and household power relations.     

Women’s Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia

Women’s perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women’s health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men’s risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman’s HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women’s misperception regarding MC. Programs should address women’s informational needs and continue to emphasize that condoms remain critical, regardless of male partner’s circumcision status.     

Genetic Determinants of Pelvic Organ Prolapse among African American and Hispanic Women in the Women’s Health Initiative

Current evidence suggests a multifactorial etiology to pelvic organ prolapse (POP), including genetic predisposition. We conducted a genome-wide association study of POP in African American (AA) and Hispanic (HP) women from the Women’s Health Initiative Hormone Therapy study. Cases were defined as any POP (grades 1–3) or moderate/severe POP (grades 2–3), while controls had grade 0 POP. We performed race-specific multiple logistic regression analyses between SNPs imputed to 1000 genomes in relation to POP (grade 0 vs 1–3; grade 0 vs 2–3) adjusting for age at diagnosis, body mass index, parity, and genetic ancestry. There were 1274 controls and 1427 cases of any POP and 317 cases of moderate/severe POP. Although none of the analyses reached genome-wide significance (p<5x10^-8), we noted variants in several loci that met p<10⁻⁶. In race-specific analysis of grade 0 vs 2–3, intronic SNPs in the CPE gene (rs28573326, OR:2.14; 95% CI 1.62–2.83; p = 1.0x10^-7) were associated with POP in AAs, and SNPs in the gene AL132709.5 (rs1950626, OR:2.96; 95% CI 1.96–4.48, p = 2.6x10^-7) were associated with POP in HPs. Inverse variance fixed-effect meta-analysis of the race-specific results showed suggestive signals for SNPs in the DPP6 gene (rs11243354, OR:1.36; p = 4.2x10^-7) in the grade 0 vs 1–3 analyses and for SNPs around PGBD5 (rs740494, OR:2.17; p = 8.6x10^-7) and SHC3 (rs2209875, OR:0.60; p = 9.3x10^-7) in the grade 0 vs 2–3 analyses. While we did not identify genome-wide significant findings, we document several SNPs reaching suggestive statistical significance. Further interrogation of POP in larger minority samples is warranted.     

Impossible “Choices”: The Inherent Harms of Regulating Women’s Testosterone in Sport

In April 2018, the International Association of Athletics Federations (IAAF) released new regulations placing a ceiling on women athletes’ natural testosterone levels to “ensure fair and meaningful competition.” The regulations revise previous ones with the same intent. They require women with higher natural levels of testosterone and androgen sensitivity who compete in a set of “restricted” events to lower their testosterone levels to below a designated threshold. If they do not lower their testosterone, women may compete in the male category, in an intersex category, at the national level, or in unrestricted events. Women may also challenge the regulation, whether or not they have lowered their testosterone, or quit sport. Irrespective of IAAF’s stated aims, the options forced by the new regulations are impossible choices. They violate dignity, threaten privacy, and mete out both suspicion and judgement on the sex and gender identity of the athletes regulated.     

Food Insecurity and Children’s Mental Health: A Prospective Birth Cohort Study

Food insecurity (which can be defined as inadequate access to sufficient, safe, and nutritious food that meets individuals’ dietary needs) is concurrently associated with children’s psychological difficulties. However, the predictive role of food insecurity with regard to specific types of children’s mental health symptoms has not previously been studied. We used data from the Longitudinal Study of Child Development in Québec, LSCDQ, a representative birth cohort study of children born in the Québec region, in Canada, in 1997–1998 (n = 2120). Family food insecurity was ascertained when children were 1½ and 4½ years old. Children’s mental health symptoms were assessed longitudinally using validated measures of behaviour at ages 4½, 5, 6 and 8 years. Symptom trajectory groups were estimated to identify children with persistently high levels of depression/anxiety (21.0%), aggression (26.2%), and hyperactivity/inattention (6.0%). The prevalence of food insecurity in the study was 5.9%. In sex-adjusted analyses, children from food-insecure families were disproportionately likely to experience persistent symptoms of depression/anxiety (OR: 1.79, 95% CI 1.15–2.79) and hyperactivity/inattention (OR: 3.06, 95% CI 1.68–5.55). After controlling for immigrant status, family structure, maternal age at child’s birth, family income, maternal and paternal education, prenatal tobacco exposure, maternal and paternal depression and negative parenting, only persistent hyperactivity/inattention remained associated with food insecurity (fully adjusted OR: 2.65, 95% CI 1.16–6.06). Family food insecurity predicts high levels of children’s mental health symptoms, particularly hyperactivity/inattention. Addressing food insecurity and associated problems in families could help reduce the burden of mental health problems in children and reduce social inequalities in development.     

Mental Health Diagnostic Frameworks,Imputed Causes of Mental Illness,and Alternative Treatments in Northern Tanzania: Exploring Mental Health Providers’ Perspectives

In Tanzania, a nation with a large mental health treatment gap, local stakeholders’ perspectives are critical for informing effective treatment. The practice-based perspectives of mental health providers may be particularly instructive. Existing foundational literature on the professional population in this region is scarce. We conducted semi-structured interviews with 29 mental health providers in northern Tanzania. Interviews focused on three topics: use of international diagnostic frameworks for mental illness, beliefs about causes of mental health concerns, and alternative treatments sought by clients. Interview data were coded and analyzed using consensual qualitative research and the constant comparative method. Usage of diagnostic frameworks varied widely. Providers believed frameworks accurately described many patients but neglected somatic symptoms and contained diagnoses that they had never witnessed. Providers described supernatural and spiritual attributions of mental illness as substantially impacting treatment decisions. Other notable attributions included physical illness, drug/alcohol use, and heredity. Providers reported their clients routinely sought treatment from traditional and spiritual healers prior to seeking care in the formal health system. This study builds a foundation for the ongoing development of the mental health system in northern Tanzania. Findings also support exploration of integrative models of care and task-shifting to incorporate traditional and spiritual beliefs.     

Attractiveness and Rivalry in Women’s Friendships with Women

Past research suggests that young women perceive their same-sex friends as both facilitating the pursuit of desirable mates and competing for access to desirable mates. We propose that similar levels of physical attractiveness between young adult female friends might be one explanation for the opposing forces in their friendships. Forty-six female friendship pairs completed questionnaires about themselves, their friend, and their friendship; in addition, each woman’s picture was rated by a set of nine naive judges. Friends were similar in both self-rated and other-rated level of attractiveness. Within-pair analyses revealed that women agreed on which friend was more attractive, and the less attractive members of each friendship pair (by pair consensus as well as outside judges’ ratings) perceived more mating rivalry in their friendship than did the more attractive members of each friendship pair. We offer directions for research on women’s friendships over the lifespan.     

Focus: Sex and Gender Health: The Effects of Gender-based Violence on Women’s Unwanted Pregnancy and Abortion

The aim of this research is to understand how gender-based violence across the life-course affects the likelihood of abortion. Women outpatients (n = 309) revealed their exposure to four different forms of gender-based abuse: child sexual abuse (25.7 percent), teenage physical dating violence (40.8 percent), intimate partner violence (43.1 percent), and sexual assault outside an intimate relationship (22 percent). Logistic regressions revealed that no single form of gender-based abuse predicted abortion. The cumulative effect of multiple forms of abuse did increase the odds of having an abortion (OR = 1.39, CI = 1.13-1.69). Child sexual abuse predicted intimate partner violence (OR = 6.71, CI = 3.36-13.41). The cumulative effect of gender-based violence on women’s reproductive health warrants further research. Priority should be given to screening for multiple forms of victimization in reproductive healthcare settings.     

Disparities in HIV Screening among Pregnant Women – El Salvador, 2011

Objectives

To provide an accurate estimate of antenatal HIV screening and its determinants among pregnant women in El Salvador and help local authorities make informed decisions for targeted interventions around mother-to-child transmission (MTCT).

Methods

A total sample of 4,730 women aged 15-49 years were interviewed from a random sample of 3,625 households. We collected data on antenatal care services, including HIV screening, during last pregnancy through a pre-established questionnaire. We used a backward elimination multivariate logistic regression model to examine the association between HIV screening and sociodemographic and health care-related factors.

Results

A total of 2,929 women were included in this analysis. About 98% of participants reported receiving antenatal care, but only 83% of these reported being screened for HIV. Screening was lower in geographic areas with higher HIV incidence and ranged from 69.1% among women who were not seen by a physician during antenatal care, to 93.7% among those who attended or completed college. Odds for screening varied also by age, employment status, household economic expenditure, possession of health care coverage, health care settings, and number of antenatal care visits.

Conclusions

We found disparities in HIV screening during antenatal care at the environmental, social, demographic, and structural levels despite a high uptake of antenatal care in El Salvador. Our findings should urge health authorities to tailor and enhance current strategies implemented to eliminate MTCT and reduce inequities and HIV morbidity among women in El Salvador.     

Canadians’ Perceptions of Food,Diet, and Health – A National Survey

Background

Poor nutrition is harmful to one’s health as it can lead to overweight and obesity and a number of chronic diseases. Understanding consumer perceptions toward diet and nutrition is critical to advancing nutrition-related population health interventions to address such issues. The purpose of this paper was to examine Canadians’ perceived health and diet status, compared to their actual health status, and general concern about their own diet and beliefs about health. Also analyzed were some of the perceived barriers to eating “healthy” foods, with a focus on the availability of “healthy” processed foods.

Methods

Two surveys were administered online to a group of Canadian panelists from all ten provinces during May 2010 to January 2011. Thirty thousand were invited; 6,665 completed the baseline survey and 5,494 completed the second survey. Panelists were selected to be nationally representative of the Canadian adult population by age, sex, province and education level, according to 2006 census data.

Results

Approximately one third of Canadians perceived their health or diet to be very good while very few Canadians perceived their health or diet to be very poor. While the majority of Canadians believed food and nutrition to be very important for improving one’s health, fewer Canadians were concerned about their own diets. The majority of Canadians reported difficulty finding “healthy” processed foods (low in salt and sugar and with sufficient vitamins and minerals). Many also reported difficulty finding healthy foods that are affordable.

Conclusion

Although consumers believe that nutrition is one of the most important factors for maintaining health, there are still a number of attitudinal and perceived environmental barriers to healthy eating.     

Innate Immunity Pathways and Breast Cancer Risk in African American and European-American Women in the Women’s Circle of Health Study (WCHS)

African American (AA) women are more likely than European American (EA) women to be diagnosed with early, aggressive breast cancer. Possible differences in innate immune pathways (e.g., inflammatory responses) have received little attention as potential mechanisms underlying this disparity. We evaluated distributions of selected genetic variants in innate immune pathways in AA and EA women, and examined their associations with breast cancer risk within the Women’s Circle of Health Study (WCHS). In stage I of the study (864 AA and 650 EA women) we found that genotype frequencies for 35 of 42 tested SNPs (18 candidate genes) differed between AAs and EAs (corroborated by ancestry informative markers). Among premenopausal AA women, comparing variant allele carriers to non-carriers, reduced breast cancer risk was associated with CXCL5-rs425535 (OR=0.61, P=0.02), while among EA women, there were associations with TNFA-rs1799724 (OR =2.31, P =0.002) and CRP-rs1205 (OR=0.54, P=0.01). For postmenopausal women, IL1B-rs1143627 (OR=1.80, P=0.02) and IL1B-rs16944 (OR=1.85, P =0.02) were associated with risk among EA women, with significant associations for TNFA-rs1799724 limited to estrogen receptor (ER) positive cancers (OR=2.0, P =0.001). However, none of the SNPs retained significance after Bonferroni adjustment for multiple testing at the level of P0.0012 (0.05/42) except for TNFA-rs1799724 in ER positive cancers. In a stage II validation (1,365 AA and 1,307 EA women), we extended evaluations for four SNPs (CCL2-rs4586, CRP-rs1205, CXCL5-rs425535, and IL1RN-rs4251961), which yielded similar results. In summary, distributions of variants in genes involved in innate immune pathways were found to differ between AA and EA populations, and showed differential associations with breast cancer according to menopausal or ER status. These results suggest that immune adaptations suited to ancestral environments may differentially influence breast cancer risk among EA and AA women.     

What Explains Differences in Men’s and Women’s Production?

Researchers commonly use long-term average production inequalities to characterize cross-cultural patterns in foraging divisions of labor, but little is known about how the strategies of individuals shape such inequalities. Here, we explore the factors that lead to daily variation in how much men produce relative to women among Martu, contemporary foragers of the Western Desert of Australia. We analyze variation in foraging decisions on temporary foraging camps and find that the percentage of total camp production provided by each gender varies primarily as a function of men’s average bout successes with large, mobile prey. When men target large prey, either their success leads to a large proportional contribution to the daily harvest, or their failure results in no contribution. When both men and women target small reliable prey, production inequalities by gender are minimized. These results suggest that production inequalities among Martu emerge from stochastic variation in men’s foraging success on large prey measured against the backdrop of women’s consistent production of small, low-variance resources.

Moral Agency,Identity Crisis and Mental Health: An Anthropologist’s Plight and His Hmong Ritual Healing

During anthropological fieldwork, the author had a serious accident on the outskirts of a Hmong village in the highland of Laos. However, this dramatic incident turned out to be the occasion of his ritual initiation into the local village community. An analysis of narratives of the incident reveals Hmong conceptions of the anthropologist’s physical, mental and moral affliction, its causative concomitants and his ritual healing. Hmong mental health and identity are situated in a moral space of exchange relationships to significant others, challenging basic assumptions of concepts of the person widely held in psychiatry and beyond. The healing ritual transformed the author’s being from indeterminate “other,” in a life-threatening state of identity crisis, to a wholesome Hmong “self,” in a state of health and moral agency. This exemplary rite de passage highlights the affinity of ritual healing and constitution of self in a moral space. The underlying relational concept of the person is in sharp contrast to psychiatry’s concepts of the person, which are deeply shaped by values of individualism. Psychiatric services must accommodate substantial differences in the concepts of the person when treating Hmong migrants from Laos.     

Neurovascular and Cognitive failure in Alzheimer’s Disease: Benefits of Cardiovascular Therapy

Alzheimer’s disease (AD) is a multifactorial and multifaceted disease for which we currently have very little to offer since there is no curative therapy, with only limited disease-modifying drugs. Recent studies in AD mouse models that recapitulate the amyloid-β (Aβ) pathology converge to demonstrate that it is possible to salvage cerebrovascular function with a variety of drugs and, particularly, therapies used to treat cardiovascular diseases such as hypercholesterolemia and hypertension. These drugs can reestablish dilatory function mediated by various endothelial and smooth muscle ion channels as well as nitric oxide availability, benefits that result in normalized brain perfusion. These cerebrovascular benefits would favor brain perfusion, which may help maintain neuronal function and, possibly, delay cognitive failure. However, restoring cerebrovascular function in AD mouse models was not necessarily accompanied by rescue of cognitive deficits related to spatial learning and memory. The results with cardiovascular therapies rather suggest that drugs originally designed to treat cardiovascular diseases that concurrently restore cerebrovascular and cognitive function do so through their pleiotropic effects. Specifically, recent findings suggest that these drugs act directly on brain cells and neuronal pathways involved in memory formation, hence, working simultaneously albeit independently on neuronal and vascular targets. These findings may help select medications for patients with cardiovascular diseases at risk of developing AD with increasing age. Further, they may identify molecular targets for recovering memory pathways that bear potential for new therapeutic avenues.     

The Impact of Sex Work on Women’s Personal Romantic Relationships and the Mental Separation of Their Work and Personal Lives: A Mixed-Methods Study

Background

Very limited research has been undertaken on sex workers’ personal romantic relationships and the impact the nature of their work has on their relationships. This exploratory study aimed to explore the impact sex work has on women’s personal romantic relationships and the use of mental separation as a coping mechanism to balance the two aspects of their lives.

Methods

Fifty-five women working in the indoor sex industry in Melbourne, Australia, were recruited to complete a self-report questionnaire about various aspects of their work, including the impact of sex work on their personal relationships. Questionnaires were completed anonymously and included both closed and open-ended questions. A further six women were interviewed to ‘member check’ the accuracy of the questionnaire findings.

Results

Most women (78%) reported that, overall, sex work affected their personal romantic relationships in predominantly negative ways, mainly relating to issues stemming from lying, trust, guilt and jealousy. A small number of women reported positive impacts from sex work including improved sexual self-esteem and confidence. Just under half of women were in a relationship at the time of the study and, of these, 51% reported their partner was aware of the nature of their work. Seventy-seven percent of single women chose to remain single due to the nature of their work. Many women used mental separation as a coping mechanism to manage the tensions between sex work and their personal relationships. Member checking validated the accuracy of the questionnaire data.

Conclusion

This exploratory study identified a number of ways in which sex work impacts negatively on women’s personal romantic relationships. The findings of this study support the need for further studies to be undertaken to determine if the findings are reflected in a larger, more representative sample of Australian sex workers and should be considered in the context of any future intervention and support programs aimed at addressing the tensions sex workers experience between their work and personal relationships. Greater public awareness and education programs aimed at addressing the negative stigma associated with the sex industry may go some way towards easing the issues faced by women in their personal relationships.