5 Social and Structural Determinants

It is essential to recognize that women are not a monolithic group. Research agenda-setting exercises must ensure that all women’s voices are heard and that the voices of women who have historically been disempowered (e.g., people of color, SGM populations, women with disabilities, and women who represent intersections of identities) are elevated. This may take many forms, from ensuring representation as decision-makers in crafting policies that impact women’s health to sourcing and recognizing women’s needs from sources beyond peer-reviewed medical journals.

Populations of women that are unhoused, from rural areas, immigrants/refugees, low-income, and face language/cultural differences, among other life circumstances and identities, face compounding factors that impact their health outcomes. Comprehensive interventions often incorporate social and structural components that improve health outcomes beyond medical treatment courses. Social determinants must be included as part of research studies on women’s health. For example, when conducting research in cardiovascular disease, in addition to including the typical risks and co-morbidities such as obesity and hypertension, measurements of social determinants should also be included, such as socio-economic status, education and health literacy, stress and mental health, workload and time constraints, and access to healthcare.

Structural and systemic factors affect women’s economic agency, such as discrimination and bias, education barriers, unpaid caretaking for children and older people, and social and cultural norms—all of which impact women’s economic choices, access, opportunities, and health outcomes. For example, traditional gender roles may assign women primary responsibility for caregiving and household duties, leading to increased stress, mental health issues, and reduced access to healthcare services. Studies have shown that gender norms influence health-related behaviors, such as care-seeking and weight control, as well as exposure risk, such as to sexual or physical intimate partner violence. These gendered expectations can also limit women’s autonomy and decision-making power regarding their own health. Understanding the prevailing gender roles in a specific context and having global perspectives and contextual variations on gender roles and women’s health is crucial for examining their impact on women’s health. Furthermore, research and interventions that address intersections of different systems of oppression are more likely to have the desired health impacts.

Women who have been historically disempowered, stigmatized, disinvested, and understudied should be better represented in the review process, particularly when grant-making agencies and funders are considering research grants that impact these populations. Adequate understanding or appreciation of the health and social contexts of these groups will allow for appropriate consideration of their needs and an informed evaluation of relevant projects. This could have important implications for the volume and quality of supported R&D research on the health of women made vulnerable by their identity or social contexts. For example, reviewers of SGM health research projects should be able to acknowledge and include SGM perspectives and considerations and to speak adequately on these topics in review panels.

In some cases, traditional cultural practices (e.g., female genital mutilation) compromise women’s health and well-being. However, other cultural practices (traditional food, social structures and support, doulas and birth attendants, massage) may promote women’s health outcomes and well-being. Women’s health stakeholders should recognize negative connotations and biases around traditional, cultural, and spiritual practices. They should seek to understand, test, and elevate efficacious and safe practices rather than stigmatize them. By intentionally studying and incorporating traditional and cultural practices into medical standards of care, women can have an improved, contextually appropriate experience of care.