International Journal of Comparative

Sociology
[Link]

Gendered vulnerabilities to a neglected disease: A comparative investigation of the

effect of women's legal economic rights and social status on malaria rates
Kelly F Austin, Mark D Noble and Maria Theresa Mejia
International Journal of Comparative Sociology 2014 55: 204 originally published online 7 July
2014
DOI: 10.1177/0020715214543158
The online version of this article can be found at:
[Link]

Published by:
[Link]

Additional services and information for International Journal of Comparative Sociology can be found at:
Email Alerts: [Link]
Subscriptions: [Link]
Reprints: [Link]
Permissions: [Link]
Citations: [Link]

>> Version of Record - Aug 10, 2014

OnlineFirst Version of Record - Jul 7, 2014
What is This?

Downloaded from [Link] by guest on August 11, 2014

543158

research-article2014

COS0010.1177/0020715214543158International Journal of Comparative Sociology X(X)Austin et al.

IJ CS

Article

Gendered vulnerabilities to a
neglected disease: A comparative
investigation of the effect of
womens legal economic rights and
social status on malaria rates

International Journal of
Comparative Sociology
2014, Vol. 55(3) 204228
The Author(s) 2014
Reprints and permissions:
[Link]/[Link]
DOI: 10.1177/0020715214543158
[Link]

Kelly F Austin
Lehigh University, USA

Mark D Noble

The University of North Carolina at Chapel Hill, USA

Maria Theresa Mejia

Lehigh University, USA

Abstract
Although seldom noted in scholarly accounts, malaria represents a leading cause of death and underdevelopment
in poor nations. Enormous cross-national variation in malaria rates across its endemic zones suggests the
importance of large-scale factors in explaining comparative disease trends. While the biological vulnerability
of women and children to malaria is often acknowledged, the literature has yet to investigate how gender
inequalities contribute to patterns of malaria prevalence. Utilizing structural equation modeling on a sample
of 90 less-developed nations and engaging insights from gender stratification perspectives, we consider the
influence of both legal economic status and social dimensions of womens status on malaria rates. We find
that womens legal economic status has an indirect relationship on malaria rates by enhancing womens social
standing and strengthening general health provisions. The results suggest that addressing issues of gender
inequality in poor nations is central to tackling this persistent pandemic.

Keywords
Development, gender, health, malaria, Sub-Saharan Africa

Introduction
Malaria is a devastating, parasitic disease that is responsible for about 13million annual deaths
worldwide (World Health Organization (WHO), 2013). This preventable and treatable
Corresponding author:
Kelly F Austin, Department of Sociology and Anthropology, Lehigh University, 681 Taylor Street, Bethlehem, PA 18015, USA.
Email: kellyaustin@[Link]

Downloaded from [Link] by guest on August 11, 2014

205

Austin et al.

affliction represents a leading threat to health, especially among women and young children, in
many less-developed nations located in tropical and subtropical zones where the Anopheles
mosquito is endemic (Breman etal., 2004, 2007; Lowassa etal., 2012; Naidoo etal., 2011;
Perez-Escamilla etal., 2009; Sabin etal., 2010; Sachs and Malaney, 2002; WHO, 2003;
Williams etal., 2009). In fact, there are about 300500million clinical cases of malaria annually, with the highest burden of disease and death occurring in Sub-Saharan Africa (Breman
etal., 2004, 2007; Lowassa etal., 2012; Naidoo etal., 2011; Sabin etal., 2010; Sachs and
Malaney, 2002; WHO, 2013; Williams etal., 2009). Despite the continued prevalence of malaria
in certain areas of the world-system, public and scholarly attention on this disease is sparse.
Thus, malaria represents what many refer to as a forgotten or neglected disease (e.g. Farmer,
2001; Packard, 2009).
While more-developed areas eradicated malaria decades ago, it remains a persistent and devastating cause of morbidity and mortality in poor regions (Sachs and Malaney, 2002; WHO, 2013).
Even within poorer, endemic zones, there is considerable variability in malaria rates across nations.
Thus, it is likely that vulnerabilities to malaria go beyond individual behaviors or characteristics
and rather derive from larger-scale social and economic conditions, as some societies have been
more successful in addressing this pandemic than others (e.g. Bates etal., 2004).
Biomedical research demonstrates that pregnant women and young children are most susceptible to contracting malaria (e.g. Packard, 2009; Sachs and Malaney, 2002; WHO, 2003, 2013). In
fact, malaria kills an African child every minute (WHO, 2013). While some of the susceptibility of
women and children to malaria may have biological underpinnings, social aspects of gender stratification also contribute to disparities in this disease. Gender stratification perspectives illustrate
that women face unequal access to resources in comparison to men, including economic, health,
and education resources that would greatly impact malaria rates. As women represent the principal
caregivers of children and the elderly, their lack of access to health resources and education also
adversely impacts other members of the household and community.
Within the comparative gender stratification literature, many studies focus on the influence of
womens status on various health outcomes, such as female life expectancy, HIV, or infant mortality. In these studies, womens status is measured using either social indicators, such as female
schooling and fertility rates, or economic rights indicators, such as legal provisions for womens
access to loans, land, and property (e.g. Austin and Noble, 2014; Brady etal., 2007; Breman etal.,
2004; Burroway, 2012; Lowassa etal., 2012; Medalia and Chang, 2011; Sabin etal., 2010;
Wickrama and Lorenz, 2002). The primary goal of this research is to consider these two dimensions of female empowerment together and examine how these elements potentially influence one
another, as well as other factors, to reduce malaria rates in less-developed nations. In other words,
rather than treating social and economic dimensions of female status as competing predictors, we
predict that increased legal economic rights for women enhances their socio-health standing,
directly influencing the malaria disease burden by reducing vulnerabilities for women and the
children in their care. Furthermore, we expect that increased access to economic resources for
women may benefit the health or social standing of the community at large, as women are more
likely to invest their economic resources in areas such as schooling and health care. Thus, the
effects of female empowerment on disease are potentially quite significant and operate in a number
of complex and interrelated ways.
A growing area of recent comparative research recognizes the importance of using direct and
indirect effects in predicting cross-national health outcomes (e.g. Austin and McKinney, 2012;
Kick etal., 2011; Shen and Williamson, 1997; Wickrama and Lorenz, 2002). In order to properly
assess the interrelationships between various dimensions of female empowerment and other key
factors on malaria rates, we employ a structural equation modeling (SEM) technique. This method

Downloaded from [Link] by guest on August 11, 2014

206

International Journal of Comparative Sociology 55(3)

allows for the specification of indirect effects, as well as the construction of latent variables, to
more appropriately assess the influence of multiple aspects of female empowerment.
While much of the disproportionate burden of malaria on women and children can be partially
understood biologically (e.g. WHO, 2013), this alone does not account for global patterns in prevalence across nations. Social and economic inequalities may limit the ability of women to take
prevention and treatment steps against diseases, such as malaria, for themselves and other members of the household or community in their care. The persistence and scale of this treatable illness
suggest that current biomedical strategies are not enough to eradicate this pathogen. Clearly, a
deeper understanding of the socio-structural causes of this disease is needed in order to address the
continued malaria burden. A comparative, social-scientific approach to malaria requires further
attention in both the scholarly literature and public policy.

Malaria: Characteristics of a neglected disease

Approximately 3billion people who live in tropical and subtropical regions where Anopheles mosquitoes are endemic are at risk of acquiring malaria (WHO, 2013). Significantly, poverty is concentrated in the tropical zones of the world, the same geographical boundaries that frame malaria
transmission (Packard, 2009; Sachs and Malaney, 2002). Those living in poverty face increased
risk of acquiring malaria for many reasons. Impoverished people lack knowledge of diseaseprevention techniques, have little access to modern Western medicine, and face limited access to
appropriate preventative strategies such as screened windows or bed nets. Also, many poor households lack adequate sanitation systems, increasing potential mosquito habitats (e.g. Bates etal.,
2004; Lowassa etal., 2012; Packard, 2009; Sachs and Malaney, 2002; Williams etal., 2009).
Malaria has afflicted human societies for centuries, representing a leading cause of death globally and historically. It was once thought that malaria came from fetid marshes, hence the name
mal-aria, which literally means bad air (WHO, 2013). However, in 1880, scientists discovered
the real cause of malaria: a one-cell parasite called plasmodium. Later they found that the parasite
spreads from person to person through the bite of a female Anopheles mosquito that requires blood
to nurture her eggs (Norris, 2004; WHO, 2013). Once inside the human host, the parasite undergoes a series of changes as part of its complex lifecycle. After 914days in the human host, the
parasite develops into a form that is able to infect another person when transmitted by a mosquito,
thus spreading the parasite (Sachs and Malaney, 2002; WHO, 2013).
Malaria symptoms also appear about 914days after the infectious mosquito bite. Typically,
malaria produces fever, headache, vomiting, and other flu-like symptoms and can progress very
quickly to death, especially among young infants. Malaria kills by infecting and destroying red
blood cells (causing anemia) and by clogging the capillaries that carry blood to the brain or other
vital organs (WHO, 2013). Thus, many people who survive an episode of severe malaria suffer
from neurological disorders, including learning disabilities, reduced fine motor functions, executive thinking impairment, or other forms of brain damage (Pattanayak etal., 2006; Sachs and
Malaney, 2002).
As previously mentioned, pregnant women, infants, and young children face a greater biological susceptibility to malaria. Socially, gender stratification and conditions of poverty only heighten
the risks of acquiring malaria for these already vulnerable segments of the population (Fried etal.,
1998; Gupta, 2004; Ogbodo etal., 2009; Packard, 2009; Sachs and Malaney, 2002; WHO, 2013).
For example, various epidemiological studies illustrate that acquiring malaria during pregnancy
leads to deleterious maternal and neonatal outcomes such as maternal anemia, preterm labor,
maternal death, stillbirths, low birth weight, and high infant mortality rates (e.g. Breman etal.,
2004, 2007; Fried etal., 1998; Lowassa etal., 2012; Ogbodo etal., 2009; Perez-Escamilla etal.

Downloaded from [Link] by guest on August 11, 2014

207

Austin et al.

2009; Sabin etal., 2010; Sachs and Malaney, 2002; Shargie etal., 2010; Verhoeff etal., 1999;
WHO, 2013; Williams etal., 2009). While biomedical explanations of malaria emphasize that the
decreased immunity of pregnant women leads to these conditions, social inequalities of women
also limit their access to health care and promote high fertility rates (e.g. Lowassa etal., 2012).
Similarly, poverty and limited health care access more generally represent broader trends connected to structural inequalities across nations. Thus, we now turn to a discussion of comparative
trends in health, followed by a key focus on dimensions of female empowerment.

Health determinants in less-developed nations

A growing body of comparative health literature examines trends in life expectancy, infant/child
mortality, hunger, and HIV across nations (e.g. Austin and Noble, 2014; Austin and McKinney,
2012; Brady etal., 2007; Burroway, 2010, 2012; Shen and Williamson, 1997; Shircliff and
Shandra, 2011; Wickrama and Lorenz, 2002). Despite modernization-related arguments highlighting the primacy of economic growth in improving human well-being outcomes (e.g.
Firebaugh and Beck, 1994), this body of research emphasizes that noneconomic factors seem
most relevant in predicting health outcomes, including measures of health service provision,
education, sanitation, clean water, and fertility rates (or other measures of female empowerment)
(e.g. Brady etal., 2007). Given the characteristics of malaria, these factors are keenly relevant to
consider here as well.
Indeed, the literature on health inequalities points to health service provisions as key to
explaining cross-national variation in disease and mortality indicators (e.g. Austin and Noble,
2014; Bates etal., 2004; Soares, 2007). Many studies document the lack of quality health services in less-developed regions; many clinics and hospitals in poorer nations are run by inexperienced or untrained staff, face shortages in medical supplies and medicines, or provide
inadequate diagnostics (e.g. Bates etal., 2004; Breman etal., 2007; Farmer, 2001). For many
impoverished families, the lack of a basic public health infrastructure, the expense of medications, and the difficulty of traveling long distances to a medical clinic or hospital represent major
barriers to effective treatment for a wide range of diseases, including malaria (e.g. Bates etal.,
2004; Breman etal., 2007; Farmer, 2001; Lowassa etal., 2012). In addition to health-care services, assessments also emphasize the importance of provisions for improved sanitation (e.g.
Austin, 2013; Austin and McKinney, 2012; Shandra etal., 2011; Soares, 2007). As mosquitoes
inhabit standing water, sanitation issues are keenly relevant to malaria; open sanitation pits and
streams represent prime mosquito habitats and lead to increased transmission (Breman etal.,
2004; Norris, 2004).
In addition to the role of health-care services and improved sanitation, numerous cross-national
analyses emphasize the importance of education in improving physical well-being in lessdeveloped nations (e.g. Austin and Noble, 2014; Brady etal., 2007; Burroway, 2010). Education
tends to improve health through a variety of mechanisms. For example, schooling exposes pupils
to information on disease vectors and transmission, leading to more successful prevention.
Educated people also tend to have more hygienic behaviors that reduce infectious disease transmission. Education also can expose individuals to techniques of modern medicine and dispel harmful
myths, again leading to more successful treatments (Bates etal., 2004; Heimer, 2007; Soares,
2007). Education is found to be especially important for women, and improving womens access
to education represents a robust predictor of a wide variety of health outcomes (e.g. Brady etal.,
2007; Burroway, 2012; Wickrama and Lorenz, 2002). While educating women is important, we
draw on gender stratification literature to examine additional dimensions of female empowerment
that are central in explaining cross-national trends in the malaria pandemic.

Downloaded from [Link] by guest on August 11, 2014

208

International Journal of Comparative Sociology 55(3)

Gender stratification in less-developed nations

Gender differences are socially constructed and maintained, including ideologies that perpetuate
the notion that males and females have different capabilities and that men are inherently superior
to women (Ridgeway and Smith-Lovin, 1999). This belief justifies the differential treatment of
women and unequal provisions for women in societies based on gender, or gender inequality
(Ridgeway and Smith-Lovin, 1999). Gender inequality, where womens economic, social, and
health status is marginalized relative to mens, is especially pronounced in less-developed nations.
Given these comparative patterns, gender stratification theory informs the relationship between
womens status and health in a number of cross-national studies (Austin and Noble, 2014; Breman
etal., 2004; Burroway, 2012; Lowassa etal., 2012; Medalia and Chang, 2011; Sabin etal., 2010;
WHO, 2008; Wickrama and Lorenz, 2002). Although gender inequality takes various forms in
economic, political, and social realms, research centered on comparative patterns in health focus
on the power or ability of women to access both economic and social resources (e.g. Holvoet,
2005; Mayoux, 2001; Parvin etal., 2005; Sherer etal., 2004; Taj etal., 2008; Tsai etal., 2011). We
begin by considering connections between womens legal economic rights and health.

Formal economic rights for women and influences on health

A growing body of scholarship acknowledges legal economic rights of women as a key dimension
of empowerment that greatly impacts health and well-being (e.g. Agarwal, 1994, 1997; Ali etal.,
2007; Burroway, 2012; Parvin etal., 2005). Legal restrictions for women legitimize discriminatory
customs that profoundly affect womens ability to access health resources and make decisions
about their health and well-being (Agarwal, 1994; Burroway, 2012; Villarreal, 2006). Many lessdeveloped nations have formal legal restrictions on the economic activities of women, thus reinforcing and facilitating gender and health inequalities (Agarwal, 1994; World Bank, 2013).
Providing women with basic economic rights allows them the opportunity to gain control over
their financial situation and have increased capacity to make decisions about how money is spent
in the household. Not only do greater economic rights reduce risks for poverty, but they also give
women the economic means to provide for themselves and their children, potentially improving
the health standing of the entire household (Agarwal, 1994, 1997; Parvin etal., 2005).
Prior empirical assessment finds that womens access to property, land, and loans significantly
reduce both female HIV prevalence and total HIV prevalence in poor nations (e.g. Burroway,
2012). Similarly, access to ownership of property, land, and loans signify economic resources and
sources of autonomy for women that may give women and households the economic means to pay
for malaria treatment and prevention practices such as bed nets. Egalitarian economic rights for
women perhaps trickle down to impact malaria in more indirect ways, such as by increasing the
social and health status of women themselves, and by facilitating increased demand and provisions
for public health resources in the broader community. A growing body of literature emphasizes that
revenues earned by women are more often used to meet basic needs that improve quality of life,
such as education fees, health care costs, clean water and sanitation services, and clothing for children, in comparison to earnings made by men (Agarwal, 1994, 1997; Taj etal., 2008). Many studies report specifically that loans targeted at women produce enhanced social and health conditions
in less-developed nations (Holvoet, 2005; Mayoux, 2001; Parvin etal., 2005; Taj etal., 2008).
Scholars link microfinance loan programs to outcomes, such as increasing food consumption,
enhancing the capacity of women to engage in and manage financial activities, heightening female
household bargaining power, and increasing contraceptive use (Parvin etal., 2005; Sherer etal.,
2004; Taj etal., 2008; Tsai etal., 2011).

Downloaded from [Link] by guest on August 11, 2014

209

Austin et al.

Research also demonstrates that in regions where women have formal access to economic
resources, women are more likely to occupy influential positions within their communities. Women
more often use their bargaining power to promote community development projects that serve to
better the health and well-being of their community or region (e.g. Agarwal, 1994, 1997; Kristof
and WuDunn, 2009; Schuler and Hashemi, 1994). A very recent WHO (2014) report highlights the
work of women in Gujarat, India, in creating the Self-Employed Womens Association (SEWA).
They used their earnings to cumulatively invest in and create various services, including health
clinics, childcare facilities, work security insurance, legal services, and housing that are available
to members as well as nonmembers in the region. The SEWA women also started their own bank,
increasing access to credit for women and avoiding the huge interest rates demanded by private
loan agents. In addition, they collectively organized a health insurance program used to subsidize
health care costs, which the women of the broader community identified as a major vulnerability
to poverty (WHO, 2014).
Schuler and Hashemi (1994) also demonstrate that the community as a whole, including nonparticipants, benefits indirectly when women gain access to savings-and-loan schemes. Programs,
such as the Grameen Bank, designed to empower women, significantly affect households and communities beyond those directly involved in the program by providing a broad range of services that
facilitate changes in social norms about gender and equality. For example, even among nonmembers of Grameen Bank, they find that contraceptive use increased in villages where programs are
implemented (Schuler and Hashemi, 1994).
These examples suggest that providing women with equal access to economic resources
enhances developmental outcomes for the community as a whole, as women are more likely than
men to push collectively for greater social and health outcomes in their communities and reinvest
their earnings into areas that promote community development. This draws on broader development thinking, adopting a wider view or definition of development. For example, Sen (1999)
argues that development cannot be measured solely by economic indicators but more appropriately
includes social and quality-of-life dimensions, as the end goal of development is generally improvements in human well-being. Using a framework of development as freedom (Sen, 1999), when
women garner the same access to economic resources as men, we are likely to see an increase in
development, particularly social development that addresses basic needs such as schooling, health
care access, and sanitation. These ideas also suggest that in addition to improvements in the broader
community, womens legal economic rights facilitate improved socio-health status of women in
particular. Indeed, while theorizations on gender stratification suggest a deep connection between
womens access to economic resources and social status, current comparative assessments tend to
treat these sets of factors independently (e.g. Burroway, 2012; Wickrama and Lorenz, 2002). We
now turn to a discussion of womens socio-health status, with continued key emphasis on how
formal economic rights and social conditions for women are linked.

Socio-health status of women and influences on health

The adoption of egalitarian economic rights likely increases participation in education and the
utilization of health care for women in particular; women tend to use part of their earnings to invest
in themselves and perhaps the well-being of their daughters specifically. Participation in education
is particularly significant, as it greatly affects womens knowledge of and access to various health
resources. Educated women are more likely to have the power and ability to make decisions about
their own health, reproductive, and well-being concerns (Austin and Noble, 2014; Burroway, 2012;
Karlsen etal., 2011; Medalia and Chang, 2011; Wickrama and Lorenz, 2002). Indeed, a wide body
of research finds that female access to education represents a key predictor of womens health

Downloaded from [Link] by guest on August 11, 2014

210

International Journal of Comparative Sociology 55(3)

outcomes as well as general health measures such as HIV prevalence, life expectancy, and infant
and child mortality (e.g. Austin and Noble, 2014; Brady etal., 2007; Burroway, 2012; Karlsen
etal., 2011; Shen and Williamson, 1997; Shircliff and Shandra, 2011; Wickrama and Lorenz,
2002).
Womens education and fertility are prominently intertwined. According to Wickrama and
Lorenz (2002), schooling influences womens health most predominantly by providing them with
the opportunity to acquire health and reproductive information and develop problem-solving and
decision-making skills, attitudes, behaviors, and aspirations that all contribute to reduced fertility,
and, therefore, enhanced health outcomes. More educated women increasingly work outside of the
home (e.g. Heimer, 2007), placing less emphasis on child rearing and reducing family size. As
pregnancy is a risk factor for a variety of health concerns, including malaria, reductions in fertility
are paramount in addressing gendered health inequalities.
Furthermore, equal economic rights for women also influences their access to health resources
(e.g. Shen and Williamson, 1997; Wickrama and Lorenz, 2002). Access to health care is especially
important during pregnancy and the month following childbirth for a number of reasons, including
malaria prevention and management (Bates etal., 2004). Thus, women assisted by trained professionals, who are knowledgeable and equipped with the skills necessary in conducting and managing pregnancies and childbirths, greatly decrease womens health issues and susceptibilities to
infectious diseases for themselves and their vulnerable infants (Austin and Noble, 2014; WHO,
2008).
These socio-health dimensions of empowerment (womens access to education, womens access
to health care, reduced fertility rates) are likely to have a more proximate or direct impact on
malaria rates, as these factors address both the biological and social conditions that facilitate
malaria vulnerabilities for women, young infants, and children. Womens legal economic rights are
likely to underlie these female socio-health status measures, thus impacting health outcomes indirectly as women use their increased economic autonomy to enhance their access to social and
health resources that reduce malaria transmission. In addition, these theorizations suggest that
economic rights for women lead to expansions in general health provisions in the broader
community.
While existing assessments examining other health outcomes, such as HIV, life expectancy, or
infant mortality, highlight the importance of womens status on improvements in aggregate health
outcomes (e.g. Austin and Noble, 2014; Brady etal., 2007; Burroway, 2010, 2012; Shen and
Williamson, 1997), these ideas have not yet been applied to the malaria pandemic. Moreover, as
previously mentioned, much of this research treats womens legal economic status, socio-health
dimensions of womens status (such as fertility rates), and general health provisions as competing
predictors, rather than carefully drawing on prior ideas to theorize how these elements work
through and with one another to shape the distribution of health inequalities across nations (e.g.
Austin and Noble, 2014; Brady etal., 2007; Burroway, 2010, 2012). Deconstructing the relationship between womens legal economic rights, general provisions for health, and womens sociohealth status can help provide further insights into how the adoption of gender-egalitarian economic
policies leads to broad improvements in physical well-being. We specify our key hypotheses formally below.

Predictions
The arguments explored above suggest that improving various dimensions of womens status
plays an important role in reducing the malaria burden in low-income nations, where women
and children are more likely to acquire the disease. In particular, it is likely that

Downloaded from [Link] by guest on August 11, 2014

211

Austin et al.

Womens SocioHealth Status

Womens Legal
Economic Rights

Malaria Rates

General Health
Provisions

Figure 1. Hypothesized causal model predicting malaria rates.

gender-egalitarian economic policies work indirectly to reduce malaria rates, as the increased
economic autonomy of women often is directed toward enhancing health provisions in the community and improving access to these resources for women that have more proximate effects on
disease transmission. In other words, economic rights for women lead to increased access to
social and health resources, for both the broader community and for women in particular, resulting in reduced malaria prevalence.
We, therefore, hypothesize that nations with egalitarian legal economic rights (including formal
access to land, loans, and property for women) have enhanced provisions for health (health-care
providers, education, and sanitation), in comparison with nations who legally prevent women from
accessing or utilizing economic resources. We also hypothesize that legal economic rights for
women (formal access to land, loans, and property) increases womens socio-health status (female
access to medical care, education, and reduced fertility), where nations with more egalitarian policies tend to have enhanced socio-health standing of women. In so doing, we recognize female legal
economic status and female socio-health status as two distinct components or dimensions of female
empowerment, where enhanced economic rights facilitate increased socio-health standing for
women across less-developed nations.
In turn, we also hypothesize that health provisions (health-care providers, education, and sanitation) and womens socio-health status (access to schooling, health care, and reduced fertility for
women) directly reduce malaria rates across nations. Taken together, we thus predict that there are
important direct and indirect relationships among these sets of predictors. To clarify these predictions, we provide a basic path diagram of these central predictions in Figure 1.
In addition to the predictions outlined above, we also draw on prior cross-national health and
malaria research to predict that economic development or gross domestic product (GDP) per capita
helps to explain cross-national trends in malaria prevalence. However, it is likely that GDP works
indirectly by impacting womens legal economic status, socio-health status, or general provisions
for health resources, as many studies document that GDP in itself is often not a significant or robust
predictor of health outcomes but acknowledge that more affluent nations tend to have increased
gender equality and better public health-care provisions (e.g. Austin and Noble, 2014; Brady etal.,
2007; Burroway, 2010, 2012). Thus, it is likely that GDP per capita has only indirect effects on
malaria prevalence across nations.1 Nations located in tropical zones experience a higher malaria
burden, and we thus hypothesize that nations located further from the equator will have lower rates
of malaria. Comparative trends also indicate that Sub-Saharan African nations face a disproportionately high malaria disease burden (WHO, 2013). We also predict that Sub-Saharan African

Downloaded from [Link] by guest on August 11, 2014

212

International Journal of Comparative Sociology 55(3)

nations have higher rates of malaria prevalence; however, similar to arguments made for GDP
above, we expect that much of this is due to the relatively low standing of women and poor provisions for public health infrastructure in this region (e.g. Heimer, 2007), making the effects of SubSaharan Africa residence on malaria also an indirect effect.

Methods
Sample
Our sample includes less-developed nations for which there is a consistent and measureable incidence of malaria for the year 2010. The World Malaria Report (WHO, 2013) provides measurable
rates of malaria on 106 malaria endemic nations; 90 nations with sufficient data were retained in
our sample.2 For a complete list of the countries included in the analyses, see Table 1.3

Analytic strategy
We employ SEM to assess the relationships between measures of womens status and malaria
prevalence in lower-income, malaria endemic nations using the statistical package AMOS.4 Our
research design utilizes a time-ordered dependent variable, where the dependent variable is measured in time after the independent variables. This is a common strategy used in cross-sectional
macro-comparative research in order to help adhere to conditions of causality, where causes must
precede effects in time (e.g. Austin and McKinney, 2012; Burroway, 2010, 2012; Shircliff and
Shandra, 2011). In this study, we measure malaria prevalence rates for the year 2010, and all independent variables are measured for the year 2009, since we would expect the influences on malaria
to be fairly immediate.
SEM can be viewed as a more general and flexible framework for modeling relationships
between variables than multiple regression (e.g. Bollen, 1989), and there are several benefits in
using SEM to model malaria prevalence. SEM allows for testing the dimensionality of the concept
of womens status, the first step of our analytic strategy. Measurement equations are used to obtain
the amount of shared and unique variance among the indicators of each dimension of womens
status. Furthermore, SEM also includes a structural model where careful consideration of the
potential interconnections or indirect pathways among indicators is taken into account. This is
especially relevant in our application here, as we predict a number of indirect relationships, including our key hypothesis that womens socio-health status serves to mediate the effects of womens
legal economic rights on malaria prevalence.
Another key benefit of the SEM framework is the ability to obtain separate measures for direct,
indirect, and total effects for predictor variables of interest on malaria prevalence. This allows us
to interrogate more closely not only the effects of our predictors, but also evaluate potential pathways leading to malaria prevalence beyond the measures of direct effects that are shown in typical
ordinary least squares (OLS) regressions. Finally, we can utilize new tests and measures of model
fit, over-and-above F-tests, t-tests, and confidence intervals, and R2 values, to evaluate models and
judge how closely our hypothesized model fits the data at hand.5

Dependent variable
The key dependent variable in our analysis is the malaria prevalence rate, measured for the
year 2010. The malaria prevalence variable was constructed using data on the confirmed number of malaria cases (WHO, 2013) and total population level from the World Bank (2013).

Downloaded from [Link] by guest on August 11, 2014

213

Austin et al.
Table 1. Countries in the analysis (N=90).
Country

Malaria prevalence
per 100,000

Country

Malaria prevalence
per 100,000

Afghanistan
Algeria
Angola
Azerbaijan
Bangladesh
Belize
Benin
Bhutan
Bolivia
Botswana
Brazil
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Chad
China
Colombia
Comoros
Congo, Dem. Rep.
Congo, Rep.
Costa Rica
Cote dIvoire
Djibouti
Dominican Republic
Ecuador
El Salvador
Eritrea
Ethiopia
Gabon
Gambia, The
Georgia
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran, Islamic Republic
Iraq
Kenya

201.82
0.03
8819.19
0.55
37.58
43.52
4779.36
60.06
138.66
52.12
171.65
4885.26
21036.37
349.10
0.01
3.63
1785.38
0.37
254.13
4972.85
3665.20
1757.35
2.45
317.80
114.66
34.39
13.05
0.39
684.89
1396.27
568.99
6731.86
0.01
4393.43
51.32
957.50
3325.65
3039.79
842.10
127.39
130.65
95.81
2.50
0.01
2217.90

Kyrgyz Republic
Lao PDR
Liberia
Madagascar
Malawi
Malaysia
Mali
Mauritania
Mexico
Morocco
Mozambique
Namibia
Nepal
Nicaragua
Niger
Nigeria
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Russian Federation
Rwanda
Sao Tome & Principe
Senegal
Sierra Leone
Solomon Islands
South Africa
Sri Lanka
Sudan
Suriname
Swaziland
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Turkey
Uganda
Uzbekistan
Vanuatu
Venezuela, RB
Vietnam
Yemen, Republic

0.06
335.44
23088.25
977.37
2043.50
20.49
1480.06
57.63
1.08
0.01
6509.31
24.35
9.32
11.96
3997.29
347.92
126.26
11.89
1369.97
0.42
100.34
19.90
0.01
6011.57
1656.62
1334.54
15918.57
7377.90
7.75
3.06
2144.28
326.32
25.39
1.61
0.09
46.99
4213.30
10237.59
0.01
4730.52
0.01
3408.71
156.60
20.15
443.60

Downloaded from [Link] by guest on August 11, 2014

214

International Journal of Comparative Sociology 55(3)

These confirmed malaria cases are reported to the WHO from national malaria control programs. The number of malaria cases for each nation is weighted by its total population and then
multiplied by 100,000 to form the prevalence rate. It is common to find a variable that is leftbounded at zero to have a nonnormal distribution. As shown in Table 1, the malaria prevalence
rate is implicitly bounded at zero, and there are large differences in the malaria prevalence from
country to country. To correct for this nonnormality and adhere to the regression assumptions,
we log-transformed malaria prevalence, as is common in macro-comparative research of highly
skewed health outcomes (e.g. Austin and Noble, 2013; Burroway, 2010, 2012). However, as a
result of this log-transformation, the interpretation of the relationships between our outcome
and its predictors must be taken into account. When interpreting this dependent variable,
changes in the independent variable result in percentage changes in malaria prevalence.6

Key independent variables

To explore the relationships between womens legal economic status, socio-health status, and
malaria prevalence, we include six key independent variables that measure womens status. We
hypothesize that there are two underlying latent factors of womens status represented by these six
key variables, womens legal economic status and womens socio-health status. We follow prior
researchers (e.g. Burroway, 2012) by measuring womens legal economic status with three key
variables: womens legal access to land, legal access to property other than land, and legal access
to credit or loans. These variables were collected from the 2009 Gender, Institutions and
Development Database (GID-DB) from the Organisation for Economic Co-operation and
Development (OECD). Access to land captures womens access to the ownership of agricultural
land. Access to property refers to womens ability to own property other than land, especially
immovable property, and access to enter into property contracts. Access to loans refers to womens
ability to acquire loans and credit. These three variables quantify womens legal and effective
access to ownership of three types of economic resources. These access variables are coded in three
ordered categories, where higher values equate to more access: legal equality of women and men
(1), legal equality of women compared to men but discriminatory practices still exist and represent
impediments to access for women (.5), and the existence of some legal restrictions or de facto
discriminatory practices that serve as impediments to access (0).
To capture womens socio-health status, we use three key variables: female-to-male schooling
ratio, fertility rate, and the percentage of births attended by skilled health staff. Female to male
secondary school enrollment ratio, measured using gross enrollment estimates, calculates the ratio
of total enrollment of females in secondary-level education to the gross enrollment of males in
secondary education. This measure appropriately captures inequality in access to education of
women versus men. Many studies demonstrate that improving access to education among women
is one of the most important predictors of general health measures (e.g. Austin and Noble, 2014;
Brady etal., 2007). Similarly, the fertility rate holds strong correlations to health (Wickrama and
Lorenz, 2002). Fertility captures key aspects of female empowerment, as more empowered women
are able to gain control of their reproductive rights and reduce fertility. Fertility rates also represent
an important control variable in this analysis, as pregnant women and young children have biological vulnerabilities to malaria (e.g. Lowassa etal., 2012). The fertility rate is an estimate of the
number of children an average woman would have if current age-specific fertility rates remained
constant during her reproductive years. In this analysis, we reverse code this variable as to construct a measure of low fertility rate. Recoding this measure allows higher values to be associated
with increased status of women. Percent of births attended represents the percentage of the total
deliveries under the supervision and care of skilled health staff. This includes guidance to pregnant

Downloaded from [Link] by guest on August 11, 2014

215

Austin et al.

women at all stages of pregnancy, including pre-labor, labor, and the postpartum period. Not only
is there direct relevance of malaria prevention with increased medical care surrounding birth, but
this measure also uniquely represents a gender-specific variable that captures womens access to
medical care more generally (e.g. Austin and Noble, 2014). We obtained each of these variables
from the World Banks (2013) World Development Indicators database for the year 2009.

Additional independent variables

To account for the influence of economic development, we include GDP per capita, the total
annual output of a countrys economy divided by its population, measured in current international
dollars for the year 2009 (World Bank, 2013). More specifically, GDP per capita is the total market
value of all final goods and services produced in a country in a given year, equal to total consumer,
investment, and government spending, divided by the midyear population. It is converted into current international dollars using purchasing power parity (PPP) rates, providing a standard measure
allowing for comparisons of real price levels between countries. We performed a log-transformation of this variable to reduce the influence of extreme outliers.
In addition to economic development, general measures of public health and education provisions (that are not gender-specific) represent important factors in the analysis. We include number
of health-care providers, for the year 2009. This represents the number of trained doctors, nurses,
and midwives per 1000 people and includes both generalist and specialist medical personnel
(World Bank, 2013). To assess the influence of education, we include secondary school enrollment.
This measure represents a gross enrollment ratio that calculates the ratio of total enrollment,
regardless of age, to the population age group that officially corresponds to secondary-level education for the year 2009. Access to sanitation is an additional public health measure that has key
relevance for malaria, since open and untreated sanitation pits can represent prime mosquito habitats (e.g. Bates etal., 2004). We thus include percent of the population with improved access to
sanitation, pertaining to disposal facilities that can effectively prevent human, animal, and insect
contact with excreta, such as piped sanitation systems or properly constructed latrines (World
Bank, 2013).
Many explanations also focus on geographical or environmental factors in contributing to crossnational disparities in malaria rates (e.g. Norris, 2004). We include a measure of latitude to measure proximity to tropical zones. Measures of latitude were obtained from the CIA World Factbook
(2010), where we estimate the absolute value to capture distance from the equator. We include a
regional indicator for Sub-Saharan Africa, as many assessments document the increased malaria
burden in this region. This measure represents a dummy variable, where countries coded with a 1
indicate location in Sub-Saharan Africa and those with a 0 indicate that a country is located in a
different region of the world.

Results
Table 2 displays the correlation matrix of all of the variables used in the analyses. The magnitude
of the relationships among the variables demonstrates that many of the predictor variables are
highly correlated. This further warrants the use of the SEM analytical technique given its superior
handling of intercorrelated independent variables through the creation of latent constructs and
direct and indirect pathways that circumvents the tendency to bias coefficient estimates (e.g.
Bollen, 1989; Byrne, 2009).
A preliminary step in our empirical assessment of the complete SEM was determining if womens legal economic status and womens socio-health status represent distinguishable components.

Downloaded from [Link] by guest on August 11, 2014

Downloaded from [Link] by guest on August 11, 2014

Malaria prevalence (ln)

Loan access
Land access
Property access
Female/male schooling
Low fertility
% Births attended
Health providers
Secondary sch.
Sanitation
Democracy
GDP p/c (ln)
Sub-Saharan Africa
Latitude
Mean
SD

GDP: gross domestic product.

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)

1.00
.45
.50
.38
.46
.67
.57
.63
.69
.66
.01
.61
.53
.61
4.9
3.2

(1)
1.00
.57
.58
.56
.59
.54
.48
.57
.57
.16
.48
.53
.26
0.7
0.3

(2)

1.00
.59
.45
.57
.54
.54
.54
.52
.11
.46
.52
.26
0.6
0.3

(3)

Table 2. Correlation matrix, means, and standard deviations.

1.00
.45
.51
.40
.42
.44
.44
.22
.44
.39
.25
0.7
0.3

(4)

1.00
.75
.61
.41
.73
.64
.50
.69
.44
.06
0.9
0.1

(5)

1.00
.66
.63
.81
.71
.24
.75
.67
.37
96.3
1.4

(6)

1.00
.59
.76
.71
.24
.70
.40
.21
68.1
24.5

(7)

1.00
.72
.65
.05
.57
.51
.67
0.8
1.0

(8)

1.00
.81
.32
.76
.62
.38
59.8
25.1

(9)

1.00
.13
.71
.65
.37
53.0
28.1

(10)

1.00
.29
.07
.22
3.9
1.5

(11)

1.00
.53
.26
7.9
0.9

(12)

1.00
.36
0.4
0.5

(13)

1.00
16.2
11.7

(14)

216
International Journal of Comparative Sociology 55(3)

217

Austin et al.

Building upon prior scholarship in gender stratification, we predict that legal economic status and
socio-health status do represent different aspects of female empowerment. Legal provisions represent institutional characteristics that may or may not influence gendered social inequalities in
access to education, health care, and improving reproductive conditions of women (e.g. Burroway,
2012). We measure womens legal economic status with a set of variables that indicate whether the
country permits formal access to land, access to loans, and access to property for women. Sociohealth status is represented by the female-to-male secondary schooling ratio, low fertility rate, and
the percentage of births attended by a skilled medical professional. To test this hypothesis, we
initially construct a confirmatory factor analysis (CFA) with two distinct factors representing
womens legal economic status and socio-health status and analyze the overall and component
measures of fit. We compared this to a model where all six indicators loaded on a single factor of
womens status. By empirical standards, we find evidence at both the component and overall model
levels to support our substantive hypothesis that the two-factor model is superior.7 This also fits
with our substantive interpretations. Therefore, we build on the two-factor model of womens status to include the other indicators in the structural equation model.
In similar fashion, we find that the number of health-care providers, secondary school enrollment, and access to improved sanitation represent a distinct factor capturing public health conditions or provisions. We initially included these variables as separate indicators but found that model
fit was greatly enhanced by modeling them together as a distinct component.8 This is theoretically
and substantially grounded, as many studies find that these social predictors or social gradients of
health-related to education, health care, and sanitation represent a bundle of components that work
together to improve health, with distinct effects in comparison to economic indicators, such as
GDP per capita (e.g. Austin and Noble, 2014; Brady etal., 2007).
Before we report the results of the SEM model, it is requisite to examine the overall model fit
statistics that assess the fit of our model to the data provided. In accordance with standards typical
for this empirical tradition, the chi-square test statistic is nonsignificant (p=.152; 65.71 with 55
degrees of freedom (df));9 the values of the Incremental Fit Index (.985), TuckerLewis Index
(.974), and the Confirmatory Fit Index (0.984) all exceed .90; the root mean squared error of
approximation (RMSEA) value (.047) is below the threshold of .05; and the Bayesian Information
Criterion (BIC) is 182, where a large negative value indicates that the hypothesized model has
superior model fit than the fully saturated model.10 Together, these fit indices demonstrate that the
model presented has excellent fit to the data and permits interpretation of the pathway coefficients,
which are all statistically significant at the .05 level.11
The results of the SEM are presented in Figure 2. We tested all theoretically and substantially
informed paths as predicted, and then eliminated all nonsignificant interrelationships, as is requisite in this tradition (Byrne, 2009). Each remaining pathway coefficient is statistically significant
and represents the standardized regression coefficient. Reporting the standardized regression coefficients allows for comparison of the relative size of the effects of independent variables on a
dependent variable, where larger numbers indicate a stronger effect in comparison to the other
predictors.12 Consistent with our predictions, womens socio-health status has the strongest direct
influence on malaria rates (.57), where increased equality in access to education for women, the
percent of births attended by skilled health staff, and lower fertility rates are associated with lower
rates of malaria prevalence across nations. Latitude has a slightly weaker direct influence on crossnational malaria rates (.43), where distance from the equator is associated with decreases in the
malaria burden.
Also consistent with our predictions, we find that womens legal economic status, indeed,
impacts malaria rates indirectly. The results demonstrate that legal economic rights for women tend
to improve womens socio-health status (.18), which in turn directly reduces rates of malaria.

Downloaded from [Link] by guest on August 11, 2014

218

International Journal of Comparative Sociology 55(3)

Loan
Access
.79

Land
Access

Fem/Male
Schooling

Property
Access
.71

.77

.77

Womens
Legal Econ
Rights

Low
Fertility
.89

Births
Attended

.79

Womens
Socio-Health
Status

.18*

.30**
.63***
.39***

-.41***

.24*

-.57***
Health
Provisions

.51***
GDP p/c (ln)
Sub-Saharan
Africa
Latitude

.46***

Health
Providers

.87

.93

.56

-.23**

Secondary
Schooling

Improved
Sanitation

-.43***

Malaria
Prevalence (ln)

Figure 2. SEM predicting malaria prevalence displaying standardized regression coefficients.

CFI: Confirmatory Fit Index; TLI: TuckerLewis Index; IFI: Incremental Fit Index; RMSEA: root mean squared error of
approximation; BIC: Bayesian Information Criterion.
Model fit statistics: 2(55)=65.72, p=.153, CFI=.984, TLI=.974, IFI=.985, RMSEA=.047, BIC=182.
Standardized coefficients flagged for statistical significance, where ***p<.001, **p<.01, *p<.05 (one-tailed directional
t-tests).

In addition, we find that womens legal economic rights are associated with improved public health
provisions (.30). This confirms other findings conducted at the case-study level that emphasize that
increased economic autonomy of women leads to greater bargaining and investment in health
resources (including education) that benefit the entire community. Thus, these findings provide
support for our key hypotheses concerning the importance of womens legal economic status in
leading to increased public health provisions and improved socio-health status for women, representing an important indirect predictor of cross-national malaria rates.
The results indicate that public health provisions (health-care providers, education, and sanitation) also greatly enhance female socio-health status (.63), suggesting that nations with increased
public health provisions tend to have more women able to access and benefit from those resources.
Somewhat surprisingly, the results indicate that public health provisions (health-care providers,
education, and sanitation) only have negative influences on malaria rates indirectly through
advancing female socio-health status.13 In essence, this finding demonstrates that improvements in
public health only serve to impact malaria rates in so far as women are able to access and utilize
these provisions. This finding certainly demonstrates the importance of increasing the social standing of women in addressing the malaria pandemic.
The results show that GDP per capita has many indirect influences on malaria by enhancing
womens legal economic status (.39), womens socio-health status (.24), and public health resources
(.51). Sub-Saharan African nations tend to have less egalitarian legal provisions of womens

Downloaded from [Link] by guest on August 11, 2014

219

Austin et al.
Table 3. Direct, indirect, and total effects of the predictors of malaria prevalence.
Predictor

Malaria prevalence (ln)

Direct

Indirect

Total

GDP per capita (ln)

Sub-Saharan Africa

Latitude

Womens legal economical rights

Womens socio-health status

Health provisions

.425***
.067
(.111)

.574***
.064
(13.558)

.406***
.058
(1.326)
.170***
.041
(1.045)

.211***
.062
(2.751)

.364***
.091
(.049)

.406***
.058
(1.326)
.170***
.041
(1.045)
.425***
.067
(.111)
.211***
.062
(2.751)
.574***
.064
(13.558)
.364***
.091
(.049)

Standardized coefficients flagged for statistical significance; standard errors reported in italics; unstandardized coefficients reported in parentheses.
***p<.001; **p<.01; *p<.05 (one-tailed directional tests).

economic rights (.41), as well as reduced provisions of public health resources in comparison to
other nations (.23). In these ways, economic development and location in Sub-Saharan Africa
have important indirect influences on malaria rates. We also find that latitude is associated with
number of health-care providers (.46), where there are fewer trained health workers in nations
closer to the equator.
Although the effects of many relevant predictors are indirect, these remain notable, especially
given the relative size or magnitude of some of the indirect parameters displayed in Figure 2.
Comparing the relative size of direct, indirect, and total effects (the combination of indirect and
direct effects) of indicators on malaria rates further illustrates the relevance of certain factors in
explaining cross-national variation in malaria rates. These results are presented in Table 3.
Comparing the size standardized regression coefficients in Table 3, we find that womens sociohealth status has the largest total influence on malaria rates (.57), accounted for entirely through
its direct effect on malaria rates. Latitude has the second largest total effect on malaria rates (.43).
GDP per capita has the third largest total effect on malaria rates (.41), accounted for by its indirect
relationships to other predictors in the model. Health resources have the next largest total effect
(.36), followed by womens legal economic status (.21), and Sub-Saharan Africa (.17). Although
many variables operate indirectly, the results presented in Table 3 suggest that the overall or total
influence of some of these indirect indicators is still quite robust, such as GDP per capita and public
health resources. While the total effect of womens legal economic status on malaria prevalence
rates across less-developed nations is relatively modest, it does represent an important predictor,
and has strong influence on other key predictors in the model (e.g. health provisions). The ability

Downloaded from [Link] by guest on August 11, 2014

220

International Journal of Comparative Sociology 55(3)

to appropriately model and assess indirect, direct, and total effects leads to more appropriate testing
and synthesis of theory and substantive evidence, and helps illuminate relevant interrelationships
that would go undetected in traditional direct effects analyses.

Conclusion
Gender disparities and issues of infectious disease represent two persistent features of global inequality. The findings demonstrate that issues of gender stratification and disease are deeply connected to one another; womens legal economic status and socio-health status represent two
dimensions of female empowerment that are crucial in explaining cross-national variation in
malaria prevalence. The connection between these dimensions of womens status and malaria
includes a complex set of relationships, where the impact of legal economic rights for women on
malaria prevalence is mediated by womens socio-health status and general public health provisions. The socio-health standing of women also completely mediates the influence of general public health provisions on malaria, demonstrating the relative importance of womens socio-health
status in curbing this infectious disease. The results strongly suggest that improvements in public
health conditions only reduce malaria rates in so far as women are able to access those resources.
This is undoubtedly due to the fact that women are the principal caregivers of children, and children and pregnant women epidemiologically are most vulnerable to this infection. Thus, it is
increasing womens participation in education, access to health care, and reduced fertility that has
the biggest direct impact on cross-national patterns in this pathogen.
To the best of our knowledge, this represents one of the first studies to carefully scrutinize the
relationship between malaria and womens status, as well as initiate examination of both legal
economic and socio-health facets of gender inequality. While prior research took substantive focus
on either one aspect of female empowerment or the other, or has set up dimensions of womens
legal economic and socio-health status as competing predictors in direct-effects analyses (e.g.
Austin and Noble, 2014; Brady etal., 2007; Burroway, 2012), we rigorously examine the interrelationships between various dimensions of empowerment using a more integrative modeling
approach. Doing so illuminates a number of important mediating or indirect relationships that
would remain undetected using more traditional methods.
Overall, we find that womens legal economic rights have an indirect, negative relationship on
malaria rates. Egalitarian economic rights for women increase their socio-health standing, but also
strengthen general provisions for public health resources. This confirms prior case-study and substantive research that finds that women tend to use their economic autonomy to invest in and promote community needs, such as provisions for health-care providers, schools, and sanitation
infrastructure (e.g. Agarwal, 1994, 1997; Kristof and WuDunn, 2009). In addition, the strong relationship between public health provisions and womens socio-health status indicates that increased
provisions for education and health services help to facilitate womens access to those resources.
However, this relationship is not deterministic, and the fact that womens socio-health status completely mediates the influence of public health provisions on malaria still speaks to the overall
importance of womens socio-health status in mitigating this deadly infection.
Although the environmental determinants of malaria are often emphasized (e.g. Bates etal.,
2004; Norris, 2004; Sachs and Malaney, 2002; WHO, 2013; Williams etal., 2009), we find that the
social environment (with regard to womens standing) is in fact a stronger predictor of crossnational malaria rates than geographical location. In some ways, this finding illustrates that through
improvements in gender equality, poor nations can potentially overcome some of their natural or
environmental predispositions to this disease, and likely other tropical illnesses as well. Indeed,
while we focus exclusively on malaria here, our results add to the growing body of literature that

Downloaded from [Link] by guest on August 11, 2014

221

Austin et al.

demonstrates the importance of womens status for improvements in broad health measures (e.g.
Austin and Noble, 2014; Brady etal., 2007; Medalia and Chang, 2011). It is probable that female
empowerment contributes to patterns in other infectious diseases that primarily afflict children,
such as dengue fever, dehydration, and pneumonia that have not yet been explored in the scholarly
literature.
Our findings also reveal that the influence of economic development on malaria is important but
indirect; economic development only reduces disease in so far as those resources are channeled to
addressing womens legal economic standing, public health provisions, and womens socio-health
status. This finding fits with emerging themes in comparative research that find social predictors to
be more relevant than economic predictors in explaining cross-national health trends using direct
effects approaches (e.g. Austin and Noble, 2014; Brady etal., 2007). This research demonstrates
that economic development is not irrelevant or unimportant, but rather it operates indirectly, by
enhancing social and political conditions which then reduce health disparities. In addition, we find
that there is nothing inherent about Sub-Saharan African nations that leads to higher rates of
malaria in this region. Rather, our findings suggest that the disproportionally high burden of malaria
in Sub-Saharan Africa can be explained by issues of gender inequality and lower provisions of
public health services in this region relative to others. The direct effects of GDP per capita, general
health provisions, and Sub-Saharan Africa are often considered without hesitation in cross-national
research on health outcomes; the results of this research indicate that future studies should be cautious when making claims of direct influence for these types of factors on health, unless the potential effects of pertinent mediating factors are properly taken into account.
We also found some unique indirect effects of latitude, where nations located nearer to tropical
zones tend to have fewer health personnel. In addition to issues of poverty, tropical nations often
are politically unstable and more dependent on natural resource extraction. These processes may
contribute to a lack of formal health training as well as the brain drain, where the most educated
and skilled people leave their home country for better opportunities elsewhere. Understanding the
true mechanisms that contribute to this finding involving health-care professionals and latitude
represents an area of needed further research.
This study contributes to a growing body of literature that emphasizes the importance of female
empowerment in reducing infectious disease rates in less-developed nations (e.g. Austin and
Noble, 2014; Brady etal., 2007; Burroway, 2012; Heimer, 2007; Shircliff and Shandra, 2011).
Indeed, the degree to which dimensions of female empowerment predict total malaria prevalence
is quite robust, given that the malaria prevalence outcome variable is not gender-specific. This
finding signifies the importance of improving social conditions of women in less-developed nations
and illustrates that improved health of women translates into improved health for the broader population. As women globally represent the primary caretakers of children, households, and even the
broader community, enhancing womens status translates into improvements in a potentially wide
range of outcomes that are central to successful development.
It is important to acknowledge the limitations of this research. Data on gender-specific malaria
rates, for example, female malaria prevalence, are not available; thus we were unable to utilize
such a measure in the present analysis. However, use of the total prevalence measure here does
illustrate the importance of female empowerment in improving general health measures crossnationally, and our findings would have likely been even more robust with the availability of more
nuanced malaria data. There is also a lack of cross-national data on womens actual economic
resources; while investigating the legal economic provisions of women begins to consider the
influence of womens economic standing, it would be valuable to assess if legal economic provisions facilitate improved access to income for women. Additional shortcomings of the research
concern issues of data quality; cross-national estimates are never perfect, but we utilize the data

Downloaded from [Link] by guest on August 11, 2014

222

International Journal of Comparative Sociology 55(3)

from reputable sources (e.g. WHO, World Bank), which represent the best estimates available for
the indicators we seek to study. Data on malaria rates may also be underreported, due to a lack of
official diagnosis or persistent inequalities that prevent people, especially women, from seeking
diagnosis and treatment in less-developed nations (Bates etal., 2004; Farmer, 2001).
New developments in the area of a malaria vaccine provide some optimism about combating
this devastating disease. However, we must remain cautious about the potentials of medical breakthroughs. Social inequalities largely determine access to medical resources, including vaccines.
The barriers identified here leading to gaps in successful malaria prevention and treatment represent the same inequalities that would prevent certain groups from accessing a new malaria vaccine.
Thus, addressing issues of female empowerment in developing nations is still essential to reducing
malaria rates and improving health. Biological susceptibilities cause pregnant women and children
to be more prone to acquiring malaria; but the social and legal economic foundations of gender
inequality also contribute to these trends. Gender stratification is most pronounced in poor nations,
and among the most disadvantaged within these nations. Undoubtedly, addressing womens social
and legal economic status should be a dominant feature of global health and development policy in
order to properly address this persistent plague.
Acknowledgements
We would like to thank Bradly Fawcett and the anonymous reviewers at IJCS for their help, advice, and contributions to this research.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.

Notes
1. This also fits with the themes that female economic status and resources in themselves do not automatically improve health, but rather, reduce disease in so far as those economic resources are directed
towards and increase access to factors like education, health providers and so on.
2. The following 16 countries were removed from the sample due to lack of available data: Argentina,
Armenia, the Bahamas, the Democratic Republic of Korea, Egypt, Equatorial Guinea, Jamaica, Myanmar,
Oman, Republic of Korea, Saudi Arabia, Somalia, Syria, Turkmenistan, Zambia, and Zimbabwe.
3. Although there were some missing data points, the level of missing data on remaining cases was
extremely low and there appeared to be no pattern to the missing values that would bias results. Using
the strengths of the SEM technique, we use full maximum likelihood missing value routine. Maximum
likelihood missing value estimation is not an imputation procedure. Instead, the likelihood for the entire
sample is created by summing the likelihoods for each case, using whatever information each case has
available. This means that each country contributes the maximum amount of information possible to
the estimation (Arbuckle, 1996; Enders and Bandalos, 2001). The estimates are consistent and efficient under the condition that the data are missing at random (MAR). This is an easier condition to
meet than missing completely at random (MCAR), which is required for methods of listwise deletion.
Analyses that compare missing data methods consistently find that the full maximum likelihood missing
value routine is superior to methods of listwise deletion, pairwise deletion, and imputation procedures in
terms of parameter estimate bias, parameter estimate efficiency, convergence failures, and model fit (e.g.
Enders and Bandalos, 2001). Furthermore, we also conducted the analyses using listwise deletion, as this
is the most common strategy used in comparative research, and achieved consistent substantive results.
This demonstrates that the results presented here are not driven by the missing data method used or the
sample size. However, in the listwise-deleted analyses, the sample size was greatly reduced and such
a strategy produces estimates that are statistically consistent but not efficient (Arbuckle, 1996; Byrne,

Downloaded from [Link] by guest on August 11, 2014

223

Austin et al.

4.

5.

6.

7.

8.
9.

10.
11.

12.

13.

2009; Enders and Bandalos, 2001). We thus prefer to report models which utilize as much information as
possible and produce consistent and efficient estimates under the less-restrictive assumption of MAR.
The statistical package assumes the analysis of a simple random sample from a well-defined population.
As stated previously, we have a sample of 90 nations from a population of 106 nations; these 16 nations
appear to be missing at random, as they come from various geographic and income groups (see notes
1 and 2). Although our sample does represent a large sample of malaria endemic countries, it is not a
population and significance tests are appropriate (Rubin, 1985: 519).
Let us be clear that we are not attempting to state that our SEM represents the true underlying causal
model leading to malaria prevalence. In fact, in a classic piece by Sewall Wright (1934), he clearly states
that this is not the purpose of SEM in this following quote: the method of path analysis [SEMs] is not
intended to accomplish the impossible task of deducing causal relations from the values of correlation
coefficients (p. 193). However, we can use SEM to evaluate competing claims in the existing literature
and judge how closely our model specification, informed by this previous work in the field, fit the best
available data for low-income, malaria endemic countries in predicting malaria prevalence.
We also acknowledge that this transformation could suggest a nonlinear, more exponential relationship between the predictor variables and the malaria outcome variable. We ran models with both the
log-transformed malaria prevalence and the raw malaria prevalence rate; the substantive relationships
reported did not change across the two measures of malaria prevalence; however, the model fit was superior in the log-transformed version of malaria prevalence, and thus, we present the results of this model
in the present analyses.
The overall fit indices for the one-factor model are as follows: 2(9)=16, p=.067, Confirmatory Fit Index
(CFI)=.968, TuckerLewis Index (TLI)=.947, Incremental Fit Index (IFI)=.969, root mean squared
error of approximation (RMSEA)=.093, Bayesian Information Criterion (BIC)=24.5. The overall fit
indices for the two-factor model are as follows: 2(8)=4.4, p=.816, CFI=1.0, TLI=1.031, IFI=1.016,
RMSEA=.00, BIC=31.6. All of the above fit indices yield empirical evidence that the two-factor model
is of superior overall model fit than the one-factor model.
These results comparing model fit are available from the authors upon request.
In structural equation modeling, the null hypothesis (also known as the fundamental hypothesis) is that
the means, variances, and covariances implied by the model represent what is actually portrayed in the
data. As the probability level from the chi-square test is larger than our alpha level of .05 for a 95%
confidence level, we cannot reject our null hypothesis that our model is an accurate representation of the
data.
When two hypothesized models are compared, the model with the more negative value is preferred.
We also provide a table with the unstandardized regression coefficients, standardized regression coefficients, and standard error estimates in Appendix 1 (Table 4). These can be interpreted just as regular
regression estimates, representing the relationship between the variables specified.
You can also interpret standardized regression coefficients in terms of standard deviation units. For
example, the standardized regression coefficient of .42 for the path from latitude from malaria prevalence indicates that a one standard deviation unit increase in latitude away from the equator relates to a
0.42 standard deviation decrease in malaria rates (ln). As standard deviation units are not very intuitive
to interpret, we prefer to maintain the focus on comparing the relative sizes of the standardized regression coefficients in the presentation of the results. For more concrete interpretations, we also suggest
that readers use the unstandardized coefficients (presented in Table 4 of Appendix 1), which have a more
intuitive interpretation than standardized regression coefficients.
We provide an example in Appendix 1 (Figure 3), which shows the inclusion of a direct relationship
from health resources to malaria as predicted, in order to demonstrate that there is, indeed, no significant
direct relationship, and that including a nonrelevant path reduces model fit. When choosing between two
competing models, we examined overall fit indices and performed a likelihood ratio difference test of
these two nested models. The model with the additional path from health resources to malaria does lead
to a statistically significant difference in model fit. This is evidence in favor of our final model, which
is more parsimonious. The same strategy was applied to other hypothesized relationships, such as the
relationship from gross domestic product (GDP) to malaria, from Sub-Saharan Africa to malaria, and

Downloaded from [Link] by guest on August 11, 2014

224

International Journal of Comparative Sociology 55(3)

from legal rights to malaria. Once again, these paths were not significant and model fit was impaired. In
line with the procedures used in the SEM tradition, we prefer to present more parsimonious models with
all nonsignificant paths eliminated (Byrne, 2009).

References
Agarwal B (1994) Gender and command over property: A critical gap in economic analysis and policy in
South Asia. World Development 22(10): 14551478.
Agarwal B (1997) Bargaining and gender relations: Within and beyond the household. Feminist Economics
3(1): 151.
Ali DA, Stefan D and Madhur G (2007) Property rights in a very poor country: Tenure insecurity and investment in Ethiopia. The World Bank Africa Region Sustainable Development Department and Development
Research Group, pp. 129.
Arbuckle JL (1996) Full information estimation in the presence of incomplete data. In: Marcoulides GA and
Schumacker RE (eds) Advanced Structure Equation Modeling Issues and Techniques. Mahwah, NJ:
Lawrence Erlbaum Associates, pp. 243277.
Austin KF (2013) Export agriculture is feeding malaria: A cross-national examination of the environmental
and social causes of malaria prevalence. Population and Environment 35(2): 133158.
Austin KF and McKinney LA (2012) Disease, war, hunger, and deprivation: A cross-national investigation
of the determinants of life expectancy in less-developed and sub-Saharan African nations. Sociological
Perspectives 55(3): 394416.
Austin KF and Noble MD (2014) Measuring gender disparity in the HIV pandemic: A cross-national investigation of female empowerment, inequality, and disease in less-developed nations. Sociological Inquiry
84(1): 102130.
Bates I, Fenton C, Gruber J, etal. (2004) Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and
disease part II: The determinants operating at environmental and institutional level. Lancet Infectious
Diseases 4: 368375.
Bollen K (1989) Structural Equations with Latent Variables. New York: John Wiley & Sons, Inc.
Brady D, Kaya Y and Beckfield J (2007) Reassessing the effect of economic growth on well-being in lessdeveloped countries, 1980-2003. Studies in Comparative International Development 42: 135.
Breman JG, Alilio MS and Mills A (2004) Conquering the intolerable burden of malaria: Whats new, whats
needed: A summary. The American Society of Tropical Medicine and Hygiene 71(Suppl. 2): 115.
Breman JG, Alilio MS and White NJ (2007) Defining and defeating the intolerable burden of malaria III.
Progress and perspectives summary. The American Society of Tropical Medicine and Hygiene 77(6):
vixi.
Burroway R (2010) Schools against AIDS: Secondary school enrollment and cross-national disparities in
AIDS death rates. Social Problems 57(3): 398420.
Burroway R (2012) A cross-national analysis of sex-specific HIV prevalence rates and womens access to
property land, and loans in developing countries. International Journal of Sociology 42(2): 4767.
Byrne BN (2009) Structural Equation Modeling with AMOS. New York: Psychology Press/Routledge
Academic.
CIA World Factbook (2010) Central intelligence agency. Available at: [Link] (accessed 5 May 2013).
Enders CK and Bandalos DL (2001) The relative performance of full information maximum likelihood estimation for missing data in structural equation models. Structural Equation Modeling 8(3): 430457.
Farmer P (2001) Infections and Inequalities: The Modern Plagues. Los Angeles, CA: University of California
Press.
Firebaugh G and Beck FD. (1994) Does economic growth benefit the masses? Growth, dependence, and
welfare in the third world. American Sociological Review 59(5): 631653.
Fried M, Nosten F, Brockman A, etal. (1998) Maternal antibodies block malaria. Nature 395(6705): 851852.
Gupta GR (2004) Globalization, women and HIV/AIDS epidemic. Peace Review 16(1): 7983.
Heimer CA (2007) Old inequalities, new disease: HIV/AIDS in sub-Saharan Africa. Annual Review of
Sociology 33: 551577.

Downloaded from [Link] by guest on August 11, 2014

225

Austin et al.

Holvoet N (2005) The impact of microfinance on decision-making agency: Evidence from South India.
Development and Change 36(1): 75102.
Karlsen S, Say L, Souza J-P, etal. (2011) The relationship between maternal education and mortality among
women giving birth in health care institutions: Analysis of the cross sectional WHO global survey on
maternal and perinatal health. BMC Public Health 11(606): 110. Available at: [Link]
Kick EL, McKinney LA and Thompson GH (2011) Intensity of food deprivation: The integrative impacts of
the world system, modernization, conflict, militarization and the environment. International Journal of
Comparative Sociology 52(6): 478502.
Kristof ND and WuDunn S (2009) Half the Sky: Turning Oppression into Opportunity for Women
Worldwide. New York, NY: Vintage Books.
Lowassa A, Mazigo HD, Mahande AM, etal. (2012) Social economic factors and malaria transmission in
Lower Moshi, Northern Tanzania. Parasites & Vectors 5(129): 19.
Mayoux L (2001) Tackling the down side: Social capital, womens empowerment and micro-finance in
Cameroon. Development and Change 32(1): 435464.
Medalia C and Chang VW (2011) Gender equality, development, and cross-national sex gaps in life expectancy. International Journal of Comparative Sociology 52(5): 371389.
Naidoo S, London L, Burdorf A, etal. (2011) Occupational activities associated with a reported history of
malaria among women working in small-scale agriculture in South Africa. The American Society of
Tropical Medicine and Hygiene 85(5): 805810.
Norris DE (2004) Mosquito-borne diseases as a consequence of land use change. EcoHealth 21(1): 1924.
Ogbodo SO, Nwagha UI, Okaka ANC, etal. (2009) Malaria parasitaemia among pregnant women in a
rural community of Eastern Nigeria; Need for combined measures. Nigerian Journal of Physiological
Sciences 24(2): 95100.
Organisation for Economic Co-operation and Development (OECD) (2009) Gender, Institutions and
Development Database (GID-DB). Available at: [Link]
(accessed 10 June 2013).
Packard RM (2009) Roll back on malaria, roll in development? Reassessing the economic burden of malaria.
Population Development and Review 35(1): 5387.
Parvin GA, Reazaul Ahsan SM and Chowdhury MR (2005) Women empowerment performance of income
generating activities supported by Rural Women Employment Creation Project (RWECP): A case study
in Dumuria Thana, Bangladesh. The Journal of Geo-Environment 4: 4762.
Pattanayak S, Dickinson K, Corey C, et al. (2006) Deforestation, malaria, and poverty: A call for transdisciplinary research to support the design of cross-sectional policies. Sustainability: Science, Practice, and
Policy 2(1): 4556.
Prez-Escamilla R, Dessalines M, Finnigan M, et al. (2009) Household food insecurity is associated with
childhood malaria in rural Haiti. The Journal of Nutrition 139(11): 21322138.
Ridgeway CL and Smith-Lovin L (1999) The gender system and interaction. Annual Review of Sociology 25:
191216.
Rubin A (1985) Significance testing with population data. Social Service Review 59(3): 518520.
Sabin LL, Rizal A, Brooks MI, etal. (2010) Attitudes, knowledge, and practices regarding malaria prevention
and treatment among pregnant women in Eastern India. The American Society of Tropical Medicine and
Hygiene 82(6): 10101016.
Sachs J and Malaney P (2002) The economic and social burden of malaria. Nature 415: 680685.
Schuler SR and Hashemi SM (1994) Credit programs, womens empowerment, and contraceptive use in rural
Bangladesh. Studies in Family Planning 25(2): 6576.
Sen A (1999) Development as Freedom. New York: Knopf.
Shandra CL, Shandra JM and London B (2011) World bank structural adjustment, water, and sanitation: A
cross-national analysis of child mortality in Sub-Saharan Africa. Organization & Environment 24(1):
107129.
Shargie EB, Ngondi J, Graves PM, etal. (2010) Rapid increase in ownership and use of long-lasting insecticidal nets and decrease in prevalence of malaria in three regional states of Ethiopia (20062007). Journal
of Tropical Medicine 2010: 112.

Downloaded from [Link] by guest on August 11, 2014

226

International Journal of Comparative Sociology 55(3)

Shen C and Williamson JB (1997) Child mortality, womens status, economic dependency, and state strength:
A cross-national study of less-developed countries. Social Forces 76(2): 667694.
Sherer RD Jr., Bronson JD, Teter CJ, etal. (2004) Microeconomic loans and health education to families in
impoverished communities: Implications for the HIV pandemic. Journal of the International Association
of AIDS Care 3(4): 110114.
Shircliff EJ and Shandra JM (2011) Non-governmental organizations, democracy, and HIV prevalence: A
cross-national analysis. Sociological Inquiry 81(2): 143173.
Soares RR (2007) On the determinants of morality reductions in the developing world. Population
Development and Review 33(2): 247287.
Taj S, Akmal N, Shah NA, etal. (2008) Gender involvement in small enterprises through micro-credit in
Rainfed Pothwar. Sarhad Journal of Agriculture 24(4): 779784.
Tsai LC, Witte SS, Aira T, etal. (2011) Piloting a savings-led microfinance intervention with women engaging in sex work in Mongolia: Further innovation for HIV risk reduction. The Open Womens Health
Journal 5: 2632.
Verhoeff FH, Brabin BJ, Hart CA, etal. (1999) Increased prevalence of malaria in HIV-infected pregnant
women and its implications for malaria control. Tropical Medicine & International Health 4(1): 512.
Villarreal M (2006) Changing customary land rights and gender relations in the context of HIV/AIDS in
Africa. In: Colloque international Les frontires de la question foncire At the frontier of land issues,
Montpellier.
Wickrama KAS and Lorenz FO (2002) Womens status, fertility decline, and womens health in developing
countries: Direct and indirect influences of social status on health. Rural Sociology 67(2): 255277.
Williams PCM, Martina A, Cumming RG, etal. (2009) Malaria prevention in sub-Saharan Africa: A field
study in rural Uganda. Journal of Community Health 34: 288294.
World Bank (2013) World development indicators online. Available at: [Link]
views/variableSelection/[Link]?source=world-development-indicators# (accessed 10 June
2013).
World Health Organization (WHO) (2003) Lives at Risk: Malaria and Pregnancy. WHO. Available at: http://
[Link]/features/2003/04b/en/# (accessed 10 June 2013).
World Health Organization (WHO) (2008) Proportion of Births Attended by a Skilled Health Worker 2008
Updates. Department of Reproductive Health Research, WHO. Available at: [Link] (accessed 5 May
2013).
World Health Organization (WHO) (2013) Malaria fact sheet. Available at: [Link]
factsheets/fs094/en/ (accessed 10 June 2013).
World Health Organization (WHO) (2014) Health promotion, Track 1: Community empowerment. Available
at: [Link] (accessed 22 March 2014).
Wright S (1934) The method of path coefficients. The Annuals of Mathematical Statistics 5(3): 161215.

Downloaded from [Link] by guest on August 11, 2014

227

Austin et al.
Appendix 1
Table 4. Regression estimates for SEM equations predicting malaria prevalence (ln).
Regression path

Coefficient

GDP per capita (ln) Womens legal

economic rights
GDP per capita (ln) Womens sociohealth status
GDP per capita (ln) Health provisions
Sub-Saharan Africa Womens legal
economical rights
Sub-Saharan Africa Health provisions
latitude health providers
Latitude Malaria prevalence (ln)
Womens legal economic rights
Womens socio-health status
Womens legal economic rights Health
provisions
Health provisions Womens sociohealth status
Womens socio-health status Malaria
prevalence (ln)
Womens legal economic rights Loan
access
Womens legal economic rights Land
access
Womens legal economic rights
Property access
Womens socio-health status Female/
male schooling
Womens socio-health status Low
fertility
Womens socio-health status % Births
attended
Health provisions Secondary schooling
Health provisions Health providers
Health provisions Improved sanitation

Standardized coefficient

SE

.097***

.030

.389

.034*

.015

.243

12.301***
.194***

2.231
.056

.505
.411

10.471**
.039***
.111***
.099*

4.088
.007
.018
.062

.229
.459
.425
.178

28.897**

11.728

.297

.004***

.001

.634

13.558***

2.196

.574

1.000#

.785

.99***

.153

.766

.957***

.158

.712

1.000#

.770

9.767***

1.226

.885

149.454***

21.974

.788

.931
.561
.868

1.000#
.025***
1.070***

.004
.094

GDP: gross domestic product; SE: standard error of estimation.

***p<.001; **p<.01; *p<.05; #not applicable.

Downloaded from [Link] by guest on August 11, 2014

228

International Journal of Comparative Sociology 55(3)

Loan
Access
.79

Land
Access

Property
Access

Fem/Male
Schooling

.71

.77

.89

.77

Womens
Legal Econ
Rights

Low
Fertility

Births
Attended

.79

Womens
Socio-Health
Status

.19*

.30**
.63***
-.41***

.25*

-.48***

.39***

Health
Provisions

.51***
GDP p/c (ln)

-.23**

Sub-Saharan
Africa

.46***

.87

.93

.56
Health
Providers

Secondary
Schooling

Improved
Sanitation
-.09

-.42***
Latitude

Malaria
Prevalence (ln)

Figure 3. Alternate SEM predicting malaria prevalence displaying standardized regression coefficients.

CFI: Confirmatory Fit Index; TLI: TuckerLewis Index; IFI: Incremental Fit Index; RMSEA: root mean squared error of
approximation; BIC: Bayesian Information Criterion.
Model fit: The overall fit indices for the one-factor model are as follows: 2(54)=65.68, p=.132, CFI=.983 TLI=.971,
IFI=.984, RMSEA=.049, BIC=177.
Note that the path from health provisions to malaria prevalence is nonsignificant, the model fit is inferior to the model
presented in Figure 2, and the inclusion of the path did not alter the other substantive relationships. Thus this path, as
well as other nonsignificant paths, is eliminated from the final model. Additional results displaying the nonsignificance of
additional paths are available from the authors upon request.
Additional notes: standardized coefficients flagged for statistical significance, where ***p<.001; **p<.01; *p<.05 (onetailed directional t-tests).

Downloaded from [Link] by guest on August 11, 2014