Noncommunicable diseases (NCDs) – mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – represent a major challenge for sustainable development in the twenty-first century. In 2015, NCDs were responsible for 39.5 million (70%) of the world’s deaths, with more than 40% (16 million) dying prematurely, or before the age of 70. NCDs affect people of all ages in high, middle and low-income countries. In particular, women and girls face unique challenges in the growing NCD epidemic due to pervasive gender inequality, disempowerment and discrimination. Without specific attention to the needs of women and adolescent girls, the impact of NCDs threatens to unravel the fragile health gains made over the past decades and undermine future efforts to ensure gender equity and healthy lives for all.
Gender inequality and NCDs
NCDs have been the leading causes of death among women globally for the past three decades, and now, NCDs account for nearly 65% of female deaths worldwide. Pervasive gender inequality particularly affects the health of women and girls, influencing their ability to improve their health literacy, access healthcare services, achieve economic empowerment and financial security and live with NCDs free from stigma and discrimination.
Nearly two thirds of illiterate people in the world are women, and this ratio has remained unchanged for two decades. Consequently, women have had fewer opportunities to improve their health literacy and equip themselves with transferable skills that will enable them to be advocates for their own health.
Women face unique challenges accessing healthcare due to their lower socioeconomic, political and legal status compared to men. The critical importance of prevention and early diagnosis of NCDs requires regular contact with the healthcare system. In some cultures, the health of a woman is often seen as secondary to the health of a man, and she may be denied access to healthcare when resources are limited. Even when given the choice, women are more likely than men to invest their money in the health of their children and other family members, rather than prioritising their own health.
Many women may experience financial vulnerability due to high out-of-pocket healthcare costs. Lower access to formal paid employment may deny women the social and financial securities required to insure them against poor health.
Additionally, women are too frequently viewed as commodities, and women living with a chronic disease may face alienation and discrimination. This is often due to the emphasis in certain social or cultural settings on a woman’s suitability for marriage and childbearing, which may be affected by chronic diseases.
The caring burden
Beyond their personal experiences with NCDs, women are indirectly affected by the increase in the burden of chronic diseases due to their traditional role as carers in families and communities. In a survey of 10,000 women from around the world, half the women were caring for a family member with an NCD, with one in five realising their own economic opportunities were diminished as a result. Another study from the United States revealed that women make 80% of the health care decisions for their families, yet often go without health care coverage themselves. Caregiving responsibilities can threaten or disrupt the education of adolescent girls, and often impacts women in their most productive years. Paid work decreases because of the burden of caring for people living with NCDs and reduces the economic contribution of women. This loss of productivity is felt by the whole society. The large amount of unpaid work undertaken by women in the family and community at all levels of society is highly under-appreciated.
Vulnerability to NCD risk factors
Women are uniquely vulnerable to the four major risk factors for NCDs, namely physical inactivity, poor nutrition, tobacco use and excessive alcohol intake. Improved social status and economic empowerment has contributed to an alarming increase in cigarette smoking amongst women and girls. The World Health Organization (WHO) estimates that the proportion of female smokers will rise from 12% in 2010 to 20% in 2025. Deaths attributable to tobacco use amongst women are also projected to increase from 1.5 to 2.5 million from 2004 to 2030. Women’s increasing social and economic status, especially in low and middle-income countries, has made them a prime target for the tobacco industry. This is especially true in Asia where regulation of tobacco advertising is lacking. Aside from the immoral promotion of health-harming products, the objectification of women is entrenched in tobacco advertising. Women’s bodies are exploited for the sale of cigarettes to men, whilst simultaneously and paradoxically, a message of health and beauty through tobacco consumption is conveyed to women and girls.
A similar trend is seen in alcohol consumption, with female alcohol consumption now rivalling male consumption, closing a historic divide. Women and girls around the world are less likely to be physically active than boys and men due to sociocultural, economic and physical limitations imposed on them. In many cultures, women are largely responsible for food preparation. As a consequence, women often eat least and last in the family, compromising their nutrition. Additionally, inhalation of indoor cooking fuels is a well-known risk factor for chronic respiratory disorders, and this risk is borne disproportionately by women. The list goes on.
The way forward
So how might we move forward at this critical time to ensure that we are effectively addressing the unique needs of women in the NCD epidemic? This problem is evidently complex and multifaceted. Presented here are some possible approaches, to firstly broaden our understanding of women’s health to include NCDs, and secondly to ensure that women are empowered and engaged in their own health.
Defining women’s health
One important step forward is to adopt a broader and more holistic definition of women’s health. Historically, the field of women’s health has focused on reproductive health, and consequently, considerable gains have been made in reducing maternal and newborn mortality and morbidity. While these gains are positive and important, it is equally important that the definition of women’s health not be confined to reproductive health. As Norton et al. posit in Women’s Health: A New Global Agenda, the currently narrow approach to women’s health firstly limits opportunities to effectively improve the health of the maximum number of women, and secondly, discriminates against women who do not have children.
In recent years, many international advocacy efforts have thus been made to expand this definition, and encompass a more holistic view of the health challenges faced by women. Such focus areas include, but are not limited to: the burden of NCDs in women, including mental health; the caring roles of women; and sexual and interpersonal violence. Additionally, the health of women must be considered across the whole life course. A reproductive focus risks excluding pre-adolescent girls and older women, all of whom face unique challenges in navigating their health in a climate of gender inequity. Indeed, women who have been through menopause have substantially increased risk of NCDs. Thus a focus on older women should be an integral of a life course approach to women’s health.
Integrating NCDs into other health programs
There are great opportunities to capitalise on existing healthcare services to better address the needs of women in the NCD epidemic. There is enormous opportunity to expand existing reproductive, communicable disease (such as HIV and tuberculosis) and sexual health services to incorporate NCDs. In particular, maternal and reproductive healthcare services are targeted at women, allowing healthcare to be delivered in an environment that is acceptable to, and accessible by, women and adolescent girls. Given the unique challenges faced by women in the NCD epidemic, these existing services can be broadened to include health promotion activities around NCD risk factors, early diagnosis and screening services (including breast and cervical cancer screening) and referral and treatment services. This will ensure that women are empowered to improve the health of themselves, their families and communities. One such approach might be to follow up women with gestational diabetes after birth and to provide screening checks and education around good nutrition for mothers and children in order to prevent the development of diabetes. There is growing evidence for the feasibility and effectiveness of health system integration to prevent and control NCDs. [9,10]
Women in medical research
There is scope for the broader scientific and research community to ensure that women are equally represented in medical research. It is increasingly apparent that NCDs do not affect men and women equally. Women who smoke have a 25% greater relative risk of ischaemic heart disease than men who smoke. Women suffer worse cardiovascular disease as a consequence of type 2 diabetes than men, and women with type 1 diabetes have a roughly 40% greater risk of all-cause mortality than men. However, taking a focused biomedical approach is not sufficient to address the burden of NCDs in women. Medical research must also consider the social and cultural effects of gender inequity in order to fully appreciate the health outcomes of women with NCDs. Increasing attention to gender-disaggregated of research data has been recognised in the Sustainable Development Goals as an important tool for discovering these important gender disparities in illness.
Engaging women at every level
Lastly, increasing female participation in decision-making will ensure the challenges faced by women are reflected in policies for health and sustainable development. Participation happens at every level. In local communities, women are attuned to the needs of other people, and as evident above, make many of the health related decisions in the community. There is a huge opportunity to harness their strength and knowledge to be a driving force for the prevention of NCDs. The impact of educating women has multigenerational effects due to their central position in the community, so improving women’s engagement with health promotion is a high yield intervention. There must be a concerted global effort to remove barriers to female participation in politics and high-level decision-making. Until this is achieved, it will be challenging to ensure that the multifaceted effects of gender inequity are accounted for in national and international policy.
Noncommunicable diseases are one of the biggest threats to health in an increasingly globalised world. Addressing gender inequity will be a necessary component of the solution. The health of women concerns everyone, and is far more than an economic, political or cultural issue. Ultimately, ensuring every woman and girl has the right to access the utmost level of health and wellbeing is an issue of human rights and justice.
Charlotte has completed 4 years of medical school at Monash University. She is currently undertaking a Bachelor of Medical Science (Honours) at the Uehiro Centre for Practical Ethics at the University of Oxford. Charlotte undertook a 3-month internship at the World Health Organization in early 2017 in the Global Coordination Mechanism for the prevention and control of noncommunicable diseases (NCDs).
Conflict of Interest
- World Health Organiz NCD mortality and morbidity [Internet]. Geneva: World Health Organization. 2017 [cited 27 May 2017]. Available from: http://www.who.int/gho/ncd/mortality_morbidity/en/
- The World’s Women 2015. 2015. United Nations Statistics Division [Internet]. Accessed from: https://unstats.un.org/unsd/gender/chapter3/chapter3.html
- Insights from 10,000 women on the impact of NCDs [Internet]. Arogya World. 2014. Accessed from: http://arogyaworld.org/wp-content/uploads/2014/12/Arogya-Full-Report-For-Web.pdf
- Matoff-Stepp S, Applebaum B, Pooler J, Kavanagh E. Women as health care decision-makers: Implications for health care coverage in the United States. Journal of health care for the poor and underserved. 2014;25(4):1507-13.
- World Health Organization. Gender, women, and the tobacco epidemic. World Health Organization; 2010.
- Slade T, Chapman C, Swift W, et al Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression BMJ Open 2016;6:e011827. doi: 10.1136/bmjopen-2016-011827
- World Health Organiz Household air pollution and health [Internet]. Geneva: World Health Organization. 2017 [cited 27 May 2017]. Available from: http://www.who.int/mediacentre/factsheets/fs292/en/
- Peters SA, Woodward M, Jha V, Kennedy S, Norton R. Women’s health: a new global agenda. BMJ Global Health. 2016 Nov 1;1(3):e000080.
- Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, Geng E, Petersen ML, Thirumurthy H, Kamya MR, Havlir DV, Charlebois ED. Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda. PloS one. 2012 Aug 20;7(8):e43400.
- Janssens B, Van Damme W, Raleigh B, Gupta J, Khem S, Soy Ty K, Vun MC, Ford N, Zachariah R. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia. Bulletin of the World Health Organization. 2007 Nov;85(11):880-5.
- Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies
- Woodward M, Peters SA, Huxley RR . Diabetes and the female disadvantage. Women’s Health (Lond Engl). 2015; 11: 833-839.
- Huxley RR, Peters SA, Mishra GD, Woodward M. Risk of all-cause mortality and vascular events in women versus men with type 1 diabetes: a systematic review and meta-analysis. The Lancet Diabetes & Endocrinology. 2015 Mar 31;3(3):198-206.
- United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. Geneva: United Nations. 25 Sept 2015.