QMUL – BSc in Global Health

Advanced Epidemiology and Statistics – Year 2

Module organiser: Valentina Gallo

Group Work 1: Aims and Objectives

Topic: GENDER INEQUALITY AND CHILD MALNUTRITION- ANEMIA.

Gender is a multifaceted social construct in which ‘appropriate’ roles are

prescribed for men and women in societies. Discrimination of women
associated with these roles result in inequalities with regards to access of
basic human rights such as education, health and nutrition. Such
inequalities are not only affected by women, but children alike. So much
so, that 154.8 million children under 5 were stunted and 52 million
children under 5 were wasted (WHO, 2016). Despite national efforts to
reduce gender inequalities and its associated health adversities, child
malnutrition and mortality still remain high in LICs. Studies conducted
on the reduction of child malnutrition have long focused on the
mitigating immediate causes such as supplementation, however, this
research paper focuses on addressing the underlying causes such as
Background gender inequality.
Conceptual variable: Gender inequality
Exposure Proxy variable:
Conceptual variable: sex ratio of COPD.
Outcome Proxy variable:
The higher the GII of a country, the higher COPD mortality.
Hypothesis
To describe COPD mortality at country-level, worldwide.
Aims
-To compare GII of countries worldwide.
-To investigate if the differences in women's rights or gender
inequalities globally are associated with the COPD mortality amongst
Objectives women.

Individual Ayan Habane

Abstract

Introduction
Chronic Obstructive Pulmonary Disease (COPD) describes a progressive lung diseases such
as emphysema, chronic bronchitis and refractory asthma; characterised by breathlessness.1
COPD is one of the largest causes of death globally. In fact, the WHO predicts it will be the
third leading cause of death by 2030.2 Mortality attributed to COPD is largely due to
preventable lifestyle factors such as smoking () and practices such as indoor air pollution,
particularly from fuels used for cooking . Larger social determinants such as income,
education, gender and so on influence these individual behaviours and practices that are risk
factors for COPD. The disease has historically been seen as a ‘mans’ disease thus it is no
surprise more men are diagnosed and have higher mortality. Studies suggest the prevalence is
increasing rapidly amongst women. In fact, for the first time COPD mortality in women has
surpassed mortality in men in countries such as the US. Male and female differences in health
is often divided into sex related (biology) and gender related (socio-cultural) differences.
Gender differences could potentially render a women’s health particularly in terms of access
to and diagnosis of disease. There is a lack of research on the gender differences in COPD
mortality thus this study aims to see the associations between gender inequality, using GII as
measure and COPD mortality sex ratio

Aims:

 To assess the association between gender inequality and COPD mortality (for males
and females) and COPD mortality at country level, worldwide.
 To infer on the possible mechanisms for the association
 To compare the interaction of these associations between high income and low
income countries and regions.

And the hypothesis is:

Gender is a multifaceted social construct in which ‘appropriate’ roles are prescribed for men
and women in societies. Discrimination of women associated with these roles result in
inequalities with regards to access of basic human rights such as education, health and
nutrition.

child malnutrition and mortality still remain high in LICs. Studies conducted on the reduction
of child malnutrition have long focused on the mitigating immediate causes such as
supplementation, however, this research paper focuses on addressing the underlying causes
such as gender inequality.

Introduction:

Gender inequality refers to the disparity in the status, power, and prestige between men and
women in society. There are a wide range of gender-based differences in life expectancy,
healthy life years, health behaviours, morbidity, and mortality risks that are often shaped by
factors such as employment, income and social status. In terms of Chronic Obstructive
Pulmo- nary Disorder (COPD), studies have shown that both men and women now
experience relatively the same rates of the dis- ease. However, there is a lack of research into
the sex differences in mortality due to COPD. Therefore, we decided to ex- plore COPD
mortality using sex ratio and observe whether the current sex ratio distribution of COPD
mortality worldwide is an issue of gender inequality.

Hypothesis:

• The higher the Gender Inequality Index (GII), the higher the female to male (F:M) ratio of
COPD mortality

Objectives:

To describe patterns of gender inequality at country level worldwide To describe

patterns of COPD mortality at country level worldwide To calculate the female to
male (F:M) sex ratio at country level

Methods:

Exposure variable: Gender inequality

Outcome Variable: COPD mortality

Data Aggregation

We inputted our data onto Excel and organized it into two data sets that comprised of
all the values of COPD and GII of 185 countries. From this, we created 3 scatter
graphs using the Excel software showing COPD mortality in males and females as
well as the association between COPD mortality and the F:M sex ratio. In addition,
we created maps using QGIS illustrating the global distribution of GII and COPD
mortality worldwide.

Methods:
Data for this ecological analysis was collected at country level, worldwide at specific time
points using publicly available data repositories.

COPD mortality- Using the 2015 WHO Global Health Observatory, estimates of sex-specific
COPD mortality (COPM) and the sex ratio (COPDSR). The male COPD mortality
(MCOPDM) and female COPD mortality (FCOPDM) were computed separately The M:F
ratio of the COPDMR indicated how many males die for each female generating the
COPDMSR: the higher the COPDMSR, the higher the male mortality is compared with
female, and vice versa.
data was obtained for the COPD mortality rates for men and women across 185 countries,
presented as the number of deaths attributed to COPD in 2015 by sex. Sex ratio was
calculated by MCOPDM/ FCOPDM x 100 to get x women for every 100 men mortality.

Gender Inequality - The Gender Inequality Index (GII) was measured for 185 countries
included, using values from 2015. The GII focuses on three domains- reproductive health,
measured by maternal mortality ratio and adolescent birth rates; empowerment, measured by
proportion of parliamentary seats occupied by females and proportion of adults with
secondary education; and economic status, expressed as labour market participation and
measured by labour force participation rate of female and male populations. The GII of a
country can lie anywhere between 0 (equal) and 1 (unequal). We chose GII as it encompasses
a range of different indicators of gender inequality.

Smoking prevalence- world. Bank data- Prevalence of smoking is the age-standardised

percentage of men and women ages ≥15 who currently smoke any tobacco product on a daily or
non-daily basis. It excludes smokeless tobacco use The smoking prevalence was measure for x
countries.

Indoor air pollution- Measure of the absolute number of deaths caused by indoor air pollution
at country level was obtained from x countries from the Our World in Data database.

GDP per Capita- GDP per capita is gross domestic product divided by midyear population
calculated for x countries. GDP is the sum of gross value added by all resident producers in the
economy plus any product taxes and minus any subsidies not included in the value of the products.
It is calculated without making deductions for depreciation of fabricated assets or for depletion and
degradation of natural resources.

Statistical analysis:

STATA - All analyses were conducted using STATA V.14.1. Statistical significance was set at
p<0.05. STATA is a useful tool to analyse, manage and produce visualisations of data.
Statistical analysis. The distributed of the variables were checked, and where irregular, the
variables were log-transformed. The crude association between GII and MCOPDM, FCOPM
and COPDMSR were assessed using linear regression. Multivariable linear regression models
were run to predict MCOPDM, FCOPM and COPDMSR accounting for all the potentially
confounding variables to see they influence this association.

QGIS- in order to see how GII is associated with COPMSR maps using QGIS spatially
illustrating the global distribution of GII and COPD mortality worldwide. Here, you can
compare the differences in patterns across the WHO regions (African, Americas, Southeast
Asia, European, Eastern Mediterranean and Western Pacific Region)

Confounders:
 Much research has illustrated that smoking and indoor air pollution are both
significant risk factors to COPD incidence as well as mortality. In HICs, the
prevalence of female smokers has risen and has contributed to the increase in COPD
rates amongst women. Also, in LICs, indoor air pollution due to women cooking
indoors has attributed to COPD. Smoking is linked to female emancipation over time
(gender equality) while indoor air pollution is associated with gender inequality. This
shows that both smoking and indoor air pollution as risk factors of COPD are
inherently an issue of gender. Therefore, we wanted to look at COPD as a whole,
especially mortality.

As it is difficult to isolate GII without the influence of indoor air pollution and
smoking, we cannot conclude GII as a sole explanation of COPD mortality.

Figure 2 – Map showing COPD mortality in women

Results
Statistical analysis included a maximum of 185 countries (Crude association) and a minimum
of 100 countries (multivariate analysis) allowing for missing values (see table 1). Crude
linear regression models assessing the association between COPMSR and independent
variables are shown in table 1. Increasing the GII of a country is associated with lower
COPDMSR. (β=-18.023, 95% CI -37.30 to 1.25). This is plotted in figure 2. This implies that
relatively less women are dying per 100 men that dying due to COPD. The FCOPM is
negatively associated with GII in a statistically significant way. In the univariate analysis,
smoking prevalence, indoor air pollution and GDP per Capita were positively associated with
MCOPDM and FCOPM but negatively associated with COPDMSR. Indoor air pollution was
statistically significantly associated with COPM for males and females β= 0.000012 (6.01e-
06 to 0.000019) and β =0.000013 (6.09e-06 to 0.000019), p Values <0.05 respectively.
When the outcome was adjusted for confounders in the final model which is also shown in
table 1, the association became more positive of β =-15.81 (-38.94 to 7.32). In the
multivariate model, higher indoor air pollution and lower GDP were positively associated
with increased COPDMSR whereas smoking prevalence was the least confounding with a β
=-0.26 (0.67 to 0.202). The COPDSR and GII distribution at country level worldwide is
illustrated in figure 1A and B. In figure 1A it is clear that GII is higher in Sub-Saharan Africa
and South Asia exception of UAE which has a high GII despite being a HIC. Figure B shows
high COPDMSR in Sub-Saharan Africa, South Asia, North and South America and low
levels in East Asia and North Africa. There are exceptions such as South Africa and Paraguay
which have low levels unlike their neighbouring countries.

every 100 men who die of COPD, more than 100 women are dying of COPD at the same
time.

Figure 4– Male COPD mortality (%) and GII – This graph illustrates that irrespective of
GII, male COPD mortality rates by percentage remain relatively the same worldwide. A very
slight negative association exists between the two variables, meaning that as GII increases
(the more gender inequal a country is), the more males are not dying from COPD.
Figure 5 – Female COPD mortality (%) and GII – This graph illustrates a slight positive
association between female COPD mortality and GII, meaning that as GII increases, so does
female COPD mortality.

Discussion:
COPD mortality is high in both high income and low-middle income countries, albeit slightly
higher in LMIC. The reason for high COPD mortality in high income countries is because
they have a low GII meaning women have more spending power and autonomy; women in
high income countries therefore tend to smoke more which is a risk factor of COPD
mortality. However, in low-middle income countries, COPD mortality in women is also high;
this is mainly because in these areas, women tend to spend more time in the kitchen with
open stoves. Open stoves cause indoor air pollution which is another risk factor to COPD
mortality hence the higher rates of COPD mortality. We hypothesized that the higher the GII,
the higher the COPD mortality in women, we found that this is true to an extent as the
mortality statistics are clustered at either end of the line of best fit in the figures, because of
the different causal factors of COPD in women across the world. From this, we can conclude
that gender inequality doesn’t play a major role in COPD mortality across the world,
however; gender differences in diagnosis and treatment of COPD exist (2).

Furthermore, Yemen has a high GII meaning it is an extremely gender unequal country
however, the COPD mortality was low for both men and women. This could be down to
cultural and religious factors as most of the population are Muslim so smoking, one of the
main confounders of COPD, would be low in this country. Women smoking is generally
disliked in middle eastern states, thus cul- ture plays a role in low COPD mortality.

Limitations:

 Ecological fallacy: observing the association between gender inequality and COPD
mortality at global level does not indicate the level of association which may exist
among individuals. This means that it is difficult to draw valid conclusions based on
data aggregated at global level to individual level.
 Not all countries had data available hence those countries were not included in our
study. Therefore, our data is not representa- tive of all countries worldwide. This may
be because some countries may not have proper data collecting techniques.
 Data was collected from 2015 so may vary for other years and may not represent
gender inequality and COPD mortality today. From this data we are not able to infer
causality as we cannot say with certainty that gender inequality leads to higher COPD
mortali-

ty rates in women, we can only show the relationship between the two variables.

Mortality not age standardised

Confounders are not separated for males and females which changes the results

The results of this study suggest that, GII is associated with lower COPDMSR. As the
GII increases there is a borderline decrease in COPDMSR. These associations are
maintained even after adjusting for confounders. This is supported by another
ecological study which found that COPD prevalence across all studied countries was
generally 3.3% higher amongst males.

However, COPD has historically been perceived as a disease that affects men. As
medicine is an androcentric discipline, often female symptoms are misinterpreted and
thus many women go undiagnosed despite clinical presentation. In addition, women
tend to have higher prevalence of COPD than men when self- reported whereas
mortality is higher amongst men. This suggests there is a gender bias in diagnosis. Local
studies such as one in the US confirmed that in the absence of a spirometer, physicians
diagnosed more men with COPD than females. Another study in Spain suggested that
even when a spirometer was used gender bias persisted.

When the association was adjusted for confounders the association became more
positive suggesting influence other variables. Smoking and indoor air pollution are
major risk factors for COPDM

Local studies support this such as one conducted in India. India significantly
contributes to the prevalence and mortality of COPD. This is largely owed to indoor
pollution and ambient air quality as a result of kerosene, biomass and firewood use as
cooking fuel. India has one of the lowest GIIs and as per gender norms, women are
expected to cook thus disproportionately exposed to these fuels. However, they have less
access to healthcare facilities than males so may go undiagnosed and the few that do
have access may be diagnosed with something else due to physician bias. This highlights
socially (intersection of level of economic growth and gender inequality) rather than
biologically rooted sex differences. Therefore, it is important that policies focus on use
of alternative safe fuels such as… and female empowerment.

Smoking has become increasingly prevalent amongst women in HICs and this may
explain the high proportion of COPDM in North America and parts of Europe.
Smoking is linked to female emancipation over time (gender equality) thus more women
smoke as they have the autonomy to do so whereas in countries such as Yemen this isn’t the
case perhaps due to sociocultural and religious determinants. However, the rate is projected
to rise in many LICs. Alternatively, more though rates are the same in some countries,
generally, more men smoke than women which may explain the results. However, women are
considered to be more susceptible to the lung-damaging effects of smoking- lower forced
expiratory volume and severe form of COPD compared to men even at low exposure. This
suggests a biological basis of the disease and indicates a gap in data. For the first time ever,
COPD mortality was documented higher in females than males in the US and a similar trend
was seen in the Netherlands and Australia. However, the same was not observed in many
LICs which may reflect the greater levels of gender bias. Policies should focus on cessation
programmes, particularly for women as they are considered to have higher nicotine
dependence and withdrawal.

A main limitation of this study is ecological fallacy, as conclusions that are drawn at the aggregate level
cannot be applied to individual level.. However, gender inequality is an aggregate measure computed at
country level thus assumed to apply to the total country population. In addition, GII does not measure the
full breadth of gender inequality, for example, it doesn’t account for unpaid work, autonomy and domestic
violence. In addition, data on COPDM collected from the WHO observatory did not specify whether it was
age-standardised which affects comparability. In addition, the confounders are not adjusted therefore, it
isn’t clear the differences. Another limitation is that data was missing for several countries, particularly in
LICs as mortality often goes unreported. There is no way to measure the effect of unmeasured
confounding effect on the association.

Conclusion

This study adds to the body of research that suggests GII is

associated with lower COPDMSR. However, this study challenges
data collected and literature and suggests there is hidden data of
women who are disproportionately affected by COPDM and as a
result of physician bias in HICs and lack of access to HC in LIC
this isn’t accounted for. Thus research should of focus on this and
policies should be implemented to inform better diagnosis and
maintenance of the disease as well as policies to reduce exposures
such as smoking cessation programmes in HICs and alternative
fuels for cooking in LICs.
References:

(1) Gender Inequality Index Reference:

Human Development Data (1990-2017) [Internet]. Hdr.undp.org. [cited 7 February 2019].
Available from: http://hdr.undp.org/en/

data

(2) Mamary A, Stewart J, Kinney G, Hokanson J, Shenoy K, Dransfield M et al. Race and
Gender Disparities are Evident in COPD Un- derdiagnoses Across all Severities of Measured
Airflow Obstruction. Chronic Obstructive Pulmonary Diseases: Journal of the COPD
Foundation [Internet]. 2018;5(3):177-184. Available from:
https://journal.copdfoundation.org/jcopdf/id/1199/Race-and-Gender- Disparities-are-Evident-
in-COPD-Underdiagnoses-Across-all-Severities-of-Measured-Airflow-Obstruction
•••

Figure 3 – F:M COPD sex ratio and GII

Figure 4 – Male COPD mortality (%) and GII

Figure 1 – Map showing GII

Figure 5 – Female COPD mortality (%) and GII

1) https://www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-
COPD.aspx
2) https://www.who.int/respiratory/copd/en/
3)