Background Increasing control and empowerment are considered central to efforts to reduce health inequalities. From our critical review of theory, low control or powerlessness emerged as a potentially fundamental mechanism underlying social inequalities in health. Amartya Sen’s theories of “freedom” and “capabilities” to live a long and healthy life have been influential: focusing attention on the health consequences of a lack of freedom for women in contexts where there is pervasive gender discrimination. We conducted a systematic review, which addressed the question: what is the empirical evidence of the extent and nature of the relationship between control in the living environment and health-related outcomes, differentiated by gender, socio-economic status or ethnicity? Findings relating to gender inequalities are presented here.
Methods Logic models developed from our critical review of theory were used to guide our search strategy and to locate relevant literature. Studies were identified by searching seven bibliographic databases, screening reference lists, consulting key informants and searching organisational websites. Observational studies of any design were included that addressed our review question. Data extraction and quality appraisal of included studies were carried out by two reviewers, with disagreements brought to the wider team for discussion. This was followed by a narrative synthesis.
Results We identified 61 studies, 25 of which reported findings on the health-related outcomes of low control/discrimination against women, all but one set in low and middle-income countries. There is some evidence that women with low control have reduced freedom of movement and control over important determinants of health such as access to food and nutrition, household resources, healthcare, education, employment, land and property ownership and reproductive rights. For women, low control or autonomy was associated with increased anxiety, stress and depression, increased childhood malnutrition and mortality, higher fertility, poorer reproductive health and higher levels of violence against women. Son preference, in societies characterised by low female control and discrimination, is associated with poorer health outcomes that include reduced survival of girls and women; resulting in the phenomenon of “missing women”. The effects of gender discrimination on survival begin before birth through selective abortion of female foetuses, leading to distorted population demographics.
Conclusion There is empirical evidence of an adverse impact on the health of women and female children living in societies in which they suffer low control and overt gender discrimination. Purposeful measures to improve the economic, social and political position of women in their societies are advocated to improve the situation.