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Global health
Original research
Impact of biological sex and gender-related factors on public engagement in protective health behaviours during the COVID-19 pandemic: cross-sectional analyses from a global survey
  1. Rubee Dev1,
  2. Valeria Raparelli1,2,3,
  3. Simon L Bacon4,5,
  4. Kim L Lavoie4,6,
  5. Louise Pilote7,
  6. Colleen M Norris1,8,9
  7. for the iCARE Study Team
  1. 1Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
  2. 2Department of Translational Medicine, University of Ferrara, Ferrara, Italy
  3. 3University Center for Studies on Gender Medicine, University of Ferrara, Ferrara, Italy
  4. 4Montreal Behavioural Medicine Centre, CIUSSS-NIM (Centre intégré universitaire de santé et de services sociaux du Nord-de-l’île-de-Montréal), Montreal, Québec, Canada
  5. 5Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, Québec, Canada
  6. 6Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada
  7. 7Research Institute of McGill University Health Centre, Division of Clinical Epidemiology, McGill University, Montreal, Québec, Canada
  8. 8Cardiovascular Health & Stroke Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
  9. 9Faculty of Medicine & School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  1. Correspondence to Dr Rubee Dev; rubee{at}ualberta.ca

Abstract

Objective Given the role of sociocultural gender in shaping human behaviours, the main objective of this study was to examine whether sex and gender-related factors were associated with the public’s adherence to COVID-19-recommended protective health behaviours.

Design This was a retrospective analysis of the survey that captured data on people’s awareness, attitudes and behaviours as they relate to the COVID-19 policies.

Setting Data from the International COVID-19 Awareness and Responses Evaluation survey collected between March 2020 and February 2021 from 175 countries.

Participants Convenience sample around the world.

Main outcome measures We examined the role of sex and gender-related factors in relation to non-adherence of protective health behaviours including: (1) hand washing; (2) mask wearing; and (3) physical distancing. Multivariable logistic regression was conducted to determine the factors associated with non-adherence to behaviours.

Results Among 48 668 respondents (mean age: 43 years; 71% female), 98.3% adopted hand washing, 68.5% mask wearing and 76.9% physical distancing. Compared with males, females were more likely to adopt hand washing (OR=1.97, 95% CI: 1.71 to 2.28) and maintain physical distancing (OR=1.28, 95% CI: 1.22 to 1.34). However, in multivariable sex-stratified models, females in countries with higher Gender Inequality Indexes (GII) were less likely to report hand washing (adjusted OR (aOR)=0.47, 95% CI: 0.21 to 1.05). Females who reported being employed (aOR=0.22, 95% CI: 0.10 to 0.48) and in countries with low/medium GIIs (aOR=0.18, 95% CI 0.06 to 0.51) were less likely to report mask wearing. Females who reported being employed were less likely to report physical distancing (aOR=0.39, 95% CI: 0.32 to 0.49).

Conclusion While females showed greater adherence to COVID-19 protective health behaviours, gender-related factors, including employment status and high country-wide gender inequality, were independently associated with non-adherence. These findings may inform public health and vaccination policies in current as well as future pandemics.

  • COVID-19
  • infectious diseases
  • health policy

Data availability statement

Data sets are available from the iCARE team upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2021-059673

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    Strengths and limitations of this study

    • The study had a large sample size with a global perspective, and availability of gender-related factors to examine the impact of gender.

    • The online nature of the International COVID-19 Awareness and Responses Evaluation survey might have limited the participation from individuals who did not have access to computers and internet, limiting the generalisation of findings.

    • Our global sample was highly educated group of people whose results are likely to be ‘best case scenario’.

    • The global sample was also mostly females, so males are under-represented in this study.

    • Self-reported behaviour of the respondents might not have accurately represented the actual behaviour; hence, the findings should be interpreted with caution.

    Introduction

    Public behaviour plays an important role during public health emergencies.1 Behaviours can be influenced by both the biological sex and sociocultural gender (gender identity, gender roles, gender relations and institutionalised gender) of an individual.2 According to the Canadian Institutes of Health and Research, sex refers to ‘a set of biological attributes and associated physical and physiological features including chromosomes, gene expression, hormone levels and function, and reproductive/sexual anatomy’ and is categorised as female or male,3 while gender refers to ‘the array of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, relative power and influence that society ascribes to women and men on a differential basis’.4 5 In the case of the COVID-19 pandemic, both men and women worldwide have shown inconsistent responses to acute infection as well as differing long-term health, economic and social consequences.6 7 Understanding these responses in relation to sex and/or gender-related attributes in the general population may be particularly valuable to inform tailored sex and gender strategies moving forward.

    It has been identified that public health responses to infectious diseases require fundamental changes in individual behaviour. Hand washing, mask wearing and physical distancing (previously referred to as social distancing) are the key transmission reduction public health behaviour-based prevention measures1 that are associated with a reduction in the global prevalence of COVID-19.8 9 Effectiveness of such responses depends on the generalised adherence of the public and may be specific to certain high-risk groups. Though recommended and proven to limit transmission rates, hand washing, mask wearing and physical distancing have been inconsistently initiated and maintained. There is a dynamic relationship between the voluntary adoption of public health behaviours and infection transmission during infectious disease epidemics.10 The COVID-19 pandemic has sparked an unparalleled global discourse around the adoption of protective behaviours and other public health and social measures to slow the person-to-person spread of SARS-CoV-2.1

    COVID-19 has highlighted the role that sex and gender play in our lives. This includes influencing an individual’s exposure to COVID-19 through sex and gender-related occupations, risk-taking behaviours and employment of precautions. Sex and gender also are known to have an impact on health through the gendered nature of the workforce and the predominant risk associated with it, increased caregiving responsibilities at home limiting the work and economic opportunities, or institutional biases and policies.2 11 Gender affects the division of labour and care duties in families and communities. Hence, it is of utmost importance that we gather, from our recent lived experience, evidence on the potential sex and gender-related differences in perception and behavioural responses experienced during COVID-19 pandemic.

    A few studies have shown sex-based differences in COVID-19-related beliefs and behaviours and have reported that compared with males, females are more likely to perceive the pandemic as a serious health problem and comply more with the preventive behaviours.12 13 In addition, as gender is culturally and geographically based, we hypothesised that there is a difference in preventive behaviours and pandemic-related concerns based on sex and gender-related factors. Also, regardless of sex-based differences, our previous studies highlight the need of focusing on the gender-related factors.14 15 Hence, the purpose of this study was to examine whether sex and gender-related factors are associated with the engagement in the recommended key protective health behaviours such as hand washing, mask wearing and physical distancing during the COVID-19 pandemic.

    Methods

    Study design

    Survey data sets from the ongoing International COVID-19 Awareness and Responses Evaluation (iCARE) study led by the Montreal Behavioural Medicine Centre (www.mbmc-cmcm.ca) in collaboration with a team of 200 international collaborators from 42 countries were used for the data analyses. The iCARE study design has been previously described.16 Briefly, iCARE is an international multiwave cross-sectional observational cohort study of public awareness, attitudes and responses to public health policies implemented to reduce the spread of COVID-19 on people around the world (www.iCAREstudy.com). It collects data on study demographics, perceptions of government policy, health behaviours, adherence to health measures, types of concerns and adherence motivators.

    Survey data were collected in 4–6 weeks of rounds using convenience snowball sampling (globally, 25 000–30 000 per wave) and parallel representative sampling (in targeted countries), generating data for multiple cohorts of participants that were added to the first round cohort launched on 27 March 2020. We analysed data from survey 1 to survey 7 that were collected between 27 March 2020 and 9 February 2021. A total of 61 552 respondents participated in the survey from over 175 countries. The data were analysed for 48 668 respondents (female=34 556, male=14 112). The questionnaire used in the survey is publicly available via the Open Science Framework (https://osf.io/nswcm/) and the survey is available in 34 languages.17

    Biological sex and gender-related factors

    For each surveyed individual the following variables were collected: sociodemographic characteristics (sex at birth, age in years, level of education, work status, perceived annual household income, number of adults and children living in the household, country of residence and likelihood of getting vaccinated; ie, respondents’ willingness to get a COVID-19 vaccine), the presence of a physician-diagnosed depressive and/or anxiety disorder, and adoption of protective health behaviours (hand washing, wearing a face mask and physical distancing).

    To account for institutionalised gender, the Gender Inequality Index (GII), developed by the United Nations Development Programme, was used as a measure of country-specific gender inequality18 and as a measure of institutionalised gender in this study. This index is a continuous measure for the degree of gender inequality per country on a scale between 0 and 1, with lower values representing near-perfect gender equality and higher values representing greater levels of inequality favouring males. The GII is based on several aspects of institutionalised gender: (1) reproductive health, measured by the maternal mortality ratio and adolescent birth rates; (2) empowerment, measured by the proportion of parliamentary seats occupied by women and the proportion of adult women and men with at least some secondary education; and (3) economic status, measured by labour force participation rate of men and women.19 GIIs in this study were divided into tertiles and later categorised into high and low/medium GII categories. We used data on GIIs from 2019. Some of the countries in the region were excluded from the analysis due to the unavailability of data.

    Outcome measures

    The main outcomes of the analysis were self-reported non-adherence to three recommended protective health behaviours, including: (1) hand washing with soap and water; (2) wearing a face mask; and (3) a composite measure of physical distancing behaviours (specifically: staying at least 1–2 m away from other people; staying/working at home rather than going to work or school; self-quarantining if returning from a trip; self-quarantining if one has the virus or believe they have the virus; avoiding going out to bars/pubs/restaurants; avoiding large social gatherings; avoiding small social gatherings; avoiding indoor social gatherings; and avoiding any non-essential travel).20 A composite binary variable was constructed, in which the participants who met the above-mentioned criteria were coded with a value of 1; otherwise, the participants were coded with a value of 0. A set of measures in the iCARE survey intended to explore the prevention measures used by the public to prevent the spread of COVID-19 by maintaining a physical distance between two people and reducing the number of times people come into close physical contact with one another21 were used to create a composite variable for physical distancing.

    Methodological steps

    To consider gender-related variables in the evaluation of health behaviour outcomes in retrospective cohort studies, a multistep methodology has been developed by the Gender Outcomes International Group: to Further Well-being Development group.22 The steps applied in this study are (1) identification of gender-related variables, (2) definition of outcomes, and (3) building of feasible final variable list. The final list of gender-related variables was included in the statistical models.

    Statistical analysis

    A global analysis of public engagement in three recommended protective health behaviours was performed to investigate whether the outcomes differed by sex. Our outcome of interest in the modelling process was the non-adherence to behavioural recommended measures. Descriptive sex-stratified analyses were run for age; baseline mental health conditions (any depressive or anxiety disorders); and previously defined gender-related factors such as level of education, work status, annual household income and GII. Continuous variables were presented as mean and standard deviation [SD]. Categorical variables were presented as counts and percentages. Sex differences in outcomes (protective health behaviours) were completed and associations between sex, gender-related factors and outcomes were tested in a multivariable model. Bivariate logistic regressions were run for crude analysis, followed by collinearity diagnostics to account for inflation in SEs of parameter estimates caused by collinear cofactors.23 If variables were collinear, we included the variable with the least amount of missing data in the multivariable models. A priori gender-related cofactors (ie, gender role (work status), gender identity (depressive and/or anxiety disorders) and institutionalised gender (education level, annual household income and GII)) were included in multivariable models adjusting for the potential confounders (ie, age and geographical regions). A two-way interaction between the sex and gender-related factors was tested by including an interaction term in bivariate models. All statistical analyses were performed using statistical software STATA V.16 (College Station, Texas, USA). Tests were two sided and the significance was defined as p<0.05.

    Patient and public involvement

    It was not possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research. However, they were involved in the survey development. For the dissemination of results, we will submit the results of the study to relevant national and international journals with the intention of publishing the results widely. Further, we will make national and international presentations in conferences and symposiums to stakeholder groups including those involving general public, researchers, clinicians and policymakers.

    Results

    Descriptive characteristics of respondents

    Our study population included 34 556 females (71%) and 14 112 males (29%) (table 1). The mean age of the respondents was 43 years (SD: 16). A majority (n=23 462; 48.8%) was between 26 and 50 years of age. Most respondents (79.7%) reported high levels of education, were employed (61.8%), were from Europe and North American countries (66.3%) and from regions with high levels of gender equity as measured by low/medium GIIs (66.9%). Females were more likely to report having a physician-diagnosed depressive disorder (9.5% vs 6.7%, p≤0.001) and anxiety disorder (17.7% vs 10.7%, p≤0.001) compared with males. Irrespective of sex, only 68.5% of responders disclosed wearing a face mask, while a higher percentage of females reported adherence to physical distancing behaviours compared with males (78.3% vs 73.7%, p<0.001). Participants aged 51 and older were more likely to engage in all three key protective behaviours as compared with younger participants: hand washing (OR=5.60, 95% CI: 4.51 to 6.94); mask wearing (OR=1.11, 95% CI: 1.04 to 1.18); and physical distancing (OR=1.50, 95% CI: 1.41 to 1.61) (table 2).

    View this table:
    Table 1

    Descriptive characteristics of survey respondents by biological sex (N=48 668)

    View this table:
    Table 2

    Bivariate association between gender-related variables and adoption of three key protective health behaviours

    Gender-related factors associated with adoption of protective health behaviours

    For the univariate analysis, the proportion of people adopting the protective health-related behaviours varied depending on the gender-related factors examined. Despite employed respondents being 84% more likely to engage in hand washing than unemployed respondents, they were 65% less likely to engage in mask wearing and 47% less likely to engage in physical distancing (p<0.001 for all comparisons). Hand washing and physical distancing were less common as the number of adults ≥18 years living in the household increased. The proportion of adoption was lowest for wearing a face mask, both for females and males (58.5% vs 57%) in low/medium-GII countries (figure 1). Respondents living in the countries with high GIIs were 4.38 times (95% CI: 4.15 to 4.63) more likely to use mask than respondents living in the countries with low GIIs; however, they were less likely to engage in hand washing and physical distancing (table 2).

    Figure 1
    Figure 1

    Percentage of adherence to protective health behaviours, per group of Gender Inequality Index (GII), stratified by sex.

    Sex and gender-related differences in the adoption of protective health behaviours

    Sex-stratified multivariate analyses demonstrated that the factors associated with the adoption of protective health behaviours varied by sex. Among females, the factors associated with not adhering to health behaviours were: (1) for hand washing—higher country gender inequality favouring males’ GII (adjusted OR (aOR)=0.47, 95% CI: 0.21 to 1.05, p=0.07); (2) for mask wearing—older age (aOR females=0.35, 95% CI: 0.12 to 1.03, p=0.05), being employed (aOR females=0.22, 95% CI: 0.10 to 0.48, p<0.001) and living in a country with more gender equity as measured by the GII (aOR=0.18, 95% CI: 0.06 to 0.51, p<0.01); and (3) for physical distancing—being employed (aOR females=0.39, 95% CI: 0.32 to 0.49, p<0.001) (table 3, online supplemental appendix table 1A,B).

    View this table:
    Table 3

    Association between gender-related variables and adoption of face mask wearing, by sex

    Among males, factors that were associated with not adhering to protective health behaviours were: (1) for hand washing—higher level of education (aOR males=0.37, 95% CI: 0.14 to 1.01, p=0.05) and with a household size of >2 (aOR males=0.46, 95% CI: 0.21 to 1.03, p=0.06); (2) for mask wearing—being employed (aOR males=0.15, 95% CI: 0.04 to 0.53, p<0.01) and living in a country with more gender equity as measured by the GII (aOR=0.29, 95% CI: 0.09 to 0.91, p<0.05); and (3) for physical distancing—being employed (aOR males=0.38, 95% CI: 0.27 to 0.52, p<0.001) and with household size of >2 (aOR males=0.66, 95% CI: 0.47 to 0.92, p<0.05) (table 3, online supplemental appendix table 1A,B).

    There was a significant interaction between sex and education level of the participants. High level of education decreased the use of mask wearing among females compared with males (p=0.03). There was a trend for living in a country with lower gender equity to be associated with poorer protective behaviours in females compared with males (p=0.056).

    Discussion

    The present study provides a comprehensive analysis on the impact of sex and gender-related factors and the association with adherence to protective health behaviours during the COVID-19 pandemic. Overall, hand washing, mask wearing and physical distancing behaviours were adopted globally. However, there were a number of gender-related factors associated with a lower adherence based on sex.

    Lower adherence to the protective health behaviours was mainly associated with younger age, being employed and living in a country with low/medium GIIs (higher gender equity) for females, while high level of education, being employed and household size of >2 were associated with lower adoption in males. Considering this group of individuals with lower adherence to protective health behaviours, this would suggest that in the current as well as future pandemics it may be useful to target interventions based on sex and gendered factors to increase adherence and reduce disease transmission. Measures such as risk assessment and mitigation considerations for public settings could be implemented to mitigate the risk of transmission and promote the adoption of protective health behaviours.

    Overall, mask wearing was lower among both sexes compared with other protective behaviours such as hand washing and physical distancing. Many countries waited to issue mask mandate months into the pandemic24 even though other behaviours were mandated right away. This may be one of the reasons for lower adherence. Further, adoption of mask wearing was less likely in males compared with females, mainly among those who were employed, indicating substantial room for improvement in male’s engagement to mask wearing. In our study, employed female respondents reported that they were more likely to wear a mask compared with male respondents. Similarly, a study conducted in the USA also reported that females were 1.5 times more likely to wear a mask compared with males.25 It has been suggested that females may be more likely to protect themselves and others by wearing a mask specifically because they handle the majority of caregiving within families and are over-represented in essential work services, which generally require mask wearing.26 Previous studies have also reported mask wearing to be significantly associated with the occupation of respondents.27 28 A study reported that women make up almost 90% of nurses and nursing assistants in the USA and over two-thirds of grocery store cashiers.28 Performing the dual function of an essential worker outside and a caregiver at home, women might face a dilemma of how to keep their families healthy and safe while continuing to work in potentially risky circumstances, suggesting that these factors may make them more adherent to the protective behaviours.

    Older females were the most likely participants to engage in hand washing and physical distancing, but less likely to engage in mask wearing. Older females may have a higher perceived risk of developing COVID-19 complications and mortality, and thus engaged in more protective health behaviours such as hand washing and physical distancing. Previous studies have shown that females and older adults are less likely to engage in the risky behaviours, feel more vulnerable to contracting diseases and have a stronger sense of responsibility to protect the society.29 30 This is consistent with the findings of an American study that reported being older and female was related to adopting more pandemic-mitigating behaviours.31 Furthermore, a study conducted in China also reported that being female and older was associated with adopting protective behaviours.30 However, our study findings are in contrast with the results of a study conducted in Portugal that reported a decline in engagement in protective health behaviours with advancing age, which was reported to be related to the increased social isolation and lack of help among older population.32 Even though the study did not report the differences by sex of the respondents, self-isolation could be the reason for lower adherence to mask wearing among females. Depending on the diverse context, public health interventions should be tailored to sex and differing age groups, and importantly institutional gender-related variables such as those measured by the GII.

    Emerging evidence shows that gender, including the institutionalised gender, shapes mask-wearing adherence.33 One of the interesting findings of the current study is respondents from low/medium-GII countries with less gender inequity reported a significantly lower adherence to mask wearing compared with respondents from countries with high GII (high gender inequity). Even among the low/medium-GII countries, adherence is reported to be poorer among males. Lower adherence among males is in line with a finding from a study conducted in the USA, in which males exhibited poorer mask wearing practices compared with their female counterparts.25 This is also supported by a review that looked at research from multiple countries and found women were 50% more likely than men to practise protective behaviour.34 The correlation between a Gini coefficient (a measure of income inequality) and GII (a measure of gender inequality) could explain the lower adherence to protective health behaviours in countries with low/medium GIIs where income inequality arises mainly through gender gaps in economic participation.35

    The strengths of this study include a large sample size, having a global perspective and availability of gender-related factors to examine the impact of gender. This study also has some limitations that should be acknowledged. First, the online nature of the iCARE survey might have limited the participation from individuals who did not have access to computers and internet, limiting the generalisation of findings. However, the advantages of online surveys have been shown to outweigh the disadvantages, mainly in terms of its external validity36; hence, the bias might be relatively low. Second, our global sample was a highly educated group of people whose results are likely to be ‘best case scenario’. The global sample was also mostly women, so men are under-represented in this study. Third, self-reported behaviour does not always accurately represent actual behaviour; hence, the findings should be interpreted with caution. Finally, although the study established the associations between sex and gender-related factors with the adoption of protective health behaviours, no causal relationships should be assumed due to the nature of the cross-sectional design of the survey.

    Conclusions

    In this analysis of a multinational study population, while a majority of respondents reported wearing a face mask, this is likely reflective of country-wide mask mandates as opposed to adopting it as a protective health behaviour. However, our study findings suggest that wearing a face mask appeared to be more difficult to adhere to for many compared with other key protective behaviours such as hand washing and physical distancing. Moreover, our study noted that this was even more apparent in countries with low GII (more equity between males and females), indicating substantial room for improvement in public engagement regarding protective health behaviours. Since widespread protective behavioural responses are paramount for a successful containment and control of an infectious disease contagion, the present study provides valuable information for identifying sex and gendered factors that may inform effective public health policies. Further, the COVID-19 pandemic highlights the urgent need to incorporate sex and gender analysis into all research and innovation processes in order to target specific groups both to help contain the transmission of the virus and to formulate vaccine policies.

    Data availability statement

    Data sets are available from the iCARE team upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The iCARE study was approved by the Research Ethics Committee of the Comité d’éthique de recherche du CIUSSS-NIM (Centre intégré universitaire de santé et de services sociaux du Nord-de-l’île-de-Montréal; approval number: 2020-2099/25-03-2020). The current secondary analysis was approved by the ethics committee at the University of Alberta (Pro107407).

    Acknowledgments

    The authors would like to thank the iCARE study team for providing access to the iCARE data. The authors would particularly like to acknowledge the valued contribution of the iCARE participants. The authors would also like to thank the lead investigators of the study and all the collaborators of iCARE study. Lead investigators: Kim L Lavoie, PhD, University of Quebec at Montreal (UQAM) and CIUSSS-NIM, CANADA; Simon L Bacon, PhD, Concordia University and CIUSSS-NIM, CANADA. Collaborators (in alphabetical order): ABU DHABI: Zahir Vally, PhD, UAE University; ARGENTINA: Nora Granana, PhD, Hospital Durand; Analía Verónica Losada, PhD, University of Flores; AUSTRALIA: Jacqueline Boyle, PhD, Monash University; Margie Danchin, PhD, Melbourne Medical School; Joanne Enticott, PhD, Monash University; Shajedur Rahman Shawon, PhD, Centre for Big Data Research in Health, UNSW Medicine; Shrinkhala Dawadi, MSc, Monash University; Helena Teede, MD, Monash University; AUSTRIA: Alexandra Kautzky-Willer, MD, Medizinische Universität Wien; BANGLADESH: Arobindu Dash, MS, International University of Business, Agriculture & Technology; BRAZIL: Marilia Estevam Cornelio, PhD, University of Campinas; Marlus Karsten, Universidade do Estado de Santa Catarina–UDESC; Darlan Lauricio Matte, PhD, Universidade do Estado de Santa Catarina–UDESC; Felipe Reichert, PhD, Universidade; CANADA: Ahmed Abou-Setta, PhD, University of Manitoba; Shawn Aaron, PhD, Ottawa Hospital Research Institute; Angela Alberga, PhD, Concordia University; Tracie Barnett, PhD, McGill University; Silvana Barone, MD, Université de Montréal; Ariane Bélanger-Gravel, PhD, Université Laval; Sarah Bernard, PhD, Université Laval; Lisa Maureen Birch, PhD, Université Laval; Susan Bondy, PhD, University of Toronto–Dalla Lana School of Public Health; Linda Booij, PhD, Concordia University; Roxane Borgès Da Silva, PhD, Université de Montréal; Jean Bourbeau, MD, McGill University; Rachel Burns, PhD, Carleton University; Tavis Campbell, PhD, University of Calgary; Linda Carlson, PhD, University of Calgary; Étienne Charbonneau, PhD, École nationale d'administration publique; Kim Corace, PhD, University of Ottawa; Rubee Dev, PhD, University of Alberta; Olivier Drouin, MD, CHU Sainte-Justine/Université de Montréal; Francine Ducharme, MD, Université de Montréal; Mohsen Farhadloo, Concordia University; Carl Falk, PhD, McGill University; Richard Fleet MD, PhD, Université Laval; Michel Fournier, MSc, Direction de la Santé Publique de Montréal; Gary Garber, MD, University of Ottawa/Public Health Ontario; Lise Gauvin, PhD, Université de Montréal; Jennifer Gordon, PhD, University of Regina; Roland Grad, MD, McGill University; Samir Gupta, MD, University of Toronto; Kim Hellemans, PhD, Carleton University; Catherine Herba PhD, UQAM; Heungsun Hwang, PhD, McGill University; Jack Jedwab, PhD, Canadian Institute for Identities and Migration and the Association for Canadian Studies; Keven Joyal-Desmarais, PhD, Concordia University; Lisa Kakinami, PhD, Concordia University; Eric Kennedy, PhD, York University; Sunmee Kim, PhD, University of Manitoba; Joanne Liu, PhD, McGill University; Colleen Norris, PhD, University of Alberta; Sandra Pelaez, PhD, Université de Montréal; Louise Pilote, MD, McGill University; Paul Poirier, MD, Université Laval; Justin Presseau, PhD, University of Ottawa; Eli Puterman, PhD, University of British Columbia; Joshua Rash, PhD, Memorial University; Paula AB Ribeiro, PhD, MBMC; Mohsen Sadatsafavi, PhD, University of British Columbia; Paramita Saha Chaudhuri, PhD, McGill University; Jovana Stojanovic, PhD, Concordia University; Eva Suarthana, MD, PhD, Université de Montréal / McGill University; SzeMan Tse, MD, CHU Sainte-Justine; Michael Vallis, PhD, Dalhousie University; CHILE: Nicolás Bronfman Caceres, PhD, Universidad Andrés Bello; Manuel Ortiz, PhD, Universidad de La Frontera; Paula Beatriz Repetto, PhD, Universidad Católica de Chile; COLOMBIA: Mariantonia Lemos-Hoyos, PhD, Universidad EAFIT; CYPRUS: Angelos Kassianos, PhD, University of Cyprus; DENMARK: Naja Hulvej Rod, PhD, University of Copenhagen; FRANCE: Mathieu Beraneck, PhD, Université de Paris; CNRS; Gregory Ninot, PhD, Université de Montpellier; GERMANY: Beate Ditzen, PhD, Heidelberg University; Thomas Kubiak, PhD, Mainz University; GHANA: Sam Codjoe MPhil, MSc, University of Ghana; Lily Kpobi, PhD, University of Ghana; Amos Laar, PhD, University of Ghana; GREECE: Theodora Skoura, PhD, Aretaieio Hospital, Athens University; INDIA: Delfin Lovelina Francis, PhD, Vinayaka Mission's Dental College; Naorem Kiranmala Devi, PhD, University of Delhi; Sanjenbam Meitei, PhD, Manipur University; Suzanne Tanya Nethan, MDS, School of Preventive Oncology; Lancelot Pinto, MD, PhD, Hinduja Hospital and Medical Research Centre; Kallur Nava Saraswathy, PhD, University of Delhi; Dheeraj Tumu, MD, WHO; INDONESIA: Silviana Lestari, MD, PhD, Universitas Indonesia; Grace Wangge, MD, PhD, SEAMEO Regional Center for Food and Nutrition; IRELAND: Molly Byrne, PhD, National University of Ireland, Galway; Hannah Durand, PhD, National University of Ireland, Galway; Jennifer McSharry, PhD, National University of Ireland, Galway; Oonagh Meade, PhD, National University of Ireland, Galway; Gerry Molloy, PhD, National University of Ireland, Galway; Chris Noone, PhD, National University of Ireland, Galway; ISRAEL: Hagai Levine, MD, Hebrew University; Anat Zaidman-Zait, PhD, Tel-Aviv University; ITALY: Stefania Boccia, PhD, Università Cattolica del Sacro Cuore; Ilda Hoxhaj, MD, Università Cattolica del Sacro Cuore, Stefania Paduano, MSc, PhD, University of Modena and Reggio Emilia; Valeria Raparelli, PhD, Sapienza–University of Rome; Drieda Zaçe, MD, MSc, PhDc, Università Cattolica del Sacro Cuore; JORDAN: Ala'S Aburub, PhD, Isra University; KENYA: Daniel Akunga, PhD, Kenyatta University; Richard Ayah, PhD, University of Nairobi, School Public Health; Chris Barasa, MPH, University of Nairobi, School Public Health; Pamela Miloya Godia, PhD, University of Nairobi; Elizabeth W Kimani-Murage, PhD, African Population and Health Research Center; Nicholas Mutuku, PhD, University of Kenya; Teresa Mwoma, PhD, Kenyatta University; Violet Naanyu, PhD, Moi University; Jackim Nyamari, PhD, Kenyatta University; Hildah Oburu, PhD, Kenyatta University; Joyce Olenja, PhD, University of Nairobi; Dismas Ongore, PhD, University of Nairobi; Abdhalah Ziraba, PhD, African Population and Health Research Center; MALAWI: Chiwoza Bandawe, PhD, University of Malawi; MALAYSIA: Loh Siew Yim, PhD, Faculty of Medicine, University of Malaya; NIGERIA: Ademola Ajuwon, PhD, University of Ibadan; PAKISTAN: Nisar Ahmed Shar, PhD, CoPI-National Center in Big Data & Cloud Computing; Bilal Ahmed Usmani, PhD, NED University of Engineering and Technology; PERU: Rosario Mercedes Bartolini Martínez, PhD, Instituto de Investigacion Nutricional; Hilary Creed-Kanashiro, M.Phil., Instituto de Investigacion Nutricional; PORTUGAL: Paula Simão, MD, S Pneumologia de Matosinhos; RWANDA: Pierre Claver Rutayisire, PhD, University Rwanda; SAUDI ARABIA: Abu Zeeshan Bari, PhD, Taibah University; SERBIA: Katarina Vojvodic, MD, University of Belgrade; SLOVAKIA: Iveta Nagyova, PhD, PJ Safarik University–UPJS; SOUTH AFRICA: Jason Bantjes, PhD, University of Stellenbosch; Brendon Barnes, PhD, University of Johannesburg; Bronwyne Coetzee, PhD, University of Stellenbosch; Ashraf Khagee, PhD, University of Stellenbosch; Tebogo Mothiba, PhD, University of Limpopo; Rizwana Roomaney, PhD, University of Stellenbosch; Leslie Swartz, PhD University of Stellenbosch; SOUTH KOREA: Juhee Cho, PhD, Sungkyunkwan University; Man-gyeong Lee, PhDc, Sungkyunkwan University; SWEDEN: Anne Berman, PhD, Karolinska Institutet; Nouha Saleh Stattin, MD, Karolinska Institutet; SWITZERLAND: Susanne Fischer, PhD, University of Zurich; TAIWAN: Debbie Hu, MD, MSc, Tainan Municipal Hospital; TURKEY: Yasin Kara, MD, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul; Ceprail Şimşek, MD Health Science University; Bilge Üzmezoğlu, MD, University of Health Science; UGANDA: John Bosco Isunju, PhD, Makerere University School of Public Health; James Mugisha, PhD, University of Uganda; UK: Lucie Byrne-Davis, PhD, University of Manchester; Paula Griffiths, PhD, Loughborough University; Joanne Hart, PhD, University of Manchester; Will Johnson, PhD, Loughborough University; Susan Michie, PhD, University College London; Nicola Paine, PhD, Loughborough University; Emily Petherick, PhD, Loughborough University; Lauren Sherar, PhD, Loughborough University; USA: Robert M. Bilder, PhD, ABPP-CN, University of California, Los Angeles; Matthew Burg, PhD, Yale; Susan Czajkowski, PhD, NIH–National Cancer Institute; Ken Freedland, PhD, Washington University; Sherri Sheinfeld Gorin, PhD, University of Michigan; Alison Holman, PhD, University of California, Irvine; Gilberto Lopez ScD, MA, MPH, Arizona State University and University of Rochester Medical Center; Sylvie Naar, PhD, Florida State University; Michele Okun, PhD, University of Colorado, Colorado Springs; Lynda Powell, PhD, Rush University; Sarah Pressman, PhD, University of California, Irvine; Tracey Revenson, PhD, University of New York City; John Ruiz, PhD, University of Arizona; Sudha Sivaram, PhD, NIH, Center for Global Health; Johannes Thrul, PhD, Johns Hopkins; Claudia Trudel-Fitzgerald, PhD, Harvard T.H. Chan School of Public Health; Abehaw Yohannes, PhD, Azusa Pacific University. Students (in alphabetical order): AUSTRALIA: Rhea Navani, BSc, Monash University; Kushnan Ranakombu, PhD, Monash University; BRAZIL: Daisuke Hayashi Neto, Unicamp; CANADA: Tair Ben-Porat, PhD, Tel Aviv University; Anda Dragomir, University of Quebec at Montreal (UQAM) and CIUSSS-NIM; Amandine Gagnon-Hébert, BA, UQAM; Claudia Gemme, MSc, UQAM; Vincent Gosselin Boucher, UQAM and CIUSSS-NIM; Mahrukh Jamil, Concordia University and CIUSSS-NIM; Lisa Maria Käfer, McGill University; Ariany Marques Vieira, MSc, Concordia University; Tasfia Tasbih, Concordia University and CIUSSS-NIM; Robbie Woods, MSc, Concordia University; Reyhaneh Yousefi, Concordia University and CIUSSS-NIM; FRANCE: Tamila Roslyakova, Université de Montpellier; GERMANY: Lilli Priesterroth, Mainz University; ISRAEL: Shirly Edelstein, Hebrew University-Hadassah School of Public Health; Ruth Snir, Hebrew University-Hadassah School of Public Health; Yifat Uri, Hebrew University-Hadassah School of Public Health; NEW ZEALAND: Mohsen Alyami, University of Auckland; NIGERIA: Comfort Sanuade. Community participants: CANADA: Olivia Crescenzi; Kyle Warkentin; DENMARK: Katya Grinko; INDIA: Lalita Angne; Jigisha Jain; Nikita Mathur, Syncorp Clinical Research; Anagha Mithe; Sarah Nethan, Community Empowerment Lab.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Twitter @DevRubee

    • Contributors All authors contributed to the preparation of this manuscript (RD, VR, SLB, KLL, LP, CMN). CMN, LP and VR developed the idea and design of the study. RD was responsible for the overall content as the guarantor. RD participated in drafting and revising the manuscript. CMN, LP, SLB, KLL and VR provided detailed comments on the draft for the revision. CMN provided substantial revisions and intellectual content to the manuscript. RD analysed the data, and CMN and LP checked for the integrity and accuracy of the data. All authors (RD, VR, SLB, KLL, LP, CMN) read and approved the final version of the manuscript.

    • Funding The GOING-FWD Consortium is funded by the GENDER-NET Plus ERA-NET Initiative (project reference number: GNP-78): the Canadian Institutes of Health Research (CIHR; GNP-161904). iCARE is supported by the CIHR (MM1-174903; MS3-173099; SMC-151518, chair holder: SLB), the Canada Research Chairs Program (950-232522, chair holder: KLL), the Fonds de recherche du Québec–Santé (FRQ-S: 251618 and 34757), the Fonds de recherche du Québec–Société et culture (FRQSC: 2019-SE1-252541) and the Ministère de l'Économie et de l’Innovation du Québec (2020-2022-COVID-19-PSOv2a-51754).

    • Disclaimer Study sponsors had no role in the design of the database and data collection.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.