4. Communicable diseases and gender norms

Tuberculosis (TB), malaria and the so-called neglected tropical diseases, including schistosomiasis, trachoma and lymphatic filariasis, continue to affect millions of women and men in LMICs. Such diseases have strong links to poverty, adding to the threats to people who already face hardship and poor living conditions.

Norms about gender roles and exposure to infection

Gender norms influence exposure to infection for both men and women. Young men working in forestry, fields or mines may be more exposed to malaria infection than women working in the kitchen, who are protected from insect bites by smoke from cooking fires. Men who sit or sleep outside, and women and girls who carry out chores before dawn may also be more exposed to malaria-carrying mosquitoes. However, the risks may be lower for women in conservative societies where they must cover their bodies for modesty.

Girls’ and women’s responsibilities for collecting water and washing clothes in rivers in several LMICs exposes them to water-borne and water-related infectious and neglected tropical diseases including schistosomiasis, but boys who play in infected rivers and canals often have a higher prevalence and intensity of the infection. Where the mobility of girls and women is restricted, as in conservative Muslim countries, they are less exposed to water and have lower rates of infection.

Care responsibilities leave women and girls more vulnerable to persistent trachoma infection than men, and with a risk of trachoma-related blindness that is two to four times greater. Young children pass the infection to their mothers, while crowded living conditions, poor hygiene and smoke from cooking fires make eyes susceptible to infection.

Norms about feminine and masculine behaviours

Because women tend to be more risk-averse, and because they have to take care of children, they are more likely to use insecticide-treated nets (ITNs) than men. One study in Nigeria has found that males aged 15-25 were the group least likely to use an ITN.

Men’s increased risk-taking, including alcohol and tobacco use, increases their exposure to TB infection. The need to conform to the masculine ideal of showing strength in adversity may also lead them to delay or avoid treatment. In urban Malawi, many low-income young men heading households have tried to display the stoicism expected of them in public and have delayed seeking care for TB or used alcohol to manage their pain in private.

Norms about gender roles and access to healthcare

Women with household responsibilities – particularly those with young children – may prioritise these and delay seeking treatment for their own severe infections. Men, meanwhile, may delay because they prioritise household income and the need to provide for their family. Men in urban Malawi, for example, delayed treatment for TB to avoid being seen as ‘less than men’. A study in Kenya on why patients missed scheduled appointments for HIV treatment found that men cited work commitments while women cited family commitments.

Norms about decision-making over use of household resources and access to healthcare

The health problems of adolescent girls and young women may be a low priority when resources are scarce, given their limited economic autonomy and the devaluing of their contribution to household income. Two reviews on factors affecting the uptake of malaria interventions during pregnancy in sub-Saharan Africa have pointed out that pregnant women depend on their husbands to access malaria treatment and for permission to do so.

While women are more likely to use ITNs than men, they may be less able to access them or re-treat them if they lack decision-making power and money. A male head of household may be given priority use of an ITN if there are not enough nets for every household member.

Norms about stigma

Studies note that stigma and women’s greater vulnerability to discrimination can shape their access to treatment for infectious diseases. Many adolescent girls in sub-Saharan Africa struggle to access reproductive health services, but pregnant adolescent girls (who are particularly vulnerable to malaria) may face even greater difficulties in accessing ante-natal care and malaria treatment because of the stigma linked to adolescent pregnancy.

While data indicate that men have higher TB prevalence and mortality rates than women, some studies suggest significant under-reporting and under-treatment of women with TB. This is linked to stigma: from Latin America to South and East Asia, women with TB face rejection, divorce and abandonment. As a result, they delay treatment, hide their diagnosis and rely on self-medication or traditional healers and informal health providers. Fear of rejection and social isolation can result in the under-reporting of female TB cases.