This Data for Health Gender Chat discussion focused on examining the relationship between gender and prevention of non-communicable diseases (NCDs), gender as a stressor in mental health, strategies to ensure complete data collection around sensitive gender norms, and next steps in the study of gender as a risk factor for NCDs.

Relationship Between Gender and Non-Communicable Diseases

When we think of gender mainstreaming, we often focus on women’s health. And yet, Data for Health has a pillar associated with non-communicable disease prevention. This entity is focused on studying issues such as heart disease and cancer risk factors, diabetes, diet, alcohol consumption, tobacco prevention, and more. All of these have a gender component in that there are different rates based on biological sex and cultural gender norms that affect “who gets what disease.”
To date, NCD risk factors have been identified as behavioral and biological factors, such as nutrition, exercise, and biological sex (i.e. in the past, men died more often from heart attacks than women because we understood male heart attack symptoms). Symptoms of many NCDs may have a different clinical presentation according to sexes but because most research studies on NCDs have been conducted on men, it’s possible that people who aren’t biologically male may be less likely to be diagnosed at early stages and avert mortality from advanced disease.
When you add gender as a risk factor for NCDs, we can incorporate sociocultural differences between people and gender roles and norms in terms of access to healthcare, rates of gender-based violence, link to chronic stress-related conditions and healthcare seeking behaviors (women may be more proactive in seeking care vs men). Risk factors for NCDs are also affected by gender-based financial inequality and access to healthy food, education, healthcare and more.

NCD Risk Factors

The WHO STEPwise approach to NCD risk factor surveillance (STEPS) is a simple, standardized method for collecting, analyzing and disseminating data on key NCD risk factors in countries globally. The survey instrument identifies and covers key behavioral risk factors: tobacco use, alcohol use, physical inactivity, unhealthy diet, as well as key biological risk factors: overweight and obesity, raised blood pressure, raised blood glucose, and abnormal blood lipids.
In 2022, Johns Hopkins Bloomberg School of Public Health, and the Data for Health Initiative, incorporated gender norms-related questions into data collection using a STEPwise approach for a multi-country study, “Risk Factors Surveillance of the Non-Communicable Disease.” The objectives of the study as conducted in Bangladesh and Uganda were to: (1) test the usability and willingness to answer gender norms-related questions over an interactive voice Response (IVR) survey, (2) understand cognitive perceptions about gender roles and practices, and (3) document challenges, barriers, and recommendations of the users’ group regarding the implementation of gender norms-based surveys at scale using IVR methods.
Prior STEPS studies that included sex-disaggregation of the data were conducted in Eastern Europe, but this is the first study that has been conducted in low- and middle-income countries with a gender component. While these prior studies conducted in Eastern Europe highlighted gender-sensitive behavioral and biological risk factors over the life course of men and women, it did not delve into the important connection between gender norms and their impact on risk factors for NCDs.
To date, discriminatory gender norms issues have not formally been categorized as risk factors in NCDs by the WHO or any other public health authority. There is a stipulation, however, that ‘mental health conditions that have a direct connection to increasing the risks of other disease conditions and contribute to intentional and unintentional injuries’ be considered as NCD risk factors, which is why it is important to explore how gender weighs into women’s and people of other genders’ mental health.
Study findings from the IVR survey that incorporated gender norms questions highlighted prevailing patriarchal values and discriminatory gender norms practices and religious beliefs that negatively affect women and girl’s status in society (education level, wealth, access to resources), and put pressure on their mental health and wellbeing. Participants from the study shared their personal experience of stressors related to their gender status and its impact on their mental health.
“In our society, boys and girls are treated separately. Society dictates that girls can’t do this, can do that. Many families do not allow girls’ education and keep them indoors. It’s stressful for her. Society dictates a school-going girl should be married; it is a pressure for us”.
-39 years old female from peri-urban group
“We are married off after quitting education at an early age. We have less freedom than boys. We hear that both boys and girls have equal rights, but in our case, the right is not given equally”.
-18 years old female from peri-urban group
“In our society, there is a dictate that girls and women go out fully veiled, which means we can’t dress like we want; it is an emotional pressure on us.”
-21 years old female from urban group

Strategies for Data Collection on Gender Norms Related to NCDs

Most of respondents from the “Risk Factors Surveillance of Non-Communicable Disease” study preferred to hear a woman’s voice on pre-recorded voice messages when asked questions about gender norms and other sensitive issues. Respondents also recommended that this type of IVR- based telephonic call survey should come from a government institute, in order to promote respect and trust and a weight of importance to the survey.
As men are most often the owners and gatekeepers to mobile phones, a call coming from an interviewer’s personal mobile phone, especially if it is a man wanting to talk to someone’s wife, could initiate an episode of abuse in households where domestic violence is present. Female surveyors, on the phone, as well as within recorded messages, have higher response rates as:
  • It can be seen as suspicious for a man to call to speak to a woman;
  • It can be seen as a form of harassment or threat;
  • It might be culturally inappropriate for a woman to speak to a man other than her husband on the phone.

Next Steps to Understand Gender Norms and NCD Risk Factors

While patriarchal gender norms are identified as a behavioral risk factor for gender-based violence, to date, literature indicates that there is dearth of data directly connecting NCD risk factors and harmful gender norms, particularly those impacting mental health and well-being outcomes. We know that stress affects chronic illness and NCDs, but we haven’t made the direct connection between gender and NCD risk factors.
This work is urgent and necessary because in some low- and middle-income countries, governments have introduced policies and programmatic interventions against gender-based violence and achieving gender equity and equality goals but the two are not connected to stress and mental health and NCDs. There have been piecemeal efforts to date, and interventions proven to be ineffective to track gender norms data associated with health and mortality at regular intervals. More research is desperately needed to connect these seemingly siloed issues in order to create gender-sensitive policies and programs around NCDs and improve health outcomes for all.