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Associations between gender equality and health: a systematic review

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DOI: 10.1093/yel/day093

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 Health Promotion International, 2018, 1–15
doi: 10.1093/yel/day093
Article

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Associations between gender equality and
health: a systematic review
Tania L. King*, Anne Kavanagh, Anna J. Scovelle, and Allison Milner
Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne,
Carlton 3010, Australia
*Corresponding author. E-mail: tking@unimelb.edu.au

Summary
This systematic review sought to evaluate the impact of gender equality on the health of both women
and men in high-income countries. A range of health outcomes arose across the 48 studies included.
Gender equality was measured in various ways, including employment characteristics, political repre-
sentation, access to services, and with standard indicators (such as the Global Gender Gap Index and
the Gender Empowerment Measure). The effects of gender equality varied depending on the health
outcome examined, and the context in which gender equality was examined (i.e. employment or do-
mestic domain). Overall, evidence suggests that greater gender equality has a mostly positive effect
on the health of males and females. We found utility in the convergence model, which postulates that
gender equality will be associated with a convergence in the health outcomes of men and women, but
unless there is encouragement and support for men to assume more non-traditional roles, further
health gains will be stymied.

Key words: gender, gender equality, health

INTRODUCTION The United Nations (UN) recognizes that addressing

Worldwide, it is broadly observed that while women
have longer life expectancies than men; they also have
higher rates of disability and poorer health (Alberts
et al., 2014). Some researchers argue that these differen-
ces are largely attributable to gender inequality, the ele-
mental cause of which is gendered relations of power;
that is, societal structures that organize and underpin
lives based on whether one is male or female (Annandale
and Hunt, 2000; Sen and Östlin, 2008). The poorer
health status of women that is due to gender inequality
therefore, is largely considered to be avoidable and
actionable (Sen et al., 2007). This accords with the
social determinants of health model, which recognizes
gender as a key structural driver of inequalities in living
conditions, and by extension, inequalities in health
(Commission on Social Determinants of Health, 2008).
gender equality is crucial for social change. This is
explicitly recognized by the third Millennium
Development Goal, which encourages a move towards
greater equality of welfare resources, roles and lifestyles
between women and men in all countries around the
world (United Nations, 2015). Inequalities in access to
resources such as education, income and political repre-
sentation are recognized as having large impacts on the
health of girls and women, particularly in low-income
countries (Sen and Östlin, 2008). The Global Gender
Gap Report, a study of gender-based disparities across
144 countries, shows that while some attenuation in gaps
between men and women on health outcomes is apparent,
persistent and large economic, educational and political
gaps remain, and are likely to continue to enact effects on
health outcomes (World Economic Forum, 2017).

C The Author (2018). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
V
2 T. King et al.
It is recognized that the levels of gender equality vary
across countries and cultural contexts (Månsdotter and
Deogan, 2016): high-income countries typically have
higher levels of gender equality than low-income coun-
tries (World Economic Forum, 2017).
Indeed, while gender inequality persists, many high-
income countries have now reached a point of relatively
high gender equality. Many assume a linear relationship
between gender equality and health outcomes: that is,
the higher the level of gender equality, the better the
health outcomes. This is likely to be true at lower levels
of gender equality, but how the association is charted at
higher levels of gender equality is not clear, and it is pos-
sible that there are diminishing returns in terms of health
gains (Månsdotter and Deogan, 2016).
This systematic review sought to evaluate evidence
of associations between measures of gender equality
and health. In this area of research, a number of
different terms are used interchangeably. We firstly
make an important distinction between ‘sex’ and ‘gen-
der’. ‘Sex’ is referred to as the largely stable biology of
being female or male, whereas ‘gender’ is a social,
rather than a biological construct (Phillips, 2005).
More specifically, ‘gender’ refers to the socially con-
structed characteristics of women and men, including
the norms, roles and relationships of (and between)
groups of women and men. These characteristics vary
across different societies and cultural contexts, and are
known to shift or change over time (WHO, 2015).
Throughout this report, we use the term ‘gender’ rather
than ‘sex’. Additionally, while acknowledging that
gender is non-binary (Richards et al., 2016), in this
report we adopt a binary approach to gender, as this is
the nature of the literature.
Finally, we distinguish between gender equity and
gender equality. ‘Gender equality’ refers to the entitle-
ment of both genders to enjoy equal rights, opportuni-
ties and treatment. Acknowledging that men and
women are not the same, gender equality asserts that
both genders have the right to develop and pursue their
interests free of discrimination, stereotypes and biases
(International Labour Office, 2000). Gender equality
as defined above, however, does not mean that true
equality necessarily arises, as males and females have
different needs and experiences based on different so-
cial and historical positions. Equality of access to edu-
cation for example, does not mean that both genders
will have equal opportunity to benefit from such ac-
cess, as girls’ opportunity to participate may be influ-
enced by social norms or biases. For both genders to
share equally in opportunities presented, there is a need
for ‘gender equity’. ‘Gender equity’, refers to fairness in
the treatment of men and women, depending on their
different needs (International Labour Office, 2000).
Gender equity aims to ensure that both genders are
not only equal in terms of their access to opportunities
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and resources, but that they both have the means to
benefit from this. Acknowledging this difference,
this report uses the term “gender equality”, because
this reflects the nature of the tools, measures and
indicators used.
Multiple theoretical frameworks have been applied
to explain how gender equality might affect health out-
comes and behaviours (Pampel, 2001; Lahelma et al.,
2002; Backhans et al., 2007). Underpinning most of
these theoretical frameworks is an acknowledgement of
the role of socioeconomic status in shaping health out-
comes: in general, people of higher socioeconomic status
have better health (Marmot et al., 2008). This is funda-
mentally due to more advantaged groups having better
access to health promoting resources and opportunities,
as well as differential exposures and vulnerabilities
(Marmot et al., 2008; Sen and Östlin, 2008). Marmot
refers to this as the status syndrome theory, and argues
that health inequalities are largely due to differences in
participation in, and control over, society (Marmot,
2004). Gender inequalities, embodied in this inequitable
distribution of power, control, resources, and norms
and values, impact on the health of millions of females
worldwide (Marmot et al., 2008). Expressed differently,
gender, and gendered processes intersect with socioeco-
nomic inequality to produce gender inequalities in
health outcomes (Sen and Östlin, 2008). This implicitly
informs the frameworks presented below, all of which
propose different ways that certain social processes ex-
plain the relationship between gender equality and
health outcomes and behaviours.
Theoretical frameworks
The ‘role expansion hypothesis’ suggests that individuals
with several life roles or identities have health advan-
tages compared with those with fewer roles (Thoits,
1983). Thus, when women’s roles shift from being ex-
clusively within the home domain, to also encompass
the public sphere, their roles are expanded, and there is
an accompanying improvement in health outcomes.
Somewhat related to this, the ‘multiple attachment hy-
pothesis’ posits that multiple roles imply multiple points
of community attachment, which are likely to boost
emotional and instrumental supports, and in doing so
strengthen women’s health (Lahelma et al., 2002).
Other theorists, however, have argued that an increase
in social roles also serves to increase role pressure,
Associations between gender equality and health
potentially resulting in role strain and ill-health
(Goode, 1960). According to the ‘double-burden hy-
pothesis’, role conflict arises when there are competing
obligations and demands stemming from multiple roles
(Bratberg et al., 2002). Women in paid employment
with dependent children, are likely to experience role
conflict and role overload, with the resultant stress
contributing to poorer health outcomes (Bratberg
et al., 2002).
According to the ‘convergence hypothesis’ increasing
levels of gender equality will result in a reduction of the
gap between health outcomes for men and women,
because behaviours and exposures will become more
similar. Women will benefit from the positive effects of
role-expansion, but may experience the detrimental
effects of certain working conditions and exposures,
while men will benefit from the adoption of less mascu-
linized beliefs and behaviours (Backhans et al., 2007).
This is aligned with the ‘reduction-in-protection hypoth-
esis’ (Trovato and Lalu, 1996), which argues that gender
equality reduces any female advantage in mortality.
According to this theory, traditional roles protect
women from dangerous and harmful activities that may
be experienced beyond the home environment. As more
women assume roles outside the traditional sphere of
home and are integrated into the wider employment and
social domains, the protection of traditional roles weak-
ens and population health outcomes converge (Pampel,
2001). Two key factors underpin this: firstly, women
may adopt risky behaviours traditionally associated
with masculinity such as harmful alcohol consumption
and risky recreational activities; and secondly, women
may be employed in traditionally male-dominated occu-
pations that carry greater short and long term health
risks (Pampel, 2001).
The ‘institutional adjustment’ theory posits that the
relationship between gender equality and health
changes over time as a society adjusts to the structural
(e.g. policies) and cultural factors (e.g. norms about
gender roles) that may accompany gender equality
(Pampel, 1998). According to the ‘institutional adjust-
ment’ hypothesis, gender equality initially reduces the
female health advantage (female health becomes more
similar to male health) and then increases the advan-
tage again (female health becomes better than male
health) (Pampel, 2001).
Emerging from feminist theory, the ‘amelioration
hypothesis’ postulates that female violence victimiza-
tion is largely attributable to patriarchy: gender equal-
ity therefore, should reduce violence against women
(Stanko, 1995). The obverse of this, the ‘backlash hy-
pothesis’, contends that gender equality jeopardizes
3
male primacy, and may provoke men to reassert their
dominance by using violence (Russell, 2003).
This review
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The purpose of this review was to evaluate available evi-
dence of associations between measures or indicators of
gender equality, and health outcomes or behaviours.
While it is generally held that women are the greatest
beneficiaries of gender equality, there is evidence that
gender equality is also beneficial to men’s health
(Sen and Östlin, 2008). For this reason, we sought to re-
view associations for both women and men (where pos-
sible). The key research question underpinning this
review was: is gender equality associated with better
population health outcomes? We hypothesized that
greater levels of gender equality would be associated
with better health outcomes for men and women.
METHODOLOGY
Systematic review
We conducted a systematic review of studies examining
associations between gender equality and health out-
comes in high-income countries. The search was con-
ducted according to the PRISMA approach to
systematic reviews (Liberati et al., 2009). In accordance
with this, inclusion and exclusion criteria were
specified in advance and documented in a protocol.
Adherence to the PRISMA approach also entailed spec-
ification of the eligibility criteria, clear statements
about information sources, the search strategy and
study selection. We also used a modified risk of bias
tool to assess study quality.
The body of work examining gender equality is
behemoth. To maximize the pertinence of articles
retrieved, we sought to narrow the focus to articles that
explicitly reported examination of either gender
equality or equity. We examined four databases that
specialized in science, medicine, social sciences and
health. We note that the search strategy implemented
resulted in an extensive number of titles (15 000
titles) which were then screened. We trialled more
complex search terms and strategies, however it was
apparent that some key papers were missed, and the
wider net cast by the more inclusive search criteria was
therefore favoured.
Study selection and inclusion criteria
The systematic review searched the PubMed, Global
Health, PsycInfo and Scopus databases using the follow-
ing search terms: ‘gender’ OR ‘women’ OR ‘sex’ (title or
4 T. King et al.
abstract) AND ‘inequalit’ OR ‘inequit’ OR ‘equalit’ OR
‘equit’ (title or abstract) AND ‘health’ (title or abstract).
The search was performed in March 2017 with no
restrictions placed on publication date, language or pub-
lication type.
Fulfilling the following criteria was a prerequisite for
inclusion in the review, and no restrictions were placed
on age of participants or subjects. To be included in the
systematic review, the study must have:
• provided a measure of gender equity/inequity/equal-
ity/inequality as an exposure. We were only inter-
ested in structural indicators of gender equality such
as labour force participation, political representa-
tion—as measured in developed indicators of the
phenomena (as described below)—rather than other
possible dimensions and influences on gender equal-
ity such as norms and values;
• provided a measure of health as an outcome;
• been conducted within high-income countries, as de-
fined by the World Bank (World Bank, 2018). We
recognized that the issues germane to gender equality
in health in developing countries are different to
those in high-income countries. As we were particu-
larly interested in associations pertinent to the
Australian context, we sought studies conducted in
high-income countries.
We defined health outcomes according to a Health
Outcomes Framework (Sansoni, 2016), which defines
health outcome measures as ‘. . . clinical/biomedical indi-
cators, health outcome-related performance indicators,
standardized clinical assessments, and PROMs’
[(Sansoni, 2016), p. 8], (where PROM is a patient
reported outcome measure). We also included health
behaviours because these are often highly demographi-
cally patterned, and they are frequently associated with
many health outcomes.
Studies were excluded if they were:
• of qualitative design;
• theoretical or descriptive publications;
• conducted in low-income or developing countries.
Examinations of associations between gender equal-
ity and health are commonly focussed on outcomes for
women. As stated above however, we did not restrict
our examination to women as we were interested in
understanding potential benefits of gender equality for
men as well (given there is evidence that men may also
benefit from gender equality). Not all studies examined
or reported outcomes and behaviours for men however,
and some studies only contained women in their
sample.
Selection of articles and extraction of data
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One investigator (T.K.) conducted the database search.
Two reviewers (T.K. and A.M.) performed the initial
screening of the titles. Abstracts and full text were
reviewed by T.K. and A.M. Where consensus was not
reached by the two reviewing authors, a third author
(A.K.) was consulted.
Study quality assessment
Two authors (T.K. and A.S.) adapted the Newcastle-
Ottawa quality assessment scale (NOS) (Wells et al.,
2011) to conduct an assessment of the quality of the in-
cluded studies (Supplementary Table S1). Only
domains from NOS appropriate to the current
topic were included in the assessment in a modified form
(see Supplementary Information A: Criteria for
Methodological Quality Assessment Scale). In particu-
lar, we assessed the sample representativeness, the study
design, how the outcome was ascertained (linked data
or objectively obtained), adjustment for confounders
and the strength of the statistical methods. As for the
NOS, an overall quality score for each study was calcu-
lated, however where the NOS is calculated on a range
of zero to nine, the modified scale used here was calcu-
lated on a range of zero to five. Those studies scoring
above average (based on the mean of all included stud-
ies) were classified as being of ‘higher methodological
quality’ and those scoring below the mean were classi-
fied as ‘lower methodological quality’.
RESULTS
Summary of review process
A total of 14 155 publications were identified. After the
removal of 1180 duplicates, two reviewers reviewed the
titles of these publications, and excluded 12 082 that did
not meet the inclusion criteria. A total of 869 abstracts
were screened and 732 were excluded. A review of the
reference lists and personal libraries yielded a further 24
studies, resulting in 161 studies for full text review.
Following full text review, 48 publications were in-
cluded in the systematic review (see Figure 1).
Systematic review summary
Table 1 provides some methodological and geographic
characteristics of the studies. A more detailed description
of the studies can be seen in Supplementary Table S2.
Associations between gender equality and health 5

Table 1 Characteristics of included studies

Variable/characteristic No. of studies

Geographic location

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International 15
European countries 5
Sweden 15
USA 10
Spain 3
Gender equality indicator (exceeds 48 due to
multiple measures)
Gender Inequality Indicator (GII) 10
Gender Empowerment measure (GEM) 6
Gender Development Index (GDI) 2
Gender Gap Index 4
Gender wage gap/Income inequality 2
Gender-based economic discrimination 1
Parental leave 2
Workplace gender equality (e.g. 3
organizational gender gap index)
Women’s status indicator (US state-based 7
measure)
Composite area level measure of (some, not 6
necessarily all of following): political
(n =113) participation, employment, legal,
reproductive rights
Gender equality within the home/compared 8
with partner
Health outcome (exceeds 48 due to multiple
measures)
Mental health/Depression/Psychological 11
distress
Fig. 1 Flow diagram of study selection. Alcohol 6
Smoking 2
Suicide/suicide ratio 2
Studies were classified into five main groups based
Physical activity/inactivity 3
on the measure of gender equality:
Human height 1
1. Work and employment-related gender equality Self-rated health 7
within countries (Group 1). Assault/Intimate partner violence/ adoles- 7
cent dating violence
2. Gender equality measured within the family domain
Sickness absences 4
(Group 2).
Obesity/BMI 2
3. Gender equality in politics, the economy, and social Healthy life years 1
services within countries (Group 3). CVD/CHD events or mortality 1
4. Gender equality in politics, the economy, and social Fertility 2
services between countries (Group 4). Mortality/NCD mortality 2
5. Gender equality between countries using established Cancer 1
indicators (Group 5). Life expectancy 2
Population
Elderly 65þ years 1
Methodological quality of the studies
Adults 39
Five of the studies included in the review scored five out
Women 7
of five on the methodological quality assessment
Adolescents 1
(Månsdotter et al., 2006, 2012a; Backhans et al., 2009;
6 T. King et al.
Sörlin et al., 2011; Norström et al., 2012). These studies
all used representative samples, ascertained the outcome
from administrative data or objective assessment, had a
study design that was either longitudinal or a cohort de-
sign with linked administrative data, adjusted for con-
founders and used strong statistical methods. While
almost all studies examined used representative samples,
adjusted for confounders, and used strong statistical
methods, fewer studies met the criteria for study design,
and ‘ascertainment of outcome’. Few studies were highly
rated on the ‘study design’ criteria, as many studies were
ecological or cross-sectional in design, and only a small
number used methodologically strong designs such
as cohort studies with linked administrative data
(Månsdotter et al., 2006, 2012a; Backhans et al., 2009;
Sörlin et al., 2011, 2012; Hammarström and Phillips,
2012; Harryson et al., 2012; Norström et al., 2012;
Elwér et al., 2013; Johansson et al., 2014). About a third
of the studies used rigorous means of ascertaining the out-
come such as administrative records (Kawachi et al.,
1999; Mayer, 2000; Pampel, 2001; Månsdotter et al.,
2006, 2012a; Backhans et al., 2007; Shah, 2008;
Backhans et al., 2009; Aizer, 2010; Sörlin et al., 2011;
Norström et al., 2012; Wängnerud and Sundell, 2012;
Wells et al., 2012; Hassanzadeh et al., 2014; Mark,
2014; Ricketts, 2014; Chon, 2016; Redding et al., 2016).
While most studies controlled for confounders, for a mi-
nority of studies, there was no reported control for poten-
tial confounding variables (Yllö, 1983, 1984; Shah, 2008;
Gressard et al., 2015; Bilal et al., 2016; Redding et al.,
2016). Failure to identify and adjust for potential con-
founding variables represents a significant threat to the
validity of results (Egger et al., 1998).
Measurement of gender equality
Gender equality was measured in a range of ways across
different study designs. In the first group (work- and em-
ployment-related gender equality), a number of studies
developed overall indicators of gender equality (Sörlin
et al., 2011, 2012; Elwér et al., 2013). For example,
Elwér and colleagues developed a five-item scale of gen-
der equality in the workplace, representing the ratio of
male/female employees, salary (ratio of males/females),
educational level of employees (ratio of males/females),
and the presence of parental leave (ratio of males/females)
and temporary parental leave (ratio of males/females)
(Elwér et al., 2013). Other studies examined the pay gap
between men and women (Aizer, 2010), and several ex-
amined parental leave, as defined by the length of paren-
tal leave taken by males compared with females
(Norström et al., 2012; Johansson et al., 2014).
In the second group of studies (gender equality mea-
sured within the family domain), indices of gender
equality reflected the extent to which men and women
shared parental and breadwinner roles (Månsdotter
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et al., 2006, 2012a,b; Backhans et al., 2009; Sörlin
et al., 2011; Hammarström and Phillips, 2012;
Harryson et al., 2012; Eek and Axmon, 2015). For ex-
ample, Månsdotter and colleagues quantified the extent
to which parents had equal responsibilities (both parents
had between 40 and 60% of income and caring roles),
‘traditional’ unequal roles (father had >60% of income
and mother had >60% caring roles), and ‘non-tradi-
tional’ unequal roles (mothers had <40% caring roles
and fathers <40% of income) (Mansdotter et al., 2012a).
In the third group (within country measures), gender
equality measures were indices that included composite
measures of political participation, labour force partici-
pation, social/economic autonomy and reproductive
rights (Yllö, 1983, 1984; Kawachi et al., 1999; Jun
et al., 2004; Chen et al., 2005; Backhans et al., 2007;
McLaughlin et al., 2011; Roberts, 2012; Wängnerud
and Sundell, 2012; Sanz-Barbero et al., 2015). For ex-
ample, Backhans and colleagues used three dimensions
and nine indicators of gender equality: political partici-
pation (proportion of women versus men in municipal
councils and municipal executive committees); division
of labour (temporary parental leave, proportion of part
time workers in women and men); public sphere (pro-
portion of men versus women of all people employed in
female versus male-dominated occupations; proportion
of women versus men in managerial positions); and eco-
nomic resources (average income and relative poverty in
females and males) (Backhans et al., 2007).
The fourth group of studies looked at the effect of
gender equality between countries using statistics such
as the proportion of females achieving higher levels of
education, the ratio of females to males in parliament,
and measures of female participation in the labour force
relative to men (Pampel, 2001; Bentley and Kavanagh,
2008; Tesch-Römer et al., 2008; Ricketts, 2014; Chon,
2016).
The fifth group of studies also compared gender
equality between countries, but used established indica-
tors to do so (Mayer, 2000; Hopcroft and Bradley,
2007; Shah, 2008; Bond et al., 2010; Grittner et al.,
2012; Wells et al., 2012; Dahlin and Harkonen, 2013;
Van Tuyckom et al., 2013; Van de Velde et al., 2013;
Hassanzadeh et al., 2014; Mark, 2014; Witvliet et al.,
2014; Bosque-Prous et al., 2015; Gressard et al., 2015;
Balish et al., 2016; Bilal et al., 2016; Dereuddre et al.,
2016; Redding et al., 2016). In particular, these studies
used: the Gender Inequality Index (GII), the Gender
Associations between gender equality and health
Empowerment Measure (GEM), the Gender
Development Index (GDI) or the Global Gender Gap
Index (GGGI). The GII is an inequality index that was
introduced in 2010 in the Human Development Report,
and produced by the UN Development programme
(United Nations, 2010). The GII measures gender
inequalities across three components of human develop-
ment: reproductive health, empowerment and economic
status. The GII superseded earlier UN measures of gen-
der inequality such as the GEM and the GDI.
Three indicators are used to produce the GEM: pro-
portion of seats held by women in national parliaments,
percentage of women in economic decision-making posi-
tions; income share (i.e. incomes of males versus
females). The GDI emerged at the same time as GEM,
and serves as the gender sensitive complement to the
Human Development Index (HDI). While the HDI
measures life expectancy, education (adult literacy, en-
rolment) and income, the GDI measures gender gaps in
these dimensions. As such, the GDI cannot be used inde-
pendently of the HDI.
The GGGI was developed by the World Economic
Forum in 2006 as a means of measuring and tracking
gender disparities across a range of dimensions. The
GGGI comprises 14 measures across 4 major subindexes
or domains: economic participation and opportunity,
education attainment, health and survival, and political
empowerment (World Economic Forum, 2014).
What effect does gender equality have on
health?
The following section provides a review of studies examin-
ing the relationship between gender equality and health,
grouped according to the measure of gender equality used.
Work and employment-related gender equality in
relation to health
Reducing the wage gap was associated with lower de-
pressive symptoms (Platt et al., 2016) and a reduction in
violence against women (Aizer, 2010). The study by
Platt and colleagues used a sample of men and women
that were matched on education, occupation, age and
other factors related to wages (Platt et al., 2016).
Among matched pairs of male and females, where
women reported greater income than men, there was no
significant difference in depression, and a substantially
reduced disparity in anxiety. When female income was
less than the matched male counterpart, odds of both de-
pression and anxiety was significantly higher among
women versus men. Aizer’s study found that a reduction
in the income gap between men and women was
7
associated with a decline in domestic violence across the
USA (Aizer, 2010).
There were three studies conducted at the workplace
level (Sörlin et al., 2011, 2012; Elwér et al., 2013).
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Elwér and colleagues found that for women, the highest
odds of psychological distress were found in tradition-
ally gender unequal workplaces (Elwér et al., 2013). The
lowest overall occurrence of psychological distress for
men and women was found in the most gender-equal
workplaces (Elwér et al., 2013). Another study by Sörlin
and colleagues found that women in companies with
‘completely equal’ or ‘quite equal’ scores on the
Organizational Gender Gap Index had higher odds of
reporting ‘good health’ compared with women who per-
ceived their company was ‘not equal’ (Sörlin et al.,
2012). Although not statistically significant, the same
trends were observed in men. Somewhat in contrast to
this, higher rates of sickness absence were observed in
gender-equal companies for men and women, although
the difference between men and women was much
smaller in gender-equal companies (Sorlin et al., 2011).
A study by Johansson and colleagues examined the
relationship between parental leave and physical activ-
ity, and found that longer parental leave was related to
greater physical activity in fathers (Johansson et al.,
2014). There was no effect of parental leave on physical
activity for women. Length of parental leave was also
examined in relation to the mental health of offspring
(measured among adolescents and young adults). For
girls, gender traditional parenting (mother dominance in
childcare) and gender untraditional parenting (father
dominance in childcare) was associated with better men-
tal health outcomes compared with having gender-equal
parenting, while for boys, gender traditional parenting
was associated with better mental health outcomes
(Norström et al., 2012).
Gender equality measured within the family domain and
health: within countries
Among this group, there were eight studies that exam-
ined gender equality within the family domain
(Månsdotter et al., 2006, 2012a,b; Backhans et al.,
2009; Sörlin et al., 2011; Hammarström and Phillips,
2012; Harryson et al., 2012; Eek and Axmon, 2015).
For some of these studies gender equality within the
family domain was associated with poorer health out-
comes for women (Backhans et al., 2009; Månsdotter
et al., 2012a,b). These studies classified gender equality
by the extent to which males and females in coupled
relationships participated in home and paid work. For
women in traditional roles (where women occupied
8 T. King et al.
most of the time in the home sphere, while their male
partners spent a greater amount of time at work) there
was a lower risk of alcohol related inpatient care or
mortality (Månsdotter et al., 2012a), lower risk of death
and sickness (Månsdotter et al., 2006) and lower sick
leave (Backhans et al., 2009). However, for men, being
traditionally unequal, as measured in both the public
and private sphere, was associated with higher risk of
death and sickness compared with men who were more
equal (Månsdotter et al., 2006). These findings were
concordant with those of another Swedish study that
found that among men, being a non-traditional father
(adopting gender-equal roles and behaviours) was asso-
ciated with less sickness, as measured by sick leave, than
for traditional fathers (Backhans et al., 2009).
In another Swedish study, the perception of gender in-
equality in the home was associated with depressive symp-
toms for women (but no effect for men) (Hammarström
and Phillips, 2012). For both genders, the perception of
gender inequality in the home, and for women, being en-
tirely responsible for domestic work, and for men, having
less than half of the responsibility for domestic work,
were all associated with greater psychological distress
(Harryson et al., 2012). Among a sample of women, per-
ceived stress, fatigue, physical/psychosomatic symptoms
and work-family conflict were associated with being in an
unequal partnership (Eek and Axmon, 2015). Better self-
rated health for men and women was also associated with
perceived gender equality (Sörlin et al., 2011).
Another study examined the influence of the gender
equality of parents’ relationship as a child, on mental
health in adulthood (Månsdotter et al., 2012b). Results
indicated that the traditional versus non-traditional roles
of parents that children are exposed to in childhood does
not influence self-reported mental health in adulthood
(Månsdotter et al., 2012b). It was also apparent that non-
traditional gender ideology in adulthood (e.g. believing
that women could be the breadwinner in a relationship)
was associated with a decreased risk of anxiety symptoms
in women, and a decreased risk of depressive symptoms in
men (Månsdotter et al., 2012b).
Gender equality in politics, the economy, social services
and reproductive rights and health: within countries
There were several studies that conducted within-
country area investigations of the association between
gender equality, measured in multiple domains at an
area level and health outcomes (Yllö, 1983, 1984;
Kawachi et al., 1999; Jun et al., 2004; Chen et al., 2005;
Backhans et al., 2007; McLaughlin et al., 2011;
Roberts, 2012; Wängnerud and Sundell, 2012; Sanz-
Barbero et al., 2015). The majority of studies in this
group found that greater gender equality (measured us-
ing composite or individual measures of political partici-
pation, reproductive rights, socio-economic status) was
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associated with positive health outcomes. In samples of
women, gender equality was associated with lower
reported intimate partner violence (Sanz-Barbero et al.,
2015), and better mental health (Chen et al., 2005;
McLaughlin et al., 2011). State level gender equality
was also associated with lower alcohol consumption
among men and women (Roberts, 2012), and lower
male and female mortality rates (Kawachi et al., 1999).
One Swedish study used data aggregated at the level of
municipalities, and found that living in more gender-
equal municipalities was associated with poorer health
for men and women, as measured by higher levels of
sickness absence and lower life expectancy (Backhans
et al., 2007). Acknowledging the methodological limita-
tions of their study, they argued that this may indicate
that unless more men take on roles and responsibilities
traditionally associated with women, positive effects of
gender equality will be stymied (as women will suffer
the effects of being over-burdened, and men will experi-
ence the effects of losing old privileges) (Backhans et al.,
2007). This is discussed further in later sections. Two
older studies among women (conducted in the early
1980s) examined state level gender equality in relation
to intimate partner violence (Yllö, 1983, 1984). High
gender equality was associated with lower levels of vio-
lence against women (Yllö, 1983), but this relationship
existed to a point; in states with the highest levels of gen-
der equality, violence against women was also high.
Further research suggested that this was a complex rela-
tionship, most particularly, the research suggested that
discordance or inconsistency between individual equal-
ity (balance of power within an individual’s intimate re-
lationship) and state level equality was predictive of
greater levels of intimate partner violence (Yllö, 1984).
Gender equality between countries using educational,
labour force or political statistics and health
There were a number of cross-country studies that used
multiple indicators of gender equality (fertility rates, ra-
tio of females to males in the labour force, women in
parliament, policies regarding families) and health out-
comes (Pampel, 2001; Bentley and Kavanagh, 2008;
Tesch-Römer et al., 2008; Ricketts, 2014; Chon, 2016).
These generally produced findings that supported the
convergence theory. Increasing gender equality (mea-
sured using individual or combined indicators of labour
force participation, parliamentary representation,
Associations between gender equality and health
education or fertility), was associated with a narrowing
in the life-expectancy gap between males and females
(Ricketts, 2014). Another study (Chon, 2016) examined
associations between gender equality and rates of female
homicide victimization, and in doing so, sought to inter-
rogate the application of ‘amelioration’ and ‘backlash’
hypotheses. There was no evidence of a relationship be-
tween female homicide victimization and gender equality.
In a study comparing 57 countries, the relationship be-
tween gender equality and gender differences in self-rated
well-being (SWB) varied according to the extent to which
the population supported gender equality (Tesch-Römer
et al., 2008). For those countries with broad support for
gender equality in the labour market, higher levels of gen-
der equality was associated with smaller gender differen-
ces in SWB; for countries where gender inequality in the
labour market was endorsed, higher levels of gender
equality was associated with greater differences in SWB
(to the detriment of women) (Tesch-Römer et al., 2008).
Gender equality between countries using established
indicators and health
The ‘GII’ was used by 10 studies (Bond et al., 2010;
Wells et al., 2012; Dahlin and Harkonen, 2013;
Hassanzadeh et al., 2014; Mark, 2014; Gressard et al.,
2015; Balish et al., 2016; Bilal et al., 2016; Dereuddre
et al., 2016; Redding et al., 2016) in relation to a range
of health outcomes including obesity, leisure time physi-
cal activity, life expectancy and self-rated health.
In a study comparing the prevalence of obesity in 68
countries, greater gender equality was associated with
reduced female excess of obesity (Wells et al., 2012).
Further, a Spanish study examined the relationship be-
tween the gender smoking ratio (GSR) and gender equal-
ity in Spain, as measured using the GII over 50 years
(Bilal et al., 2016). A strong negative correlation was ob-
served between gender inequality and the GSR over the
50-year study period: as gender equality increased, the
female to male smoking ratio increased. The social pat-
terning and chronology of adoption of cigarette smoking
was apparent, with men and the highly educated the
early adopters, and women and those of lower educa-
tional attainment adopting later, and ceasing later. The
authors observed that, as in many Western countries,
sweeping social, economic and political changes had
transformed the cultural and social climate of Spain in
the last half century (Bilal et al., 2016). They observed
that by co-opting the message of liberation and emanci-
pation accompanying such social changes, tobacco com-
panies presented cigarette smoking as symbolic of gender
equality and emancipation, thus driving the increasing
9
female to male smoking ratio (Amos and Haglund, 2000;
Bilal et al., 2016). Hassanzadeh and colleagues used a
dataset with 123 countries and found negative associa-
tions between gender inequality and: smoking; alcohol
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consumption; life expectancy, cancer, body mass index
(BMI) and blood pressure (Hassanzadeh et al., 2014).
The ‘GEM’ was used as a measure of gender equality in
six studies that arose in the literature review (Mayer, 2000;
Shah, 2008; Tesch-Römer et al., 2008; Bond et al., 2010;
Van de Velde et al., 2013; Bosque-Prous et al., 2015).
In a study across 25 European countries, gender
equality was associated with lower levels of depression
among men and women, leading the authors to conclude
that in terms of depression, both genders benefit from
higher levels of gender equality (Van de Velde et al.,
2013). However, another study across 16 countries (also
in Europe) found that greater gender equality was asso-
ciated with reduced gender differences in hazardous
drinking (i.e. there was higher consumption of alcohol
among women in countries of higher gender equality)
(Bosque-Prous et al., 2015). The fact that the association
between hazardous drinking and GEM was stronger in
women than men led the authors to suggest that im-
proved social conditions for women may lead them to
adopt risky behaviours that have typically been associ-
ated with males (Bosque-Prous et al., 2015).
Four studies examined health outcomes in relation to
the ‘GGGI’ (Bond et al., 2010; Grittner et al., 2012; Van
Tuyckom et al., 2013; Witvliet et al., 2014), with null
findings emerging for two of these (Witvliet et al., 2014)
(Grittner et al., 2012). Van Tuyckom and colleagues
found that greater gender equality was associated with a
reduced gender gap in sedentary behaviour, however,
these differences disappeared in countries with high gen-
der equality (Van Tuyckom et al., 2013). The study by
Bond and colleagues used multiple measures of gender
equality and is discussed elsewhere (Bond et al., 2010).
Using the ‘GDI’, Hopcroft and Bradley, found that
rates of depression were higher in countries with low
gender equality, however the gender gap in depression
was larger in countries with high gender equality
(Hopcroft and Bradley, 2007). The authors interpreted
the results as suggesting that the benefits of living in a
country with high gender equality are greater for male
mental health than for female mental health.
DISCUSSION
Main findings
The results of this review provide broad evidence that
gender equality is good for the health of males and
10
females. These results, however, were not unequivocal,
and it is clear that the effects of gender equality on
health vary depending on gender, the outcome studied,
domain of life examined (e.g. work and home), measure
of gender equality used, and the level and time period
that the association was studied.
Of note, however, when the results are considered in
terms of the outcomes assessed (rather than the exposure
measure), and the context in which they were measured
(i.e. in the home or workplace), a somewhat more coher-
ent story emerges. Among studies assessing associations
between gender equality and mental health in this review,
greater gender equality was associated with improved out-
comes for women (Chen et al., 2005; Hammarström and
Phillips, 2012; Harryson et al., 2012; Månsdotter et al.,
2012b; Elwér et al., 2013; Van de Velde et al., 2013; Eek
and Axmon, 2015;), or reduced differences between
women and men (Elwér et al., 2013; Van de Velde et al.,
2013; Platt et al., 2016). This pattern was also observed
in studies examining self-rated health and well-being,
where higher levels of gender equality was associated with
better outcomes (Jun et al., 2004; Sörlin et al., 2012;
Wängnerud and Sundell, 2012). Looking at risky health
behaviour, gender equality was associated with higher
levels of risky health behaviours such as smoking
(Hassanzadeh et al., 2014; Bilal et al., 2016) and alcohol
consumption (Hassanzadeh et al., 2014; Bosque-Prous
et al., 2015) for women.
Viewed in this way, the results of this review provide
general support for the convergence theory, which postu-
lates that greater gender equality will be associated with a
convergence in health between men and women
(Backhans et al., 2007). This framework theorizes that a
society with a similar distribution of welfare resources,
roles and stressors between men and women will reduce
gender differences in health (Backhans et al., 2007).
According to this theory, as women experience greater
gender equality, their roles and experiences will become
more similar to those of men, and as a consequence, their
health outcomes will converge (Månsdotter and Deogan,
2016). Furthermore, the life expectancy of men would be
expected to increase with gender equality; and self-rated
health and morbidity from mental health conditions, typi-
cally poorer among women, would be expected improve
to a level similar to that observed in men.
It has long been recognized that a large part of the
gender gap in mortality is related to risky or damaging
health behaviours such as drinking, smoking and vio-
lence that are more common in males (Waldron, 1976).
The reasons underpinning this gender gap are complex,
and are likely related to expressions and performances
of masculinity (Courtenay, 2000), but also men’s greater
T. King et al.
economic independence and reduced caring responsibili-
ties (Backhans et al., 2007). According to the conver-
gence hypothesis, gender equality may lead to the
appropriation of more risky, traditionally masculine
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behaviours in women, as they gain greater economic in-
dependence and have reduced caring responsibilities
(Backhans et al., 2007). Studies showing that women
with more traditional roles (such as primary carer of
children, where they are less likely to engage in risky
health behaviours) had better health outcomes than
women living in more gender-equal arrangement, where
they potentially had greater opportunity to adopt risky
health behaviours, also support this (Backhans et al.,
2009; Månsdotter et al., 2012a). According to the con-
vergence theory, through increased economic indepen-
dence and autonomy, gender equality should have a
positive effect on health behaviours such as physical ac-
tivity for women, and this was supported by some stud-
ies (Van Tuyckom et al., 2013; Balish et al., 2016). The
results of this review regarding mental health, self-rated
health and health behaviours then, clearly accord with
the convergence theory.
The convergence theory also proposes that, as men
adopt roles and behaviours typically associated with
women, they are likely to benefit from healthier habits
and behaviours associated with caring and domestic
roles (Månsdotter et al., 2006; Månsdotter and Deogan,
2016). Studies demonstrated that higher levels of gender
equality in the workplace, home or at an area level were
associated with better health behaviours and outcomes
for men, such as more physical activity (Johansson et al.,
2014), lower risk of sickness and death (Månsdotter
et al., 2006), less sickness (Backhans et al., 2009),
improvements in mental health (Harryson et al., 2012;
Van de Velde et al., 2013) and better self-rated health
(Sörlin et al., 2011).
In relation to suicide, evidence was mixed: increasing
gender equality was associated with increased suicide
rates for men and women, but particularly for women in
one study (Mayer, 2000). Another study, however,
found no association between gender equality and
suicide among elderly populations (Shah, 2008).
Studies examining violence against women were
mostly ecological. In a study conducted more than
30 years ago, the most severe rates of violence against
women were highest in the US states with the highest
levels of gender inequality (Yllö, 1983). The author
noted that while gender equality was associated with re-
duced levels of violence against women, this protection
was conferred to a point—in states where gender equal-
ity was highest, violence against women was also high,
and violence against men perpetrated by their spouses
Associations between gender equality and health
was comparably high. Subsequent research by Yllö fur-
ther elucidated the relationship, revealing that violence
against women was highest when the social context
(prevailing gender equality norms) was discordant with
the distribution of power within the home/intimate rela-
tionship (Yllö, 1984). These results provide some sup-
port for the backlash hypothesis, which proposes that
increasing gender equality may lead to greater levels of
violence against women (Russell, 2003). We note how-
ever, that these studies by Yllö were conducted more
than 30 years ago in what is likely to have been a vastly
different social and cultural context. We also note that
the relationship between gender equity and violence
against women is complex, and more recent studies of
violence against women included in this review (Aizer,
2010; Gressard et al., 2015; Sanz-Barbero et al., 2015;
Chon, 2016), produced mixed findings. Higher gender
equality, was shown to be associated with lower levels
of violence against women (Aizer, 2010), and lower lev-
els of female physical dating violence (Gressard et al.,
2015), however, no association was observed between
increasing gender equality and rates of female homicide
(Chon, 2016). One Spanish study found that higher gen-
der equality, measured in terms of lower gender-based
income discrimination, was associated with higher levels
of intimate partner violence, however, the authors noted
that their study was conducted during an economic
downturn, in a period of high unemployment; factors
that are known to create stress and disrupt the social or-
der, potentially leading to greater levels of violence
(Sanz-Barbero et al., 2015).
Limitations
There are several limitations of this review and the stud-
ies included within it. Firstly, many of the health out-
come measures studied were obtained from self-reported
measures, which are likely to be subject to reporting
bias, particularly if reporting on sensitive and subjective
behaviours or outcomes such as mental health or vio-
lence against women. Further, many of the items (both
outcomes and exposures) were derived from single-item
measures that are unlikely to capture more nuanced ele-
ments of experiences and behaviours. It was noted that
in the case of division of household duties, for instance,
a single item may fail to account for the broader division
of household responsibilities (Eek and Axmon, 2015).
We also note that given the absence of an accepted
quality assessment tool for cross-sectional and ecological
studies, the tool used here was an adaption of the NOS
for cohort studies. The NOS has been criticized for sev-
eral reasons, including having unknown validity, and the
11
privileging of different study attributes such as sample
representativeness (which may introduce bias by having
low response rates and follow-up) (Stang, 2010). It is
also true that among those studies that did control for
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confounding variables, residual confounding, which
arises when confounding factors are not measured with
sufficient precision or are omitted, may have led to bi-
ased estimates (Egger et al., 1998). The extent to which
these findings, therefore, adduce evidence of causal asso-
ciations between gender equality and health is indetermi-
nate. This highlights the need for more robust evidence
on the relationship between gender equality and health.
The heterogeneity of outcomes and exposures (in
terms of the types of outcomes and gender equality
exposures, and the way these were measured) precluded
pooled analysis for this review. As a consequence, there
is a risk that this review has failed to detect publication
bias (Dickersin, 1997).
In some studies there was insufficient data on some
components of gender equality measures, and the means
of handling this was sometimes inadequate. Related to
this, gender equality was operationalized in many ways,
making comparisons of associations difficult. Another
limitation was the fact that many of the studies reported
here were cross-sectional—it is therefore not possible to
make causal inferences, and indeed in some cases reverse
causation cannot be ruled out.
It is also likely that there is some lag between expo-
sure to gender inequality and health outcomes. While it
is likely that within a country or state context, gender
equality at different time points will be highly corre-
lated, the fact that many studies measured gender equal-
ity and the health outcome at the same time needs to be
noted as a limitation. It is also worth noting that differ-
ent outcomes may be more sensitive to shifts in social
contexts than others, so more careful consideration of
temporality is needed.
There was a high degree of heterogeneity among
studies included in this review. This heterogeneity typi-
fies the domain of research examining associations be-
tween gender equality and health outcomes, and this
review seeks to highlight this diversity. The multifarious
nature of this body of work does however, make the pre-
sentation of a consistent and unified message about
associations between gender equality and health diffi-
cult, however we have found use in several theoretical
frameworks, principally the convergence model.
While not necessarily a limitation, it is worth noting
that several studies included in this review were con-
ducted in Europe, roughly around the time of, or after,
the 2008 economic recession, when there were signifi-
cant shifts in labour force participation, as well as
12
economic austerity measures, which are likely to have
altered the social milieu and attitudes to gender equality
in many countries.
It is also important to note that this review reports
on the results and interpretations of the studies included.
It does not examine the operation of gender norms, atti-
tudes and stereotypes, all of which are known to delimit
the autonomy and control that women have over their
lives to a greater extent than for men (World Health
Organization, 2002). Gender norms and attitudes are
sustained by social traditions and institutions that pre-
scribe and codify normative behaviours in both males
and females, and are known to impact on health
(Keleher, 2010). Challenging, and shifting gender norms
however, is critical to the advancement of gender equal-
ity, and requires multilevel programmes that are pro-
tected by policy and legislation that is premised on the
universal rights of girls and women to gender equality
(Keleher, 2010).
CONCLUSIONS AND
RECOMMENDATIONS
While, overall, the results of this review broadly suggest
that gender equality has a positive effect on population
health outcomes, it is clear that advancement towards
gender equality does not necessarily produce a linear as-
sociation between gender equality and health outcomes.
We have found utility in the application of the con-
vergence hypothesis, which holds that as a society
becomes more equal in terms of gender, women and
men will have similar access to resources and will share
similar risks and exposures, which will translate into
similar health and disease outcomes. Notwithstanding
the merit of the convergence theory in interpreting the
results of this systematic review, the diversity of findings
highlights the fact that gender equality is an iterative
and evolving process. The role-expansion hypothesis,
which proposes that having several life roles is associ-
ated with health benefits (Thoits, 1983), and the double-
burden hypothesis, which suggests that competing obli-
gations can lead to role conflict that may impair health
outcomes (Bratberg et al., 2002), also have some appli-
cability to these findings. Others have noted that gender
equality involves women and men entering non-
traditional domains: women must enter the workforce,
and men must enter the domestic realm. However, these
two processes have typically not occurred simulta-
neously—at a societal level, women tend to enter the
workforce before men enter the domestic realm (De
Beauvoir, 1949; Månsdotter and Deogan, 2016). As a
consequence of these two processes being slightly out of
T. King et al.
step, associations between gender equality and health
outcomes do not always progress in a linear way, and
leaders in the field have suggested that the process of ad-
vancing gender equality comprises of distinct phases
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(Månsdotter and Deogan, 2016). Firstly, gender equality
acts to improve education, nutrition, and fundamental
rights for women such as reproductive rights. This pro-
duces clear associations between gender equality and
better health outcomes. If behavioural shifts are one
way however, and largely related to women entering tra-
ditionally male realms, it is argued that increasing gen-
der equality is likely to return decreasing gains for both
genders: gender equality leads to women becoming over-
burdened by multiple roles, and men retaining risky
health behaviours (Backhans et al., 2007)
However, the increased participation of males in the
domestic realm has the potential to realize benefits both
for women in terms of improved psychological health
and reduced health-related burdens; and for men, likely
related to the adoption of healthier behaviours. We ar-
gue that the continued and increased participation of
men in the domestic realm represents a key cornerstone
of the advancement of gender equality. Until this occurs,
gender equality will remain incomplete. Scandinavian
countries are leaders in closing gender gaps (World
Economic Forum, 2017), however, research there pro-
vides a prescient reminder that gender equality must in-
volve role expansion for both men and women
(Backhans et al., 2007). Evidence suggests that the role-
expansion of women (into male roles), may reach a criti-
cal point, beyond which further gains are not realized,
and gender equality may, in fact, be detrimental, unless
there is a complementary shift of men, into more tradi-
tionally female roles (Backhans et al., 2007). This needs
to be supported by policy and legislation: evidence sug-
gests that where there is institutional support for less tra-
ditional gender norms and work-family arrangements,
there are smaller differences in division of housework
(Fahlén, 2015).
In summary, the results of this review suggest that
the continued encouragement of men to share roles tra-
ditionally associated with women, such as caring for
young children, represents a key strategy for policy and
health promotion interventions. We recognize that pro-
gressing gender equality is dependent on much more
than women entering the workforce, and men sharing
caring and household responsibilities, however the evi-
dence of this review suggests that much can be gained by
supporting this. Policies and reforms that institutionally
embed equitable and egalitarian norms are critical to
this. Such initiatives might include taxation reforms that
support dual-earner and dual-career norms, and the
Associations between gender equality and health
provision of shared parental leave and benefits. Social
policies that seek to do this, we believe, have the potential
to deliver significant gains in health outcomes for women
and men, and in doing so, build a more equitable society.
ACKNOWLEDGEMENTS
This work was supported by: a University of Melbourne,
Melbourne School of Population and Global Health, Business
Improvement Program (BIP) Reinvestment grant; an ARC
Linkage Project - Gender equality in Australia: impact on social,
economic and health outcomes (LP180100035); and the
Victorian Health Promotion Foundation.
AM is supported by a Victorian Health and Medical
Research Fellowship.
We would also like to thank the anonymous reviewers for
their feedback which we believe has benefited this paper.
SUPPLEMENTARY MATERIAL
Supplementary material is available at Health
Promotion International online.
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