European strategy for child and adolescent health and development Gender tool World Health Organization Regional Office for Europe Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. E-mail: [email protected] Web site: www.euro.who.int Gender tool European strategy for child and adolescent health and development Working document Acknowledgements 1. Introduction The WHO Regional Office for Europe developed the tool in a consultative process with the support of the Observatory of Women’s Health, Ministry of Health and Consumer Affairs, Madrid, Spain, and the collaboration of the Institute of Child Health IRCCS Burlo Garofolo, Trieste, Italy. Raúl Mercer and Dalia Szulik were the main authors. The WHO Regional Office for Europe promotes and supports the implementation of the European strategy for child and adolescent health and development, which the European Member States adopted at the 55th session of the WHO Regional Committee for Europe in September 2005. The strategy gives policy-makers a concrete means of addressing health issues to improve the health of children and adolescents. Support and contributions were received from: Concepción Colomer and the staff from the Observatory of Women’s Health, Ministry of Health and Consumer Affairs; Laura Cogoy and Giorgio Tamburlini from the Institute of Child Health IRCCS Burlo Garofolo; Michael Rigby from Keele University, United Kingdom; Richard Parish from the Royal Society for the Promotion of Health, London, United Kingdom, Mikael Østergren and Isabel Yordi Aguirre from the WHO Regional Office for Europe; and Adepeju Olukoya and Anayda Portela from WHO headquarters. This tool was developed to accompany the existing assessment, information and action tools intended to provide support to Member States in building and developing their own policies and programmes within the framework of the strategy. It can also be used as a stand-alone document that allows policy-makers and programme staff to assess how gender sensitive their current child and adolescent health programmes and policies are. Thanks to all the staff of the WHO Regional Office for Europe and participants in country workshops who have contributed to the gender tool. The gender tool is based on the evidence that shows how gender differences and inequality influence various aspects of illness and health among girls and boys. Objectives The objectives of the gender tool are: • to assist countries, institutions and policy-makers in the process of incorporating gender analysis into their child and adolescent health programmes and policies; and • to enable countries, institutions and policy-makers to identify interventions with a gender perspective that have proven effective in protecting the health of children and adolescents and promoting their development. © World Health Organization 2007 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 2 Rationale The health of children and adolescents is determined by their environment, by the socioeconomic position of their parents, by their access to education, by their ethnic background and by gender. Gender means the characteristics of women and men that are socially constructed; sex refers to those that are biologically determined. Gender defines the socially perceived roles, responsibilities, opportunities and interactions for females and males that are influenced by familial, cultural, political, and economic determinants. The access to resources and the roles that society imposes on women determine their health and that of their children. Expectations related to what it means to be a boy or a girl determine the sexual behaviour of children and adolescents, their attitudes towards risk-taking, their health behaviour and their use and access to services. This acquired behaviour comprises gender identity and determines, together with the biological differences, the gender roles of children. The purpose of gender analysis is to unearth sex differences and gender inequality and inequity and how they affect specific health problems, health services and successful responses. Inequality and inequity often create, maintain and exacerbate exposure to risk factors that threaten health. They often affect the control over and access to resources, including decision-making processes, that are conducive to promoting and protecting health. Finally, these differences influence the responsibilities and types of relationships established between health service providers and the population served, a field that has not been thoroughly explored for the early stages of life. Gender equality is the absence of discrimination on the basis of a person’s sex in opportunities, in the allocation of resources and benefits or in access to services. 3 Gender equity refers to fairness and justice in the distribution of benefits and responsibilities between women and men. The concept recognizes that women and men have different needs and power and that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes. Gender equity in health requires that men and women be treated equally where they have common needs and that their differences be addressed in an equitable manner. The following factors demonstrate gender inequity in the health of children and adolescents. 2. Conceptual framework applied to the life cycle The conceptual framework shows how gender affects key factors influencing the development of the health of children and adolescents throughout their lives (Fig. 1). These factors, selected from the European strategy for child and adolescent health, might be also influenced by other social determinants that interact with gender, such as education and economic background. Gender-related outcomes express how gender affects these factors (gender pathways). • Differences in health risks and protective factors: greater risk-taking behaviour among boys means that they tend to have a higher prevalence of hazardous use of substances and a higher prevalence of injuries from road crashes, whereas protective factors of the role of care assigned to women by society tend to make girls have healthier eating behaviour. In contrast, boys often engage in more health-promoting physical activity than girls. Providing a gender scope to health and developmental problems among children and adolescents implies the need to develop gender-based interventions. Intervention at different levels (individuals, families, communities, health services and policies) will contribute to promoting gender equity during childhood and adolescence. However, timely gender-based intervention can influence the development of gender equity in health and development and how this can be reproduced within the social and intergenerational context. • Imbalance between health needs and access to resources: due to biological differences, adolescent boys have different health needs than girls. In most countries, the sexuality of boys is overlooked when health services are designed. Systems for funding health services and efforts to privatize health services need to address the fact that women have fewer economic resources than men on average. Research must be conducted to ascertain how this affects the health of children. Fig. 1. Relationships between factors influencing health during the life course, gender pathways, gender-related outcomes and the quality of the interventions • Differences in how health policies and programmes affect girls versus boys: public policies should incorporate gender equality into socioeconomic and political analysis to avoid discriminatory bias. It is important to evaluate how any planned action will affects boys and girls, including legislation and policies or programmes, in any sector and at all levels, with the ultimate aim of achieving gender equity. For example, programmes to prevent the use of tobacco have often been more successful among young boys than among young girls because they have not addressed the gender dimensions of tobacco uptake, advertisement, control policies, etc. The following examples show the need to have data stratified by sex that allow the differences to be examined and analysed to determine the reasons for these differences and how to address them (Box 1). Box 1. Analysing the health of children and adolescents from a gender perspective: examples of important factors • Role of parents, such as partner support for child care • Various behaviour-linked risk conditions, such as road crashes • Differences in the access to and control of health-related resources, such as preventing HIV transmission • Considering gender perspectives in biologically determined situations, such as pregnancy • Greater prevalence among girls than boys or vice versa, such as eating disorders • Different outcomes (physical, mental and social) for boys and girls, such as depression and suicide • Links to risk factors differing for boys and girls, such as youth violence and sexual violence • Involving responses differing in boys and girls, such as use of contraceptive services • Systems (institutional, family and community) respond differently to boys and girls, such as sexual behaviour 4 Box 2. Definitions of terms used in Fig. 1 Factors influencing health: factors influencing the health and development of children and adolescents at various stages of the life course. They were selected from the European strategy for child and adolescent health and development with the purpose of developing interventions to improve the situation of children and adolescents to promote equity in health between boys and girls. Gender pathway: the expression of a sequence of events mediated through gender that can lead towards gender equality and equity in health and development or towards inequality and inequity. Gender-related outcome: the potential effects of the gender pathways in terms of health and development expressed as positive or negative results. Outcome may include gender-based effects on the mother and father and effects on gender-based differences between boys and girls. 5 The tool includes some considerations related to the health of women during pregnancy and childbirth and after birth. This is because the health and socioeconomic status of the woman and the care received during pregnancy and at the time of birth are strong determinants of the health and survival of newborn babies. Children’s mortality and morbidity are closely linked to poverty and to women’s ability to access services and make decisions about their reproductive health and the care of their children. Efforts to ensure access to quality skilled care during pregnancy and childbirth and immediately after birth for all mothers and newborn babies are crucial for the development of infants, as stated in Improving maternal and perinatal health: European strategic approach for making pregnancy safer.1 3. How to use the gender tool The conceptual framework can be applied: • • to identify the gender pathways (Box 2) that influence the main factors influencing health among children and adolescents during the life course (the life-cycle table); and to identify the main actions that health systems and other sectors can undertake to address the gender issues identified, including defining the information needed (the health priority table). 3.1 The life-cycle table This table may be used to identify and to illustrate the relevance of performing gender analysis of the main factors influencing the health of children and adolescents throughout their lives. The following example shows how this table can be filled in. It is not meant as an exhaustive list of factors influencing health and outcomes but as a selection of relevant examples. 1 Improving maternal and perinatal health: European strategic approach for making pregnancy safer. Copenhagen, WHO Regional Office for Europe, 2007 (http://www.euro.who.int/pregnancy/20071024_1, accessed 19 October 2007). 6 7 Life-cycle table: example Life-course stage Life-cycle table: example Factors influencing health Gender pathways Pre-conception and early pregnancy Planning and spacing of pregnancy Extent to which women have access to safe abortion Inequality or equality in negotiation power, such as negotiation of condom use or timing of pregnancy Gender differences or equality in access to and use of contraception Level of education of women and men Differences in awareness of contraception among adolescents Differences or equality in the value placed on the lives of boys and girls Extent of unwanted and unplanned pregnancies Extent of sexual violence Extent of sexually transmitted infections and HIV infection Extent of unsafe abortions Extent of teenage abortion Extent of selective abortion During pregnancy Extent to which women have access to high-quality antenatal care Women’s decision power to access antenatal care Women’s decisions about maternal and perinatal practices Extent to which the partner and family participates and provides support in pregnancy Extent to which health services are gender- and culture-sensitive Adequacy of antenatal care Access to antenatal services Extent of stress and postpartum depression Extent to which pregnancy is free from the hazardous use of tobacco, alcohol or drugs Gender differences or equality in risk behaviour Inequality or equality in the involvement of partners in behavioural change Birth weight of infants and extent of perinatal morbidity Potential transmission of HIV and sexually transmitted infections Greater risk of acquiring HIV and sexually transmitted infections associated with negotiation skills and knowledge among women Incidence of mother-to-child transmission of sexually transmitted infections and HIV Extent of exposure to gender-based violence Higher risk of gender violence during pregnancy Extent of mental and physical health problems for women Quality of care services during childbirth Women’s decisions about maternal and perinatal practices Staff sensitive to gender and cultural issues Women’s decisions about partner and family involvement during childbirth Extent of harmful practices (such as excessive use of caesarean section, episiotomies and forced position for childbirth) and lack of use of beneficial practices (such as support) Extent of maternal distress Success in early bonding between the mother and father and the baby and in initiating breastfeeding Women’s decisions and extent to which women’s needs are considered (institutional barriers) Fathers’ involvement Extent of maternal distress Success in mother–child and father–child bonding Extent to which breastfeeding practices are improved Success in achieving exclusive breastfeeding Extent to which women’s needs (privacy, work and others) and cultural differences are considered Value placed on women’s mental health needs during the postpartum period Partner involvement Partner and family involvement in care at home Success in breastfeeding Extent of postpartum depression During childbirth During the first four weeks of life (newborn period) Maternal postpartum care 8 Gender-related outcomes Life-course stage First year of life Early childhood (cont.) Factors influencing health Gender pathways Gender-related outcomes Success in continued breastfeeding and initiating healthy eating habits Extent to which working hours are adapted Fathers’ participation in childrearing The extent to which women take responsibility for childrearing Legislation on maternity and paternity leave Differences in the value placed on the health of boys versus girls Breastfeeding continues or is interrupted Growth and development differs between boys and girls or differences are reduced Fathers develop positive or negative attitudes and practices towards fatherhood, which influences the health and development of the mother, the child and the father himself Mental health of the mother and father are affected positively or negatively, which influences the mental health of the child Infants are healthy or unhealthy Balance or imbalance in exposure to hazards between boys and girls Gender differences or equality in the incidence of injuries, other diseases and effects of immunization Extent of access to immunization Level of education of mothers Cost of immunization in relation to mothers’ and fathers’ access to resources Immunization gaps or good coverage Differences or similarities between boys and girls in coverage Extent of stimulation through play, communication and social interaction Discriminatory or equal access to leisure activities Development of or reduction in gender-based stereotypes through leisure activities Extent to which there is early socialization of positive (such as empathic and caretaker roles) and negative (such as excessively risky and violent) behaviour among boys and positive (such as being physically active) and negative (such as eating disorders and image problems) behaviour among girls Extent to which developmental problems and learning disabilities are detected and treated Gender differences or equality in expectations concerning developmental capabilities and skills Gender differences or equality in the detection and treatment of developmental problems (such as autism and developmental disability) and learning disabilities Exposure to child abuse and neglect Differences or equality between boys and girls in whether and how adults expose them to sexual and physical abuse and neglect Gender differences or equality in the detection of child abuse and action by the health system to prevent and stop it Extent to which the environment is safe Extent to which exposure to accidents differs between boys and girls Gender differences or equality in rates of accidents Health of the infant secondary to maternal depression (adequacy of feeding and bonding) 9 Life-cycle table: example Life-course stage Late childhood Adolescence 10 Factors influencing health (cont.) Gender pathways Gender-related outcomes Extent to which lifestyles, diet Discrimination or equality in ability to and and physical activity develop encouragement to participate in physical in healthy directions activity and sports Discrimination or equality in exposure to risky behaviour Differences or equality in eating habits Extent to which the incidence of accidents differs between boys and girls Building of body image and behaviours based on stereotyped or genderequality models Differences or equality in the incidence of eating disorders Prevention, early detection and management of mental health problems Gender differences in the detection and treatment of depression, learning difficulty and behavioural problems Gender norms and values conditioning behaviour Prevalence of aggressive conduct generally greater among boys Prevalence of hyperactivity syndrome generally greater in boys Prevalence of diagnosed depression generally greater among girls Exposure to exploitation and hazardous child labour Differences or equality in risk, vulnerability and health impact between boys and girls Differences or equality between boys and girls in disabilities and opportunities to develop Diet and physical activity Discrimination or equality in ability to and encouragement to participate in physical activity and sports Gender differences or equality in relation to body mass index and self-perception of weight Gender differences or equality in eating habits Extent to which boys have a higher incidence than do girls of sports accidents and road crashes (cars and motorbikes) Extent to which girls have more problems than do boys linked to the development of body image Extent to which risky behaviour (tobacco, alcohol or other substance misuse and unsafe sex) is prevented Gender-based patterns in risk-taking behaviour and protective factors Gender bias or equality within health services, mass-media campaigns and policies Gender differences or equality in hazardous use of substances Gender differences or equality in suicide rates Gender differences or equality in (diagnosed) depression rates Extent of gender-based violence and sexual exploitation, early marriage and adolescent pregnancy Initiation to sexual life Discrimination or equality in access to sexual and reproductive health services (especially male adolescents) Unequal or equal position of female adolescents in negotiation of sexual relations and contraception use Discrimination against or equal treatment of adolescents with sexual orientation other than strictly heterosexual Extent of unsafe sex among male and female adolescents Gender-based differences or equality in vulnerability to sexually transmitted infections and HIV transmission and the desirability of pregnancy Other health outcomes as a consequence of discrimination or equal treatment (such as effects on mental health) Extent to which accidents are prevented Development of high-risk and protective behaviour based on gender-based stereotypes or on gender equality Gender-based differences or equality in the proportion of accidents linked to other risks (such as alcohol consumption and weapon use) Gender-based differences or equality in the prevalence of aggressive behaviour Gender-based differences or equality in the prevalence of preventive behaviour 3.2 The health priority table: gender-sensitive actions for selected health priorities Once the gender issues have been identified, gender-sensitive actions are to be defined. This table follows the eight priority areas identified by the European strategy for child and adolescent health and development and the main factors influencing health for each area defined in the action tool. It offers a diverse set of examples on how to mainstream the gender perspective into designing, planning and implementing actions to promote health and development among children and adolescents. It is a flexible tool, and its usefulness, reading and interpretation has neither a unidirectional nor a linear sequence. Each country, programme or decision-maker can establish priorities based on: • • • • age group (life course) health problem levels of intervention what is relevant. 11 Health priority table: example Gender-sensitive actions for selected health priorities Priorities 1. Health of mothers and neonates Gender pathways Information needed Health system actions Intersectoral actions Preventing preterm delivery, intrauterine growth retardation and congenital anomalies Extent to which negotiation power is equal Level of education of the mother and the father Extent to which the partner and family participate, provide support and take responsibility Extent to which health services are gender- and culturesensitive Extent of sexual violence Prevalence of low-birth-weight infants Percentage of partners or families participating in antenatal care visits Quality perceived by women and men during antenatal care Prevalence of alcohol and tobacco consumption in both parents Providing adequate provision and equitable access to antenatal care services for both parents, including advice on nutrition, counselling on tobacco and alcohol use during pregnancy and screening for HIV and sexually transmitted infections Training health care teams for pregnant women in gender-sensitive issues such as violence and empowerment Promoting the participation of the partner or family and support network Using gender-sensitive guidelines in antenatal care Improving and implementing legislation to support working women during pregnancy Revising and adjusting legislation to allow pregnancy to be terminated in selected cases Promoting information, education and communication activities for pregnant women and partners on healthy motherhood, preventing congenital anomalies and birth planning Promoting women’s empowerment Ensuring adequate referral systems for victims for violence Educating girls and women Ensuring skilled attendants at childbirth for all women and the right place of birth in high-risk cases Extent of autonomous decision-making of the woman in the use of medical procedures during the perinatal period Extent to which childbirth is medicalized Extent to which the family provides appropriate care and support Percentage of deliveries attended by qualified professionals Quality perceived by women and their families during childbirth Using gender-sensitive evidence-based clinical guidelines and antenatal care during childbirth Implementing an appropriate referral system for high-risk pregnancies and deliveries Promoting legal frameworks that empower women on decisions about childbirth Educating girls and women Providing essential care to all newborn babies Extent to which the demands of the woman immediately after childbirth (mental health, privacy and health care) are acknowledged as a relevant issue for the health of the newborn baby Existence of barriers to or factors promoting early mother-to-baby bonding Prevalence of practices recommended for neonatal care Percentage of newborn babies exclusively breastfed at hospital discharge Percentage of newborn babies kept with mothers during the hospital stay Ensuring that professionals are trained in providing evidence-based and humanized, gender-sensitive care for the baby and family Promoting the participation of men in caring for the newborn baby Promoting early mother-infant bonding Providing mother- and baby-friendly environments Ensuring the child’s right to identity and the construction of citizenship Adopting legislation on maternity and paternity leave Managing preterm and low-birth-weight infants Extent of early bonding Fathers’ involvement in child care Differences or equality in the value assigned to the lives of girls and boys Prevalence of early support (partner or family) during the hospital stay Promoting the father’s involvement in care of low-birth-weight newborn babies, such as involving fathers in Kangaroo mother care practices Providing parent education for caring for newborn babies after discharge from a health facility Establishing community networks for following up high-risk infants Ensuring appropriate monitoring and evaluation of maternal and newborn health services Value placed on the health of mothers and newborn babies Gender perspective in information systems (such as qualitative information on empowerment, participation, equity and indicators of satisfaction with care) stratified by sex Performing gender analysis of maternal and newborn services by considering indicators of socioeconomic status, geographical locations, ethnic group, etc. Building capacity among health care providers on how gender affects the quality of services Promoting systems to evaluate gender equity that take into account multiple information sources (education, socioeconomic status, ethnic group and geographical location), stratified by sex Ensuring adequate nutrition among pregnant women and mothers Value assigned to women’s health Extent of men’s support for healthy nutrition among pregnant women Socially determined models of body image of pregnant women Women’s access to resources Prevalence of micronutrient deficiencies among pregnant women stratified by economic condition, family status and ethnic group Prevalence of supplementation programmes of micronutrients relevant to pregnancy (iron and folate) Qualitative information about the impact of cultural and ethnic differences on eating habits Continuing gender-sensitive education of health care teams and the population in nutrition Counselling on nutrition in antenatal visits that include the partner Training health care providers on the specific cultural needs of migrants and various ethnic groups Training health care providers on specific cultural needs for pregnant women among migrants or ethnic minority groups Enacting legislation to promote folic acid supplementation Promoting access to supplementation programmes with micronutrients (iron and folate) Reflecting cultural diversity in healthy eating programmes Protecting, promoting and supporting exclusive breastfeeding Women’s ability to decide feeding practices and receive adequate support in all cases Extent to which institutional resources and regulations take into account women’s needs (such as privacy and employment) Partner involvement in supporting breastfeeding Norms and values in communities and families related to breastfeeding Prevalence of breastfeeding by age groups, socioeconomic background and ethnic group Prevalence of exclusive breastfeeding by age group, socioeconomic background and ethnic group Qualitative information on partners and family support for breastfeeding Training health professionals in counselling related to breastfeeding and gender issues Acting to address men’s support for breastfeeding Emphasizing more strongly the beneficial effects of breastfeeding for the mother and the child versus benefits for the child only Implementing the Baby-Friendly Hospital Initiative with a gender perspective Improving and applying legislation to protect working mothers who breastfeed Promoting information campaigns on breastfeeding Promoting paternity leave Preventing malnutrition and micronutrient deficiencies Gender differences in patterns of distribution of food and resources within families Prevalence of malnutrition and deficiency of micronutrients stratified by sex and ethnic group Providing food supplementation and advice about culture- and gender-sensitive nutrition Involving men in healthy nutrition Empowering women in decision-making processes Providing access to food fortification programmes with micronutrients (iron, folate and iodine) Preventing overweight and obesity Unequal or equal access to information and opportunities for physical activity Extent of gender-based stereotypes about physical activity Differences or equality in the priority placed on preventing obesity among boys versus girls Prevalence of overweight and obesity stratified by sex, age, socioeconomic background and ethnic group Data on diet and physical activity by sex and age Promoting gender-sensitive healthy eating habits and physical activity Providing gender-sensitive services for obese and overweight boys and girls Supporting schools in gender-sensitive screening and programmes for overweight and obesity Implementing programmes that promote equal opportunities for physical activity among boys and girls Regulating aspects of information in the mass media about adolescent eating habits with a gender perspective Implementing gender-sensitive nutrition programmes in schools Promoting oral and dental health Differences or equality in the use of family resources for dental care among boys versus girls Prevalence of dental health problems stratified by sex and socioeconomic level Patterns of access to dental health care stratified by sex and educational level Promoting access to oral and dental health care services with a gender perspective Implementing campaigns for oral and dental health promotion with a gender perspective Promoting oral health education with a gender perspective in the education system 2. Nutrition 12 13 Health priority table: example (cont.) Gender-sensitive actions for selected health priorities Priorities 3. Communicable diseases Gender pathways Information needed Health system actions Intersectoral actions Providing immunization for vaccine-preventable diseases Effect of women’s level of education and socioeconomic background on immunization Fathers’ involvement in immunization of children Coverage of immunization programmes stratified by sex Coverage of immunization programmes stratified by level of education and the socioeconomic background of the mothers Implementing immunization programmes targeting mothers with low education and socioeconomic status Involving fathers in immunizing their children Empowering women in decision-making processes within the family Ensuring legal mechanisms for equal access to vaccines free of user charges Managing the most common infectious diseases of childhood Women’s level of education and socioeconomic background Fathers’ involvement in the care of children Decision-making power on health issues within families Providing child-care services that address gender barriers to accessing services Training health care providers to identify gender barriers Involving men in child care Empowering women to access resources Implementing campaigns targeting men on the responsibility for the care of their children Controlling HIV and sexually transmitted infections Extent to which male adolescents are more likely to use intravenous drugs Extent to which girls lack power to negotiate condom use Differences or equality in the early and timely detection of sexually transmitted infections Extent to which social pressure is applied to boys or girls for sexual debut Extent to which girls are exposure to more sexual abuse than boys Extent of sexual exploitation of girls and boys Gender differences in access to information on the prevention of sexually transmitted infection and HIV transmission Information on infectious diseases of childhood stratified by sex and age and socioeconomic background Qualitative information about the role of fathers and mothers in prevention and care decisions for boys and girls Prevalence of sexually transmitted infection and HIV infection stratified by sex and age Prevalence of intravenous drug use stratified by sex and age Access to harm reduction programmes stratified by sex and age Condom use Qualitative studies on the perception of condom use negotiation among boys and girls Access to services and counselling stratified by sex Initiation of sexual activity stratified by sex Numbers of victims of violence, abuse and sexual exploitation stratified by sex and age Promoting access to gender-sensitive information and counselling services Providing treatment for preventing the mother-to-child transmission of HIV Empowering professional teams on the gender dimensions of sexual and reproductive health Integrating the gender dimension and respecting sexual diversity as a quality issue for health care delivery for adolescents Developing, strengthening or instituting gender-sensitive harm reduction programmes for vulnerable populations Including gender-sensitive prevention of sexually transmitted infections and HIV in school curricula Providing condoms through various civil society organizations Implementing legal frameworks that respect diversity in sexual orientation and gender identity and promote sexual and reproductive rights Controlling tuberculosis Extent of gender gradients in the prevalence of tuberculosis linked to HIV and AIDS and poverty Gender differences or equality in risk behaviour and stigma Differences or equality in community and family support for males and females with tuberculosis Role of women in the home care of people with tuberculosis Incidence and prevalence of tuberculosis by sex, socioeconomic status and comorbidity Numbers of young men and women seeking care Prevalence of tuberculosis among young women and men in prisons Gender-sensitive awareness-raising among health professionals Gender-sensitive health services addressing the needs of vulnerable groups: groups in poverty and ethnic minorities Integrating the prevention of tuberculosis into programmes oriented to empower vulnerable populations Preventing and reducing the morbidity and mortality arising from poor water supply and inadequate sanitation Differences or equality in access to water and basic sanitation and recreational areas for boys and girls Links between gender differences or equality in general access to resources and access to clean water and adequate sanitation Role of women in ensuring the use of clean water Prevalence of morbidity and mortality linked to deficiencies in access to water and basic sanitation, stratified by sex Training health professionals in issues related to the environment and health of children and adolescents with a gender perspective Advocating for clean water and sanitation as a poverty alleviation issue Addressing gender roles in water and sanitation programmes Preventing and reducing respiratory diseases due to indoor and outdoor air pollution Extent to which young girls have higher exposure to harmful air pollution during household activities (such as solid fuel for cooking, etc.) Impact on the health of children of gender differences or equality in parents’ exposure Prevalence of asthma, poisoning, acute respiratory infection and allergies stratified by sex and age Prevalence of secondary exposure to cigarette smoke at home and public places stratified by sex Training health professionals in children’s and adolescents’ environment and health with gender perspective Informing and advocating on the dangers of indoor air pollution Educating caregivers, health care providers and school personnel on ways to prevent and reduce children’s and adolescents’ exposure to indoor air pollution with a gender perspective. Prevalence of illnesses produced by exposure to hazardous chemicals and physical and biological agents stratified by sex Training health professionals in environmental health among children and adolescents with a gender perspective Raising awareness on gender-based health effects due to differences in exposure and/or susceptibility Consider sex-specific exposure patterns and susceptibility to air pollutants in the development of risk reduction programmes School dropout stratified by sex and age Prevalence of child labour stratified by sex and age Prevalence of trafficking and sexual exploitation stratified by sex Training health professionals in health problems related to exploitation and labour among children and adolescents Developing protective legislative frameworks for eradicating all types of child labour and exploitation Ensuring the enrolment of boys and girls in the education system Generating greater social awareness of the risks of child labour and exploitation 4. Physical environment Differences or equality in occupational exposure in farms Reducing the risk of diseases and and factories, such as gender differences or equality in disabilities arising from exposure to chemical, physical and biological exposure to ultraviolet radiation during work agents Preventing child exploitation and hazardous child labour 14 Extent of sexual exploitation of boys and girls Extent of gender-based stereotypes based on the male role as provider and the female limited to domestic domains Extent to which boys work in hazardous environments (such as construction work or mechanical work) 15 Health priority table: example (cont.) Gender-sensitive actions for selected health priorities Priorities 5. Adolescent health Gender pathways Information needed Health system actions Intersectoral actions Promoting the health and well-being of adolescents Gender differences or equality in health and risk behaviour Effect of gender roles on the access of boys and girls to education and job opportunities Differences or equality in how families distribute resources on the education of boys versus girls Extent to which the development of opportunities for participation and leadership is conditioned by gender Studies of self-perception and well-being among adolescents stratified by sex and ethnicity Coverage of education and employment of young people stratified by sex Absenteeism and school dropout stratified by sex, age and level of education Population of institutionalized adolescents stratified by sex Promoting the development of youth-friendly and -responsive services from the perspectives of gender and the right to satisfy basic human needs Promoting public health policies and campaigns addressing the specific health needs of boys and girls Training health care professionals in gender-sensitive health promotion Promoting the participation of young boys and girls in developing gender-sensitive services Providing opportunities for developing gender-sensitive life skills in school programmes Disseminating gender-specific and -sensitive health messages in the mass media Promoting peer-to-peer services Preventing unwanted pregnancies among adolescents and ensuring appropriate support for adolescent mothers Extent of gender and culturally sensitive reproductive health services for young people Inequality or equality in access to information and resources for preventing unwanted pregnancies Inequality or equality in negotiation power on condom use Extent of programmes for pregnant teenagers in the education system Prevalence of adolescent pregnancy stratified by the age of both partners Contraception use stratified by method and sex Access to reproductive health services stratified by sex and age Coverage of sex education activities stratified by sex and level of education Implementing reproductive health policies addressing gender differences and inequality Facilitating access to gender specific programmes, information, resources and contraceptive services for adolescents Providing counselling for pregnant girls and their partners in unplanned pregnancy Training health teams in aspects of sexual and reproductive health from perspectives of gender and the right to satisfy basic human needs Promoting social support networks for adolescent mothers and their partners Promoting sex education in schools Promoting collaboration among sectors to ensure contraception services Promoting programmes conducive to keep pregnant girls in the education system Promoting culturally sensitive services and programmes for migrant populations and ethnic minorities Preventing and managing HIV infection and sexually transmitted infections among adolescents Extent to which male adolescents are more likely to use intravenous drugs Extent of differences between boys and girls in the possibility of negotiating condom use Extent to which social pressure is applied to boys about starting to become sexually active Extent to which girls are more exposed to sexual abuse, rape and exploitation Extent to which pregnancy is a situation of greater vulnerability linked to less protection Differences or equality in access to information on preventing sexually transmitted infections and HIV transmission Extent to which women are more likely to contract HIV infection and other sexually transmitted infections during sexual activities with an infected partner Information stratified by sex and age on the prevalence of sexually transmitted infection and HIV infection and alcohol and other substance use (cannabis, heroin and ecstasy) Qualitative studies on the perceptions of negotiating condom use among males and females Access to counselling services Initiation of sexual activity stratified by sex Victims of violence, sexual exploitation and abuse stratified by sex and age Qualitative studies on homosexuality in adolescence Developing gender-specific campaigns on risk behaviour related to HIV infection and sexually transmitted infections Promoting access to confidential information and counselling activities and prevention and testing in HIV and sexually transmitted infections Providing treatment for preventing the mother-to-child transmission of HIV Training health professionals on gender-sensitive sexual and reproductive health Gender-sensitive harm reduction programmes Providing legal frameworks for sexual and reproductive rights that include access to information services for adolescents Introducing aspects of preventing sexually transmitted infection and HIV infection in the school curricula Providing information through institutions (schools, churches, community-based organisations, etc.) Providing condoms through various organizations to ensure equal access among girls and boys Ensuring appropriate management and support for adolescents with chronic diseases and disabilities Extent of stigma and gender-based discriminatory attitudes towards people with disabilities Extent to which disabled girls are more highly exposed to abuse Extent to which stigma is attached to women when disability affects their reproductive capability Information on disability and discrimination stratified by sex Access to programmes and services for young disabled people stratified by sex Prevalence and incidence of chronic illness and disabilities stratified by sex Providing gender-sensitive health services for young people with disabilities Empowering health professionals in issues of inclusive development, emphasizing gender and disability Integrating gender and health issues into social policies addressing the needs of young people with disabilities Preventing hazardous use of substances Extent to which boys are more likely to engage in hazardous use of substances Extent to which the prevalence of smoking among girls is increasing or decreasing Extent to which substances are used that are linked to gender-based stereotypes (greater autonomy among women and greater virility among men) Prevalence of hazardous use of substances stratified by type and sex Knowledge of risk and protective factors stratified by sex Access to services stratified by sex Developing gender-specific prevention programmes on hazardous use of substances Providing appropriate services for care of adolescent consumers of alcohol, tobacco and other substances, including harm reduction Providing gender training for health care providers to identify and address risk factors and vulnerability among adolescents Developing legal frameworks for preventing the consumption of tobacco and alcohol Developing mass-media campaigns for reducing the consumption of alcohol and tobacco Preventing overweight and obesity See table on nutrition See table on nutrition See table on nutrition See table on nutrition Preventing bullying and violent behaviour among adolescents Gender differences or equality in risk and protective factors Extent to which adolescents with sexual orientation other than strictly heterosexual or with nontraditional gender identity are at greater risk Extent to which power relationships between boys and girls and between adolescents of the same sex are imbalanced Extent to which there are violent masculine stereotypes Extent to which knowledge of patterns of girls’ violent behaviour is lacking Prevalence of bullying in school settings stratified by sex Qualitative information on experiences among girls and boys on violent situations and peer pressure Providing gender-sensitive psychological services for adolescents Developing gender-sensitive programmes that promote nonviolent dialogue and conflict resolution in the education system Implementing gender-sensitive prevention campaigns Preventing and managing eating disorders Gender differences or equality in social pressure to have the ideal body image Extent to which detecting eating disorders among boys or girls is difficult Prevalence of eating disorders stratified by sex Qualitative information on risk and protective factors Training professionals in the early detection and treatment of eating disorders with a gender approach Developing gender-sensitive support programmes for boys and girls with eating disorders Promoting realistic female and male body images through the mass media 16 17 Health priority table: example (cont.) Gender-sensitive actions for selected health priorities Priorities2 6. Injuries and violence 2 Gender pathways Information needed Health system actions Intersectoral actions Preventing home-related unintentional injuries Differences or equality in exposure to domestic accidents based on different gender roles Information on home accidents stratified by age, sex, ethnicity and socioeconomic background Promoting gender-sensitive education of parents on reducing hazards Empowering health teams with a gender perspective for detecting possible hazards at home Implementing gender-sensitive prevention campaigns Preventing road crash injuries Extent of gender dimensions of driving habits and pedestrian attitudes Extent to which gender roles influence how people drive and how pedestrians behave Extent to which masculine role models are linked to risky behaviour and fearlessness Extent to which gender-based stereotypes push boys to avoid protective behaviour and affect how conflicts are resolved Information on road crashes stratified by sex, age, cause and location Information on road crashes linked to hazardous use of alcohol, drugs and other substances, stratified by sex and age Self-perception of risky behaviour stratified by sex Self-perception of protective and self-care behaviour stratified by sex Considering gender differences in the consequences of temporary or permanent disability resulting from accidents Including information on habits and gender-based stereotypes in school consultations with adolescents Implementing public campaigns that consider gender differences in behaviour Promoting school programmes on road safety that address gender-based stereotypes and various types of behaviour Designing interventions that challenge gender roles Preventing drowning (in pools, etc.) Extent to which gender-based stereotypes push boys to avoid protective behaviour Extent of gender-based stereotypes surrounding physical activity Mortality from drowning stratified by sex, age and place of occurrence Qualitative and quantitative information about swimming, family habits and physical activity among boys and girls Information on links between drowning and alcohol consumption stratified by sex and socioeconomic background Gathering information on habits and gender-based stereotypes and risks for adolescents and how they affect health Addressing gender-based stereotypes on risk behaviour among adolescents in schools Reducing the incidence and consequences of intrafamilial violence Extent to which gender-based stereotypes are perpetuated within families Extent to which girls are more highly exposed to intrafamilial violence Extent to which boys are more highly exposed to violent family behaviour due to masculine role models Extent of differences in whether and how parents’ gender-based violence affects boys versus girls Incidence of intrafamilial violence stratified by sex and ethnic and socioeconomic background Qualitative information on the circle of violence in families with a gender perspective Ensuring that health professionals incorporate methods of assessing intrafamilial violence that are gender specific Ensuring a gender-based approach in managing children and adolescents affected by the consequences of intrafamilial gender-based violence Providing psychological support for children and adolescents whose mothers suffer from gender-based violence Building capacity among health providers to identify gender-based violence in children’s families Promoting gender-sensitive awareness campaigns on intrafamilial violence in schools and community centres Developing gender-sensitive community-based programmes that provide opportunities for positive youth socialization Ensure that social and judiciary services are gender sensitive Preventing child abuse and neglect Extent to which girls are exposed to sexual abuse more often than boys Gender differences or equality in parents’ violence Extent to which boys lack attention as possible victims of neglect and abuse Differences or equality in the effects of abuse on the future sexuality and reproductive health of boys and girls Gender differences or equality in exposure to neglect Incidence of child abuse and neglect by sex and age and socioeconomic background Information by the sex and socioeconomic background of the perpetrator Data on neglected children stratified by sex Ensuring that the health services addressing child abuse and neglect cases are gender sensitive Ensuring home visiting for all mothers and newborn babies and follow-up for those that have special needs or are at high risk Promoting bonding after childbirth Involving the father during pregnancy, childbirth and care of the child Promoting specific gender-sensitive child protection and psychosocial support programmes for children and adolescents in situations of high vulnerability (conflict, marginal communities, etc.). Setting up campaigns for preventing intrafamilial gender violence Preventing child trafficking and sexual exploitation Extent to which girls are exposed to sexual exploitation more often than boys Extent to which boys lack attention as possible victims of child trafficking and sexual exploitation Gender discrimination or equality and extent of empowerment promoting or retarding trafficking and sexual exploitation Information on trafficking from the judicial system stratified by sex Information on sexual exploitation stratified by age and sex Qualitative information on risk and protective factors stratified by sex and socioeconomic background Training health workers and emergency services to identify the victims of trafficking and sexual exploitation Developing gender-sensitive protocols of conduct within the health services to address trafficking and sexual exploitation Enacting gender-sensitive legislation on child abuse and neglect, paedophilia, child trafficking and exploitation Strengthening social services to address trafficking and sexual exploitation in a gender-sensitive way Implementing gender-sensitive public campaigns addressing vulnerable populations The table on adolescence reported prevention of bullying and violent behaviour among children and adolescents. 18 19 Health priority table: example (cont.) Gender-sensitive actions for selected health priorities Priorities 7. Psychosocial development and mental health Promoting the psychosocial development and mental well-being of children and adolescents Gender pathways Development of gender-based stereotypes or equality associated with various childrearing and socialization practices Extent to which there are gender-based discrimination and negligence situations in the early stages of life Gender differences or equality in suicide and attempted suicide among adolescents Extent of prejudice and stigma towards the behaviour of children who do not respond to gender-based expectations Gender differences or equality in responses to contexts of deprivation, risk and violence and unfortunate life events Extent to which gender-based stereotypes prevent boys from seeking help in case of depression Extent of gender bias in health services addressing the mental health needs of adolescents Information needed Health system actions Intersectoral actions Information on psychosocial development and mental health problems stratified by age, sex and socioeconomic background Suicide among adolescents stratified by age and sex Depression among adolescents stratified by age and sex Qualitative information on gender-based stereotypes Qualitative information on gender identity Promoting gender-sensitive childrearing guidelines Building capacity among health professionals to deal with gender differences in mental health among children and adolescents Training professionals in gender-specific aspects of psychosocial development and mental health problems (including diversity according to sexual orientation) Gender-sensitive suicide prevention campaigns Preventing child neglect and its consequences Promoting gender-sensitive joint work with the education community Gender-sensitive campaigns for promoting the rights of children and adolescents Promoting the inclusive development (equal conditions and opportunities from the early stages of life) without discriminating by sexual orientation or gender Promoting sensitivity to issues related to gender and children and adolescents in the mass media Implementing gender-sensitive empowerment activities during childhood and adolescence Incidence of mortality and morbidity rates of chronic diseases by sex, age and socioeconomic background Access to health services by sex, age and socioeconomic background Information on abuse and neglect stratified by sex, age and type of disability Health-related quality of life indicators stratified by sex, age and socioeconomic background Providing gender-sensitive care of children and adolescents with chronic diseases and disabilities, adequately equipped and with specifically trained professionals Ensuring equal access for boys and girls to care for chronic diseases Acknowledging and addressing the role of women as informal caregivers for children and adolescents with disabilities Integrating the health, education and employment sectors for an inclusive and gender-sensitive approach to children and adolescents with disabilities Promoting community and family participation in the approach to children and adolescents with chronic diseases and disabilities that takes gender differences into consideration 8. Management and care of children with chronic diseases and disabilities Ensuring early detection, diagnosis and management of mild mental retardation and developmental disability 20 Gender differences or equality in access to care for chronic diseases and disabilities Extent to which stigma and discrimination are linked to gender and disability issues Extent to which girls with disabilities are exposed to abuse and neglect Extent of gender roles and stereotypes that pose different forms of interaction for children and adolescents with disabilities Role of women as informal caregivers 21 Background documents to support the use of the gender tool General documents European strategy for child and adolescent health and development. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/childhealtdev/strategy/20060919_1, accessed 19 October 2007). European strategy for child and adolescent health and development: information tool. 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