Integrating a gender perspective into health statistics

1. Integrating a gender perspective into health statistics Workshop on Integrating a Gender Perspective into National Statistics, Kampala, Uganda 4 - 7 December 2012 Ionica Berevoescu Consultant United Nations Statistics Division

2. A Manual onIntegrating a Gender Perspective in StatisticsUnited Nations Statistics Division Chapters and structure of the manual • Users, uses and production of gender statistics: an overview • Bringing gender issues into statistics Covers: • Ten topics divided in subtopics: population, households and families; health; violence against women; migration, displaced persons and refugees; education; work; power and decision-making; poverty; food security; environment. • For each subtopic: gender issues; data needed; sources of data; gender-related conceptual and measurement issues Three uses of the chapter: • As an overall framework for identifying gaps in gender statistics and developing a national coherent and comprehensive plan for gender statistics • As a framework for use of gender statistics in analytical publications or reports • As a framework for assessing availability and quality of gender statistics • Integrating a gender perspective into data collection • Analysis and presentation of gender statistics

3. A Manual onIntegrating a Gender Perspective in StatisticsUnited Nations Statistics Division Four topics from chapter 2 (Bringing gender issues into statistics) are covered in this workshop Two “more traditional” topics • Health • Work Two topics reflecting emerging issues in gender statistics • Poverty • Environment

4. Integrating a gender perspective into health statistics

5. Biological and gender-based issues • Women and men’s health concerns differ because of both biological and socio-economic factors. • Some of the major health risks for women are directly linked to pregnancy and delivery, and many others are associated with women’s reproductive biology. • On the socio-economic and cultural side, women and men have different roles and responsibilities in society and in the family, with consequent different life styles, nutrition and exposure to diseases. Gender-based differences also affect the way women and men seek care and receive treatment.

6. Biological and gender-based issues • Examples of biological influences: • Girls seem to have a biological advantage on boys: mortality is particularly higher for boys than girls during the first month of life, when perinatal conditions are most likely to be the cause of death, and in general during early childhood. • The biological advantage of women continue through all life stages and, in absence of gender-based discrimination, women live longer than men. • Certain conditions, such as anaemia, malnutrition, hepatitis, malaria, tuberculosis, sickle cell disease, diabetes, and heart disease may be exacerbated by pregnancy. • Women have a higher risk per exposure of becoming infected with sexually transmitted diseases (STDs) and HIV.

7. Biological and gender-based issues • Examples of socio-economic influences: • Men are engaged in life-threatening jobs much more often than women • Because of lifestyle, men are at higher risk than women for most injuries. • Social and cultural factors have traditionally led men to take up dangerous habits, such as alcohol, drinking and smoking • Women may have difficulties in negotiating condom use with their partners, increasing their risk of becoming infected with HIV • Social and cultural factors put girls at risk of becoming sexually active at young ages facing serious risks for their health (STDs and maternal diseases) • Women are more affected than men by harmful traditional practices. • Women in many countries, because of their household responsibilities, are more exposed than men to indoor air pollution. • Cultural factors may restrict women’s ability to use health services.

8. Such biological and gender-based issues are presented in the four health-related sub-topics covered in the manual: • Health and nutrition of children • Maternal health • Mortality and causes of death • HIV and AIDS • Health risk factors related to life style

9. Example: Health and nutrition of children 1. Gender issues: Are girls or boys disadvantaged in terms of overall health, nutrition, immunization, or curative health care due to social factors? (Issues often specific to countries with a strong son preference) Systematic neglect of girls in terms of nutrition, immunization or curative health care is uncommon. Yet: • Infant mortality: A small gap between female and male infant mortality, mostly observed in some Asian countries, suggests a gender-based discrimination against girls (infant mortality should be higher for boys than for girls, due to greater male biological vulnerability). • Higher child mortality for girls, also observed in a small number of countries, mostly located in Asia, suggest discrimination against girls (child mortality should be higher among boys, due to biological vulnerability). • Measles immunization: In a small number of countries in Asia, considerably lower proportions of girls than boys have received immunization. • Access to curative health care: disadvantage of girls in a small number of countries in South-Central Asia. • Nutritional status: in a few countries, girls between ages 2 and 5 are more likely to be underweight than boys of the same age.

10. From gender issues to gender statistics – Health and nutrition of children

11. From gender issues to gender statistics – Health and nutrition of children (cont)

12. Health and nutrition of children 2. Data needed (summary): (Mortality) • Infant deaths by sex and age (number of months); deaths between ages 1 and 5 by sex and age; and number of live births by sex • Children ever born and children surviving by sex of the child and age of the mother (Nutrition) • Distribution of children under 5 by sex, age, weight and height (Health care) • Number of children aged 12-23 months by sex and type of vaccines received. • Children under 5 with diarrhoea in previous two weeks by sex and type of treatment received • Children under 5 with fever in previous two weeks by sex and type of treatment received • Children under 5 with cough or breathing difficulty in previous two weeks by sex and type of treatment received • Household expenditure on health for each child by sex and age of the child

13. Health and nutrition of children 3. Sources of data (Summary) • Civil registration systems with complete coverage are the preferred source of data on deaths under the age of 5 and live births. • Household surveys such as DHS and MICS for retrospective data on births, deaths, anthropometric, immunization, and health care of children; and LSMS for health expenditure • Population censuses for recent births and deaths and children ever born/children surviving • Health administrative sources and immunization coverage surveys for data on vaccinations

14. Health and nutrition of children 4. Gender conceptual and measurement issues • Ascertaining sex differentials in infant and child mortality is difficult in countries where civil registration system has limited coverage and not well maintained. • Some sex bias in reporting births and child deaths occur in all types of sources • Recall errors in censuses and surveys, and sampling errors in surveys • In addition, estimates of sex-specific mortality based on household surveys may have large standard errors and wide confidence intervals, making difficult the comparisons between boys and girls • Child mortality measured as probability of dying between ages 1 and 5 is more likely to highlight the potential disadvantage of girls, compared to other measures of mortality, such as infant mortality or under-5 mortality (until age 1, the biological disadvantage of boys is most relevant) • Sex differentials in nutrition may be clearer when data on weight and height of girls and boys under 5 are disaggregated by age (after age 2, biological factors become less relevant).

15. A similar exercise can be conducted with regard to Maternal Mortality…

16. …Mortality and causes of death

17. … or HIV/AIDS

18. A summary of sources of health statistics and statistics they provide I. Civil registration and other administrative sources Civil registration systems with complete coverage are the preferred source of data on • all deaths (child, adult, maternal) • live births • causes of death. However, many countries have incomplete civil registration, affecting the availability and quality of health statistics, including of gender statistics. Other administrative sources • Health administrative sources: data on causes of death. • Health administrative sources and immunization coverage surveys: data on vaccinations performed by service providers • Reports from health facilities, including antenatal clinics attended by pregnant women, may provide information on results from HIV-tested blood from sample of patients, and information on access to antiretroviral therapy.

19. A summary of sources of health statistics and statistics they provide (cont) II. Population censuses can provide data on: • children ever born and children surviving. • births and deaths in the past 12 or 24 months, including additional questions on the pregnancy status of female deaths of reproductive age (thus, capturing pregnancy-related deaths as a proxy measure of maternal mortality). • survival of parents or survival of siblings, which may be used in combination with data by age and sex, data on live births by age of mother, and data on age gap between husbands and wives to obtain indirect estimates of adult mortality. - Population censuses have the advantage of eliminating sampling errors and allowing for breakdown of data, including maternal mortality data by some individual, household or geographic characteristics. - The disadvantage is related to lack of specialized interviewers used for data collection, with impact on quality of data.

20. A summary of sources of health statistics and statistics they provide (cont) III. Household surveys have been increasingly important in collecting health-related data on a variety of topics: -child mortality, child nutrition, immunization, and curative health care (as presented already) -relevant factors in reducing maternal mortality: prenatal care visits; deliveries attended by skilled health personnel; deliveries in health facilities; use of contraceptive methods. -data for direct and indirect measurement of maternal mortality using the sisterhood method (respondents are asked about the survival of their adult sisters). -data on survival of siblings and parents to estimate mortality. Selected health-related surveys with large sample may also collect data on recent deaths, and causes of death data may be obtained by using additional questions on causes of death, following a verbal autopsy approach

21. A summary of sources of health statistics and statistics they provide (cont) III. Household and population-based surveys also important for: • Estimates of HIV prevalence based on HIV testing, as done by some DHS and by AIDS Indicators Surveys. More commonly, DHS, MICS and reproductive health surveys provide other HIV-related data, such as: knowledge of HIV transmission and prevention, multiple sex partners, use of condom during sexual intercourse with a non-marital, non-cohabiting sexual partner in the last 12 months, and access to antiretroviral therapy. • Coverage of health risk factors such as smoking, drinking, drugs, lack of exercise and poor diet, or access to health services for adult population, such as in health or multi-purpose surveys. • Measurement of time spent caring for household members who are disabled or ill, including HIV infected, as done in time use surveys. • data collection on health expenditure for each child in the household, in some living standard surveys.

22. A summary of sources of health statistics and statistics they provide (cont) IV. Surveys of selected populations • Demographic surveillance systems • usually maintained by research institutions • provide information on births and deaths by cause of death in small populations of selected areas, such as a community, or a district. Where death certificates are not available, a cause of death is assigned based on interviews with family members (a method called “verbal autopsy”). • useful, but expensive and time-consuming to conduct. • Reproductive-age mortality studies (RAMOS) • involve identification of causes of all deaths of women of reproductive age in a selected population by using multiple sources of data for a defined area or population. • Civil records, health facility records, burial records and interviews with traditional birth attendants and family members are used to identify deaths of women of reproductive age and to classify those deaths as maternal or otherwise. • Surveillance surveys focused on HIV • collect data on HIV status and sexual behaviour for populations with high risk behaviours such as sex workers, injecting drug users and men who have sex with men

23. A summary of gender-relatedmeasurement issues • Underreporting of deaths and births with potential sex-bias in underreporting • Female births and deaths may be more underreported, at younger ages, especially in countries with strong son preference • At adult ages, deaths of temporary migrants, among whom men are overrepresented, may be more likely to be underreported when collecting data on survival of siblings • Male respondents in censuses and surveys are less likely than female respondents to give accurate information on births and deaths in the household -> as much as possible, data should be obtained from the mother • Underreporting of maternal deaths, especially among early pregnancy deaths and in the later postpartum period, among youngest and oldest ages. • proportion of maternal deaths among all deaths of females of reproductive age considered as not significantly underreported, and therefore, it may be used to estimate maternal mortality • Misclassification of causes of death, including maternal deaths, especially when the information is collected from community members or relatives

24. A summary of gender-relatedmeasurement issues (cont) • Large standard errors and wide confidence intervals for data obtained from surveys make difficult the assessment of sex differences in child mortality; and trends in maternal mortality • Important to interpret indicators of maternal mortality within the context of other maternal health indicators (presence of skilled health personnel at delivery; antenatal care); similarly, interpret indicators on child mortality in the context of other indicators on child health • Non-participation in HIV-testing in population-based surveys is often higher for men than for women which may have an impact on sex-disaggregated estimates of HIV prevalence • Underreporting of use of contraceptive methods where use of traditional methods or use of contraceptive sterilization are common. • Respondents should be reminded of various types of contraceptive methods

25. Challenges in measuring the gender gap in healthExample: Sex differentials in child mortality • Three factors at play: • In general, greater biological vulnerability for boys, therefore parity should not be used as a standard in deciding on gender gap. • At high levels of mortality, smaller sex differences (reflecting historical trends in more developed regions and current situation in sub-Saharan Africa) • Data quality issues and sex differentials in underreporting of births and deaths, particularly in countries with incomplete civil registration. Therefore, before interpreting the results in terms of gender gap (or lack of), take into account: • more sources of data, and trends over time. • more than one health-dimension – for example, nutrition, immunization or curative health.

26. Historical change in the male-to-female ratio of mortality as under-five mortality declined in selected developed countries. Trends in the male-to-female ratio of under-five mortality by level of under-five mortality. Sawyer, C.C. 2012. "Child Mortality Estimation: Estimating Sex Differences in Childhood Mortality since the 1970s." PLoS Med 9(8):e1001287.

27. Trends in the male-to-female ratio of child mortality (ages 1–4 y) by level of under-five mortality. Countries where excess female child mortality (ages 1–4 y) was found in the 2000s. Sawyer, C.C. 2012. "Child Mortality Estimation: Estimating Sex Differences in Childhood Mortality since the 1970s." PLoS Med 9(8):e1001287.

28. Trends in the male-to-female ratio of infant mortality by level of under-five mortality. Countries where excess male infant mortality was found in the 2000s. Sawyer, C.C. 2012. "Child Mortality Estimation: Estimating Sex Differences in Childhood Mortality since the 1970s." PLoS Med 9(8):e1001287.

30. Time trends in 4q1 Male/Female ratio, Mauritius and Niger

31. Exercise: • Prepare a table on gender issues, data needed and sources of data for the topic health risk factors (life style related)

32. Table: health risk factors