IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 88 Women’s empowerment under the lens of global health equity: Literature review of challenges, best practices, and societal impact Walaa Al-Chetachi1, Agafya Krivova1, Hana’a Badran1, Saida Azam1, Eman Radwan1,2, Yasmine Shalaby1,3, Mithila Orin1, Edith Quintanilla1, Shafi Bhuiyan1,4,5 1Ryerson University, Toronto, Canada; 2Queen’s University, Kingston, Canada; 3McMaster University, Hamilton, Canada; 4University of Toronto, Toronto, Canada; 5Bangladesh University of Health Sciences Corresponding author: S. Bhuiyan (shafi.bhuiyan@utoronto.ca) ABSTRACT Introduction: Women’s empowerment refers to strengthening the social, economic, and educational powers of women. Numerous global initiatives have been implemented to enable women to make decisions about their health and lives. The purpose of this literature review was to review women’s health barriers, related best practices, and their impacts on women's empowerment in the global context. Methods: We comprehensively searched databases: PubMed, CINAHL, and Google Scholar and key program websites. To expand our review, we used a snowball strategy to scan articles, documents, reports, and research outputs of global programs and best practices to overcome barriers. Also, we screened publications posted on websites of organizations working on women’s empowerment and monitoring the Sustainable Development Goals progress. Results: Findings suggest significant advancements have been made in the status of women's health over the past two decades. However, the COVID-19 pandemic has aggravated health barriers, impeding, and even reversing progress, which has resulted in widening women’s inequity in access to health care services worldwide. Conclusions: Findings suggest that successful and sustainable programs should have a multisectoral, multilevel and multistakeholder, diversified interventions approach with social empowerment, as well as the need for legislative enforcement against discrimination and harmful practices towards women. KEYWORDS Literature Review; Global Initiative; Women’s Empowerment; Women’s Health INTRODUCTION Women’s empowerment and promoting women’s rights have emerged as part of a major global movement and continue to break new ground in recent years. These efforts are essential to the health and social development of families, communities, and countries (World Health Organization, 2019a). The World Health Organization (WHO) defined health as “a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity” (World Health Organization, 2021b). Women empowerment refers to strengthening the social, economic, and educational powers of women and it is defined as “the process by which women take control over their lives, acquiring the ability to make strategic choices” (UN Commission on the Status of Women, 2002, p.1). Numerous global initiatives are implemented to empower women from the health point of view and to address the most impactful and essential health-related challenges. The United Nations (UN) 2030 Agenda for Sustainable Development embraces three main principles, with the second and third ones emphasizing “leave no one behind (LNOB)” and “gender equality and women's IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 89 empowerment” respectively (United Nations Sustainable Development Group (UNSDG), 2021). Whereas Sustainable Development Goal (SDG) 3 focuses on health “for all at all ages,” and SDG 5 highlights women's empowerment and reinforces the necessity of scientifically robust indicators to address women’s multiple health priorities (United Nations Department of Economic and Social Affairs (DESA), 2021). The SDGs urge universal health coverage as necessary for meeting essential women’s health needs. Hence, barriers to women’s empowerment including social, cultural, financial, legal, and structural gender inequalities still impede women’s autonomy and decision-making power over their health and limit their healthcare services access and utilization (World Health Organization, 2019a, p.9). Various research illustrates the significant impact of the barriers mentioned above on women’s health. WHO 2017 report showed that each day about 810 women around the world lost their lives due to pregnancy and childbirth preventable causes, with 94% of these deaths reported in low-resource settings (World Health Organization, 2019b). Moreover, 66% of maternal deaths occurred in the sub-Saharan Africa region due to a lack of access to sexual and reproductive care (World Health Organization, 2019c, p.33). Statistics show that 15% of women in the UK have experienced mental illness, including anxiety, post- traumatic stress disorder, and depression, during the perinatal period. These mental illnesses account for 9% of maternal mortality (Ford et al., 2019a). A report from the US demonstrated that about 900,000 women develop postpartum depression (PPD) each year; however, only 6% of them ask for psychological support (Grissette et al., 2018). Several systematic studies indicated that the main barriers to health- seeking behavior for PPD are lack of knowledge and support, fear of social stigma, and judgment or inability to guarantee their rights in child custody (Ford et al., 2019; Hadfield & Wittkowski, 2017). WHO recorded that cardiovascular diseases (CVDs) mortality among women in low- and middle-income countries (LMICs) is 1.7 times higher compared to those living in high-income countries (HICs) (World Health Organization, 2016). This reflects a lack of awareness of women’s CVDs symptoms among patients themselves and healthcare providers, leading to delays in diagnosis, hospitalization, and treatment (World Health Organization, 2019a, p.18). Any emergency, such as natural disaster, war, conflict, or pandemics, magnify the barriers and worsen the condition of vulnerable people, especially women and children. For instance, the recent COVID- 19 pandemic exacerbates fears of getting infected and limits women's ability to access healthcare services and programs; thus, it impedes or even reverses the progress of ongoing initiatives (Cousins, 2020). Violence against women and girls (VAWG) has been intensified during the last 12 months of the pandemic, with 243 million women and girls having experienced physical or sexual violence (United Nations Women Organization (UN Women), 2020). France reported an increase of VAWG cases by 30% (United Nations Department of Economic and Social Affairs, 2020, p.19). Moreover, UN Women recently reported a five-times increase in the helpline calls due to intimate partner violence (UN Women, 2021a). Women account for more than 2/3 (70%) of healthcare providers worldwide and are more likely to be at the frontline. (United Nations Department of Economic and Social Affairs, 2020, p.10). Women also contribute to unpaid healthcare services up to 2.35% of global GDP, which is about US$ 1.5 trillion (United Nations Department of Economic and Social Affairs, 2020, p.14). Women also make up most of support staff, including cleaners, laundry, and catering workers, who have a higher risk of COVID-19 exposure (United Nations Department of Economic and Social Affairs, 2020, p.10). Moreover, in the US, recent research showed that women constitute 3/4 of COVID-19 infected healthcare workers (Team et al., 2020). There are numerous studies on specific topics related to women's empowerment; however, there is limited information available that focuses on all aspects of women's health empowerment (Andrés López Cabello & Ana Cecilia Gaitán, 2021; Clark Helen & Sy Elhadj As, 2020; Heymann et al., 2019). Thus, this literature review aims to investigate women’s empowerment health barriers in terms of physical, mental, and social well-being in the global context and describe the best practices, programs, and interventions and their impacts on health. We consider this review as a guideline for policy makers and other stakeholders to facilitate knowledge IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 90 translation and address women’s multiple health priorities. METHODS Journal articles and grey literature were reviewed to identify best practices and programs aimed at improving women’s health by addressing gender inequity. PubMed, CINAHL, and Google Scholar were also reviewed for relevant articles, as well as programs and initiatives published on websites of the organizations that address global health issues. Websites searched included WHO, the United Nations (UN), the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), and the International Center for Research on Women (ICRW). Keywords used included: “barriers of women empowerment,” “women’s physical health,” “women’s mental health,” “social determinants of women’s health,” and “COVID-19 impact on women’s health”. To expand our search, a snowball strategy was used by scanning the references list of articles, documents, reports, and varied global programs. The reviewed resources were articles written in English and containing the most recent data. We focused on displaying the gaps between LMICs vs. HICs and women vs. men to illustrate the current situation and provide the context for potential advancement. RESULTS Women Physical Wellbeing Challenges and Best Practices The physical health of women is not only limited to equal access to essential health care services on endemic infectious diseases or emergency services, but also encompasses the access to female-specific care to reduce maternal mortality, eliminate female genital mutilation and violence against women, and decrease the burden of non-communicable diseases (NCDs) (cardiovascular diseases; cancers; chronic respiratory diseases; and diabetes). Many stakeholders strive to improve women’s health and prevent NCDs premature deaths, such as “The NCD Alliance” which consists of International Diabetes Federation, International Union Against Tuberculosis and Lung Disease, Union for International Cancer Control, and World Heart Federation, that was established in 2008 (NCD Alliance, 2015); “The Taskforce on Women and NCDs” and many others (Women and NCDs Taskforce, 2021). According to UN and WHO data published in 2019, out of 193 countries, only 35 will achieve the 2030 Sustainable Development Goal (SDG) target 3.4 for women, which aim to decline the probability of NCD related deaths by 1/3 among 30 to 70 years old women compared to 2015 levels (NCD Alliance, 2019). Most maternal deaths worldwide can be prevented through access to quality health services. Recent statistics highlight health inequality between rich and poor countries, where the maternal mortality of low-income countries (LICs) is 130 folds more than in HICs (World Health Organization, 2021c). Over a five-year period (2014 – 2019), it was reported that more than 80% of all deliveries were attended by skilled health professionals worldwide (World Health Organization, 2021a). In fact, almost 2/3 of maternal deaths, stillbirths, and newborn deaths (67%, 65%, 64%, respectively) could be averted by midwifery service (Nove et al., 2021). However, there is still a shortage of approximately 900,000 midwives. Furthermore, the COVID-19 pandemic has magnified this problem as midwives have been transferred to other healthcare services (United Nations Population Fund (UNFPA), 2021). Hence, maternal mortality increased by 2.3 per 100,000 deliveries compared to the pre-COVID era (United Nations Development Programme (UNDP), 2020, p.17). Table 1 describes certain women's physical health challenges, such as maternal mortality, female genital mutilation (FGM), violence against women and NCDs, and the interventions with their impacts. Mental Well-Being Globally, mental health conditions are on the rise (WHO, 2021c). In 2017, it was found that almost 1 billion people, without significant gender difference, suffered from a mental health problem or substance abuse (Our World in Data, 2021). This accounted for 14% of the global burden of disease, with the majority (75%) of people affected in many LICs lacking access to the required standard treatment (WHO, 2020f). IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 91 Specifically, suicide accounted for more than 700,000 deaths annually, with 77% occurring in LMICs (WHO, 2021b, p.1), with the highest rate of 7.1 per 100,000 among females (WHO, 2021f). Moreover, suicide is considered the third leading cause of death among girls aged 15–19 (WHO, 2021b, p.1). In addition, depressive disorders cause about 1/3 of psychiatric illness disability among men compared to 2/5 among women (WHO, 2020g), affecting almost 1 in 4 women in LMICs (NCD Alliance, 2019). Moreover, in 2020, it was found that unipolar depression was the second leading cause of disability, with women affected 2 times more often compared to men (WHO, 2020g). In developed countries, approximately 20% of men compared to 8% of women have alcohol dependence during their lifetime (WHO, 2020g). However, a US study reported that during the COVID-19 pandemic, there was a more than 40% increase in the number of heavy drinking days for females over the baseline (0.44 days per month) (Pollard et al., 2020). Recent statistics showed that about 20% of people who lived in post-conflict settings suffered from mental health problems (WHO, 2021c). Moreover, it was reported that women and children formed 80% of the 50 million people affected by violent conflicts, civil wars, disasters, and displacement (WHO, 2020g). The COVID-19 pandemic has interrupted essential mental health services in 93% of countries globally, despite increased demand (The World Bank, 2021b). In Table 2, we summarize the most prevalent challenges related to mental health, with best practices and their impact. Namely, general mental health challenges, mental illness related to physical abuse, eating disorder (ED), and perinatal depression (prenatal and postnatal). Social Well-Being WHO defined the social determinants of health (SDH) as the non-medical factors in which people are born, grow, work, live, and age. For instance, “poor health” is claimed 100% more often in the low educated population compared to people with post- secondary education. Moreover, the difference in life expectancy between high- and low-income countries accounts for 19 years (WHO, 2021h). The United Nations Educational, Scientific and Cultural Organization (UNESCO) recent report illustrates that due to the COVID pandemic, 11 million adolescent girls are not expected to return to school (UNESCO, 2021c). SDH are more essential than lifestyle choices at affecting peoples’ health, where many studies illustrate that these factors influence 30-55% of health outcomes (WHO, 2021h). Table 3 demonstrates particular social challenges that hinder women’s empowerment and impact their health, as well as the global and local best practices to address these challenges. DISCUSSION According to our findings, significant advancements have been made in women's health status over the past two decades. The major turning points in achieving gender equity are ratifications of the Beijing Declaration and the Sustainable Development Goals (SDGs). Some countries (e.g., Norway, Australia) have a proven success in reaching all 3 SDGs targets. Maternal mortality goal is achieved by developed countries as well as some developing countries (e.g., Brazil, Argentina, Egypt, Morocco, Saudi Arabia, Iran, Oman, Malaysia, Thailand). While gender parity goals are achieved by few countries (Argentina, Namibia, Norway, Sweden), others are still lagging. Moreover, the COVID-19 pandemic has aggravated health barriers, impeded, and even reversed indicators progress, and revealed women's inequality in access to health care services worldwide. Overall, a substantial decline of 38% in MMR was achieved globally between 2000 and 2017, with the best outcome of a 60% reduction reported in Southern Asia (from an MMR of 384 down to 157 per 100,000 live births) (World Health Organization, 2019d). One of the most important interventions attributed to maternal death reduction is the attendance of skilled health professionals, where more than 65% of these deaths could be averted by midwives’ assistance (Nove et al., 2021). Unsafe abortions alone cause 4.7% - 13.2% of maternal deaths annually (WHO, 2021k). Hence, unwanted pregnancy prevention is highly essential, particularly IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 92 among adolescents, through easy access to family planning and safe abortion services. In 2020, UNFPA reported that contraceptive provision prevented 14.5 million unwanted pregnancies and 4.1 million unsafe abortions and saved the lives of 39,000 mothers (UNFPA, 2020b). Another point to consider is the political influence on women’s empowerment and health autonomy. 700 million women's lives are affected by inaccessibility to safe and legal abortion services, causing 23,000 women’s deaths (Center for Reproductive Rights, 2021a). Moreover, it leads to 7 million hospital admissions annually in developing countries with the cost of more than half a billion US$ to manage unsafe abortion complications globally (WHO, 2021k). The legalization of abortion and sexual education are proven to prevent death and disability (WHO, 2021k). Encouragingly, more than 600 million women, or 37%, ages ranging between 15-49 years, in 73 countries worldwide, are legally able to request an abortion (Center for Reproductive Rights, 2021b, p.1). It could be done mainly within the first 12 weeks of pregnancy, and even in some countries, women could terminate their pregnancies up to 22 weeks, at their personal request (i.e., Iceland, some states in Australia) (Center for Reproductive Rights, 2021a). Despite numerous interventions to tackle VAWG, as the COVID-19 pandemic evolves, an alarming level of violence has been reported around the globe, with some experts describing it as “the shadow pandemic.” Moreover, current statistics do not reflect the actual extent of the problem due to under- reporting, where fewer than 4 in 10 victims reporting or seeking any kind of help. Lack of access to the helplines and disruption of public health and social services are the main reasons for inadequate reporting (Phumzile Mlambo-Ngcuka, 2020). Currently, women in 25% of countries are not legally protected against domestic violence (Phumzile Mlambo-Ngcuka, 2020). Law enforcement, women's education, and economic independence, as well as school and community awareness programs targeting women and men, are fundamental to combat VAWG (UN Women, 2020a), (Lancet Child & Health, 2021). The cornerstone to achieving SDG targets is education. Evidence reveals that women with secondary education compared to those without formal education are more likely to be employed, with a 200% increase in earnings, a 20% drop in mortality among their children under the age of five, a 75% decrease in adolescent pregnancy, and reduction in early marriage to the point where it almost is eliminated (UNESCO, 2021a, p.6). Unfortunately, in 10 countries worldwide (Benin, Cameroon, Guinea, Haiti, Mali, Nigeria, Pakistan, Papua New Guinea, Senegal, and Timor-Leste), the least privileged girls have fewer than 2 years of schooling. This includes over 80% of girls in Guinea, Mali, and Pakistan (UNESCO, 2021c). This reflects the fact that small monetary incentives for school fees, uniforms, books, and other supplies, such as menstrual hygiene products, are required to enroll girls at school and continue their education (Tai Kuncio, 2018, p.5). It is predicted that when girls are educated at the same level as boys, this has the potential to add US$ 1 billion annually to the economy of some African countries (UNESCO, 2021d). Moreover, if gender equity is adopted in the labor market, it will add around US$ 30 trillion to the global GDP by 2025 (McKinsey Global Institute (MGI), 2015, p.8). Mental health promotion and awareness programs were proven to alleviate stigma and change attitudes toward mental diseases, provide information about available services, and increase help-seeking behaviors (WHO, 2021b, p.26). WHO mental health intervention targeted school students using socioemotional learning curriculum to prevent suicide showed 50-100 healthy life years gained annually per 1 million population globally (WHO, 2021j, p.5). Another mental health initiative is community- based mental health support, which focuses on human rights and patient recovery, such as KeyRing living arrangements for mentally ill people. This program demonstrated a 30% reduction in psychiatric inpatient admission and homelessness, a 25% decrease in the necessity of weekly visits for community mental health care providers, and a 20% drop in the need for drug/substance dependence worker weekly visits (WHO, 2021a). Thus, successful, and sustainable interventions resulting in long-term health improvements are found to have multisectoral, multilevel and diversified approaches and social mobilization and empowerment (Heymann et al., 2019). Finally, IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 93 increasing women's representation in leadership positions will facilitate the initiation and implementation of laws and policies to support equity in all aspects of women’s lives, not only health (Heymann et al., 2019). LIMITATION The methodology used was limited to articles written in English, so some articles in other languages might be missed. We excluded all programs, even high- quality ones, that were evaluated exclusively by qualitative methods. In addition, we extracted reviews from three electronic databases (PubMed, CINAHL, and Google Scholar) and complemented the search with web screening. Hence, our analysis may have missed reviews located within other resources. Although there are different types of barriers to women's empowerment, we only searched articles discussing women’s empowerment through the dimension of health and gender equity. This paper also does not focus on cultural and religious differences that might influence the definition of women’s empowerment or mental health. Hence, the statistics reported are likely underestimated, especially for women living in developing countries. At the same time, we did not spotlight different gender subgroups due to the scarce amount of disaggregated data. Although we comprehensively reviewed global initiatives on women’s empowerment in the context of health, not all ongoing global programs have established reporting and/or monitoring and evaluation systems. Our search was constrained by the under-representation of women and under- reporting of sex-specific data, especially during the COVID-19 pandemic. IMPLICATIONS In practice, holistic approach should be considered to achieve women health autonomy embedded in all sectors with a focus on development of gender equity culture, education, economic independency, policy, and legislation, as well as society engagement. Other countries shared experience and lesson learnt are crucial to develop a roadmap in adopting successful interventions, programs, legislations, which should be tailored to the cultural context and resources availability of a particular country. This study provides an understanding of women health empowerment barriers and reflects the real situation based on scientific data to study and support interventions and policy changes that may affect and improve not only women health but the whole community. RECOMMENDATION AND CONCLUSON Exploring the barriers to women’s empowerment through the lens of physical, mental, and social well- being dimensions of health has illustrated an in-depth understanding of various factors that should be focused on to achieve health equity. Gender norms and relations intersect with socioeconomic, geographic, and cultural factors fueling gender inequities and magnifying these barriers. Numerous governmental, non-governmental organizations and stakeholders are continuously working all over the world to overcome these barriers, and many have been able to achieve significant results. While significant advancements have been made in policies towards better equity for women, we still have a long way to cover all the aspects of women’s empowerment. The COVID-19 pandemic has aggravated health barriers/challenges, impeded, and even reversed indicators progress, and revealed the extent of women's inequity in access to health care services worldwide. Finally, successful, and sustainable programs that achieve long-term health improvements should include a multisectoral approach, multilevel and multistakeholder engagement, diversified interventions, and lastly, social involvement and empowerment. REFERENCES Amiri, S., Behnezhad, S. (2021). The global prevalence of postpartum suicidal ideation, suicide attempts, and suicide mortality: A systematic review and meta- analysis. 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Maternal and reproductive health. https://www.who.int/data/gho/data/themes/mater nal-and-reproductive-health World Health Organization, London School of Hygiene and Tropical Medicine, & South African Medical Research Council. (2013). Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. https://apps.who.int/iris/handle/10665/341726 https://www.who.int/data/gho/data/themes/maternal-and-reproductive-health https://www.who.int/data/gho/data/themes/maternal-and-reproductive-health IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 101 Grhttps://www.who.int/publications/i/item/978924 1564625 Yan, H., Ding, Y., & Guo, W. (2020). Mental health of pregnant and postpartum women during the coronavirus disease 2019 pandemic: A systematic review and meta-analysis. Frontiers in Psychology, 11, 3324. https://doi.org/10.3389/FPSYG.2020.617001/BIBTEX . IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 102 Table 1. Women’s Physical Well-Being Challenges and Best Practices with Impacts Maternal Mortality Challenges 1. 2019 UNFPA report indicated that maternal mortality ratio (MMR) was • 211 per 100,000 live births (UNFPA, 2019a) 2. In 2017, WHO reported deaths due to preventable causes related to maternal mortality toll: • 295,000 women worldwide • two-thirds (196,000) of them occurred in Sub- Saharan Africa (WHO, 2019a) 3. A woman’s lifetime risk of maternal death is: • 1 in 5400 in HICs • 1 in 45 in LICs (WHO, 2019a) 4. Birth attendance by skilled health personnel varied from: • Less than 50% in LICs and LMICs • more than 90% in HICs (WHO, 2019a) 5. WHO data indicated that women’s social independence is related to antenatal care coverage (have ≥ 4 visits): • 73% of women with higher social independence • 44% of women with low social independence (World Health Organization, 2019a, p.7) 6. Worldwide, only 41% of women were provided with maternity benefits (International Labour Organization (ILO), 2019, p. 54) Best Practices 1. The ending preventable maternal mortality (EPMM) is a collaborative global framework that has five main strategic objectives summarized in: • Address all causes of maternal mortality, reproductive and maternal morbidities, and all inequities in the access • Ensure Universal Health Coverage (UHC) and accountability to improve the quality of sexual, reproductive, maternal, and newborn health care • Strengthen health systems (WHO, 2015, p.15) 2. Maternal and Newborn Health Thematic Fund (MHTF) is UNFPA’s program that supports 32 countries in four key thematic areas: • midwifery, emergency obstetric and newborn care (EmONC) • maternal and perinatal death surveillance and response (MPDSR) • obstetric fistula (UNFPA, 2019c, p.8) 3. EmONC launched an innovative approach to key obstetric emergencies training, providing both: • mobile learning • e-learning (UNFPA, 2019c, p.12) Impact IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 103 1. Out of 155 reporting countries, most healthcare services are free of charge: • 97% for maternal and child immunizations • 82% HIV testing and treatment • 80% antenatal care • 71% normal deliveries • 70% family planning • 68% cesarean sections • 65% contraceptives • 33% infertility management (World Health Organization, 2019a, p.11) 2. Since the implementation of the MHTF in 2008: • 150,000 midwives underwent standardized training • 26 million safe births managed annually • 750 midwifery schools were provided with all learning resources • over 12,000 midwifery tutors participated in certification upgrades (UNFPA, 2019c, p.12) 3. The MHTF reported that as of 2019 in Benin and Guinea, more than half of the population now has access to EmONC facilities within ≤ 2 hours of travel distance (UNFPA, 2019c, p.15) 4. Between 2000 and 2017, the average rate of reduction in global maternal mortality per year was 2.9% (WHO, 2020b) Female Genital Mutilation (FGM) Challenges 1. Globally, statistics showed that: • 200 million girls and women experienced some form of FGM during their life • almost 3.9 million girls underwent FGM annually • 4.6 million girls are predicted to be at risk for FGM in 2030 and onward • 68 million girls are predicted to be mutilated during the period between 2015 to 2030 • almost 20% of FGM procedures among girls were done by a trained medical professional (UNFPA, 2021b) • 22% of countries with data on FGM do not ban or legally criminalize it • 16% of those countries did not develop any national strategy or plan to end FGM (UNFPA, 2019b, p.5, p.6) • about 600,000 women living in Europe underwent FGM outside the EU, and a further 180,000 girls are at risk in 13 European countries, although this procedure is illegal (News European Parliament, 2020) • 2 million more cases of FGM are expected to occur during the next 10 years due to the disruption of prevention programs caused by COVID (UNFPA, 2019b, p.12) Best Practices 1. 59 countries have legislation to ban FGM, including 26 of the 29 African countries where FGM is prevalent (UN Women, 2020d) 2. The UNFPA-UNICEF Joint Program to Eliminate Female Genital Mutilation (FGM) is the largest global program: • implemented in 17 countries, in partnership with governments, civil societies, social movements, religious leaders, and communities to provide culturally sensitive interventions (United Nations Children’s Fund (UNICEF), 2021) Impact 1. The UNFPA-UNICEF joint program to eliminate FGM started in 2008 and resulted in: • 31.5 million people in over 21,700 communities have declared the abandonment and disappearance of FGM (UNFPA, 2021c) IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 104 • 3.3 million women and girls have benefited from FGM-related prevention, protection, and care services (UNFPA, 2020c, p.9) • 350,630 girls have been protected from FGM during the 2018-2020 period (UNFPA, 2020d) Violence Against Women Challenges 1. 1 in 3 women has experienced physical and/or sexual violence in their lifetime, mainly by an intimate partner (WHO, 2021i) 2. The prevalence of lifetime intimate partner violence ranges from • 20% in the Western Pacific • 33% in the WHO African and South-East Asian regions (WHO, 2021i) • 55-95% of women survivors of violence do not disclose or seek any type of services (WHO, 2019c, p.5) • 137 women are murdered daily by a family member globally (United Nations Office on Drugs and Crime (UNODC), 2019, p.13) • 38% of murdered women are killed by intimate partners worldwide (WHO, 2021i) 3. Statistics showed that women who experienced violence are: • more than twice as likely to undergo induced abortion • > 1.5 times likely to be infected with syphilis, Chlamydia, or gonorrhea • 1.5 times more likely to contract HIV • 16% more likely to deliver a low birth-weight newborn (World Health Organization et al., 2013, p.1) • 43% more likely to experience preterm births (World Health Organization, 2019a, p.20) 4. During the COVID-19 lockdown, a significant increase in VAWG has been reported with: • 300% increase in helpline calls in Vancouver (UN Women, 2020b, p.2), 33% in Singapore, and 25% in Argentina (UN Women, 2020a, p.2) • More than three-fold increase in the number of visits to the domestic violence resource website over a period of 3 weeks in New York (UN Women, 2020b, p.2) 5. Providing services remotely is challenging for frontline healthcare staff: • 40 % of them have reported increased demand for help by survivors • 70 % have reported an increase in complexity of cases in New South Wales, Australia (United Nations Department of Economic and Social Affairs, 2020, p.18) • 67% of frontline healthcare staff acknowledged IT barriers • 42% of them express concern about women’s safety while using phone or online services in the UK (UN Women, 2020c, p.4) Best Practices 1. UN Women’s Global Flagship Initiative “Safe Cities and Safe Public Spaces for Women and Girls” is the first global program implemented in 2011 to prevent and respond to sexual violence against women and girls (SVAW) in public spaces (UN Women, 2019b, p.22) 2. The European Union (EU) and the UN collaboratively launched in 2017 The Spotlight Initiative, a EUR 500 million program that deploys targeted, large-scale investments to protect the rights of women in Africa, • Relationship strengthening • Empowerment of women (economic and social) • Services ensured (legal, police, health, social) • Poverty reduced strategies • Environments made safe: (schools, public spaces, and work) • Child and adolescent abuse prevented IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 105 Asia, the Caribbean, Latin America, and the Pacific (UN Women, 2021c) 3. WHO and UN Women, with endorsement from 12 other UN and bilateral agencies, published RESPECT women in 2019, which aimed at policy makers to prevent violence against women • Transformed attitudes, beliefs, and norms: (UN Women, 2019a) 4. During the COVID-19 pandemic, certain interventions have been taken: • COVID-19 Global Gender Response Tracker, focusing on best practices and gaps in the COVID-19 policy response (UN Women, 2021b) • In Canada, the government assigned CAD 50 million to maintain shelters for women who experienced sexual and other forms of gender-based violence as a part of the COVID-19 response package • In Australia, AUD 150 million was designated for family violence response (United Nations Department of Economic and Social Affairs, 2020) Impact 1. Worldwide, Statistics shows: • 155 countries have passed laws on domestic violence, • 140 have legislation on sexual harassment in the workplace (UN Women, 2021a) 2. Out of 144 countries, a majority implemented post- rape services: • 90% of them provided first-line support • 94.6% of them offered post-exposure prophylaxis • 88.2% of them provided emergency contraceptives • 48.2% of them gave safe abortion services (World Health Organization, 2019a, p.20) 3. In France, during the COVID-19 pandemic, the initiative to increase the shelter for victims of abuse included: • housing pop-ups at grocery stores • 20,000 hotel room nights (United Nations Department of Economic and Social Affairs, 2020, p.18) 4. According to the UNFPA report: • 930,351 VAWG survivors received required services in 2020 (UNFPA, 2020a) Non-Communicable Diseases (NCDs) Challenges IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 106 1. More than 2/3 (73%) of all deaths among women are caused by NCDs, where CVDs and cancer constituted 45% and 20%, respectively (World Health Organization, 2019a, p.15) • Women’s deaths from CVDs are 1.7 times higher in LMICs compared to HICs (World Health Organization, 2016) • Almost 90% of 311,000 cervical cancer deaths globally in 2018 occurred in LMICs(WHO, 2020d, p.12) • 70% of cervical cancer worldwide is attributed to HPV types 16 and 18 (WHO, 2020d, p.13) 2. In 2020, the availability of publicly funded cancer care services: • Around 30% in LICs compared to more than 90% in HICs (WHO, 2020d, p.14) 3. 5-year breast cancer survival rate: • 90% in North America • 60% in LICs • This difference is caused by the lower accessibility of diagnostic procedures and treatment. (World Health Organization, 2019a, p.7) 5. Acute coronary syndrome (ACS): • 41% of women with ACS have delayed hospital visits (after 12 hours from the onset of the symptoms) compared to 37% of men • 5% of ACS among women were initially misdiagnosed compared to 3% of ACS among men (European Society of Cardiology (ESC), 2021) 6. In the US, 13% of females under the age of 65 do not have health insurance (2020 data) (Cohen et al., 2021, p.3) Best Practices 1. The NCD Lab on Women and Girls has been recently launched under WHO guidance in 2021 and targets: • NCDs • mental health • gender inequalities (The George Institute for Global Health, 2021) 2. The “90-70-90” target of the WHO global strategy to eliminate cervical cancer and save 62 million lives by 2030: • 90% of girls by the age of 15 to be fully vaccinated with HPV vaccine • 70% of women screened at the age of 35 and repeated the test at 45 years • 90% of women diagnosed with cervical disease are treated (WHO, 2020e) 3. Go Red for Women-women’s heart health awareness global program. (The American Heart Association, 2021) 4. In 2021, The Global Breast Cancer Initiative was launched to reduce breast cancer mortality by 2.5% annually by 2040, thus saving about 2.5 million lives (WHO, 2021e). It is based on 3 main pillars: • Health promotion and early detection • A timely breast cancer diagnosis • Comprehensive breast cancer management (Anderson et al., 2021) Impact 1. Cervical cancer • 34% of 155 reporting countries have human papillomavirus (HPV) vaccinations free of charge. (World Health Organization, 2019a, p.11) • ¼ of low-income countries included the HPV vaccine into their national immunization plan. (WHO, 2020d, p.14) • 100 million girls had at least one dose of the HPV vaccine during period from 2006 – 2017: o 95% of girls were in HICs (WHO, 2020d, p.14) 2. Breast cancer: • 40% of breast cancer mortality decreased in HICs between 1989 -2017 • >20% breast cancer mortality lowered by population-wide mammographic IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 107 screening, where at least 60% of invasive breast cancers are diagnosed at stage I or II (Anderson et al., 2021) IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 108 Table 2. Women’s Mental Well-Being Challenges and Best Practices with Impacts Mental Illness Challenges 1. Globally, > 80% of people with mental health conditions lack standardized and affordable mental health care(WHO, 2019d, p.1) 2. Individuals living with mental health conditions are more likely to have physical illnesses and die prematurely by 10-20 years (WHO, 2019d, p.2) 3. WHO Mental Health Atlas 2017 statistics showed that there are: • 11.9 vs. 0.1 psychiatrists per 100,000 population in HICs vs. LICs countries, respectively • 23.5 vs. 0.3 mental health care nurses per 100,000 population in HICs vs. LICs (WHO, 2017, p.32) 4. Every 40 sec a person loses their life due to suicide (WHO, 2018), with > 90% of them suffering from mental illness (Bertolote & Fleischmann, 2002) Best Practices 1. In 2019, WHO Universal Health Coverage for Mental Health (2019-2023) was launched, aiming to provide more than 100 million individuals with quality and affordable mental health care in 12 priority countries (WHO, 2021d) 2. In 2008, WHO Mental Health Gap Action Programme (mhGAP) initiative was launched in over 100 countries to prevent suicide and promote mental health well-being (WHO, 2021g) 3. WHO initiated LIVE LIFE program to tackle the suicide problem through: • restricting access to means of suicide • media for responsible reporting • life skills development among young adults early identification (WHO, 2018) Impact 1. 90% of all institutions in rural areas of Liberia implemented Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) pre-service education and trained a total of 1,251 students, which accounted for 16% of all nursing, midwifery staff, and physician assistants (WHO, 2020c, p.5) 2. Means of suicide restriction have proven to cause significant suicide reduction: • 40% reduction in suicides in Estonia after implementing the alcohol restriction policies (Canadian Centre on Substance Abuse, 2016, p.6) • 70% and 65% decrease in suicide after banning highly harmful pesticides products in Sri Lanka and Bangladesh respectively (WHO, 2019b, p.33, p.34) 3. > 1% of suicides can be averted by responsible media reporting strategies (The Centre for Addiction and Mental Health, 2020, p.9) Mental Illness Related to Physical Abuse Challenges 1. Violence prevalence rate against women in their lifetime accounts for 16% to 50% (WHO, 2020g) 2. Women exposed to intimate partner and sexual violence compared to other women are: • 7 times more likely to have post-traumatic stress disorders (PTSDs) (Trevillion et al., 2012) • 1 in 5 women in Canada suffered from online harassment in 2018 • 1 in 5 women aged 18-19 years reported online sexual harassment in the U.S. (UN Women, 2020e, p.2) IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 109 • 4.5 times more likely to attempt suicide (World Health Organization, 2019a, p.20) • 2 times more likely to suffer from depression and disorders related to alcohol abuse (World Health Organization, 2019a, p.20) 3. Globally, 85% women experienced some form of online violence: where harassment accounts almost 40%(The Generation Equality Forum, 2021, p.42) 4. Cyberviolence includes a variety of forms, such as physical threats, sexual harassment, stalking, zoom bombing, and sex trolling (UN Women, 2020f): • 1 in 10 women in the European Union has been exposed to cyber-harassment since the age of 15 • 4 out of 10 female college students in Pakistan experienced cyber-harassment in 2016 (UN Women, 2020f) 5. Online and Information Communication Technology (ICT)-facilitated violence has increased during the COVID-19 pandemic with: • 50% increase in online bullying and violence in Australia in March 2020 • 200% increase in government helpline calls in the United Kingdom for adults suffering intimate image abuse during a one-week period in March 2020 (UN Women, 2020f) Best Practices 1. “Access Now Digital Security Helpline” provides • digital security practices • rapid-response emergency assistance for women already under attack • digital rights information during the humanitarian crisis (UN Women, 2020e, p.5) 2. The “Net Tech Project” at the National Network to End Domestic Violence (NNEDV) addresses technology, privacy, and safety to stop intimate partner violence, sexual assault, and violence against women during COVID-19 (UN Women, 2020e, p.5) 3. In the US, “The SHIELD Act” is an amendment to “The Violence Against Women Reauthorization Act” of 2021, focusing on protection against an egregious form of cyber sexual abuse that disadvantageously influences women and girls (Cyber Civil Rights Initiative, 2021) Impact 1. > half a million gender-based violence survivors were provided with mental health and psychosocial support according to UNFPA report in 2020 (UNFPA, 2020a) 2. Around 12,000 advocates, law enforcement, legal professionals, and other service providers were trained in one year by the Technology Safety organization along with the “Net Tech Project” to tackle online harassment (Technology Safety Organization, 2021) 3. >235 million people accessed World Mental Health Day online awareness activities based on the International Association for Suicide Prevention (IASP) report (International Association for Suicide Prevention, 2020, p.13) Eating Disorder (ED) Challenges 1. The lifetime ED prevalence is 8.4% for women vs. 2.2% for men, with the highest prevalence of 4.6% in America, 3.5% in Asia, 2.2% in Europe (Galmiche et al., 2019) 2. In 2019, almost 42 million individuals suffered from eating disorders globally, with: • 4.7 million disability-adjusted life years (DALYs) among women vs. 2 million DALYs among men were due to anorexia nervosa and bulimia due to health system barriers(The Project HEAL Organization, 2020) 4. A recent national study on more than 36,000 Americans reported that attempted suicide prevalence rates were: • 31.4% among bulimia nervosa (BN) patients, • Almost 25% among anorexia nervosa (AN) patients IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 110 nervosa eating disorders (Santomauro et al., 2021) • Only about one in five persons with eating disorders consult care providers at the late stage of the disease requiring complex treatment (The Lancet Editorial Board, 2020) • The most affected group was 25–29 years for females and 30–34 years for males (Santomauro et al., 2021) 3. 80% out of the 30 million Americans suffering from eating disorders did not have access to treatment • 22.9% among binge eating disorder (BED) patients (Udo et al., 2019) 5. Effect of media: Statistics related to more than 10,000 women and girls from 13 countries showed that 90% of them claimed they are risking their health by unhealthy dieting due to unsatisfactory self-body image (The National Eating Disorders Association (NEDA), 2021) 6. COVID-19 effects: • In 2020, eating disorder hospitalization increased by almost 70% in Ireland (Break Binge Eating, 2021) Best Practices 1. There are many media campaigns promoting positive body image, i.e.: • The Dove Self-Esteem Project launched in 2004 (The Dove Self-Esteem Project, 2016) 2. “The World Eating Disorders Day” is a collaborative annual awareness event led by > 200 organizations from over 50 countries (World Eating Disorders Day Organization, 2021) 3. National Eating Disorder Information Center (NEDIC) in Canada offers a toll-free helpline and live chat to increase awareness and provide referrals and support. (National Eating Disorder Information Centre (NEDIC), 2021) 4. “The Beat” eating disorders organization, established in 1989 in the UK, provides services, such as: • helpline • specialist coaching “Bolster” program • training family and healthcare professionals, and others (Beat Eating Disorders Organization, 2021a) Impact 1. 56% of females claimed to have a better self-image because of body diversity media campaigns (NEDA, n.d.) 2. 60 million young people were provided with self- esteem education by the Dove Project (The Dove Self-Esteem Project, 2016) 3. The impacts of the NEDIC initiative are: • 3,500 individuals annually are provided with NEDIC services, with more than 98% of helpline users are supported and referred within 24 hours • 160,000 professionals have received NEDIC education since 2004 • > 10,000 students annually reached out by “Body Pride programming curriculum” starting from 4th grade • > 30,000 middle- to high-school students annually participate in “The Beyond Images and Au-delà de l’image” curricula (National Eating Disorder Information Centre (NEDIC), 2021) 4. The coaching specialists support - “Bolster” program of The Beat eating disorder organization reported • 36% reduction in the severity of eating disorders • 50% reduction in the severity of depression among eating disorder patients 5. Helpline support service users of The Beat eating disorder organization claimed • 67% mental health improvement 6. “Structured training Raising Resilience” program of The Beat eating disorder organization indicated • 60% improvement of knowledge of eating disorders (Beat Eating Disorders Organization, 2021b) Perinatal Depression (Prenatal and Postnatal) Challenges https://www.thejournal.ie/eating-disorders-hospital-admissions-ireland-5331990-Jan2021/ IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 111 1. The prevalence of prenatal and postnatal depression in LMICs is higher compared to HICs: • 15% in HICs vs. 25% in LMICs for prenatal depression • 10% in HICs vs 19% in LMICs for postnatal depression (Fatori et al., 2020) 2. Globally, 12% of women suffer from postpartum depression (PPD) (Shorey et al., 2018) 3. A literature review in 2020 showed that PPD ranged between 6.1% to 50.3% in Africa (Atuhaire et al., 2020) 4. Globally, 10% of women in the postpartum period claimed to have suicidal ideation (Amiri & Behnezhad, 2021) 5. During the COVID-19 Pandemic, an almost double increase in the prevalence of PPD compared to the pre-pandemic era was reported, with: • 28.4% in Mexico (Chávez-Tostado et al., 2020, p.3) • 22% in China (Yan et al., 2020) At the same time, mental health screening services for PPD had been significantly decreased: • 40% reduction in the US (Sakowicz et al., 2021) Best Practices 1. The WHO Thinking Healthy Programme (THP) intervention for perinatal depression incorporating cognitive and behavioral techniques into community health providers’/primary care professionals’ routine practice (Mental Health Innovation Network (MHIN), 2021) 2. During the COVID-19 pandemic, telehealth, and electronic applications for mental health services, primarily depression, has been widely used for counseling, supervision, training, and psychoeducation, such as: • Better Help, Beyond Blue in Australia (Better Help Organization, 2021; Beyond Blue, 2021); • MindMum, Lifeline4Mums in the US and Canada (Ryan Van Lieshout, 2020) Impact 1. The WHO THP Programme showed significant impact: • > 900 cases of perinatal depression were detected after screening 4000 pregnant women in a rural area of Pakistan with a population of 1.2 million • 75% of women with PPD recovered after the intervention, with the annual cost of < US$10 per woman (Mental Health Innovation Network (MHIN), 2021) 2. Impact of Innovative interventions during Covid- 19 Pandemic: • Better Help: 2.03 million people were reached, with 70% of depression patients showing improvement (Better Help Organization, 2021) IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 112 Table 3: Women’s Social Well-Being Challenges and Best Practices with Impacts Education Challenges 1. Globally, 2018 reports indicated: ● two-thirds of 773 million illiterate adults are women (United Nations (UN), 2020, p.2) ● 132 million girls are out of school (UNESCO, 2019) ● 5.5 million more girls are out-of-school than boys (UNICEF, 2020a; United Nations (UN), 2020, p.1) 2. UNESCO Institute for Statistics predicted that by 2030, 16 million girls would never be enrolled in school (UNESCO, 2021b) 3. COVID-19 impact, based on 2020 UNESCO reports: • 11 million girls aged 12-17 in LIC and lower-middle-income countries are predicted not to be able to resume school (UNESCO, 2021c) • Only 55% LICs compared to 93% HICs were able to switch to online learning for primary and secondary education (Global Education Monitoring Report Team & UNESCO, 2021, p.2) • Only 15% of women vs. 28% of men have access to the internet (Global Education Monitoring Report Team & UNESCO, 2021, p.2) • Females are 8% less likely than males to have a cell phone and 20% less likely to access the internet on their phone, which negatively impacts their chance of engaging in online learning (Global Education Monitoring Report Team & UNESCO, 2021, p.2) Best Practices 1. The “Convention against Discrimination in Education” was adopted in 1960 to “advance the ideal of equality of educational opportunities without regard to race, sex or any distinctions, economic or social.” It was ratified by only 106 countries (Canada’s Human Right Commitments, 2020, p.1) 2. UNFPA (2018-2020) 19,861 communities built the platforms to advocate and abolish discriminatory gender and socio-cultural norms that negatively impact women and girls (UNFPA, 2020d) 3. The Global Education Coalition was established by UNESCO during the pandemic to ensure the right to education: • 175 members from 112 countries • 5 global surveys on education responses to COVID-19 • 3 large campaigns (Save our Future, Teacher Protection, and Keeping Girls in the Picture campaigns) (UNESCO & Global Education Coalition, 2021, p.4, p.5) Impact 1. Following the adoption of the “Convention against Discrimination in Education” in 1960 and Beijing Platform for Action in 1995, remarkable progress has been achieved, with more than two-thirds of countries reaching gender parity (with the gender parity index [GPI] value between 0.97 and 1.03) to close the gender gap and accomplish universal primary education (UNICEF, 2020a) 3. Almost 9,000 adolescent girls in Sierra Leone returned to school, supported by monetary incentives for school fees, uniforms, books, and other supplies (UNICEF, 2020b, p.4) 4. Global Education Coalition actions are positively impacting: • 400 million learners • 12 million teachers IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 113 2. 40 of 153 countries have reached gender parity (World Economic Forum, 2020, p.4) • It is targeting to help 5 million girls to ensure their right to education (UNESCO & Global Education Coalition, 2021, p.4, p.5) Economic Challenges 1. Globally, statistics indicated: ● over three decades from 1990 to 2020, the labor force participation rate among females aged 15+ has decreased from 51.2% to 46% (The World Bank, 2021a) ● only 55% of 15-64 years old women are represented in the labor market compared to 78% of men ● the ratio of women's unpaid work compared to men is 2:1 (World Economic Forum, 2020, p.11) ● only 28% of women were represented in managerial positions(UN DESA Statistics Division, 2020b), 25% in parliament, 21% at a ministerial level in 2019 (World Economic Forum, 2020, p.5) ● 50.5% of women worked with a lack of labor legislation protection, compared to 48.2% for men. (UN Women, 2013, p.2) ● 104 out of 189 countries still legally prohibit women from certain occupations ● 59 countries lack legislation to protect women from sexual harassment at work ● in 18 countries, by law, spouse can prohibit women from work (UN Women, 2018) ● for every dollar a man earns, on average, a woman is paid 54 cents (World Economic Forum, 2019a) ● the “motherhood penalty” accounts for about a 7% wage reduction per child(World Economic Forum, 2019a) ● It is predicted that due to job automation, for each position gained by a woman, they will lose 5, while the ratio for men is 1:3 (UNESCO et al., 2021, p.3) Best Practices 1. Worldwide, the Women’s Empowerment Principles on corporate social responsibility for gender equality, established by UN Women and the UN Global Compact is signed by more than 1,000 CEOs (UN Women, 2013, p.2) 2. The EU’s gender pay gap action plan launched in 2017 (UNESCO et al., 2021, p.29): • France, Ireland, and Portugal adopted labor laws to penalize companies without initiatives to bridge the gender pay gap ● In 2018, Iceland established a regulation for companies with 25+ employees to be certified in terms of gender-equality to close the gender pay gap by 2022 (UNESCO et al., 2021, p.29) Impact 1. Since 2017: • 40 countries implemented 62 reforms enhancing gender equality (The World Bank, 2020, p.7) • The economies that improved the most are Saudi Arabia, the United Arab Emirates, Nepal, 3. Data from 500 companies showed that the total return to shareholders was 34% higher among the firms with the greatest representation of women managers compared to those with the lowest female proportion (UN Women, 2013, p.2) http://www.oecd.org/newsroom/lackofsupportformotherhoodhurtingwomenscareerprospectsdespitegainsineducationandemploymentsaysoecd.htm http://www.oecd.org/newsroom/lackofsupportformotherhoodhurtingwomenscareerprospectsdespitegainsineducationandemploymentsaysoecd.htm IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 114 South Sudan, São Tomé and Príncipe, Bahrain, the Democratic Republic of Congo, Djibouti, Jordan, and Tunisia (The World Bank, 2020, p.7) 2. Almost USD 28 trillion, or 26%, could be added to the global GDP if gender equity is adopted in the labor market (McKinsey Global Institute (MGI), 2015, p.8) 4. Between 2018-2020, 6.2 million underprivileged girls were provided with life skills training programs led by UNFPA(UNFPA, 2020d) Early Marriage and Adolescent Pregnancy Challenges Early marriage: The total number of girls married in childhood stands at 12 million per year. By 2030, more than 120 million additional girls will marry before their 18th birthday (UNICEF, 2021) Adolescent pregnancy: Statistics from developing countries showed: • at least 777,000 girls under 15 years give birth each year (WHO, 2020a) • 90% of births by adolescent girls happen within both marriage and union • The leading cause of death among 15 to 19 years old girls is pregnancy and childbirth-related complications (UNFPA, 2021) Best Practices 1. UNFPA-UNICEF Global Programme to End Child Marriage was launched in 2016 and extended for four more years in 2020 to cover more than 14 million girls from 12 countries in Africa, the Middle East, and South Asia. (UNICEF, 2020c) This program encompasses: • Enhance girls’ access to education and health care service • Increase parent's and community’s awareness • Promote gender equity • Establish partnerships for families’ economic support • Strengthen and enforce laws to determine the minimum age of marriage at 18 (UNICEF, 2020c) Impact 1. Since UNFPA-UNICEF Global Programme to End Child Marriage was introduced, over 7.7 million adolescent girls and over 4.2 million community members have been provided with services, knowledge, and practices to exercise their rights (UNICEF, 2020c) 2. Girls’ child marriage in sub-Saharan Africa decreased from 1 in 3 to 1 in 5 during the ten years of program implementation (UNICEF, 2020c) 3. UNFPA (2018-2020): • 12,949communities publicly declared eradication of harmful practices, such as early and forced marriage and female genital mutilation (UNFPA, 2020d) • > 6 million girls were provided with all forms of services and care to prevent child, early, and forced marriages (UNFPA, 2020d) Menstrual Hygiene Practices Challenges IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 115 Menstrual hygiene practices have three layers of barriers:(World Economic Forum, 2019c) 1. Insufficient awareness: ● 71% of adolescent girls in South Asia (India) are unknowledgeable about menstruation until their menarche (The United States Agency for International Development (USAID) et al., 2014, p.8) 2. Lack of acceptance: ● Cultural unacceptance and lack of social services and support have led to the continuation of the existence of bigotry practices such as “menstruation hut”(Clark Helen & Sy Elhadj As, 2020) 3. Limited access: 3.a Lack of basic sanitation globally: ● affects over 1.2 billion women (Rhona Scullion, 2017; The Water Supply and Sanitation Collaborative Council (WSSCC), 2020) ● negatively impacts 698 million school-age children (UN DESA Statistics Division, 2020a) ● presents in more than one third of schools (37%) (UN DESA Statistics Division, 2020a) ● exists in only 20% of healthcare facilities, among 19 countries from UNICEF Multiple Indicator Cluster Surveys, in 2019 (UN DESA Statistics Division, 2020a) 3.b Lack of female hygiene products: ● 88% of women and girls in India are using homemade substitutes, such as old cloth, rags, hay, sand, or ash (The United States Agency for International Development (USAID) et al.,2014, p.6) ● In Scotland, 1 in 4 women at schools and universities had trouble accessing menstrual products(Nadia Khomami, 2018) All these factors lead to absenteeism during the menstrual period: ● > 33% of schoolgirls in South Asia(WaterAid, 2018) ● At least 10% of females aged 15–49 at work, school, or social activities among 19 countries (UN DESA Statistics Division, 2020a) Best Practices 1. The WASH SDG Programme was launched in 2017 in 7 low- and middle-income countries, with three core practices: 1. WASH facilities and practices 2. Quality of service provision 3. Governance of the sector (WASH Alliance International, 2021) 2. UNICEF Menstrual Health and Hygiene (MHH) Program is based on four main ‘pillars’: 1. Social support 2. Knowledge and skills 3. Facilities and services 4. Materials (UNICEF, 2019, p.39) 3. UNHCR, in collaboration with AFRI pads, implemented an intervention: • “AFRI pads Menstrual Kit” with 4 reusable sanitary pads, underwear, soap, and bucket (Tai Kuncio, 2018, p.4) 4. The Water Supply and Sanitation Collaborative Council established the Sanitation and Hygiene Fund (SHF). (Clark Helen & Sy Elhadj As, 2020) 5. The Scottish Parliament approved a plan to provide menstrual products publicly free (Nadia Khomami, 2018) • Making menstrual products available and free of charge in public spaces such as community centers, schools, pharmacies, and youth clubs • Subsidize distribution of female hygiene products in low-income localities. • Promote tax-free policies for female hygiene products (Nadia Khomami, 2018) https://www.theguardian.com/uk-news/2018/aug/24/scotland-to-offer-free-sanitary-products-to-all-students-in-world-first IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 116 Impact 1. The WASH SDG Programme targets to enhance hygiene behaviors for a population of 2 million in 7 countries in Africa and Asia(WASH Alliance International, 2021) 2. In South Asia, the number of women using sanitary protection has increased from 10 million to more than 70 million women today (World Economic Forum, 2019c) 3. AFRI pads intervention has decreased absenteeism among schoolgirls by 50% (Tai Kuncio, 2018, p.5) Contraceptive Use Challenges Based on data from 57 countries: • only 50% of women can decide their health care, choose contraceptive methods, and refuse sexual intercourse (UN DESA Statistics, 2020) • in 21% of countries, women cannot access contraceptive services without the consent of a parent, a spouse, a judge, or a medical committee (UN DESA Statistics, 2020) Best Practices 1. WinS4Girls (WASH, MHM) (UNICEF, 2019, p.23) 2. UNFPA (2020): 2.a Plan:(UNFPA, 2020d) • 25 countries have established a consolidated sexual and reproductive health national plan 2.b Sexual Education: • 11 countries have implemented internationally standardized sexual school curricula • 4 countries have a roadmap to provide out-of-school sexual education 2.c Services: • 6 countries have incorporated teenage sexual and reproductive health strategies beyond the health sector (UNFPA, 2020d) Impact 1. The economic impact of long-term investment of every $1 in family planning methods such as contraceptives resulted in annual benefits a total of $120, including $30-50 related to the reduction in infant and maternal mortality and the increase in economic growth by $60-100.(Family Planning 2020, 2020, p.2) 2. Between 2018-2020: • 210 million couple-years of modern contraceptives were offered by UNFPA.(UNFPA, 2020d) • 107 million women and girls were provided with sexual and reproductive healthcare services (UNFPA, 2020d) • 16 million sexually transmitted diseases were prevented (UNFPA, 2020d) 3. In 2020, UNFPA reported that contraceptive provision prevented: • 14.5 million unwanted pregnancies • 4.1 million unsafe abortions • saved lives of 39,000 mothers (UNFPA, 2020b) Women’s Autonomy Challenges IHTP, 2(1), 88-117, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 117 Recent UN report across 57 countries indicates: • 75.2% of women have a decision on their own health care • This rate ranges as high as 92.3% in Eastern and South-Eastern Asia to 59.1% in Central and Southern Asia • Around 75% of women can refuse to have sex • This rate ranges from 94.1% in Latin America and Caribbean to around 70% in both Sub-Saharan Africa and Central and Southern Asia • In 28% of those countries, married women cannot undergo abortion without their spouse consent (UN DESA Statistics, 2020) Best Practices WHO and international human rights law advocated for the abortion-inducing drug availability at home (Andrés López Cabello & Ana Cecilia Gaitán, 2021) France and the UK amended their medical abortion regulation temporary to allow medical abortion at home, during the COVID-19 pandemic (Andrés López Cabello & Ana Cecilia Gaitán, 2021) Impact 1. According to a recent UN report, in over 93% of 57 countries abortion has been legalized (UN DESA Statistics, 2020) 2. 71 countries have bridged at least 97% of the gap and 48 countries reached the target of near parity in healthcare (World Economic Forum, 2019b, p.14) 3. According to UK data, in the six weeks following the amendment of their medical abortion regulation, almost 16,500 women underwent safe medical abortion at home at a time when many in-person services were on hold (Andrés López Cabello & Ana Cecilia Gaitán, 2021)