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
A Manual on
Integrating a Gender Perspective in Statistics
United Nations Statistics Division
Chapters and structure of the manual
1.
Users, uses and production of gender statistics: an overview
2.
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; genderrelated 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
3.
4.
Integrating a gender perspective into data collection
Analysis and presentation of gender statistics
A Manual on
Integrating a Gender Perspective in Statistics
United 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
Integrating a gender perspective
into health statistics
Biological and gender-based issues
•
Women and men’s health concerns differ
because of both biological and socioeconomic 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.
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.
Biological and gender-based issues
•
•
•
•
•
•
•
•
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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.
Such biological and gender-based issues are
presented in the four health-related subtopics 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
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.
From gender issues to gender statistics –
Health and nutrition of children
Examples of gender
issues
Data needed
Sources of data
Does the gap between
male and female child
mortality suggest that
social factors may
disadvantage girls or
boys?
Number of deaths under
age 1 by sex; number of
deaths under age 5 by sex;
number of live births by sex.
Civil registration system
Population registers
Household surveys such as
DHS (Demographic and
Health Survey)
Population censuses
Children ever born and
children surviving by sex of
child and age of mother
Household surveys such as
MICS (Multiple Indicator
Cluster Survey)
Population censuses
From gender issues to gender statistics –
Health and nutrition of children (cont)
Examples of gender
issues
Data needed
Sources of data
Do girls receive the
same health care as
boys?
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 surveys such as
DHS and MICS
Household expenditure on health for
each child by sex and age of child
Household income and
expenditure surveys, budget
surveys, living standard
measurement surveys
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
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
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).
A similar exercise can be conducted
with regard to Maternal Mortality…
Examples of gender
issues
Data needed
Sources of data
Has the maternal mortality
declined?
Maternal deaths and number of live
births for at least two periods of
time
Civil registration system
Population censuses
Household surveys based on
large samples
Has women’s access to
prenatal care
increased?
Pregnant women by number of visits to
a health facility or health care
provider. Data needed for at least
two points in time.
Household surveys
Are birth deliveries
increasingly attended
by skilled personnel?
What groups of
women are most
disadvantaged?
Births by type of personnel attending
the delivery for at least two points
in time.
Data should be disaggregated by: age,
marital status and educational
attainment of the mother;
urban/rural areas; geographic
areas; and wealth status of the
household.
Household surveys
…Mortality and causes of death
Examples of gender
issues
Data needed
Sources of data
Do women or men have a
longer life
expectancy? Do adult
women have the same
mortality risk as adult
men?
Deaths by sex and age
Civil registration systems
Population censuses or
demographic and health
household surveys
Population by sex and age
Population censuses combined
with civil registration system
or household surveys;
population registers
Are adult women more
likely or less likely
than adult men to die
of communicable
diseases or any other
cause of death?
Deaths by sex, age and cause of
death
Civil registration system
Health administrative sources
Population by sex and age
Population censuses, combined
with civil registration system
and/or household surveys
Population registers
Do main causes of death
rank the same for
women and for men?
Deaths by sex and cause of death
Civil registration system
Health administrative sources
… or HIV/AIDS
Examples of gender
issues
Data needed
Sources of data
Are there more women or
men among people
living with HIV?
Among young people
living with HIV?
Among older persons
living with HIV?
Number of people infected with HIV by
sex and age
Population-based surveys
with HIV testing, such as
DHS
Health facilities reports
Is knowledge of HIV
prevention different
for young women than
for young men?
Number of people aged 15-24 with
comprehensive correct knowledge
of HIV prevention by sex
Household surveys such as
DHS, MICS, or
Reproductive health
surveys
Are young women or
young men more
likely to use condom
during sex with nonregular partners?
Use of condom among people aged
15-24 during sex with a nonmarital, non-cohabiting sexual
partner in the last year by sex
Household surveys such as
DHS, MICS, or
Reproductive health
surveys
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.
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.
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
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 HIVrelated 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.
A summary of sources of health statistics
and statistics they provide (cont)
IV. Surveys of selected populations
•
Demographic surveillance systems
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–
–
•
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)
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–
•
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
A summary of gender-related
measurement issues
•
Underreporting of deaths and births with potential sex-bias in
underreporting
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–
–
•
Underreporting of maternal deaths, especially among early pregnancy
deaths and in the later postpartum period, among youngest and oldest
ages.
–
•
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
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
A summary of gender-related
measurement 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
Challenges in measuring the
gender gap in health
Example: 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.
Historical change in
the male-to-female
ratio of mortality as
under-five mortality
declined in selected
developed countries.
Trends in the maleto-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
Trends in the maleto-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
Trends in the maleto-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
Male/Female sex ratio: 4q1
OECD vital registration
DHS other regions
DHS sub-Saharan Africa
OECD VR trend
DHS other regions trend
DHS SSA trend
.5
1
1.5
2
DHS in sub-Saharan Africa and elsewhere and OECD VR
.3
.2
.1
Female 4q1
Time trends in 4q1 Male/Female ratio, Mauritius and Niger
Exercise:
•
Prepare a table on gender issues, data
needed and sources of data for the
topic health risk factors (life style
related)
Table: health risk factors
Examples of gender
issues
Data needed
Sources of data
Are young women or
young men more
likely current
drinkers?
Number of current drinkers by sex and
age
Household surveys such as
World Health Surveys
School-based surveys such
as Global School-based
Student Health Survey
(GSHS)
Is tobacco use more
common among
young women or
young men?
Number of tobacco users by sex and
age
Household surveys such as
World Health Surveys
School-based surveys such
as Global School-based
Student Health Survey
(GSHS)
Are women or men more
likely to be obese?
Number of obese people by sex
Household surveys such as
World Health Surveys