Manifesto for women’s health 2018 – Background Briefing

Healthy Women—Healthy Europe

Background Briefing on our 2018 manifesto for women’s health

Europe Can Do More The European Union must prioritise women’s health. Together, we can provide equitable opportunities in order to improve health for all in Europe.

Introduction

The promotion of sex and gender equity has been a long-standing theme in the philosophy and operations of the European Union.1 In line with Articles 160 and 168 of the Treaty on the Functioning of the European Union and the UN Sustainable Development Goals (SDGs), the European Institute of Women’s Health (EIWH) together with the Manifesto signatories call on the EU to provide equitable opportunities to improve health policy, research, prevention, treatment and care for all. Concerted action must be taken to reduce inequities in order to improve women and family health and consequently, the health of all in Europe.

The State of Women’s Health in Europe Biological and social influences (sex and gender) are critical to health. Women face higher rates of diseases, such as in breast cancer, osteoporosis and auto-immune diseases than do men.

Other diseases affect men and women differently, including diabetes, depression and cardiovascular disease. Women do not present the same for conditions and respond differently to treatment than do men.2,3,4,5

Strategies must account for these differences!.

Many factors outside of the health sector—such as socioeconomic status, education, culture and ethnicity—affect behaviour and resource access.  For example, women in Europe have lower paid, often less secure and informal occupations than do men.  They earn 16% less than men and receive pensions that are 40% lower than do men.6  Lack of resources or decision making power, unfair work divisions and violence against women all impact health.

These social determinants have large repercussions for health and access to healthcare. In Europe, women outlive men by on average more than five years, but their healthy life expectancy advantage is less than nine months.7

Sex and gender have important implications for healthcare (health service delivery) and health systems (policies and organisation).  Due to women’s reproductive role, their health affects the health of their unborn child and that of future generations.

Women also play a vital role as healthcare professionals, caregivers, patients, mothers, daughters and friends, particularly in an ageing Europe.  Healthcare and health systems should be highly responsive to women, but too often fail them.

Europe Can Do More To:

Combat Socioeconomic Inequities:

Socioeconomic, political, educational, cultural and ethnicity differences all impact the patterns of behaviour and access to resources. Inequities, like violence against women, lack of decision-making power, less financial resources and unfair work divisions, all impact health. An holistic approach to improving women and family health must be taken that includes addressing socio economic inequities.

Ensure that sex and gender is integrated into all policies. A myopic view of health adversely impacts policy, programming and practice. Social factors impact physical and mental health, including healthcare access, health behaviours and working conditions with substantive cross-national variation.

Clear and systematic differences exist between men and women with regard to social determinants.8

Health inequalities result in an economic loss of about €980 billion, 9.4% of GDP, per year in the EU.9

Sex and gender must be integrated into all policies that influence health and wellbeing, including research, employment, justice, education and technology through gender mainstreaming, budgeting and implementation of the EU Gender Action Plan 2016-2020.

Health must be a key strategic objective in all EU policy. Sex and gender equity in health must be strengthened in the Multiannual Financial Framework in order to fully implement the EU Treaty requirements to protect health in all policies to promote wellbeing and social equity. Good practice and reliable data on promoting gender equity through programmes, like the OECD Gender Initiative,10 that monitor progress should be supported throughout Europe.

Eliminate the pay and pension gap. Women in Europe have lower paid, often less secure and informal occupations than men. Women earn 16% less than do men and receive pensions that are 40% lower than do men.11 These inequities have large repercussions for their health.

The Equal Treatment Directive (2006/54/EC), the Equal Pay Recommendation (2014/124/EU) and European Pact for Gender Equality must be evaluated and enforced in order to better combat socioeconomic inequities and consequently, the gender pay and pension gap. Equity of opportunities for women and men in all policies should be insured as enshrined in the European Pillar of Social Rights.12

Adopt the Work Life Balance Directive. Women are in the main the caregivers for children, older parents and family members and perform the majority of domestic household chores. In the EU, 80% of care is provided informally, and 75% of informal carers are women.13 These mostly unpaid duties are often performed at the expense of their own health.

Issues surrounding health, employment and caregiving must be urgently and systematically addressed to support those combatting chronic health conditions. The Work Life Balance Directive for Parents and Carers (2017) must be adopted in order to start to address women’s underrepresentation in the labour market as well as to support women as patients and employees as well as in their vital caregiving and domestic duties.

Promote Health and Prevent Disease:

Promote Health and Prevent Disease Society must invest in a life course approach to health promotion and disease prevention, targeting existing gaps and challenges. Action must be taken early and at critical points to ensure health and wellbeing from pre-conception to childhood through older age.

Develop a coordinated, comprehensive EU life-course immunisation strategy.

Vaccination prevents 2 to 3 million deaths globally each year. Yet, 1.5 million deaths could be prevented by improved immunisation.14 Immunisation across the life-course has been missing from much of the European disease prevention agenda, despite the great successes of past vaccination efforts, eliminating many infectious diseases.

The EIWH welcomes the European Joint Action on Vaccination (EU-JAV).  A coordinated and comprehensive European life-course immunisation strategy must be developed that reaches from childhood to old age, including pregnant women, migrants, and undocumented persons. Women—who are on the frontline of health as healthcare providers, caregivers and patients—must be explicitly targeted in programming.

Support programming to reduce antimicrobial resistance (AMR).

From 2000 to 2010, global antibiotic consumption increased by nearly 40%. Annually, 25,000 people in the EU die from antibiotic-resistant bacterial infection, which costs €1.5 billion in healthcare services and lost productivity. If the trend continues, 300 million people globally will die prematurely from antimicrobial drug resistance over the next 35 years.15

The EIWH applauds the G20 on highlighting AMR in the Health Working Group during the 2018 Argentine presidency.

Programming to tackle antimicrobial resistance, including the EU One Health Action Plan Against AMR, must be promoted and expanded. Efforts to combat AMR must explicitly target women who serve as traditional family caregivers.

Advocate for and implement European standards of maternal care.

Maternal and child health is a vital point for public health intervention. The protection of mother and child is of paramount importance to society. Every woman has a fundamental right to high quality maternity care. Yet, large variation exists across the EU with regard maternal mortality and morbidity prevention, strategies and outcomes. One in ten women in Europe do not have access to care during the first months of pregnancy.16 Far too many women in Europe continue to die during pregnancy and childbirth. Two-thirds of newborn deaths could be prevented with appropriate care prenatal, maternal and infant care.17

European standards of maternal care must be implemented across Member States’ national health strategies, including the pre-conception stage, to improve pregnancy outcomes and encourage the reduction of maternal and infant mortality and morbidity. Efforts should draw insight from the European Board and College of Obstetrics and Gynaecology Standards of Care for Women’s Health in Europe18 and the WHO/Europe’s European strategic approach for making pregnancy safer.19 The EU should fund a European-wide initiative to determine and share best practice.

Adopt a sex and gender life-course approach to health.

Early intervention is key to improving women and family health and wellbeing. Action must be taken early and at critical points to ensure health and wellbeing from childhood through old age. Health promotion and disease prevention effectively utilise limited healthcare resources. Yet, only 3% of health budgets are spent on prevention while 97% is spent on treatment. 20 Health = issues, like obesity, are on the rise in Europe. As of 2014, about 52% of the EU population was overweight or obese.21 Maternal obesity ranges from 7 to 25% and is strongly correlated with social and educational inequalities.22 Research suggests a strong relationship between increased advertising of non-nutritious foods and childhood obesity rates.23

A sex and gender life course approach to health promotion must be adopted and enforced as a priority theme in the future 4th Public Health Framework Programme, including encouraging healthy lifestyles and behaviours, including obesity and nutrition. For example, stakeholder partnerships to battle obesity and nutrition, starting from the pre-conception period, should be set up. Available evidence must be used to best identify entry points for various interventions—both at the population and individual level—specific to girls and women throughout their life. Efforts like the EU Action Plan on Childhood Obesity 2014-2020, 2013 Council Recommendation on promoting Health-Enhancing Physical Activity across sectors and the 2014 Council Conclusions on Nutrition and Physical Activity must be supported and expanded. The EIWH commends the G20 on highlighting childhood obesity in the Health Working Group during the 2018 Argentine presidency.

Research and Personalise Medicine

Translating the evidence from sex and gender research into regulatory practice leads to more targeted, safe and effective opportunities for health and healthcare. Although some sex and gender considerations are integrated into research and policy, many gaps continue to persist, so steps must be taken to improve future European research.

Explicitly fund health research on sex and gender.

Every cell in the body has a sex, starting from pre-conception. Despite the evidence base, biomedical research fails to systematically integrate sex and gender.24 For example, approximately 80% of rodent drug studies are conducted solely on males.25 Sex and gender biases have been documented in eight out of ten of the major disciplines in health research.26 approximately 80% of rodent drug studies are conducted solely on males.25 Sex and gender biases have been documented in eight out of ten of the major disciplines in health research.26

Funding agencies have been shown to be key in driving health policy change. 27 Research on sex and gender in health must be explicitly funded at EU level from basic research through implementation. Sex and gender should be included as a priority in the future EU Framework Programme (Horizon Europe) and Horizon 2020 Research Programmes. An EU project should be supported examining the use of EU funding to tackle sex and gender inequities in health.

Support the Clinical Trials Regulation (536/2014).

Women are the heaviest medicine users, yet they are under-represented in research and data. Consequently, the evidence base is weak for women as well as for older people. Women have more than a 50% greater risk of developing adverse drug reactions compared to men.28

The Clinical Trials Regulation must be implemented in order to combat the systematic underrepresentation of women in clinical trials. At national level, Ethics Committees must be encouraged to develop guidelines based on the Council for International Organizations of Medical Sciences’ (CIOMS) Requirements on the Inclusion of Women in Clinical Research.

Ensure that data is sex, gender and age-disaggregated in policy, health and research.

Improved reporting of sex and gender results in more accurate conclusions, thereby improving the health of all.29 Yet, studies overwhelmingly fail to analyse by sex. 30 Very few, less than one-tenth, of health publications specifically examine sex and gender.31 Data is key to monitoring and improving health policy, programming and practice.

All future EU Research programmes, including Horizon Europe and Horizon 2020 Research Programme, must require sex, gender and age-specific data disaggregation as a funding criterion. Data disaggregation by sex, gender and age must be referenced in the guide for applicants, the proposal application form and the evaluation guide. The European Medicines Agency (EMA) must be encouraged to require rigorous sex, gender and age-specific pharmacovigilance reporting. The EMA and key stakeholder should draft guidelines on sex and gender risk/benefit analysis. Sex, gender and age specific data collection and disaggregation must be required in health technology assessment and reviews.

Support an EU system on the safe use of medicines during pregnancy and lactation.

Most of the 5 million babies born in Europe every year have been exposed to medications taken by their mothers during the pregnancy.32 Yet, there is a lack of information and data about the safe use of medication during pregnancy and lactation.

A publicly-funded comprehensive European Pharmacovigilance system must be established at EU level to collect data on the safe use of medicines during pregnancy and lactation. The system must employ a life course approach, starting at pre-conception.

Educate, Train and Encourage Health Literacy

The quality of healthcare provision is compromised by the failure to integrate sex and gender. A commitment must be made to mainstream an evidence-based sex and gender perspective in all healthcare professional curricula and training.

Invest in improved healthcare professional education and training.

Apart from reproductive health, sex and gender are rarely considered in healthcare professional education curricula, despite the fact that over the last decade, the importance of sex and gender in healthcare has been increasingly recognised. The need for integration of this knowledge into healthcare professional education curriculum remains a challenge.

Investment must be made in improving healthcare professional education and training across Europe through cross-national, multi-sectorial and multidisciplinary collaboration across the policy and health sectors. The incorporation of sex and gender into training, curricula and professional standards must be fostered and systematically integrated. The importance of health promotion and disease prevention must be made a priority in healthcare professional education and training programmes. Cross-national exchange of best practice should be encouraged.

Establish an EU coalition for sex and gender in healthcare professional education.

The lack of one pan-European regulatory institution impedes regulatory development at a European level. Healthcare professional education involves many bodies at multiple levels, such as governments, physician associations and local universities. There is no EU mandate in healthcare education, but cross-national collaboration should be encouraged.

A European coalition for the integration of sex and gender into healthcare professional education should be established to promote and exchange best practice and drive the agenda across Member States and throughout the EU. The first workstream should focus on healthcare professional education and training with regard to immunisation.

Support the availability of accessible, accurate and multilingual health information. Multilingual, easy to understand and accessible information that empowers patients, caregivers and their families remains lacking despite the fact that health informed people experience better health outcomes with lower health service use.33,34,35

Accessible, accurate and multilingual health information must be developed and supported in order to empower patients, caregivers, their families and healthcare professionals, following the recommendations such as those from the European Centre for Disease Prevention and Control (ECDC). Digital health and e-health initiatives should be encouraged to help improve health and health outcomes throughout the EU.

Foster Responsive Healthcare Systems

Women and men utilise services in different ways and biases affect the provision of care to female and male patients. Healthcare must be adapted to better respond to individualised needs. Health systems must be flexible and responsive to changes to meet citizen needs and reduce health inequities through personalised patient care.

Call on healthcare systems to overcome sex and social inequities.

As women and men utilise healthcare services in different ways, services must be adapted to better meet everyone’s needs.36 For example, the symptoms of cardiovascular disease in women can be different from those of men, women are slower than men to react when these symptoms appear.37 Many policy mechanisms to address issues in women’s health are available, but few are being implemented.

Women’s health must be advanced through improved healthcare and better policy design. Healthcare systems must be supported to systematically and more effectively overcome sex and social inequities. Treatments must be delivered that respond to differences—such as sex, gender and age— and adapt treatment in order to ensure that all people and patients in Europe receive the best available care. A European Alliance on Women’s Cancer should be established to better prevent and combat women’s cancers in Europe and to support those living with as well as caring for those with cancer.

Empower women to manage their health and the health of their families.

Women comprise the majority of health professionals and caregivers. As mothers, daughters, wives and friends, women are the managers of health and key health decision-makers. Women often take care of their families at the expense of their own health.

Policies and programming must be developed to empower and support women in managing their own health and the health of their families by making it a priority in future EU Work Programmes. The European Parliament should consider an own initiative report on the role of women on the frontline of health in Europe.

Promote a positive approach to ageing and health.

Women outlive men by more than five years, but their healthy life expectancy advantage is less than nine months.38 Ageing is a major risk factor for women’s ill health. Women are at the forefront of ageing due their greater longevity than men and their multiple carer and societal roles. One of the biggest challenges facing European society, which has the highest proportion of older women in the world, is retaining and maintaining health during old age.

A comprehensive life-course approach must be employed in health and healthcare, including physical and mental health, in order to empower women to actively and healthily age. Specific attention must be devoted to cancer, Alzheimer’s disease/dementia, chronic disease and caregiving, including a multidisciplinary Network on Women and Alzheimer’s disease. Existing policies, such as the implementation of the Social Protection Committee and the Employment Committee’s guiding principles for active ageing, must be leveraged and integrated.

Improve access to quality treatment and care.

Today, healthcare must shift to a citizen and patient-focused view of health. Society has the opportunity to improve healthcare to adequately meets the needs of all people, starting from prevention. The use of healthcare services changes across the lifespan; differences between men and women in healthcare seeking behaviour and biases in the provision of care. Large variations exist across the EU with regard to access to appropriate treatment and care.

Healthcare systems should continuously change to reduce all health inequities. Policies and programmes must be developed to support exchange best practice to better adapt services to ensure that everyone has access to the best available treatment and care. The EU should encourage healthcare systems to be responsive to sex and gender considerations as well as to meet the needs of vulnerable groups. Work on healthcare quality, like the European Commission Initiative on Breast Cancer (ECIBC) and the European Commission Initiative on Colorectal Cancer (ECICC), should be supported and expanded. Quality data collection is key to monitoring and improving healthcare systems.

Prioritise Women’s Health

Equity must underpin health and healthcare. The current model predominately employs a “one-size fits all” approach. Interventions do not need to be the same, but rather result in better outcomes for both women and men. Society must invest in women’s health and wellbeing today in order to not only combat inequities, but also to lay a strong foundation as the health of women affects that of future generations.

Actively involve women in health policy, programmes, research and practice.

Women need to be involved in health from the very start, at basic medical research through treatment and care. Women therefore need to be involved in political decision-making, which ultimately influences healthcare systems. Yet, women are underrepresented in STEM (Science, Technology, Engineering, and Mathematics), with a European averaging at 17%. Closing this gender gap in STEM would increase GDP by an estimated €610 to €820 billion by 2050 while increasing female labour participation and improving health through diversity.39,40

Policies need to be made not only for women, but also by women themselves. Women need to be engaged and involved throughout the decision-making process. The European Pact for Gender Equality and the European Commission’s Strategic Engagement for Gender Equality 2016–2019 needs to be actively enforced. Targeted measures need to be taken and monitored in order to increase female participation broadly across healthcare and policy. Tailored programming needs to be implemented to encourage and support women in STEM. Europe should enact recommendations from The Charlevoix G7 Summit Communiqué to support the advancement of women and children’s health and rights.

Ensure equity of opportunities for women and men in all policies.

Sex and gender equity in not only health but also in social, economic and political policy benefits all in the EU. By 2050, the GDP per capita in the EU would increase by 6-10% or €23 trillion if gender equality is improved. Gender policies have been shown to have a stronger impact on GDP growth than labour market and education policies.41

The EIWH commends the Argentine presidency of the G20 in designating gender issues aa transversal theme for 2018 and encourages other stakeholders to follow suit. The EIWH also applauds the Gender Equality Advisory Council for Canada’s G7 Presidency’s and encourages the implementation of the recommendations of its report, Make Gender Inequality History, to help eliminate inequities and empower women.42 Equity of opportunities for women and men must be included in all policies as enshrined in the European Pillar of Social Rights.

Prioritise women’s health in all European funding mechanisms.

Gender budgeting is not systematically applied to the general EU budget. For the 2014-2020 period, overall about 0.6% of EU funding appropriations were allocated to gender equality measures. For example, for projects funded at September 2016 by Horizon 2020, only 0.007% in total addressed gender equality.43

The biological and social influences that affect women’s health must be prioritised in the European Semester—including explicitly earmarking funding for women’s health and wellbeing initiatives in streams such as the European Social Fund, Health for Growth, 4th Public Health Framework Programme, Horizon Europe and the Horizon 2020 Research Programme. Recommendations should be implemented from the WHO/Europe’s Strategy on women’s health and well-being in the WHO European Region in EU policy and programming.

References

1.European Institute of Women’s Health. 2000. Gender Equity in Public Health in Europe. https://eurohealth.ie/reports/ [Accessed 12 September 2018].

2 European Institute of Women’s Health. 2018. European Action Plan for Women’s Health. https://eurohealth.ie/action-plan-2108/ [Accessed 23 May 2018].

3 ENGENDER Project. 2011. Gendered Exposures and Vulnerabilities. https://eurohealth.ie/gender-exposures-and-vulnerabilities/ [Accessed 23 May 2018].

4 European Institute of Women’s Health. 2006. Women’s Health in Europe: Facts and Figures. [Accessed 22 May 2018].

5 European Institute of Women’s Health. Policy Briefs. https://eurohealth.ie/policy_briefs/ [Accessed 23 May 2018].

6 European Parliament. 2017. The 40% gender pension gap: how Parliament wants to narrow it (interview). [Accessed 23 May 2018].

7 Eurostat. 2017. Healthy life years statistics. http://ec.europa.eu/eurostat/statistics-explained/index.php/Healthy_life_years_statistics [Accessed 22 May 2018].

8 APA Huijts, T., Stornes, P., Eikemo, T. A., & Bambra, C. (2017). The social and behavioural determinants of health in Europe: findings from the European Social Survey (2014) special module on the social determinants of health. European journal of public health, 27(suppl_1), 55-62.

9 EuroHealthNet. 2015. What do EU Member States need from the EU health policy? https://eurohealthnet.eu/sites/eurohealthnet.eu/files/2015_04_17_Letter%20for%20informal%20EPSCO%20Council_final.pdf [Accessed 1 September 2018].

10 OECD. 2018. Gender Equality. [Accessed 18 September 2018].

11 European Parliament. 2017. The 40% gender pension gap: how Parliament wants to narrow it (interview). http://www.europarl.europa.eu/news/en/headlines/society/20180503STO03029/eye2018-photo-contest-winners-revealed [Accessed 23 May 2018].

12 European Commission. 2017. European Pillar of Social Rights.

13 European Commission. 2018. Informal Care in Europe. http://ec.europa.eu/social/BlobServlet?docId=19681&langId=en [Accessed 30 August 2018].

14 World Health Organization. 2018. Immunization Coverage. http://www.who.int/news-room/fact-sheets/detail/immunization-coverage [Accessed 12 September 2018].

15 DG Health and Food Safety 2017. EU Action on Antimicrobial Resistance. [Accessed 30 August 2018].

16 Alliance for Maternal Health Equality. 2015. Maternal Mortality in the EU. http://www.maternalhealthalliance.eu/pdf/Alliance_infographic_A4_270815.pdf [Access 12 September 2018].

17 WHO Europe. Health at key stages of life – the life-course approach to public health. Accessed 1 September 2018].

18 European Board and College of Obstetrics and Gynaecology. 2014. European Board and College of Obstetrics and Gynaecology Standards of Care for Women’s Health in Europe https://www.uems.eu/__data/assets/pdf_file/0020/8750/Item-5.3.8-EBCOG-Standards-of-Care-for-Gynaecology-PDF-FEB-11-2014-FINAL-DRAFT.pdf [Accessed 2 September 2018]/

19 WHO/Europe. 2008. European strategic approach for making pregnancy safer . [Accessed 20 September 2018].

20 EuroHealthNet. 2015. What do EU Member States need from the EU health policy? https://eurohealthnet.eu/sites/eurohealthnet.eu/files/2015_04_17_Letter%20for%20informal%20EPSCO%20Council_final.pdf [Accessed 1 September 2018].

21 Eurostat. 2018. Overweight and obesity – BMI statistics. https://ec.europa.eu/eurostat/statistics-explained/index.php/Overweight_and_obesity_-_BMI_statistics [Access 14 September 2018]/

22 Devlieger, R., Benhalima, K., Damm, P., Van Assche, A., Mathieu, C., Mahmood, T., … & Bogaerts, A. (2016). Maternal obesity in Europe: where do we stand and how to move forward?: A scientific paper commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG). European Journal of Obstetrics & Gynecology and Reproductive Biology, 201, 203-208.

23 “The impact of food advertising on childhood obesity.” American Psychological Association. American Psychological Association.

24 Ritz, S. A., Antle, D. M., Côté, J., Deroy, K., Fraleigh, N., Messing, K., … & Mergler, D. (2014). First steps for integrating sex and gender considerations into basic experimental biomedical research. The FASEB Journal, 28(1), 4-13.

25 Klein, S. L., Schiebinger, L., Stefanick, M. L., Cahill, L., Danska, J., De Vries, G. J., … & Zucker, I. (2015). Opinion: sex inclusion in basic research drives discovery. Proceedings of the National Academy of Sciences, 112(17), 5257-5258.

26 Beery, A. K., & Zucker, I. (2011). Sex bias in neuroscience and biomedical research. Neuroscience & Biobehavioral Reviews, 35(3), 565-572.

27 Johnson, J. L., & Beaudet, A. (2012). Sex and gender reporting in health research: why Canada should be a leader. Can J Public Health, 104(1), 80-81.

28 Rademaker, M., 2001. Do women have more adverse drug reactions?. American journal of clinical dermatology, 2(6), pp.349-351, https://www.ncbi.nlm.nih.gov/pubmed/11770389ﾧ [Accessed 5 June 2018].

29 Johnson, J. L., & Beaudet, A. (2012). Sex and gender reporting in health research: why Canada should be a leader. Can J Public Health, 104(1), 80-81.

30 Beery, A. K., & Zucker, I. (2011). Sex bias in neuroscience and biomedical research. Neuroscience & Biobehavioral Reviews, 35(3), 565-572.

31 Oertelt-Prigione S, Parol R, Krohn S, Preißner R, Regitz-Zagrosek V. Analysis of sex and gender-specific research reveals a common increase in publications and marked differences between disciplines. BMC Med. 2010;8:70.

32 Kristel Van Calsteren, Ksenija Gersak, Hildrun Sundseth, Ingrid Klingmann, Lode Dewulf, André Van Assche, Tahir Mahmood. 2015. Position Statement from the European Board and College of Obstetrics & Gynaecology (EBCOG): The use of medicines during pregnancy—Call for Action. .

33 Parker RM, Jacobson KL. Emory Schools of Medicine and Public Health, National Academy of Sciences. 2012. Why is health literacy so important? [Accessed 23 May 2018].

34 World Health Organization. 2013. Health Literacy: The Solid Facts. [Accessed 23 May 2018].

35 Graham S, Brookey J. “Do Patients Understand?” The Permanente Journal. 2008;12(3):67-69, https://www.ncbi.nlm.nih.gov/pubmed/21331214 [Accessed 23 May 2018].

36 European Institute of Women’s Health. 2018. Right from the Start: Resetting the Agenda in Women’s Health Conference Executive Report. https://eurohealth.ie/report21st-anniversary-expert-conference/ﾧ [Accessed 5 June 2018].

37 European Institute of Women’s Health. 2017. Women and Cardiovascular Disease in the EU. https://eurohealth.ie/women-and-cardiovascular-diseases-in-the-eu-2017/ﾧ [Accessed 5 June 2018].

38 Eurostat. 2017. Healthy life years statistics. http://ec.europa.eu/eurostat/statistics-explained/index.php/Healthy_life_years_statisticsﾧ [Accessed 22 May 2018].

39 WISE (Women into Science and Engineering). 2012. Engaging girls in science, technology, engineering and maths: What works? [Accessed 23 May 2018].

40 European Institute for Gender Equality. 2018. How gender equality in STEM education leads to economic growth? [Accessed 23 May 2018]. .

41 European Institute for Gender Equality. 2017. Economic case for gender equality in the EU. [Accessed 30 August 2018].

42 G7. 2018. Making Gender Inequality History. [Accessed 18 September 2018].

43 Director General for Internal Policies. 2016. The use of funds for gender equality in select Member States. http://www.europarl.europa.eu/RegData/etudes/STUD/2016/571393/IPOL_STU(2016)571393_EN.pdf [Accessed 1 September 2018].