1. Introduction
]. Examples of direct impacts include influencing health-seeking behaviours and health care received [
]. Indirect impacts may include differential work experiences, with implications for personal income, occupational exposures, and other factors affecting health and health care [
–
].
]. Globally, an excess of 5 million girls of primary school age remain out of school compared with their male peers, and only three in four girls complete their lower secondary education [,
]. Women are also far less represented in the formal labour market, trailing men’s participation rate by more than 25% [
]. Amongst those able to secure formal employment, women are consistently compensated less for their work than men, and frequently relegated to jobs with low potential for promotional growth [
,
,
,
,
].
,
,
,
]. Important research exploring the relationship between various measures of women’s empowerment and health has shown that higher female educational attainment and improved gender equality are associated with reduced maternal and infant mortality, as well as increased health service utilisation [
,
,
,
,
,
,
]. However, these findings have been restricted almost exclusively to low and middle income countries (LMIC), and focus heavily on reproductive and child health, without examination of impacts to long-term survival or wellbeing of both women and men. Examinations of the relationship between health and improved female participation in the workforce are also lacking.
In this study, we carry out original analyses of the association of girl’s educational participation and women’s labour force participation, resulting in higher gender parity in school and work, with life expectancy of both women and men. We also extend past examinations of maternal mortality beyond LMIC to examine the global relationship between varying levels of educational and occupational gender parity and maternal mortality across a sample of countries from all geographic regions and income levels. Implications for future research and for population health policy are discussed.
2. Methods
2.1 Measures of gender parity
Our goal for each parity index was to describe concisely both the overall proportion of girls or women participating in each social sphere out of a total age-eligible population of female participants at the national level (absolute participation), and how that proportion of participants compares with the same measure for boys or men (relative participation). Absolute measures of participation were included to identify distinctions between countries with poor participation rates for both men and women and countries with high participation rates for both, which would otherwise be masked. Participation at higher levels of education and occupation, as well as overall participation, is incorporated into each index.
2.2 Gender parity in education
]. We then sum these ratios and divide by 3 to create an educational parity index score that can be interpreted as the average product of a country’s F:M enrolment ratios and gross enrolment rates for girls across all three levels of schooling, as follows:
where n represents the education level (1=primary school, 2=secondary school, 3=tertiary school). Finally, the index was normalised on a scale of 0 to 100 (100 representing the country with the greatest gender parity) to produce common measures for international comparison.
]. National data were sufficient to construct an educational gender parity index score for 97 countries, including countries in all six World Health Organization (WHO) regions and all four World Bank income levels (Fig. 1).
Fig. 1Country representation in gender parity indices, by region and income level designation.
WHO, World Health Organization; WB, World Bank; n, sample size; WPR, Western Pacific Region; SEAR, South-East Asian Region; EUR, European Region; EMR, Eastern Mediterranean Region; AMR, Americas Region; AFR, African Region.
Panel (a) shows the total distribution of countries across WHO regions, as well as the number of countries in each region for which data from the year 2015 were sufficient to create educational and work gender parity indices for use in the statistical analysis. Panel (b) shows the total and parity index-specific distribution of countries by WB income-level designation.
2.3 Gender parity in work
where k represents the job class designation, as classified by ILOSTAT (1=managers, 2=professionals, 3=technicians and associate professionals). Thus, the work parity index score assigned to each country can be interpreted as the product of mean F:M ratios of professional, technical, and managerial workers and total female labour force participation. Each ratio was constructed by stratifying ILOSTAT’s measures of occupational distribution per country by gender, and taking the fraction of eligible proportions of female over male participants in each occupational category. Similar to the construction of the education index, all female-to-male ratios were capped at a maximum value of 1, and the index was normalised on a scale of 0 to 100 to facilitate cross-country comparisons.
], and female labour force participation information from the World Bank’s DataBank [
]. National data were sufficient to construct work gender parity index scores for 71 countries, including countries in all regions and income levels (Fig. 1).
2.4 Measures of population health
Three population health outcomes were examined in this analysis, with the intention of examining broad measures of population health as reflected by mortality and survival. Female and male life expectancy at birth, defined as the number of years a newborn infant would live given prevailing patterns of mortality at the time of birth remain constant throughout its life, were collected for the year 2015 from the World Bank’s DataBank (interpolated annually from rolling five-year estimates by the United Nations Population Division). Life expectancy was examined as a broad measure of population health across the lifecourse.
,
]. Global estimates of maternal mortality—produced every five years by WHO (most recent estimates from 2015) via reproductive-age mortality studies and modelling household survey results—were accessed from the Global Health Observatory []. National estimates of maternal mortality were assessed as rates, specifically as the number of maternal deaths per 100 000 live births for the year 2015.
2.5 Data sources
], World Health Organization’s Global Health Observatory [], and International Labour Organization’s ILOSTAT [
] databases were used to access indicators for inclusion in our school and work indices, to serve as covariates and outcome measures of interest in regression analysis. These indicators draw from several different sources including household surveys, national and regional surveys (such as the EU Labour Force Survey), census data, and other estimates generated by individual governments. All national data utilised in this report represent information for the year 2015, for which the greatest number of country-specific data points were available across indicators.
2.6 Statistical analysis
First, we tabulated the distribution of countries represented by each gender parity index according to geographic region and income level. Gender parity indices were then plotted against health outcomes of interest, with Pearson correlation coefficients generated to quantitatively describe crude associations. Next, using the health and development indicators described above, we ran multivariable ordinary least squares regression models to examine the ecologic relationship between broad health outcomes and national gender parity in education and work. All regression models included control for country per capita gross domestic product (GDP; logarithmically transformed to meet regression assumptions of normality), national unemployment rate, urban population as a percent of the total national population, and domestic government health expenditures as a percent of national GDP. Control for these factors allowed for the assessment of the relationships between our indices and outcomes of interest independent of national wealth, economic climate, development and urbanisation, or government prioritisation of health-care spending. Homoscedasticity and the appropriateness of other linear regression assumptions were assessed for all models to ensure validity. SAS software version 9.4 (Cary, NC, USA) was used to perform all data compilation and analyses. Plots and tables were generated in SAS or Microsoft Excel 2016 (Redmond, WA, USA).
2.7 Role of the funding source
The funding source had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data and had final responsibility to submit the paper for publication.
4. Discussion
In this paper we demonstrate that changes in girls’ and women’s participation and parity in the educational and occupational spheres are associated with greater longevity. Specifically, increased gender parity in education was associated with significantly lower maternal mortality and longer life expectancy for men and women, while increased gender parity in work was associated with lower maternal mortality and lengthier female life expectancy. Notably, greater female participation in school and work was found to have either positive or null associations with men’s longevity. This finding suggests that improvements for women in these domains do not come at the expense of men’s wellbeing, and may actually play a role in improving men’s health. Eliminating gender gaps in education and work can thus serve as upstream, complementary interventions to more downstream health care system improvements ensuring clinical medicine provides equal access and quality care for people of all genders in order to advance the health and survival of all.
]. This result also corroborates the inverse correlation between levels of female empowerment and maternal mortality ratios noted by other studies, including two analyses of composite (2012 Gender Equity Index and Social Institutions and Gender Index) and education-specific (2010 Gender Gap Index educational attainment sub-index) measures of gender equality [
,
].
,
,
]. Female employment in higher-level technical, professional, and managerial roles may also generate greater household income, removing financial barriers to antenatal care and health facility deliveries, including the use of skilled birth attendants [
]. Finally, increased representation of women in the workforce has been associated with increased reproductive autonomy [
,
]. This can reduce maternal mortality through decreased fertility rates and safer pregnancies, for instance through birth spacing [
].
]. Of note, the magnitude of the female life expectancy–educational advancement relationship was greater than that for professional work attainment, perhaps due to the upstream effects of education which lead it to affect education itself and also work and income outcomes, or as a result of lower work index score variance across countries.
] we extend this finding by showing that higher female educational attainment may also offer a path towards male longevity. One explanation for this result is the society-wide effect of increased human capital and of the role greater gender parity plays in investment and economic outcomes. Improved female participation in public life has been demonstrated to induce strong economic growth and sustained development [
,
]. Moreover, compared with men, women are more likely to invest back in their own families and communities, and put a larger share of their income into health care, communal infrastructure, and other means of raising living standards [
]. Socialised gender norms may also play a role. As documented by the World Health Organization, gender stereotypes reinforce masculine behaviours that increase risks to injury and death, including through substance abuse, sexual behaviours linked to sexually transmitted infections, accidents, and violence [
,
]. Increasing boys’ exposure to and socialisation with girls as equal peers in early life, including in the classroom, may help reshape or deconstruct gender norms that encourage behaviours with hazardous consequences to men’s health. Finally, maternal education supports improved outcomes for both female and male children, and may thus serve as a means of increasing offspring survival and longevity [
,
].
In the adjusted analysis, men’s life expectancy was neither negatively nor positively associated with occupational gender parity. One possible explanation is that the extended female life expectancy observed in countries with more equal labour participation might be partially attributable to reductions in maternal mortality, a pathway for improving survival not available to men. Alternatively, this lack of association may reflect a greater impact of educational parity as an upstream exposure to workplace participation, or could reflect data constraints. Missing job classification information for numerous countries in the ILOSTAT database may have influenced our findings and weakened our measures of association. Only two countries from the South East Asian region (18%), five countries from the African region (11%), and four countries from the Western Pacific region (15%) had complete data available for work index construction, thereby limiting our estimation precision and ability to infer with confidence the full effect of occupational gender parity on global health patterns.
,
].
Independent measures of gender parity in education and work offer important insights into their distinct relationships with mortality and life expectancy. Unlike composite measures of gender equality and women’s empowerment, the indices constructed here provide estimates of female participation in school and work which are actionable and easily interpretable. This study demonstrates that gender parity across these key social determinants of health is associated with better health outcomes even after controlling for country-level markers of wealth, investment, and urbanisation. Given limitations in global, longitudinal data for measures of participation and parity in school and workplace advancement, this cross-sectional snapshot provides an initial understanding of the links between national measures of gender equality in education and work with population health.
While further research is warranted, this study marks an important step in quantitatively debunking the notion that women’s improved social standing and access to secure livelihoods can only come at men’s expense; indeed, our research suggests that male life expectancy may potentially be extended through educational equality or in environments where educational equality thrives. Improvements in gender parity in access to and quality of clinical care received, as well as the biomedical research that supports this care, have a profound role to play in reducing morbidity and mortality alongside social determinants of health. Advances in access to and gender parity in education and work are likely to accelerate extensions in life expectancy for all people.
