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Despite global commitments to achieving gender equality and improving health and well-being for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and sub-national data provide key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies demonstrated that: 1) gender norms are complex and may intersect with other social factors to impact health over the life course; 2) early gender-normative influences by parents and peers may have multiple and differing health consequences for girls and boys; 3) non-conformity with, and transgression of, gender norms may be harmful to health, in particular when they trigger negative sanctions; and 4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programs. Limitations of survey-based data are described that resulted in missed opportunities for exploring certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

ContributorsKH and AR led conceptualisation and drafting of the paper. AD led the study on nurses in Uttar Pradesh, ND the study on accredited social health activists in Uttar Pradesh, HW and JR the study on community health workers and community health worker policy in Sierra Leone, LM, JK, and AR the study on gender parity in the global physician workforce, and KH, YA, and NS the study on selfhelp groups in India. FS and RF-M led development of the case on the nurse from eSwatini. VP, RH, and EBa did the systematic literature review on health systems models. JGS and AR led the systematic review on gender transformative clinical interventions. KH, LM, JK, FS, RF-M, AD, YA, JY, EBl, NB, JGS, and AR did the critical reviews of the literature on gender inequalities and gender norms affecting health and helped draft pieces of those reviews, with consideration of diverse geographic contexts. All authors offered critical inputs and reviews of this work, contributed intellectual and substantive revisions to the writing, and provided final approval of the submitted version.

The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the significant impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper we draw on evidence from the Series on Gender Equality, Norms and Health to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academia, and the corporate sector to 1) focus on health outcomes and engage actors across sectors to achieve them; 2) reform the workplace and workforce to be more gender equitable; 3) fill gaps in data and eliminate gender bias in research; 4) fund civil society actors and social movements; and 5) strengthen accountability mechanisms. Paper 5 Lancet Series on Gender Equality, Norms and Health Key Messages of the Series • Gender norms and inequalities affect health outcomes for girls and women, boys and men, and gender minorities.

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Although research has established the criterion-related validity of assessment centers for selection purposes, the construct validity of dimension ratings has not been demonstrated. A quasi-experimental design was used to investigate the influence of retranslated behavior checklists on the construct validity of dimension ratings for two assessment center exercises. Assessor use of behavior checklists increased the average convergent (i.e., same dimension across exercise) validity from .24 to .43 while decreasing the average discriminant (i.e., different dimension within exercise) validity (.47 to .41). Behavior checklist sums were moderately correlated with corresponding dimension ratings and demonstrated a comparable level of construct validity. It is suggested that using behavior checklists may improve dimension construct validity by reducing the cognitive demands placed on raters.

This article presents evidence supporting the hypothesis that promoting gender equality and women's and girls' empowerment (GEWE) leads to better health and development outcomes. We reviewed the literature across six sectors-family planning (FP); maternal, newborn and child health (MNCH); nutrition; agriculture; water, sanitation and hygiene; and financial services for the poor-and found 76 studies from low and middle-income countries that met our inclusion criteria. Across these studies, we identified common GEWE variables that emerged repeatedly as significant predictors of sector outcomes. We grouped these variables into 10 thematic categories, which we termed 'gender-related levers'. These levers were then classified by the strength of evidence into Wedges, Foundations and Facilitators. Wedges are gender-related levers that had strong associations with improved outcomes across multiple sectors. They include: 'control over income/assets/resources', 'decision-making power' and 'education'. Elements of these levers overlap, but combined, they encapsulate agency. Increasing female agency promotes equality and broadly improves health and development for women, their families and their communities. The second classification, Foundations, displayed strong, positive associations across FP, MNCH and nutrition. Foundations have a more proximal relationship with sector outcomes and include: 'equitable interpersonal relationships', 'mobility' and 'personal safety'. Finally, the third group of levers, Facilitators, was associated with improved outcomes in two to three sectors and include: 'access to information', 'community groups', 'paid labour' and 'rights'. These levers make it easier for women and girls to achieve their goals and are more traditional elements of development programmes. Overall, gender-related levers were associated with improvements in a variety of health and development outcomes. Furthermore, these associations were cross-sectoral, suggesting that to fully realize the benefits of promoting GEWE, the development community must collaborate in co-ordinated and integrated ways across multiple sectors. More research is needed to identify the mechanisms by which gendered interventions work and under what circumstances.

When this Series on gender equality, norms, and health was first conceptualised in 2015, we were surprised by how little targeted effort had been achieved at this intersection, despite compelling evidence that gender equality improves health and wellbeing. 1,2 The 2030 Agenda for Sustainable Development and universal health coverage goals demand greater attention to the social determinants of health, including gender, and more integrated, multisectoral programming to enable all people to reach their full human potential. Yet potential advances in health and development are thwarted by systemic neglect of gender norms and inequalities in programme design, implementation, monitoring, and evaluation, despite the adoption of gender mainstreaming 3 [A: ref added here] by global health institutions. However, the same systems that perpetuate these injustices against women and girls also harm men and boys and gender and sexual minorities, and affect a broad array of health outcomes for all people. We aim for this Series 4-8 to provide new understanding of the impact of gender inequalities and norms on health, and the opportunities that exist within health systems, programmes, policies, and research to transform gender norms and inequalities.