2021 GLOBAL REPORTThe Hologic
Global Women’s
Health Index
Pathways to a Healthy
Future for Women

MEASURED BY

Table of Contents

1

3

A Letter From Hologic’s CEO

5

Introduction

7

Key Findings From the 2021 Hologic Global Women’s Health Index

9

The Hologic Global Women’s Health Index

15

Global Results

25

The Growing Divides in Women’s Health

29

The Building Blocks for Improving Women’s Health30

Inequities Became Worse in 2021

44

2021 Set New Records for Negative Emotions

50

Women Feel Less Safe, Less Satisfied With Healthcare Options

58

Women Struggled More to Afford Food, Shelter in 2021

64

More Women Experiencing Pain and Health Problems

72

Country in Crisis Spotlight: Afghanistan

76

Country in Crisis Spotlight: India

78

Conclusions From the 2021 Hologic Global Women’s Health Index

80

Index Scores by Country and Territory Rank

84

Appendix 1: About the 2021 Hologic Global Women’s Health Index

110

Appendix 2: Hologic Global Women’s Health Index: Methodology and Data Analysis

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“Critical data for global, regional andnational development policymaking is stilllacking. Many governments still do nothave access to adequate data on their
entire populations. This is particularly true
for the poorest and most marginalized...1
U N I T E D N AT I O N S

1

2

United Nations. (n.d.). Big Data for Sustainable Development. https://www.un.org/en/global-issues/big-data-for-sustainable-development

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FO R E WO R D

A Letter From Hologic’s CEO
The world needs healthy and vibrant women. They
are critically important to our shared success andfuture, but you might not know that by looking at how
women’s health is prioritized across the world.
With our passion for championing women, we at Hologic
noticed a troubling lack of reliable information about
the state of women’s health globally. As science-based
innovators, we know that only what gets measured
gets improved. So we partnered with Gallup in 2019
to develop a groundbreaking study that would create
foundational benchmarks, heighten awareness andguide actions that increase the life expectancy andquality of life for women everywhere.
Our collaboration led to the Hologic Global Women’s
Health Index, the world’s most comprehensive studyof women’s health. Now in its second year, the study
provides new data-driven insights from 122 countries
and territories, representing the experiences of 94% of
the world’s women and girls aged 15 and older.
Reflecting on this year’s findings, I worry that women’s
health is moving backward. The data show that
more than 1 billion women didn’t go to a healthcare
professional in the past year. We also learned that
more than 1.5 billion women weren’t tested for highblood pressure, diabetes, cancer or STDs/STIs — allconditions that harm or kill tens of millions of womeneach year.
Women’s health has taken a back seat to nearly
everything else going on in the world. No matter whatpandemics, wars or other crises roil our societies,
we must commit ourselves to improving the healthof women, because they form the backbone of ourfamilies, communities and societies.

We also see with greater clarity that healthcare
disparities impact women in every country. The growing
divides between women in high-income and low-income
economies, and in urban and rural communities, arepreventing all women from achieving better health.
We must work together to narrow these equity gaps.
Over the past year, several important aspects ofwomen’s well-being have lost ground in many ways.
Fewer women feel safe walking alone at night. Moreare struggling to provide food and shelter. And they areeven less satisfied with the healthcare options available
to them. We must all do more to improve access tothese essentials.
The Hologic Global Women’s Health Index creates aframework for breakthrough solutions by identifying
insights and offering comparative analysis. We’reencouraged by the dozens of heads of state,policymakers, scholars and other health influencers
worldwide who have met with us in the past year to see
how this unprecedented resource will benefit their work.
We’re committed to expanding this engagement to help
drive change.
Ultimately, we can improve women’s health if we
act together. I ask anyone reading this letter to takeaction by scheduling routine visits with a healthcare
professional — and encourage the women in your life
to do the same.
Women are telling us what they need. It’s imperative that
we act on this knowledge.

Stephen P. MacMillan
Chairman, President andChief Executive Officer of Hologic

3

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Introduction
Hologic launched the Hologic Global Women’s HealthIndex — a multiyear, comprehensive global survey
about women’s health — to help fill a critical gap inwhat the world knows about the health and well-beingof the world’s women and girls.
The findings from the first year of the survey, based on
Hologic and Gallup’s interviews with nearly 120,000
women and men in 116 countries and territories in
2020, provided a sobering baseline account of thestate of women’s health worldwide.
The data showed that every country in the world —high-income and low-income alike — fell short whenit comes to women’s health and creating policies that
support it.
Millions of women worldwide were in crisis. Too few
were being tested for deadly diseases. Their emotional
health was suffering. They couldn’t meet basic needs
and they didn’t feel safe.
But the findings also revealed a data framework thatprovides a pathway through this crisis.
Hologic and Gallup researchers discovered thatfive dimensions of health explain more than 80%of the variance in women’s life expectancy at birth:
Preventive Care, Emotional Health, Opinions of Healthand Safety, Basic Needs, and Individual Health.

The results from the 2021 Hologic Global Women’s
Health Index, this time conducted with nearly 127,000
women and men in 122 countries and territories, showthat leaders need this framework more than ever.
Health situations for women and girls worldwide did
not get better in 2021. The divide between women in
high-income and low-income economies grew evenlarger than the year before.
The findings in this year’s report provide a crucial
update on the state of women’s health worldwide in
the second year of the COVID-19 pandemic, as womenaround the world lived through an uneven economic
recovery and a “hurricane of humanitarian crises.” 2, 3This year’s report answers key questions about
women’s knowledge, attitudes and behaviors
regarding healthcare and, most importantly, whether
women are getting preventive care and using
health services.
Hologic and Gallup also share discoveries from thedata collected in 2021, including new insights into how
the five dimensions of health and going to a healthcare
professional relate to women’s life expectancy at birth.

Further, the researchers discovered that improvementsin even one of these dimensions could potentially help
women live healthier, longer lives.

52

Miranda, C., Blanco, F., & Nenova, T. (2021, May 7). An uneven global economic recovery in 2021 promises to invert a longstanding principle of success andfailure. World Bank Blogs. https://blogs.worldbank.org/developmenttalk/uneven-global-economic-recovery-2021-promises-invert-longstanding-principle-success3

United Nations. (2021, July 16). UN deputy chief warns of ‘hurricane of humanitarian crises’. UN News. https://news.un.org/en/story/2021/07/1096022

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Key Findings From the 2021 Hologic
Global Women’s Health Index
The gap in Index scores between
women in high-income and low-income
economies nearly doubled between
2020 and 2021.

In nearly 50 countries and territories,
less than 10% of women said they
had been tested for cancer in theprevious year.

In 2021, 22 points separated women in high-income
economies — whose score remained unchanged at 61— and women in low-income economies, whose score
dropped from 49 to 39.

Worldwide, just 12% of women in 2021 were tested
for any type of cancer in the past 12 months, whichmeans more than 2 billion of the world’s women
went untested.

Women’s ability to meet their basic needs— such as affording food — fell, while
men’s ability to do so did not change.

Belief in the value of going to a healthcare
professional declined among women with
an elementary education or less.

Women were slightly more likely than men to say there
were times in the past year when they did not haveenough money to afford needed food (37% of womenvs. 33% of men). This gap was wider in 2021 than it wasin 2020 — as women lost ground while men largely
remained steady.

While belief in the value of going to a healthcare
professional remained relatively stable among womenwith four years of education beyond high school or acollege degree (92%), it dropped seven points among
those with an elementary education or less — from 87% to
80% — leading to a 12-point gap between the two groups.

Women in 2021 were more stressed,
worried, angry and sad than they
were in 2020 — or at any point in thepast decade.4

Annual visits to healthcare professionals
correspond with two additional years ina woman’s life expectancy.

Stress, worry and anger each increased by three
percentage points within the span of a year, whilesadness notably rose by six points. More than four in 10
women in 2021 said they experienced worry (43%) andstress (41%) during a lot of the day before the survey,
nearly one in three experienced sadness (32%), andmore than one in four experienced anger (26%) —all at record levels.

4

7

Even after accounting for gross domestic product (GDP)per capita, life expectancy for women who said they
had been to a healthcare professional in the past year
was 78, compared to 76 for women who said they
hadn’t been.

Based on Gallup World Poll data from 2011-2021.

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The Hologic Global Women’s Health Index
What is the Hologic Global Women’s
Health Index?
Launched in 2020, the Hologic Global Women’s HealthIndex is a global, multiyear survey of women and menthat annually tracks multiple health factors. It provides
data that global leaders and policymakers can use tocraft policies that improve the health, quality of life andlife expectancy of the world’s women and girls.
Each year, Hologic and Gallup ask questions in fivedimensions that, taken together, account for morethan 80% of the variance in a woman’s average life
expectancy at birth: Preventive Care, Emotional Health,Opinions of Health and Safety, Basic Needs, andIndividual Health.
Based only on women’s answers to these questions,Gallup and Hologic calculate global and country-level
scores for each of the individual dimensions, as well
as a single-number indicator that summarizes thehost of complex factors that contribute to women’s
health — the Hologic Global Women’s Health Index.
Scores on the individual dimensions and overall Index
can be compared over time and across countries
and territories.

What do the scores mean?
The overall Index and the five individual dimensions
are scored from 0 to 100. A higher score on theoverall Index means more women are having positive
experiences in the five dimensions. Higher scoreson the individual dimensions mean more womenare having positive experiences in each of theserespective areas.

How can we tell whether women’s
health situations are getting better orworse from year to year?
At the country level and demographic level (age,education, or urban or rural status, for example),increases or decreases need to be at least five points
to be considered meaningful change. For moredetail on interpreting meaningful change, please see
Appendix 2.

Global and country-level results on the overall Index,
as well as the five individual dimensions, are discussed
in further detail throughout this report. A detailed
explanation of how the Index was constructed and how
the Index and its dimensions are scored is available inAppendix 1.

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What does the Hologic Global Women’s Health Index measure?
The Gallup and Hologic research team has identified a set of 15 questions that provide a comprehensive view ofwomen’s health. Each of the questions falls into one of five dimensions: Preventive Care, Emotional Health, Opinionsof Health and Safety, Basic Needs, and Individual Health.
Dimension of Women’s Health

Survey Item

Preventive CareTo the best of your knowledge, were you tested for any of the following in the past
12 months?

• High blood pressure• Cancer• Diabetes• Sexually transmitted diseases or infections
Emotional Health

Did you experience the following feelings during a lot of the day yesterday?

Opinions of Health and Safety• In the city or area where you live, are you satisfied or dissatisfied with the• How about worry?
• How about sadness?
• How about stress?
• How about anger?
availability of quality healthcare?

• Do you think most pregnant women in the city or area where you live receivehigh-quality healthcare during their pregnancies, or not?

• Do you feel safe walking alone at night in the city or area where you live?
Basic Needs• Have there been times in the past 12 months when you did not have enoughmoney to buy food that you or your family needed?

• Have there been times in the past 12 months when you did not have enoughmoney to provide adequate shelter or housing for you and your family?

Individual Health• Do you have any health problems that prevent you from doing any of the things
people your age normally can do?

• Did you experience the following feelings during a lot of the day yesterday?
How about physical pain?

From these items, Gallup calculates individual dimension scores by first creating a simple average of the responses
to the questions included in each dimension and then creating a weighted average for each dimension score. Eachdimension is given a different weight depending on how much the dimension accounts for the variance in the overall
Index. For example, the Preventive Care dimension explains more of the variance in the overall Index than the otherdimensions, so it is given more weight. The overall Index score is the weighted sum of each dimension score.
This approach provides the foundation for the calculation of country averages and allows for a granular
understanding of how different groups of women score differently based on health determinants such as age,education, income, urban or rural status, and age at first pregnancy.
For more information on how Hologic and Gallup developed the Index, please see Appendix 1.

10

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Why is the Hologic Global Women’s Health Index important?
The 2021 study reaffirms a finding from the 2020 study that improvements in any or all of the fivedimensions of health are related to longer life expectancy at birth.
From the inaugural study in 2020, Hologic and Gallup
discovered that the Hologic Global Women’s HealthIndex was strongly related to women’s average life
expectancy at birth — one of the most frequently used
health indicators around the world.

Positive improvements on any one of the fivedimensions could help women live healthier, longer
lives. In 2021, Gallup researchers found these
dimensions continue to account for more than 80%of the variance in why some women live longer thanothers, providing a framework for changing women’s
lives through improvements to their health and safety.5

CHART 1:

Female Life Expectancy at Birth by Hologic Global Women’s Health Index 2021

Hologic Global Women’s Health Index 2021

100

75

LatviaSouth
Africa50

Laos

Norway
Japan
Japan

Malta

Mali
Benin
Benin

Gabon

India
India

Venezuela
Venezuela

Ecuador25

Afghanistan

0

60

65

70

75

80

85

Female Life Expectancy at Birth (Years)

511

For more information on this analysis, please see Appendix 1.

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These five dimensions also track closely with key global health and well-being indicators the world
has prioritized as part of the United Nations’ Sustainable Development Goals (SDGs).
UN SDGs are priorities and targets, agreed to by morethan 178 nations, which offer a blueprint for peace andprosperity for people and the planet, now and into the
future.6 Unfortunately, despite the global consensus
on the importance of these priorities, data on progress
toward these goals is insufficient. On average, between
2015 and 2019, countries reported just one or moredata points on only about half of the SDG targets.7
All countries can benefit from access to more robust,
timely data they can use to track their progress toward
these goals.

Supplementary data sources such as the Hologic
Global Women’s Health Index, which is uniquely basedon women’s experiences and perceptions, havecorrelations to several UN SDGs and offer free, widely
available and timely metrics that gauge a country’s orterritory’s progress.

SDG 3.4: By 2030, reduce by one-third premature
mortality from noncommunicable diseases.

SDG 3.7: By 2030, ensure universal access tosexual and reproductive healthcare services.

The Index explains 81% of the variance of the WHO
probability of dying between ages 30 and 70 fromcardiovascular diseases, cancer, diabetes or chronic
respiratory diseases.

The Index explains 63% of the variance in the WHOadolescent birth rate (per 1,000 girls aged 15 to 19).

CHART 2:

CHART 3:

Probability of Dying Between Ages 30 and 70 From Cardiovascular
Diseases, Cancer, Diabetes or Chronic Respiratory Diseasesby Hologic Global Women’s Health Index 2021

Adolescent Birth Rate (per 1,000 Girls Aged 15 to 19)
by Hologic Global Women’s Health Index 2021

Data from the World Health Organization (WHO) arerecognized as official indicators for progress against
many of these SDGs. There are strong correlations
between the Hologic Global Women’s Health Index
and several of these indicators.8

100

75

Austria
Austria

LatviaUzbekistan

50

Albania
Albania

PakistanPeru
25

LebanonRepublic ofCongo
the Congo

Afghanistan
0

0%

10%

20%

30%

Female Probability of Death From Disease

12

Hologic Global Women’s Health Index 2021

Hologic Global Women’s Health Index 2021

100

75

LatviaParaguay
Paraguay

Tanzania

50

Malawi

LebanonMali

25

Afghanistan
0

0

50

100

150

Adolescent Birth Rate (per 1,000 Girls Aged 15 to 19)

6

United Nations. (n.d.). The 17 Goals. Department of Economic and Social Affairs. https://sdgs.un.org/goals

7

Kitzmueller, L., Stacy, B., & Mahler, D. G. (2021, August 10). Are we there yet? Many countries don’t report progress on all SDGs according to the World Bank’s
new Statistical Performance Indicators. World Bank Blogs. https://blogs.worldbank.org/opendata/are-we-there-yet-many-countries-dont-report-progress-all-sdgsaccording-world-banks-new

8

For more information on this analysis, as well as relationships to other SDGs, please see Appendix 1.

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What can leaders and policymakers do with these scores?
The Hologic Global Women’s Health Index
provides leaders with an actionable framework
to help prioritize and focus efforts to improve
women’s lives, as well as increase their future
longevity and quality of life.

They can also use the Index to identify areas ofstrength and opportunities for improvement in theircountries, as well as use those insights to direct theirpolicies more effectively.

Leaders can use the Index to see where their countries
stand relative to the rest of the world and understandwhich health dimension contributes to the greatest
differences in women’s health scores.

Contribute, Question, Contextualize

OP T IMIZE DATAUSE DATASHAR E DATA

AccessIdentify

Integrate

Analyze

DesignImplement

MonitorPublicly
available data

Specificuse cases

Additional
data sources

Data in specificcontext

Interventions
and policy todrive change

Track over timeusing Index

To driveaccountability

Connect, Post, Write, Drive AwarenessOngoing dialogue with the global health community
helps Hologic optimize the data by contextualizingthem to specific situations and shifting dynamics.
Hologic’s desire is for these organizations to use these
data, in conjunction with complementary data sources,
to evaluate progress and design more effective
solutions and interventions over time.

13

Hologic is currently working with leading researchersand policymakers worldwide to analyze the datafor insights that advance women’s health. Hologic’s
partnerships with these organizations are built on thegoal of working with the global health community to
optimize, use and share Index data.

The Hologic Global Women’s Health Index | Global Report

As lessons are learned and the data supports
decision-making, Hologic hopes organizations sharethese experiences in forums ranging from social media
to academic publications to conferences. Through thispartnership model, the reach, awareness and impact ofthese data will grow.

© 2022 Hologic, Inc. All rights expressly reserved.
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Global Results
The world has much more work to do to improve women’s health.
With an overall score of just 53 out of 100 in 2021
on the Hologic Global Women’s Health Index — one
point lower than the score in 2020 — the health of theworld’s women and girls did not improve last year.
The bigger story is the growing divide in women’s
health and the millions of women whose lives were
worse in 2021 than in 2020. Women in countries anddemographics already at a disadvantage when it comesto their health fell even further behind in 2021, while
women in countries and demographics doing relatively
well saw only small improvements, if any at all.

Even the countries that showed signs of improvement
have work to do. The second year of the Index shows
every country or territory still has room for improvement
in women’s health. Not one country or territory scoredhigher than 70 out of 100 on the Index.

Scores in 2021 ranged from a high of 70
in Taiwan to a low of 22 in Afghanistan.

CHART 4:

Women’s Health Around the World
Women’s Health Around the World in 2021
The 2021 Hologic Global Women's Health Index
Hologic Global Women’s Health Index
0

100
22

15

70

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Most of the countries and territories with the highest scores on the overall Hologic
Global Women’s Health Index in 2021 are high-income economies, but a country’s
GDP per capita does not tell the whole story.
Most of the high-income countries and territories
with the highest scores on the Index appeared at
the top of the rankings in 2020 as well. This includes
the Czech Republic, which gained six points in thePreventive Care dimension over the span of a year.
However, a country’s income only tells part of the story.
The Czech Republic’s score of 34 in the Preventive
Care dimension is notably higher than scores incountries with much higher GDP per capita, including
Norway (26), Denmark (27) and Switzerland (21).

The increase in the Czech Republic’s spending on
healthcare during the COVID-19 pandemic may
have helped boost its scores in the Preventive
Care dimension. In 2020, the country had one of
the highest ratios of expenditure to GDP in the EU.9
But even before the pandemic, the Czech Republicalready had one of the lowest levels in the EU for
unmet medical needs due to financial reasons,distance or waiting times.10

Female friends walking on Charles Bridge.
Prague, Czech Republic

9

Eurostat. (2022, March 11). How much did governments spend on health in 2020? https://ec.europa.eu/eurostat/web/products-eurostat-news/-/ddn-20220311-1

10 OECD/European Observatory on Health Systems and Policies. (2021). Czech Republic: Country Health Profile 2021. State of Health in the EU: Country HealthProfiles. https://www.oecd.org/czech/czech-republic-country-health-profile-2021-8b341a5e-en.htm

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Women living in countries and territories that scored the highest on the overall Hologic Global
Women’s Health Index in 2021 almost all scored better than the global average in all five dimensionsof health, but their scores clearly show women’s health still requires urgent action.

Top Countries/Territories on the 2021 Hologic Global Women’s Health Index
Countries with an absolute increaseor decrease greater than 5

Female Life
Expectancy(WHO)

D IME N SIO N SC O R E Y E A R OV E R
Y E A R ( YOY ) C H A N GE
Overall
Index
Index Score Score YoY
2021
ChangePreventive
Care

Emotional
HealthOpinions of
Health and
Safety

Basic
Needs

Individual
Health

75

53

-1

0

-4

-4

-2

-4

Province of China

N/A

70

1

-3

-1

3

1

3

2

Latvia

80

69

4

2

3

3

6

3

3

Austria

84

67

0

3

-3

-4

-1

2

4

Denmark

83

67

3

3

1

1

0

8

5

Estonia

83

66

2

5

2

-4

4

-4

6

Switzerland

85

66

2

2

4

1

0

-1

7

Germany

85

66

1

3

0

1

-4

3

8

Czech Republic

82

65

3

6

3

0

4

-3

9

Israel

84

65

3

0

7

-4

6

2

10

Norway

84

65

0

3

-3

-4

3

-2

GLOBA L AVE RAG E

1

Taiwan,Note: Higher scores indicate more women are having positive health and health experiences. WHO estimated life expectancy not available for Taiwan.
Source: Hologic Global Women’s Health Index, 2021

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Countries and territories that spend more per capita on healthcare tend to earnhigher scores on the overall Hologic Global Women’s Health Index, except for theUnited States.
In many countries and territories around theworld, particularly the higher-income ones, higher
healthcare expenditures per capita usually translate
into better healthcare outcomes, including longer
life expectancy for women. The U.S., however,continues to be a well-documented exception. The
country spends nearly twice as much as an average
Organisation for Economic Co-operation andDevelopment (OECD) country does on healthcare,but it has a lower life expectancy.11

Countries and territories that spend more per capita
on healthcare tend to earn higher scores on theoverall Index — except for the U.S., which spends
the most and scores a 61. Most of the countries thatlead the world on the Index also lead the world in
how much of their wealth they funnel back into theirhealth system, including places such as Austria (67),
Switzerland (66) and Norway (65). The inverse is true
for countries and territories that spend the least on
healthcare — such as the lowest-ranking country,
Afghanistan (22).

CHART 5:

Healthcare Spending per Capita by Hologic Global Women’s Health Index
75

LatviaHologic Global Women’s Health Index 2021

Iceland
Iceland
CyprusCyprus50

Italy

Switzerland

Denmark
Denmark

Israel

NorwayNorwayCanadaCanadaUnitedStatesLebanonLebanon25

0

Afghanistan
Afghanistan

0

2,000

4,000

6,000

8,000

10,000

Healthcare Spending per Capita (U.S. dollars)Possible index scores range from 0 to 100.

11

18

OECD. (n.d.). Health Spending. OECD Data. https://data.oecd.org/healthres/health-spending.htm

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[The United States]
spends nearly twice as muchas an average Organisation for
Economic Co-operation andDevelopment (OECD) country
does on healthcare, but it
has a lower life expectancy.

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Many of the countries and territories with the lowest scores on the overall Hologic
Global Women’s Health Index in 2021 also scored among the lowest in 2020; they all
have weak or destabilized infrastructure for healthcare.
Most of the countries that score lowest on the Index
have scores below the global average on Preventive
Care — the dimension where the world has the mostwork to do. None of the lowest-scoring countries
improved in this dimension in 2021. Lebanon’s score
dropped significantly from 16 to 11, which is about half
the global average score of 19.

Afghanistan debuted on the Index in 2021 with thelowest overall score in the world. The country was
surveyed amid turmoil as the Taliban took control
and the U.S. withdrew its troops.
Afghanistan scored lower than any other country
in all dimensions except Preventive Care andIndividual Health. The country scored in the bottom
20 countries on Preventive Care and bottom 10 on
Individual Health.

An Afghan woman sits outside a shop in central Kabul.
Kabul, Afghanistan

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Women living in these countries have a worse quality of life and are likely to die younger than womenelsewhere, and the lack of improvement in their scores means they are at higher risk today than in 2020.

Bottom Countries/Territories on the 2021 Hologic Global Women’s Health Index
Countries with an absolute increaseor decrease

greater than 5
D IME N SIO N SC O RE YOY C H A N G E

Female Life
Expectancy(WHO)Overall
Index
Opinions ofIndex Score Score YoY Preventive Emotional Health and2021
ChangeCare
HealthSafety

Basic
Needs

Individual
Health

GLOBAL AVE RAG E

75

53

-1

0

-4

-4

-2

-4

113

Gabon

70

40

2

-4

5

0

8

2

114

Peru

81

40

4

-1

11

4

4

2

115

Ecuador

81

40

0

3

0

-7

3

-5

116

Benin

66

40

-6

-4

- 12

-4

2

- 14

117

Togo

67

40

NS

NS

NS

NS

NS

NS

118

Lebanon

79

40

-1

-5

3

- 20

6

7

119

Türkiye

81

40

-4

5

-5

-9

- 12

- 11

120

Venezuela

78

39

2

2

5

-8

3

1

121

Republic of the Congo

66

38

0

-2

1

0

-4

-4

122

Afghanistan

63

22

NS

NS

NS

NS

NS

NS

Note: Higher scores indicate more women are having positive health and health experiences. “NS” indicates the country or territory was not surveyed the prior year.
Source: Hologic Global Women’s Health Index, 2021

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The fastest-improving countries show signs of progress.
The fastest-improving countries — those where
overall Hologic Global Women’s Health Index scores
increased by at least five points in one year — typicallysaw substantial improvements in their Emotional Healthand Basic Needs dimensions, which are highly related
to one another.

+

The Basic Needs dimension has the strongest
relationship with each of the other dimensions, whichmeans that if these needs aren’t met, it’s less likely thatwomen’s other health needs will be.

Fastest-Improving Countries/Territories in 2021

Countries with an absolute increaseor decrease greater than 5

D IME N SIO N SC O R E YOY C H A N GE

OverallIndex Score
2021

Index Score
YoY Change

Preventive
Care

Emotional
HealthOpinions of
Health and
Safety

Basic
Needs

Individual
Health

GLOBA L AV ERAG E

53

-1

0

-4

-4

-2

-4

Tajikistan

55

7

-3

15

3

10

16

Zimbabwe

49

6

-4

14

6

6

3

Tunisia

48

6

-6

14

6

16

3

Costa Rica

55

5

5

9

-1

6

7

Indonesia

56

5

0

9

3

12

4

Mexico

52

5

12

3

4

0

1

Malaysia

61

5

-4

14

2

11

-3

Poland

60

5

6

8

2

-1

4

El Salvador

49

5

2

7

-6

13

5

Uzbekistan

56

5

2

3

0

14

5

North Macedonia

54

5

4

6

1

7

4

Iran

50

5

4

7

4

1

4

Kosovo

60

5

-5

11

-2

13

5

Source: Hologic Global Women’s Health Index, 2021

22

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But some countries are falling behind — quickly — on women’s health.
The countries with the biggest year-over-year declines— those where overall Hologic Global Women’s HealthIndex scores fell by at least five points in one year —typically saw substantial declines in their Opinions of
Health and Safety and Individual Health dimensions.
In India, where scores declined more than in any
other country, scores dropped sharply in every
dimension of women’s health except Preventive
Care.

–

However, India was already one of the worstperforming countries on Preventive Care in 2020, witha score of 10.
Read more about India’s tumultuous changes inwomen’s emotional health in the Country Spotlight at
the end of the report.

Fastest-Declining Countries/Territories in 2021

Countries with an absolute increaseor decrease greater than 5

D IME N SIO N SC O RE YOY C H A N GE

OverallIndex Score
2021

Index
Score YoY
ChangePreventive
Care

Emotional
HealthOpinions of
Health and
Safety

Basic
Needs

Individual
Health

53

-1

0

-4

-4

-2

-4

India

41

-14

-1

- 26

- 20

- 12

- 22

Bangladesh

43

-9

-4

- 14

4

- 25

- 12

Jamaica

49

-8

- 11

-3

- 17

0

- 13

Cambodia

45

-7

- 16

1

-2

- 11

-5

Benin

40

-6

-4

- 12

-4

2

- 14

GLOBA L AV ERAG E

Source: Hologic Global Women’s Health Index, 2021

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The Growing Divides in Women’s HealthSocioeconomic status and income are determinants of health that are linked to how long people live, how they live
and their disease risk, with people from low socioeconomic status generally at the highest risk.12
In 2021, Hologic and Gallup found that across nearly all these determinants, the divides were growing — withthe gulfs becoming wider between women in high-income and low-income economies, those living in urban
and rural settings, and across educational levels.

The gap between women in high-income and low-income economies nearly doubled
between 2020 and 2021.
• The overall Hologic Global Women’s Health Index score for women in high-income economies, who also scoredhighest on the Index in 2020, remained unchanged at 61. In low-income economies, women’s scores dropped
10 points to 39.

• The gap between women’s scores in high-income economies and low-income economies widened from12 points in 2020 to 22 points in 2021.

• Index scores dropped among women in lower-middle and low-income countries, while they improved or stayed
the same for women in upper-middle and high-income countries.

CHART 6:

Hologic Global Women’s Health Index
Country Income Level by Hologic Global Women’s Health Index
Score by Country Income Level
65

Overall Index Score

61

61

High income

57

Upper middle income

46

Lower middle income

39

Low income

54
50

51
49

35
2020

2021

Possible index scores range from 0 to 100.

1225

WHO. (2019, May 30). Social determinants of health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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CHART 7:

Hologic Global Women’s Health Index
Overall Index Scores by Demographic
2020 Index score2021 Index score
YoY
ChangeOverallGlobal female population

-1

54
53

Age 15-50

-1

53
52

Age 51-75-2

Age 76+-5

Elementary education or less-3

Secondary education/
Some education beyond secondary0

Four years beyond high school and/or
received a 4-year college degree+2

Urban (a large city/
a suburb of a large city)

0

Rural (a rural area or on a
farm/a small town or village)-3

18 years or younger

-4

19-24

-2

25+

+1

Age

Education

Urbanicity

57
55
60

48

The Hologic Global Women’s Health Index | Global Report

51
55
55
59
61

56
56
50

Age of first pregnancy

26

65

44

53

48
54
52
58
59

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A woman talks about her health experienceswith the team from the Hologic Global Women’s
Health Index video project.
Istanbul, TürkiyeLess-educated women fell further behind, while more-educated women had slightly improved
health outcomes.

• The existing gap in health outcomes between women with an elementary education versus those with four years
or more beyond high school expanded from eight points in 2020 to 13 points in 2021.

• Women with an elementary education or less lost ground, with their scores on the overall Hologic Global Women’s
Health Index dropping from 51 to 48. The health situation for women with the highest level of education improved
slightly, with their overall Index scores rising from 59 to 61.

The gap between health outcomes among women in urban and rural areas was twice as wide in 2021
as it was the previous year.

• Urban women’s scores on the overall Index stayed level at 56 in 2021, while rural women’s scores fell threepoints to 50.

Women who became pregnant before age 19 continued to score worse in every one of the fivedimensions than those who became pregnant later.

• The overall Index scores declined among women who experienced their first pregnancy before age 19 — from

48 in 2020 to 44 in 2021. The gap in the scores between those who became pregnant before 19 and those who
became pregnant after 25 widened from 10 points in 2020 to 15 points in 2021.

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The Building Blocks for Improving
Women’s HealthTogether, the five dimensions of the Hologic
Global Women’s Health Index — Preventive Care,
Emotional Health, Opinions of Health and Safety,
Basic Needs, and Individual Health — are strongly
related to women’s life expectancy at birth, a globally
important and widely used metric.

These five dimensions account for
more than 80% of the variance in awoman’s life expectancy at birth.13

Preventive Care

Individual Health

Basic Needs

13

29

Emotional Health

Opinions of
Health and Safety

For more detail on the life expectancy calculation, please see Appendix 1.

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P R E V ENT IV E CA RE

Inequities Became Worse in 2021
Preventive care aims to help people avoid illnesses
and detect medical problems early, ideally before
the onset of symptoms. The right test, screening or
immunization at the right time can save someone’s life,
help them stay healthy and even live longer.
Because screening or testing are essential first steps
toward better health, the Hologic Global Women’s
Health Index asks women whether they have beentested14 in the past 12 months for four of the mostfrequent, fast-growing, and/or deadly diseases andconditions for women globally: high blood pressure,cancer, diabetes, or sexually transmitted diseases andinfections (STDs/STIs).

Testing or screening recommendations for these
diseases vary based on a person’s age, gender andthe healthcare resources available to them in theircommunity. The 12-month period in the survey question
is not a globally agreed-upon cadence, but because
the Index has been conducted for two years in a row,
it captures testing that may be recommended in a
two-year period.15

The future will be better for women when as many women as possible can say
they have been screened or tested for high blood pressure, cancer, diabetes and
STDs/STIs in the past year.
But at present, preventive care remains inaccessible to many women. Changing
this dynamic requires a robust healthcare system with public communicationthat incorporates the needs of the patient population, provider and patientcommunication, technical training, and equipment to test and screen large numbersof women.
For the second consecutive year, the Hologic Global Women’s HealthIndex shows the majority of women worldwide were not screened ortested for high blood pressure, cancer, diabetes and STDs/STIs.

14

The survey questionnaire asked people whether they had been “tested” for these four conditions rather than “screened,” the clinical term typically used to referto scheduled preventive tests. This wording choice was made to help ensure the questions were easily comprehensible to all respondents.

15 Please see Appendix 1 for information on testing recommendations.

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Women were not tested for deadly diseases in the second year of the COVID-19
pandemic any more than they were in the first.

60%

The percentage is similar to the 61% of women who
said they were not tested in 2020 — meaning morethan 1.5 billion women missed out on these tests eachyear. Studies suggest this may already be affecting
women’s health, with women receiving late diagnoses
that decrease survival and are more difficult andexpensive to treat.16

of women in 2021 reported they were
not tested for any of the four diseases
or conditions asked about in the survey.

Inequities in preventive care are large — and getting bigger.
Women in higher-income economies showed somesigns of recovery in the second year of the pandemic.
Screening and testing rates improved from 2020, or
at least remained stable, for women in high-income
and upper-middle-income groups — many of whom
had ready access to testing, vaccines and treatments
for COVID-19.17 But overall, screening and testing
rates for preventable diseases still remained lower
than recommended.18

Meanwhile, reported screening and testing rates
for women in low-income groups dropped evenlower in 2021. These lower screening rates mean
more women in low-income groups are at higher
risk of dying because they may not be getting
treatment at earlier stages of diseases.

CHART 8:Preventive Care Testing by Country Income GroupTo the best of your knowledge, were you tested for any of the following in the past 12 months?

Care Questions by Country Income Groups(% Preventive
Yes)
2020
2020

2021
2021

– Decrease+ Increase

High blood pressure
Low income

Lower middle income

Upper middle income

High income

32

CancerDiabetes

14

21

STDs/STIs

26

24

8

11

29

5

15

9

29

4

12

6

21

31

15

21

12

33

15

22

14

45

20

25

11

48

23

30

13

–
–
+
+

16 Zhou, J. Z., Kane, S., Ramsey, C., Akhondzadeh, M., Banerjee, A., Shatsky, R., & Gold, K. A. (2022). Comparison of Early- and Late-Stage Breast and Colorectal
Cancer Diagnoses During vs Before the COVID-19 Pandemic. JAMA Network Open, 5(2). https://doi.org/10.1001/jamanetworkopen.2021.48581

31

17

Oxfam International. (2022, May 25). Rich countries have received more vaccines in run-up to Christmas than African countries have all year. Oxfam. https://www.oxfam.org/en/press-releases/rich-countries-have-received-more-vaccines-run-christmas-african-countries-have-all

18

Please see Appendix 1 for information on testing recommendations.

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C
H A R TBlood
9:
High
Pressure Testing

To the Blood
best of yourknowledge,
were you tested
High
Pressure
Testing

for any of the following in the past 12 months?
To the best of your knowledge, were you tested for any of the following in the past 12 months?
(% Yes for high blood pressure)(% Yes, high blood pressure)
0

100
8

74

Testing rates forhigh blood pressure
varied from a low of
8% in Togo to a highof 74% in Latvia.

Blood pressure screening is one of the least expensive and technically simple screening procedures.19
On average, only one in three women in 2021 were screened for high blood pressure in theprevious 12 months — even though heart disease remains the leading cause of death globally.20• The 34% of women who said in 2021 that they had
been tested for high blood pressure is essentiallyunchanged from the 33% who said so in 2020,
meaning approximately 1.7 billion women were
not screened for high blood pressure in each ofthese years.

• Only one age group of women — those older than75, who are at the highest risk of any age group forstroke and other cardiovascular complications fromhypertension21 — reported being screened in greaternumbers in 2021. The majority of women in this age
group (65%) reported in 2021 that they had beentested for high blood pressure, compared with the 54%
who said they were the year before.

• Screening rates for high blood pressure varied acrossthe globe in 2021, from a low of 8% in Togo to a high of
74% in Latvia — which also had the highest percentageof reported screenings in the world in 2020 (at asimilar 76%). However, even with three in four womenin Latvia saying they had been screened, like mostcountries where heart disease is a leading cause ofdeath, there is still room for Latvia to improve.22

19 WHO. (2019, June 20). Hypertension. World Health Organization. https://www.who.int/health-topics/hypertension#tab=tab_1
20 WHO. (2020, December 9). The top 10 causes of death. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death21

Rodgers, J. L., Jones, J., Bolleddu, S. I., Vanthenapalli, S., Rodgers, L. E., Shah, K., Karia, K., & Panguluri, S. K. (2019). Cardiovascular Risks Associated with Genderand Aging. Journal of Cardiovascular Development and Disease, 6(2). https://doi.org/10.3390/jcdd6020019

22 OECD/European Observatory on Health Systems and Policies (2021), Latvia: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris,
https://doi.org/10.1787/919f55f0-en.

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Cancer Testing

Testing for cancer varies
from a low of less than 1% in
To the best of your knowledge, were you tested
CancerPakistan and Afghanistan to a
for any of Testing
the following in the past 12 months?
highof 38% in South Korea.
Tothe bestof your knowledge, were you tested for any of the following in the past
12 months?
(% Yesfor cancer)
CHART 10:(% Yes, cancer)
0

100

<1

38

Testing for cancer
varied from a low ofless than 1% in Pakistan
and Afghanistan
to a high of 38% in
South Korea.

Between 30% and 50% of all cancer deaths are preventable, according to the WHO, with early detection
playing an important role in reducing the cancer burden.23 However, worldwide, just 12% of women in
2021 were tested for any type of cancer in the past 12 months.

• The 12% of women who said they had been tested forany type of cancer (skin, cervical, breast, ovarian or lung,for example) remains unchanged from 2020, whichmeans more than 2 billion of the world’s women went
untested in each of these years.

• The data do yield some positive news for womenover age 75 — who, because of their advancing age,are more at risk than younger women of developing
cancer.24 Women older than 75 were the most likely of
any age group to say they had been tested for cancer,
and they were the only age group more likely to havebeen tested in the past year than the year prior (27% in
2021 vs. 18% in 2020).

• In nearly 50 countries and territories, less than 10% of• Testing rates for Pakistani women remained

unchanged from 2020 to 2021, highlighting the needfor better reporting and awareness in a country where
breast cancer rates are thought to be the highest in
Asia.25 But in neighboring Afghanistan, notably, no
women — zero female respondents — said they were
tested for any type of cancer.

• South Korea led the world in reported cancer

screening in both 2020 and 2021. The country’s
relatively high rate of testing (38% in both years) may
reflect the availability of cancer screening throughits National Cancer Screening Program, whichhas provided low-cost and free cancer screening
for decades.26

women said they had been tested for cancer in theprevious year.

23 WHO. (2019, July 12). Cancer. World Health Organization. https://www.who.int/health-topics/cancer#tab=tab_2
24 NIH. (2021, March 5). Risk Factors: Age. National Cancer Institute. https://www.cancer.gov/about-cancer/causes-prevention/risk/age
25 Khan, N. H., Duan, S. F., Wu, D. D., & Ji, X. Y. (2021). Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women. Cancer
Management and Research, Volume 13, 2125–2129. https://doi.org/10.2147/cmar.s270671
26 National Cancer Screening Program. (n.d.). National Cancer Center. https://ncc.re.kr/main.ncc?uri=english/sub04_ControlPrograms03

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C
H A R T 1 1 : Testing
Diabetes

To the best Testingof your knowledge, were you tested
Diabetes

for any of the following in the past 12 months?
To the best of your knowledge, were you tested for any of the following in the past 12 months?
(% Yes for diabetes)(% Yes, diabetes)
0

100
3

49

Testing for diabetes
varied from a low of
3% in Ivory Coast to ahigh of 49% in Latvia.

Although diabetes is a leading cause of death for women — and one of thefastest-growing chronic diseases in the world — fewer than one in five women(19%) in 2021 said they were tested for diabetes in the past 12 months.27, 28• The 19% of women who said they had been tested for• Testing for diabetes varied across the globe, from a• Type 1 and Type 2 diabetes are different diseases and• An estimated 80% of people who are living withdiabetes remains unchanged from 2020 and, when
projected to the entire population of the world’s womenand girls, means approximately 2 billion women went
untested in each of these years.

tend to affect different age groups. Women over theage of 50, who are more at risk than younger womenof developing Type 2 diabetes, were more likely than
younger women to report being tested for diabetes in
the past 12 months.29 About one in three women over
the age of 50 were tested, compared to about one inseven women younger than 50.

low of 3% in Ivory Coast — where diabetes is the ninth
leading cause of death and disability — to a high of
49% in Latvia, where the disease accounted for 2% ofdeaths in 2018.30, 31
diabetes today are living in low-income andlower-middle-income countries.32 Low testing rates
in many of these countries, including Ivory Coast,
illustrate the need for cost-effective screening tools
and approaches to identify individuals at risk ofdeveloping diabetes.

27 WHO. (2020, December 9). The top 10 causes of death. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
28 Sørensen, H. T. (2022). Prevention of diabetes mortality at ages younger than 25 years: access to medications and high-quality health care. The Lancet Diabetes& Endocrinology, 10(3), 151–152. https://doi.org/10.1016/s2213-8587(22)00009-2
29 Mayo Clinic. (2021, January 20). Type 2 diabetes - Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/
syc-20351193
30 IHME. (2017, September 18). Cote d’Ivoire. Institute for Health Metrics and Evaluation. https://www.healthdata.org/cote-divoire
31

Flood, D., Seiglie, J. A., Dunn, M., Tschida, S., Theilmann, M., Marcus, M. E., Brian, G., Norov, B., Mayige, M. T., Gurung, M. S., Aryal, K. K., Labadarios, D.,
Dorobantu, M., Silver, B. K., Bovet, P., Jorgensen, J. M. A., Guwatudde, D., Houehanou, C., Andall-Brereton, G., . . . Manne-Goehler, J. (2021). The state of diabetes
treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults.
The Lancet Healthy Longevity, 2(6), e340–e351. https://doi.org/10.1016/s2666-7568(21)00089-1

32 WHO. (2019, May 13). Diabetes. World Health Organization. https://www.who.int/health-topics/diabetes#tab=tab_3

34

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SexuallyC
H A R T 1 2 : Transmitted Diseases/Infections Testing
To the best of your knowledge, were you tested

STD/STI
Testing
for any of thefollowing in the past 12 months?

Toof your transmitted
knowledge,diseases/infections)were you tested for any of the following in the past 12 months?
(% theYes best
for sexually(% Yes, sexually transmitted diseases or infections)
0

100
1

42

Testing for STDs/
STIs varied froma high of 42% in
Zambia to a low of
1% in countries such
as Tunisia, Lebanon
and Indonesia.

Note: Item not asked in Iran or Saudi Arabia.

Worldwide, testing for STDs/STIs in 2021 was just as infrequent as it was in 2020.

• STDs/STIs can have serious long-term healthconsequences — particularly for women — including
fertility problems, contracting HIV and an increased
risk of cervical cancer.33 However, only about one innine women (11%) said they had been tested in thepast 12 months. This percentage remains unchanged
from 2020, meaning more than 2 billion women went
untested again in the past year.

• Women younger than 50, who are at high risk ofcontracting STDs/STIs, were the most likely of any
age group to report being tested in the past year, at
11%. This percentage was statistically unchanged from
12% in 2020.
34• Testing rates for STDs/STIs varied worldwide. In

Zambia, which also led other countries in reported
testing in 2020, a high of 42% of women said they
had been tested in the past 12 months. The country’s
relatively high rate may reflect the availability of
testing for HIV and other STDs, particularly during
prenatal care.35• On the other end of the spectrum, as few as 1% of

women in countries such as Tunisia, Lebanon andIndonesia — which is facing one of the fastest-growing
HIV epidemics in the world — said they had beentested in the past 12 months.36

33 WHO. (2022, February 22). Cervical cancer. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/cervical-cancer
34 Ibid.
35 UNAIDS. (n.d.). Country Progress Report - Zambia. Global AIDS Monitoring 2020. https://www.unaids.org/sites/default/files/country/documents/ZMB_2020_
countryreport.pdf
36 Gedela, K., Wirawan, D. N., Wignall, F. S., Luis, H., Merati, T. P., Sukmaningrum, E., & Irwanto, I. (2021). Getting Indonesia’s HIV epidemic to zero? One size does
not fit all. International Journal of STD & AIDS, 32(3), 290–299. https://doi.org/10.1177/0956462420966838

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Measuring Preventive Care
The Hologic Global Women’s Health Index’s Preventive Care dimension measures whether women in the past year havebeen tested for any of these serious health conditions by asking:
To the best of your knowledge, were you tested for any of the following in the past 12 months?

• High blood pressure• Cancer• Diabetes• Sexually transmitted diseases or infections
Scores on this dimension are calculated at the individual level. To get a score, individuals need to answer at least
three of the four questions. The resulting score is a simple mean of the positive answers. Higher scores on the Preventive
Care dimension mean more women are getting tested for these health factors.

Preventive Care Dimension
Higher scores on the Preventive Care dimension of the Index mean more women are getting tested for these healthfactors. Worldwide, countries and territories do not perform well on this dimension of the Index, with a global score of
19 — unchanged from 2020.
Country-level scores on the Preventive Care dimension range from a low of 5 in Ivory Coast to a high of 46 in
Latvia — the same countries with the top and bottom scores in 2020.

• Among the countries and territories with thehighest scores on this dimension, the United Statesand Argentina made significant progress between
2020 and 2021. The U.S. now ranks second in theworld on this dimension. Argentina’s No. 5 rank inPreventive Care significantly overperforms its 60th
rank on the Index overall.

36

The Hologic Global Women’s Health Index | Global Report• Among the countries with the lowest scores, only

the United Arab Emirates dropped substantiallybetween 2020 and 2021. Despite a relatively
strong ranking of 35 on the overall Index, the U.A.E.
ranks 119th on the Preventive Care dimension.

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Top Countries/Territories for Preventive Care in 2021
Countries with an absolute increaseor decrease

greater than 5Country/Territory

Preventive
Care Score
2021

Overall Index
Score 2021

Preventive
Care YoY
Score Change

2

Latvia

46

69

2

2

23

United States

40

61

8

3

82

Zambia

37

49

-3

4

39

Portugal

37

58

-5

5

60

Argentina

36

54

8

Preventive
Care Score
2021

Overall Index
Score 2021

Preventive
Care YoY
Score Change

Preventive
Care Rank
2021

Overall
Rank
2021

1

Bottom Countries/Territories for Preventive Care in 2021
Preventive
Care Rank
2021

Overall
Rank
2021

118

90

Myanmar

8

46

-1

119

35

United Arab Emirates

8

59

-7

120

116

Benin

8

40

-4

121

117

Togo

7

40

NS

122

108

Ivory Coast

5

42

-3

Country/Territory

Note: “NS” indicates the country/territory was not surveyed the prior year.
Source: Hologic Global Women’s Health Index, 2021

37

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A woman talks about her health experiences with the teamfrom the Hologic Global Women’s Health Index video project.
Cape Town, South Africa

Preventive Care: Fastest-Improving and Fastest-Declining
Countries and Territories
In 2021, more women in Mexico reported being tested
for high blood pressure, diabetes and STDs/STIs
than in 2020 — making Mexico the fastest-improving
country in Preventive Care in 2021. The country’s
12-point increase in this dimension vaulted Mexico
to the No. 6 spot for Preventive Care, although thecountry’s position on the overall Hologic Global
Women’s Health Index is much lower.
From 2020 to 2021, the percentage of Mexican women
who reported being tested for high blood pressure
jumped from 40% to 54%, diabetes testing rates
increased from 27% to 40% and STD/STI testing rates
more than doubled from 11% to 26%. Cancer testing
was the only area that did not increase substantially:
19% of Mexican women reported being tested forcancer in 2021, similar to the 16% who said so in 2020.

By some estimates, as many as 8.74 million patient
visits were lost in Mexico in 2020, including cancer
screenings and female contraceptive services.37
Surges in COVID-19 cases and deaths in 2021 in a
number of countries may help explain some of the big
declines in Preventive Care scores between 2020 and
2021. In Cambodia, for example, surging COVID-19
cases — and an accompanying lockdown in April and
May — likely shifted attention away from more routine
health tests.38
The percentage of women in Cambodia who said
they were tested for cancer dropped from 24% to
5% in the span of a year. Testing for diabetes and
STDs/STIs followed suit.

Although it is not factored into the Preventive Caredimension score, the percentage of Mexican women
who went to a healthcare professional also rose —from 57% to 73% in the span of a year — which further
suggests that after the disruption in health services in2020 due to the pandemic, women may have beenplaying catch-up.
37 Doubova, S. V., Leslie, H. H., Kruk, M. E., Pérez-Cuevas, R., & Arsenault, C. (2021). Disruption in essential health services in Mexico during COVID-19: an
interrupted time series analysis of health information system data. BMJ global health, 6(9), e006204. https://doi.org/10.1136/bmjgh-2021-006204
38 Chorn, A., & Stromseth, J. (2021, May 19). Covid-19 comes to Cambodia. Brookings. https://www.brookings.edu/blog/order-from-chaos/2021/05/19/covid-19comes-to-cambodia/

38

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Fastest-Improving Countries/Territories for Preventive Care in 2021
Countries with an absolute increase

Preventive
Care Rank
2021

Overall
Rank
2021

6

–

or decrease

greater than 5Country/Territory

Preventive
Care Score
2021

Overall Index
Score 2021

Preventive
Care YoY
Score Change

64

Mexico

35

52

12

32

80

Sri Lanka

26

49

9

20

26

Belgium

30

61

8

5

60

Argentina

36

54

8

2

23

United States

40

61

8

Fastest-Declining Countries/Territories for Preventive Care in 2021

Preventive
Care Rank
2021

Overall
Rank
2021

Preventive
Care Score
2021

Overall Index
Score 2021

Preventive
Care YoY
Score Change

104

96

Cambodia

12

45

- 16

81

49

Vietnam

17

56

- 15

75

76

Tanzania

18

49

- 12

16

55

South Africa

31

55

- 12

91

89

Egypt

16

47

- 11

Country/Territory

Source: Hologic Global Women’s Health Index, 2021

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Annual Visits to a Healthcare Professional Could Add Years
to Women’s Life Expectancy
Just as the right test, screening or immunization at the right time can save a person’s life and help them stay healthy,
annual visits with a healthcare professional can detect potential health issues at a time when treatment may be
more successful and lower in cost.39 How often people should make these visits is the subject of debate, but
annual visits with a healthcare professional are often recommended for many adults, particularly for those who areover age 65 or those who may have other health risk factors.40 It is important to note that cultural, demographic,
geographical and other situational factors may also be barriers that prevent or discourage women from visiting
healthcare professionals.
Hologic and Gallup asked women about the value of routine checkups and whether they went to a healthcare
professional in the past 12 months, though their responses are not factored into the overall Hologic Global
Women’s Health Index score.41 However, women’s likelihood of having been to a healthcare professional in thepast 12 months provides insight into the low numbers of women being tested for high blood pressure, cancer,
diabetes and STDs/STIs.
Asking these questions also makes it possible to investigate how routine visits and going to healthcare professionals
may help women live longer, quality lives, and what factors might increase their likelihood of getting annual
checkups.

Annual visits to healthcare professionals correspond with two additional years in awoman’s life expectancy.
Overall, women were not any more likely to havebeen to a healthcare professional in 2021 than they
were the year before. Fifty-nine percent of womenreported going to a healthcare professional in thepast 12 months, while 41% did not. Although thewomen who did go to a healthcare professional may
not have thought about it at the time, doing so may
have added years to their lives.

Even after accounting for differences by GDP
per capita — because women who live longer
tend to live in wealthier countries with better
access to healthcare — Hologic and Gallup
found the life expectancy for women who said
they had been to a healthcare professional was
about 78 years, compared with 76 years for
women who said they hadn’t been.

39 Liss, D. T., Uchida, T., Wilkes, C. L., Radakrishnan, A., & Linder, J. A. (2021, June 8). General Health Checks in Adult Primary Care: A Review. JAMA.
https://jamanetwork.com/journals/jama/article-abstract/2780614
40 Jin, J., MD. (2022, April 12). Routine Checkups for Adults. JAMA Network. https://jamanetwork.com/journals/jama/fullarticle/2790936
41

40

For more information on which questions are included in the Index and why, please see Appendix 1.

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CHART 13:

Women
Who Wentand
to aWomen
Healthcare
Professional
by Female Life Expectancy at BirthLife Expectancy
Going
to the Doctor
90

Japan

Singapore

South
Korea

Spain
Australia

Female Life Expectancy at Birth (Years)

Peru
80

LatviaEgypt

MyanmarMongolia

70

Tajikistan

South
AfricaTogo
Nigeria
Mozambique

60

50

30

40

50

60

70

80

90

Women Who Went to a Healthcare Professional Out of 100

Source: Hologic Global Women’s Health Index, 2021

41

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Belief in the value of going to a healthcare
professional declined substantially in
2021 among women with an elementary
education or less.

Trust — and a need for healthcare — mayhelp more women get back to a healthcare
professional.

• Most women (85%) in 2021 continued to believe

high-quality healthcare to pregnant women are
48% more likely to say they went to a healthcare
professional in the past 12 months than those who
do not report that high-quality care is available.

that checkups help improve health, but fewer (59%)
reported going to a healthcare professional in thepast 12 months.

• While belief in the value of going to a healthcare

professional remained relatively stable among
women with four years of education beyond highschool or a college degree (92%), it dropped sevenpoints among those with an elementary educationor less — from 87% to 80% — leading to a 12-point
gap between the two groups.

Women over age 75 returned to healthcare
professionals in 2021, while women
younger than 75 did not.

• Women over the age of 75 were more likely to

say they went to a healthcare professional in 2021
(82%) than in 2020 (74%), while women younger
than 75 were just as likely to have been to ahealthcare professional in both years. Fewer thansix in 10 women aged 50 and younger (56%) went
to a healthcare professional in 2021, comparedwith 82% of those over 75. This difference may
reflect the higher health risks associated withaging, though preventive care is also highly
effective among younger women.

42

The Hologic Global Women’s Health Index | Global Report• Women who believe their communities provide• Women who said they have health problems thatkeep them from normal activities are 24% more
likely than those without such problems to havebeen to a healthcare professional in the past
12 months. This is likely based on the need forcare when a chronic health issue is present andlimits activities.

• Women who said they experienced physical pain

the day before the survey were 23% more likely
than those who didn’t experience pain to havebeen to a healthcare professional in the past
12 months. This may be related to the need fortreatments for underlying health conditions leading
to pain and the pain itself.

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E M OTIO NA L H EA LT H

2021 Set New Records for
Negative Emotions
Stress, worry, sadness, anger andother emotions are all a normal part oflife. But when these feelings become
chronic, they can be overwhelming
and interfere with a person’s ability
to carry out everyday tasks.

Negative emotions can become unhealthy andsignal more serious conditions, such as anxiety anddepressive disorders or other mental health diagnoses.
Moreover, there is a growing body of evidence thatemotional health can positively or negatively affectcardiovascular health and other physical healthrisk factors.42, 43, 44

The future will be better for women when as many women as possible do notexperience worry, sadness, stress or anger a lot in a typical day.
At present, these figures are at new highs, and reducing the incidence of thesenegative feelings is more of a challenge today than it was in 2020. A global
commitment to doing so is more imperative than ever — because it may lead tobetter health outcomes for women. Women’s experiences with health problems andpain (Individual Health) and their ability to afford food (Basic Needs) are related to ahigher incidence of feeling negative emotions.

42 Mayo Clinic. (2018, February 3). Depression (major depressive disorder) - Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/depression/
symptoms-causes/syc-20356007
43 Levine, G. N., Cohen, B. E., Commodore-Mensah, Y., Fleury, J., Huffman, J. C., Khalid, U., Labarthe, D. R., Lavretsky, H., Michos, E. D., Spatz, E. S., & Kubzansky,
L. D. (2021). Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association. Circulation,
143(10). https://doi.org/10.1161/cir.0000000000000947
44 NIMH. (n.d.). Chronic Illness and Mental Health: Recognizing and Treating Depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health

44

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Women in 2021 were more stressed, worried, angry and sad than they were in 2020
— or at any point in the past decade based on Gallup’s long-term trends of asking
these questions.45
More than four in 10 women in 2021 said they experienced worry (43%) and stress (41%) during a lot of the day before
the survey, nearly one in three experienced sadness (32%), and more than one in four experienced anger (26%) — allrecord levels. Stress, worry and anger each increased by three percentage points within the span of a year, whilesadness notably rose by six points.
CHART 14:

Negative Emotions Among Women in 2021
Did you experience the following feelings during a lot of the day yesterday?
(% Yes)
2020

2021

43%

41%

Worry

32%

StressSadness

+6

26%

+3

Anger

+3

+3

Women weren’t alone in how they felt, but the gap between men and women increased on all emotions between
2020 and 2021, with at least five points separating them on anger and sadness. These gender gaps aren’t new.
Previous studies show that women are substantially more likely than men to suffer from severe stress and anxiety.46
However, understanding how women are feeling — and how it differs from men — is crucial to tailoring strategies for
improving women’s emotional wellness.
CHART 15:

Negative Emotions in 2021 by Gender% Women

% Men

43

39

Worry

41

39

Stress32

26

Sadness

26

21

Anger

45 Ray, J. (2022, July 16). World Unhappier, More Stressed Out Than Ever. Gallup.com. https://news.gallup.com/poll/394025/world-unhappier-stressed-ever.aspx
46 Remes, O., Brayne, C., van der Linde, R., & Lafortune, L. (2016). A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brainand Behavior, 6(7), e00497. https://doi.org/10.1002/brb3.497

45

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Measuring Emotional Health
Feelings and emotions are life’s intangibles that “hard data” like GDP or mortality rates were not designed to capture.
The Emotional Health dimension of the Hologic Global Women’s Health Index gauges women’s daily experiences ofnegative feelings with four questions that have been asked as part of Gallup’s World Poll for more than a decade:• Did you experience the following feelings during a lot of the day yesterday? How about worry?
• Did you experience the following feelings during a lot of the day yesterday? How about sadness?
• Did you experience the following feelings during a lot of the day yesterday? How about stress?
• Did you experience the following feelings during a lot of the day yesterday? How about anger?
Scores on this component are calculated at the individual level. To get a score, individuals need to answer at least
three of the four questions. The resulting score is a simple mean of the positive answers. Higher scores on the
Emotional Health dimension mean fewer women are experiencing negative feelings on a given day.

Emotional Health Dimension
Higher scores on the Emotional Health dimension of the Index mean fewer women are experiencing negative
feelings on a given day.
Overall, women worldwide scored a 64 on the Emotional Health dimension in 2021 — down from 68 in 2020.

Women in countries facing uncertainty experienced the most negative feelings.
Many of the countries where women posted the lowest
scores on the Emotional Health dimension reflected
the political or economic strife that engulfed them in
2021. In Lebanon, for example, Gallup World Poll data
show quality of life has deteriorated so much during
the country’s economic collapse that a record-high 63%
of adults last year said they would leave the country ifthey could.47 This number included 59% of all women in
Lebanon, but the percentage of women who said theywanted to leave was higher among those experiencing
stress, worry or sadness.

With a score of 22 in this dimension, women’s emotional
health in Afghanistan — where surveys coincided with
the Taliban’s takeover and the chaotic exit of U.S. troops— was the worst in the world.48 As women faced an
uncertain fate under the Taliban’s rule, the percentageof women who said women were treated with respect intheir country dropped to a record-low 31%.49

47 Loschky, J. (2022, July 16). Leaving Lebanon: Crisis has most people looking for exit. Gallup.com. https://news.gallup.com/poll/357743/leaving-lebanon-crisispeople-looking-exit.aspx
48 See Appendix 2 for the dates of survey fieldwork.
49 Nusratty, K., & Ray, J. (2022, April 4). Afghan women and men see women treated worse after Taliban. Gallup.com. https://news.gallup.com/poll/391403/afghanwomen-men-women-treated-worse-taliban.aspx

46

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Women in Taiwan and Kazakhstan scored highest on the Emotional Healthdimension for the second consecutive year.
The two countries or territories with the highest scores on Emotional Health — Taiwan and Kazakhstan — also had
the highest scores in this dimension in 2020. Unlike the rest of the world, which is getting more negative with eachpassing year,50 levels of stress, anger, worry and sadness have remained relatively low and stable in Taiwan andKazakhstan for more than a decade.51
Even in Taiwan, where women’s anger, worry and stress increased slightly from single digits in 2020, the numbers in
2021 were still within the general range of where they have been in the past.

Top Countries/Territories for Emotional Health in 2021
Countries with an absolute increase

Emotional
HealthRank 2021

Overall
Rank
2021

1

1

2

or decrease

greater than 5

Emotional
HealthScore 2021

Overall Index
Score 2021

Emotional
Health YoY
Score Change

Taiwan, Province of China

88

70

-1

31

Kazakhstan

88

60

2

3

21

Malaysia

85

61

14

4

33

Kosovo

84

60

11

5

19

Mauritius

83

62

-1

Overall Index
Score 2021

Emotional
Health YoY
Score ChangeCountry/Territory

Bottom Countries/Territories for Emotional Health in 2021
Emotional
HealthRank 2021

Overall
Rank
2021

Country/Territory

Emotional
HealthScore 2021

118

115

Ecuador

49

40

0

119

118

Lebanon

48

40

3

120

97

Jordan

48

45

NS

121

119

Türkiye

46

40

-5

122

122

Afghanistan

22

22

NS

Note: “NS” indicates the country/territory was not surveyed the prior year.
Source: Hologic Global Women’s Health Index, 2021

50 Ray, J. (2022, July 16). World Unhappier, More Stressed Out Than Ever. Gallup.com. https://news.gallup.com/poll/394025/world-unhappier-stressed-ever.aspx
51 Based on Gallup World Poll data.

47

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Emotional Health: Fastest-Improving and Fastest-Declining Countries
Tajikistan saw the most improvement in women’semotional health, with their scores in this dimension
rising from 55 to 70 between 2020 and 2021.
Tajikistani women’s stress, sadness, worry and anger all
hit record highs in 2020 as their social and economic
well-being suffered in the first year of the COVID-19
pandemic. The country recovered quickly in 2021, withthe gains reflected in women’s emotional state.52+

Fastest-Improving Countries/Territories for Emotional Health in 2021
Countries with an absolute increase

Emotional
HealthRank 2021

Overall
Rank
2021

49

52

3

–

Between 2020 and 2021, Indian women’s emotional
health deteriorated at nearly twice the rate of any othercountry in the Hologic Global Women’s Health Index —dropping a staggering 26 points overall. Likely affectedby the pandemic, negative emotions rose dramatically
across India, with large increases in all four: sadness(up 34 points), worry (29 points), stress (21 points) andanger (20 points).

or decrease

greater than 5

Emotional
HealthScore 2021

Overall Index
Score 2021

Emotional
Health YoY
Score Change

Tajikistan

70

55

15

21

Malaysia

85

61

14

86

85

Tunisia

62

48

14

14

81

Zimbabwe

77

49

14

4

33

Kosovo84

60

11Country/Territory

Fastest-Declining Countries/Territories for Emotional Health in 2021

Emotional
HealthRank 2021

Overall
Rank
2021

Country/Territory

Emotional
HealthScore 2021

Overall Index
Score 2021

Emotional
Health YoY
Score Change

112

109

India

53

41

- 26

114

106

Bangladesh

51

43

- 14

101

116

Benin

58

40

- 12

99

112

Guinea

58

41

-9

56

30

United Kingdom

68

60

-8

Source: Hologic Global Women’s Health Index, 2021

52 World Bank. (2021, September 10). Tajikistan Economic Update – Summer 2021. World Bank Group. https://www.worldbank.org/en/country/tajikistan/publication/
economic-update-summer-2021.

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O P INIO NS O F H EA LT H A N D SA F E T Y

Women Feel Less Safe, Less Satisfied
With Healthcare Options
Women’s satisfaction with the availability of quality
healthcare where they live and their perceptions of
the quality of prenatal care women receive in theircommunities are largely missing from standard global
health statistics. But including them could help save
lives: According to the WHO, “most maternal deaths arepreventable with timely management by a skilled healthprofessional working in a supportive environment.” 53

Finding out how safe women feel in their communities
is also a critical social determinant of their health. Safety
and other important healthcare metrics are closely
linked. In environments where women feel personallysafe, adolescent pregnancy rates and maternal mortality
rates are lower and health expenditures per capita
are higher. 54

The future will be better for women when as many women as possible reporthigh-quality prenatal and health care in the city or area where they live and feelsafe walking alone at night. Together, these contribute to women living longer,
healthier lives.
At present, many women worldwide can answer these questions affirmatively,
but there is an increasing number who cannot. As of 2021, this includes nearly
1 billion women who do not feel safe walking alone at night where they live.

53 WHO. (n.d.). Maternal health. World Health Organization. https://www.who.int/health-topics/maternal-health#tab=tab_1
54 Gallup World Poll Methodology 2021

50

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The majority of women are satisfied withthe availability of quality healthcare where
they live and think most pregnant womenin their communities receive high-quality
maternal care. But fewer women felt thisway in 2021 than in 2020.

• While most women are satisfied with theavailability of quality healthcare (65%) and thinkmost pregnant women receive high-quality care(65%), both percentages are down slightly, from
68% and 69% respectively, in 2020.

• Satisfaction with the availability of quality

healthcare dropped most among women incountries in the lower-middle and low-income
groups. Women with the highest level of
education felt more favorably about theavailability of quality healthcare, while womenwith primary education or less felt less favorably.

Women felt less safe walking alone atnight in 2021 than they did in 2020. Morethan one in three do not feel safe walking
alone in their neighborhoods, whichtranslates into nearly 1 billion women
who feel unsafe.

• More than one in three women (37%) in 2021 said

they do not feel safe walking alone at night where
they live, up from 32% the year before. However,these percentages continued to be much higher
in a host of countries in Latin America andsub-Saharan Africa that have some of the world’s
highest rates of female intentional homicide.56
In Venezuela, for example, 81% of women said in
2021 that they do not feel safe walking alone atnight, and in South Africa, 76% said they do not
feel safe.

• Women continued to evaluate the quality ofpregnancy care higher than men did, yet that’s
largely because many men said they do not knowwhether pregnant women get high-quality care.
Based on the data, more than one in eight men(11%) said they do not know or could not say, butthese percentages are more substantial in somecountries, and rose to the majority level in a few
countries, such as Latvia (53%) and Lithuania (51%).
While cross-sectional data are not available,
individual country studies show men’s
involvement in perinatal care has benefits,
including reduced preterm childbirth andbetter child development.55

55	Nasiri, S., Waseghi, F., Moravveji, S., & Karimian, Z. (2021). Attitude and participation of men regarding prenatal care, Childbirth, and postpartum care in Kashan
City, Iran. Iranian Journal of Nursing and Midwifery Research, 26(4). https://doi.org/10.4103/ijnmr.ijnmr_140_20
56 World Bank. (n.d.). Intentional homicides, female (per 100,000 female). The World Bank Data. https://data.worldbank.org/indicator/VC.IHR.PSRC.FE.P5?most_recent_value_desc=true

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Measuring Opinions of Health and Safety
The Opinions of Health and Safety dimension of the Hologic Global Women’s Health Index gauges women’s satisfaction
with access to quality healthcare in general, whether they think pregnant women receive high-quality care and whether
they feel safe walking alone at night. Three questions make up this dimension:• Do you think most pregnant women in the city or area where you live receive high-quality healthcare during theirpregnancies, or not?

• In the city or area where you live, are you satisfied or dissatisfied with the availability of quality healthcare?
• Do you feel safe walking alone at night in the city or area where you live?
Scores on this dimension are calculated at the individual level. To get a score, individuals need to answer at least two of thethree questions. The resulting score is a simple mean of the positive answers. Higher scores on the Opinions of Health and
Safety dimension mean more women feel safe and satisfied with the quality and availability of healthcare where they live.

Opinions of Health and Safety Dimension
Higher scores on the Opinions of Health and Safety dimension mean more women feel safe and are satisfied with
the quality and availability of healthcare where they live. Overall, women worldwide scored a 66 on the Opinions of
Health and Safety dimension, down from 70 in 2020.
At the country level, women’s scores range widely, from a high of 97 in Singapore to a low of 11 in Afghanistan.

Singapore debuted in the top spot on the Opinions of Health and Safety dimension,
Afghanistan at the bottom.
The top country for Opinions of Health and Safety, Singapore, is new to the Index in 2021, as is the bottom country,
Afghanistan. Neither country was polled in 2020 because of the pandemic, but Gallup has surveyed both countries
regularly as part of its World Poll for well over a decade.
Women’s life expectancy in Singapore is among the highest in the world (86) and the country has a relatively low
maternal mortality rate (eight women per 100,000 live births in 2017).57, 58 The country’s high debut score on the Index— 97 — largely reflects the conditions that make high life expectancies and low mortality rates possible. Almost all
women in the city-state feel safe walking alone at night where they live (98%) and are satisfied with the availability ofquality healthcare (96%). Nearly nine in 10 (87%) are satisfied with the quality of prenatal care where they live.
In Afghanistan, where women on average can expect to live 20 fewer years than their counterparts in Singapore,
and where they are 80 times more likely to die in childbirth,59, 60 the Index score of 11 reflects the increasingly direcircumstances that Afghan women found themselves in in 2021. Few Afghan women — just 8% — said they felt safe
walking alone at night where they live, and just 14% were satisfied with the availability of quality healthcare. Tenpercent said they thought pregnant women received high-quality care.

57 World Bank. (2022, January 1). Life expectancy at birth, female (years). The World Bank Data. https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN
58 World Bank. (2022, January 1). Maternal mortality ratio (modeled estimate, per 100,000 live births). The World Bank Data. https://data.worldbank.org/indicator/
SH.STA.MMRT
59 Ibid.
60 Ibid.

52

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Top Countries/Territories for Opinions of Health and Safety in 2021
Countries with an absolute increase

Opinions
Health& Safety
Rank 2021

Overall
Rank
2021

1

11

2

or decrease

greater than 5

Opinions
Health & Safety
Score 2021

Overall Index
Score 2021

Opinions
Health & Safety
YoY Score Change

Singapore

97

64

NS

6

Switzerland

91

66

1

3

35

United Arab Emirates

91

59

-4

4

52

Tajikistan

89

55

3

5

10

Norway89

65-4Country/Territory

Bottom Countries/Territories for Opinions of Health and Safety in 2021
Opinions
Health& Safety
Rank 2021

Overall
Rank
2021

118

69

119

Opinions
Health & Safety
Score 2021

Overall Index
Score 2021

Opinions
Health & Safety
YoY Score Change

Mongolia

35

51

- 12

113

Gabon

33

40

0

120

118

Lebanon

28

40

- 20

121

120

Venezuela

19

39

-8

122

122

Afghanistan

11

22

NS

Country/Territory

Note: “NS” indicates the country/territory was not surveyed the prior year.
Source: Hologic Global Women’s Health Index, 2021

53

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Opinions of Health and Safety: Fastest-Improving andFastest-Declining Countries and Territories
Nicaragua’s dramatic improvement of 15 points on theOpinions of Health and Safety dimension in 2021 may
be a return to pre-pandemic levels after a tough year
for women in 2020, and may at least partly reflect a
shift from telephone to face-to-face interviewing in
2021. For example, the 55% of Nicaraguan women who
said they felt safe walking alone at night in 2021 is thesame as the 55% who said so when Gallup asked thisquestion in its World Poll in 2019.61 Both of these figures
are much higher than the 40% of Nicaraguan women
who said they felt safe in 2020.

However, women’s attitudes bear watching in coming
years as the political environment continues to shift in
Nicaragua. President Daniel Ortega began shuttering
hundreds of non-government agencies in 2021 —including those that assist women — throughout
the country.62
Myanmar’s staggering decline in Opinions of
Health and Safety — 23 points in the span of ayear — likely reflects the ongoing deadly violencein the country after the military seized power in
2021, and the crippling effect the civil war has hadon the country’s healthcare system.63

Women discuss their health experiences with the team fromthe Hologic Global Women’s Health Index video project.
New Delhi, India
61 Please see Appendix 2 for more discussion of mode changes from year to year.
62 BBC. (2022, May 5). Nicaragua shuts down 50 non-profits in new crackdown. BBC News. https://www.bbc.com/news/world-latin-america-61333797
63 Win, S., Aung, K. K., & Stylianou, N. (2022, February 1). The deadly battles that tipped Myanmar into civil war. BBC News. https://www.bbc.com/news/worldasia-60144957

54

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Fastest-Improving Countries/Territories for Opinions of Health and Safety in 2021
Countries with an absolute increase

Opinions
Health& Safety
Rank 2021

Overall
Rank
2021

39

67

93

–

or decrease

greater than 5

Opinions
Health & Safety
Score 2021

Overall Index
Score 2021

Opinions
Health & Safety
YoY Score Change

Nicaragua

70

51

15

47

Paraguay

50

56

9

89

81

Zimbabwe

50

49

6

22

68

Laos

78

51

6

80

112

Guinea53

41

6Country/Territory

Fastest-Declining Countries/Territories for Opinions of Health and Safety in 2021

Opinions
Health& Safety
Rank 2021

Overall
Rank
2021

78

90

64

Opinions
Health & Safety
Score 2021

Overall Index
Score 2021

Opinions
Health & Safety
YoY Score Change

Myanmar

54

46

- 23

109

India

59

41

- 20

120

118

Lebanon

28

40

- 20

97

79

Jamaica

48

49

- 17

87

42

Hungary

50

57

- 14

Country/Territory

Source: Hologic Global Women’s Health Index, 2021

55

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Shadow Pandemic: Women, Men See Domestic Violence
as a Problem
Domestic violence was a major public health andsafety problem before the COVID-19 pandemic, but inthe shadow of it, gender-based violence has increased
and placed additional pressure on women and healthresources. According to UN estimates, 47,000 womenand girls were killed in 2020 by an intimate partner orfamily member, which translated into one woman or girlevery 11 minutes.64
Because of the problem’s lack of global visibility,
Hologic and Gallup asked women and men in 2020
and 2021 about the scope of domestic violence in theircountries. Due to the sensitivity of the topic, the survey
question frames the issue indirectly, allowing womenand men to express their views without having todiscuss their own victimization or that of loved ones.
“Domestic violence can be physical, psychological, or
involve sexual acts done to someone against their willby a person they live with. In your opinion, is domestic
violence a widespread problem in [country name],or not?”

The findings show domestic violence is perceived
as just as big of a problem in 2021 as it was in
2020. In 2021, two in three women worldwide (65%)— representing roughly 1.7 billion women — said
domestic violence is a widespread problem in theircountry. Nearly six in 10 men (56%) agreed.

• While both women and men in many countries

see domestic violence as an issue, the gender
gap shows country leaders and policymakers mayneed to tailor their messaging for efforts related toawareness, response and prevention.

• In most of the countries studied, women weremore likely than men to consider domestic
violence a widespread issue. In 44 of the 122
countries surveyed, there was a gap of more than
10 percentage points separating women and men.

• Worldwide, the percentage of women who said

domestic violence is widespread continued torange widely, from a low of 14% in the United ArabEmirates to a high of 95% in Albania.

Testing in 2020 and 2021 revealed the results were nothighly related to any of the dimensions of health andthe question was not factored into the overall Hologic
Global Women’s Health Index. However, because theissue is so important to women’s quality of life andlongevity on its own, Hologic and Gallup will continue
to ask this question in future surveys and monitor
the trends.

64 United Nations. (2021, November 25). UNODC Research: 2020 saw a woman or girl being killed by someone in their family every 11 minutes. Office on Drugs
and Crime. https://www.unodc.org/unodc/frontpage/2021/November/unodc-research_-2020-saw-every-11-minutes-a-woman-or-girl-being-killed-by-someone-intheir-family.html

56

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CHART 16:

Difference in Perception of Domestic Violence by Gender
Domestic violence can be physical, psychological, or involve sexual acts done to someone against their will by aperson they live with. In your opinion, is domestic violence a widespread problem in [country name], or not?
(% Yes)Percentage point gap between women and men who said domestic violence is a widespread problem, with men’s scores
subtracted from women’s scores-10 or larger

0 to -9+1 to +9

+10 to +19+20 or larger

A woman who took part in the Hologic Global
Women’s Health Index video project walks down
the street in Istanbul, Türkiye.
Istanbul, Türkiye

57

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BAS IC NEEDS

Women Struggled More to Afford Food,
Shelter in 2021
Having enough resources to meet daily needs, such as
having enough food to eat and finding safe, affordable
housing, are all basic needs for healthy living.
Of the social determinants of health, food insecurity
likely has one of the most extensive influences:
Adults who are food insecure — meaning they lackregular access to enough safe and nutritious food —are disproportionately at risk of obesity and chronic
diseases, including hypertension, diabetes, cancer
and heart disease.65, 66

Monitoring how many women are struggling to afford
food in the years to come is critical. COVID-19-related
disruptions that pushed hundreds of millions of themost vulnerable populations — including women — into
acute food insecurity in 2020 continued throughout
2021. The United Nations estimates that nearly 50
million more people were undernourished in 2021 thanthe previous year.67 The Russia-Ukraine war, which is
driving up food prices around the world, could pushmillions more into hunger in 2022 and 2023.68

The future will be better for women when as many women as possible say they
are not having trouble affording the food or shelter they or their families need.
When women can meet their basic needs, their life expectancies go up, emotional
health improves, and mortality rates of mothers and children go down.69
At present, hundreds of millions of women worldwide cannot afford the foodand shelter they or their families need, and it is getting tougher each year.
Current efforts to fight hunger won’t be enough in the face of uncertainty with war,rising inflation and concerns about recession. Governments must rethink how they
allocate their spending to stave off the growing global hunger crisis.

65 Coleman-Jensen, A., & Gregory, C. (2017). Food Insecurity, Chronic Disease, and Health Among Working-Age Adults. USDA. https://www.ers.usda.gov/
publications/pub-details/?pubid=84466
66 FAO. (n.d.). Hunger. Food and Agriculture Organization of the United Nations. http://www.fao.org/hunger/en/
67 FAO. (2022, July 22). The State of Food Security and Nutrition in the World 2022. Food and Agriculture Organization of the United States. https://www.fao.org/
documents/card/en/c/cc0639en
68 Ibid.
69 Gallup Worldwide Research and Methodology Codebook (2022)

58

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GWHI_Global_Section2_072922_kn_hsMore women struggled to afford thebasics — food and shelter — in 2021 thanthey did the previous year. More than
one in three, representing nearly 1 billion
women, said they did not have enoughmoney to buy the food they needed.

• Overall, the percentage of women who at times

could not afford needed food rose from 34% to37%, with the growth in food insecurity most acuteamong women over age 50 (increasing from 29%
to 35% in the 51 to 75 age group and 11% to 18% in
the 76 and older age group).

• Women in rural areas also experienced more

hardship than their urban counterparts: The gap
between them widened to more than 15 points in
2021. Forty-four percent of women in rural areas
struggled to afford food at times, compared with
28% of those living in urban areas.

While women’s ability to meet their basic
needs fell, men’s situations didn’t change.

• While men and women similarly could not afford

shelter, women were slightly more likely than men
to say there were times when they did not haveenough money to afford needed food (37% of
women vs. 33% of men). This gap was wider in
2021 than it was in 2020 — women lost ground
while men largely remained steady — whichcorresponds with the rising food insecurity among
women that the United Nations found in 2021.70• This gap has important implications for families,

as women are culturally the primary caregivers
and typically eat last and least in countries facing
conflict, famine and hunger.71

Slightly fewer women — though still in thehundreds of millions — didn’t have enoughmoney for shelter. Like food, without
shelter, healthcare is often deprioritized.

• Three in 10 women (30%) — representing nearly

800 million — said there were times in the past
year when they were unable to afford adequate
shelter or housing for themselves or their families.
This is similar to the 29% who reported being
unable to afford shelter at times in 2020.

• Women younger than age 50 and those withthe least education continue to be the mostvulnerable: Women younger than 50 were nearly
twice as likely as those over 75 (31% vs. 16%) to
struggle with affording shelter. Nearly four in 10
women (38%) with primary education or less could
not afford shelter at times, compared with 15%of those with more than four years of education
beyond high school or a college degree.

70 FAO. (2022, July 22). The State of Food Security and Nutrition in the World 2022. Food and Agriculture Organization of the United States. https://www.fao.org/
documents/card/en/c/cc0639en
71

59

WFP. (2022). Women are Hungrier. World Food Program USA. https://www.wfpusa.org/women-are-hungrier-infographic/

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Measuring Basic Needs
The Basic Needs dimension of the Hologic Global Women’s Health Index gauges women’s ability to meet their basic
needs with two questions that Gallup’s World Poll has asked for more than a decade:• Have there been times in the past 12 months when you did not have enough money to buy food that you or yourfamily needed?

• Have there been times in the past 12 months when you did not have enough money to provide adequate shelteror housing for you and your family?

Scores on this dimension are calculated at the individual level. To get a score, individuals need to answer both questions.
The resulting score is a simple mean of the positive answers. Higher scores on the Basic Needs dimension mean fewer
women are struggling to afford the food and shelter they need.

Basic Needs Dimension
Higher scores on the Basic Needs dimension of the Index mean fewer women report struggling to afford the foodand shelter they need. Women worldwide scored a 66 on this dimension of the Index, down from 68 in 2020.
At the country level, women’s scores on the Basic Needs dimension range from a low of 25 in Afghanistan to ahigh of 97 in Singapore and Sweden.

Women in sub-Saharan Africa and Asia scored the lowest on Basic Needs.
Afghanistan debuted on the Index in 2021 with thelowest scores in the world on several dimensionsof health, including Basic Needs — with a score of
25. Previous Gallup research in Afghanistan72 shows
women were struggling to afford much needed foodand shelter long before the Taliban seized control andthe U.S. withdrew in 2021, but their struggles became
even more acute in the past year: A record-high 86%
of Afghan women in 2021 said they could not afford
food at times and a record 64% said they could notafford shelter.

As high as these numbers are, they may be even higher
now. After the Taliban came to power, governments cut
off aid. As food prices soared, the number of Afghans
needing aid reached nearly 20 million — many ofthem women.73
With the war between Ukraine and Russia making theworld’s hunger crisis even tougher to fight — driving
food prices up for those who can least afford it —Afghan women, as well as women in other countries
who are struggling to afford the basics, face even morerisks in the days and years ahead.

72 Ray, J. & Nusratty, K. (2022, April 4). Afghan Women and Men See Women Treated Worse After Taliban. Gallup.com. https://news.gallup.com/poll/391403/afghanwomen-men-women-treated-worse-taliban.aspx
73 IPC. (n.d.). Afghanistan: Acute Food Insecurity Situation for March - May 2022 and projection for June - November 2022. IPC Portal. https://www.ipcinfo.org/ipccountry-analysis/details-map/en/c/1155595/?iso3=AFG

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Women in many high-income countries almost universally have their basic needs met.
Countries where women have the highest scores on
the Basic Needs component are mostly high-income
economies with social safety nets. Worries about foodand shelter are relatively nonexistent. In Sweden andSingapore, for example, the “yes” responses on bothquestions in 2021 were in the low single digits, whichmeans few women were struggling with either.

However, even though high-income economies
dominate the top of the list, many women in a numberof high-income countries are still struggling in thisdimension. The United States, which spends more on
healthcare than any other country in the world, is one
example.74 Nearly one in four women (23%) in the U.S.
said they could not afford food at times in the past year.75

Top Countries/Territories for Basic Needs in 2021
Countries with an absolute increase

Basic Needs
Rank 2021

Overall
Rank
2021

1

11

2

or decrease

greater than 5

Basic Needs
Score 2021

Overall Index
Score 2021

Basic Needs YoY
Score Change

Singapore

97

64

NS

12

Sweden

97

63

4

3

10

Norway

96

65

3

4

9

Israel

95

65

6

5

1

Taiwan, Province of China

94

70

1

Country/Territory

Bottom Countries/Territories for Basic Needs in 2021
Basic Needs
Rank 2021

Overall
Rank
2021

Country/Territory

Basic Needs
Score 2021

Overall Index
Score 2021

Basic Needs YoY
Score Change

118

82

Zambia

35

49

1

119

93

Philippines

35

45

-4

120

110

Sierra Leone

34

41

NS

121

96

Cambodia

32

45

- 11

122

122

Afghanistan

25

22

NS

Note: “NS” indicates the country/territory was not surveyed the prior year.
Source: Hologic Global Women’s Health Index, 2021

74 Statista. (2022, July 27). Per capita health expenditure by country 2020. https://www.statista.com/statistics/236541/per-capita-health-expenditure-bycountry/#:~:text=health%20care%20services.-,Health%20Expenditure%20in%20the%20U.S.,U.S.%20exceeded%20four%20trillion%20dollars.
75 OECD. (2021). Health spending. OECD Data. https://data.oecd.org/healthres/health-spending.htm

61

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Basic Needs: Fastest-Improving and Fastest-Declining
Countries and Territories
Tunisia’s sharp economic contraction in 2020, followed
by a moderate rebound the following year, may at least
partly explain the country’s 16-point surge in women’sscores on the Basic Needs dimension between 2020
and 2021.
However, a World Bank study suggests that Tunisians
were also coping with higher food prices by drawing
from their savings or changing their consumption
habits.76 Slightly more than one in five Tunisian women(22%) in 2021 said they were unable to afford food attimes in the past year — almost half of the 40% who said
so in 2020.

Although Bangladesh’s food security had improved inrecent years, the sharp decline in the country’s scoreon the Basic Needs dimension — 25 points — likely
reflects record prices for staple goods in March 2022
(when fieldwork took place) after the start of the RussiaUkraine war.77 The percentage of Bangladeshi women
who said they could not afford food at times in the past
year surged from 37% in 2020 to 61% in 2021.

Women talk about their health experiences with the team fromthe Hologic Global Women’s Health Index video project.
New Delhi, India

76 World Bank. (n.d.). The World Bank in Tunisia. https://www.worldbank.org/en/country/tunisia/overview#1
77 Mamun, A., Glauber, J., & Laborde, D. (2022, April 20). How the war in Ukraine threatens Bangladesh’s food security. IFPRI Blog. https://www.ifpri.org/blog/howwar-ukraine-threatens-bangladeshs-food-security

62

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Fastest-Improving Countries/Territories for Basic Needs in 2021
Countries with an absolute increaseor decrease

greater than 5

Basic Needs
Rank 2021

Overall
Rank
2021

Country/Territory

Basic Needs
Score 2021

Overall Index
Score 2021

Basic Needs YoY
Score Change

46

85

Tunisia

81

48

16

64

44

Uzbekistan

64

56

14

104

74

Namibia

43

50

14

88

77

El Salvador

48

49

13

43

63

Algeria

82

53

13

Basic Needs
Score 2021

Overall Index
Score 2021

Basic Needs YoY
Score Change–

Fastest-Declining Countries/Territories for Basic Needs in 2021

Basic Needs
Rank 2021

Overall
Rank
2021

Country/Territory

96

106

Bangladesh

46

43

- 25

89

109

India

48

41

- 12

98

119

Türkiye

45

40

- 12

121

96

Cambodia

32

45

- 11

83

98

Morocco

51

44

-9

Source: Hologic Global Women’s Health Index, 2021

63

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INDIV IDUA L H EA LT H

More Women Experiencing Pain and
Health Problems
Health-related statistics, such as life
expectancy, infant mortality and disease
rates, provide a great deal of insight
into a country’s overall health.

However, these statistics shed little light on women’s
experiences and how individuals see health problems
affecting their quality of life and keeping them fromdoing the things that people their age normally do.

The future will be better for women when as few women as possible
experience daily physical pain and suffer health problems that prevent themfrom doing things that women their age normally do.
At present, this will be no small task. Worldwide, more than half a billion
women experience physical pain and health problems that limit theiractivities on any given day.

64

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A street vendor woman in Vietnam makes a call on her cellphone.
Hoi An, Vietnam

Nearly a billion women worldwide
spent a lot of yesterday in pain.

• Three in 10 women (34%) — which represents

nearly 900 million women worldwide — reported
experiencing physical pain during a lot of theprevious day in 2021, up from 30% in 2020.

More than half a billion women have healthproblems that keep them from normal activities.

• In 2021, one in four women (25%) — which

represents nearly 650 million women globally —said they have health problems that prevent themfrom doing things people their age normally do, up
from 20% in 2020.

• Women with elementary education or lessdisproportionately reported these experiences,with the gap between these women and thosewith secondary education nearly doubling in theexperience of daily pain and health problems.

• The individual health experiences of rural women

were also staggering. Rural women’s dimension
scores in 2020 were near parity with those ofurban women (76 for urban women vs. 74 for rural
women), but this gap widened to 11 points in 2021
(77 for urban women vs. 66 for rural women). The
introduction of several low-income, highly ruralcountries in 2021 may at least partly explain the
difference, but it bears continued observation.

• Women over age 75 experienced the only

increase across any age group, with a five-point
bump in experiencing health problems thatprevent them from doing things others their age
can do. While this is an aging population and one
would anticipate some limitations, this increase
merits monitoring.

65

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Measuring Individual Health
The Individual Health dimension of the Hologic Global Women’s Health Index gauges women’s dailyexperiences of pain and health problems with two questions that have been asked as part of Gallup’s
World Poll for more than a decade:• Did you experience the following feelings during a lot of the day yesterday? How about physical pain?
• Do you have any health problems that prevent you from doing any of the things people your age normally can do?
Scores on this dimension are calculated at the individual level. To get a score, individuals need to answer bothquestions. The resulting score is a simple mean of the positive answers. Higher scores on the Individual Healthdimension mean fewer women are experiencing health problems and pain on a given day.

Individual Health Dimension
Higher scores on the Individual Health dimension of the Index mean fewer women are experiencing health problems
and pain on a given day. Women worldwide scored a 71 on the Individual Health dimension of the Index in 2021,
down from 75 in 2020. Out of the five dimensions of health, Individual Health has the third-highest correlation with
GDP, after Basic Needs and Opinions of Health and Safety.
At the country level, scores on the Individual Health dimension range from a low of 50 in Iraq to a high of 88 in Taiwan.

Individual Health scores are highest in Asian countries.
While countries at the top of the Individual Healthdimension in 2020 represented a mix of regions, thetop five countries and territories for Individual Health in
2021 were all geographically in Asia. Taiwan, Israel andVietnam also made the top of the list in 2020.

The appearance of so many Asian countries on this listin both years suggests how different cultures view pain
may play a role in admission of this pain to others, which
is an important part of effective pain management.78
Women in most of the countries with the highest scoreson the Individual Health dimension are also among theleast likely to say they experienced a lot of pain theprevious day.

78 Chen, L.-M., Miaskowski, C., Dodd, M., & Pantilat, S. (2008). Concepts within the Chinese culture that influence the cancer pain experience. Cancer Nursing, 31(2).
https://doi.org/10.1097/01.ncc.0000305702.07035.4d

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Top Countries/Territories for Individual Health in 2021
Countries with an absolute increase

Individual
HealthRank 2021

Overall
Rank
2021

1

1

2

or decrease

greater than 5

Individual Health
Score 2021

Overall Index
Score 2021

Individual HealthYoY Score Change

Taiwan, Province of China

88

70

3

49

Vietnam

85

56

2

3

14

China

85

63

5

4

9

Israel

84

65

2

5

43

Indonesia

83

56

4

Country/Territory

Bottom Countries/Territories for Individual Health in 2021
Individual
HealthRank 2021

Overall
Rank
2021

Country/Territory

Individual Health
Score 2021

Overall Index
Score 2021

Individual HealthYoY Score Change

118

116

Benin

55

40

-14

119

112

Guinea

52

41

- 10

120

91

Senegal

52

46

1

121

121

Republic of the Congo

51

38

-4

122

111

Iraq

50

41

-3

Source: Hologic Global Women’s Health Index, 2021

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Individual Health: Fastest-Improving and Fastest-Declining
Countries and Territories
Hologic and Gallup conducted the second Hologic
Global Women’s Health Index on the heels of India’s
deadly second COVID-19 wave in 2021, after Indianstates started to emerge from another roundof lockdowns.

+

Fastest-Improving Countries/Territories for Individual Health in 2021
Countries with an absolute increase

Individual
HealthRank 2021

Overall
Rank
2021

54

52

24

–

The results suggest the second year of the pandemic
exacted a toll on Indian women’s physical and mental
health, as is evident in the 22-point drop in their
Individual Health score.

or decrease

greater than 5

Individual Health
Score 2021

Overall Index
Score 2021

Individual HealthYoY Score Change

Tajikistan

71

55

16

4

Denmark

75

67

8

19

55

South Africa

77

55

8

113

89

Egypt

56

47

8

98

118

Lebanon61

40

7Country/Territory

Fastest-Declining Countries/Territories for Individual Health in 2021

Individual
HealthRank 2021

Overall
Rank
2021

Country/Territory

Individual Health
Score 2021

Overall Index
Score 2021

Individual HealthYoY Score Change

109

109

India

57

41

-22

118

116

Benin

55

40

-14

99

82

Zambia

61

49

-14

70

79

Jamaica

68

49

-13

102

39

Portugal

60

58

-12

Source: Hologic Global Women’s Health Index, 2021

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obal Women's Health Index
100
70

COUNTRIES IN CRISISSPOTLIGHT

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“Today, we are witnessing
the attempt to steadily erase
women and girls from public
life in Afghanistan…79
INDEPENDENT UN HUMAN
RIGHTS EXPERTS

79 United Nations. (2022, January 17). Afghanistan: Taliban attempting to steadily erase women and girls from public life – UN experts. OHCHR. https://www.ohchr.
org/en/press-releases/2022/01/afghanistan-taliban-attempting-steadily-erase-women-and-girls-public-life-un

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C OU N T RY I N C R I S I S S P OT L I G H T

Afghanistan
Life was already extremely difficult for Afghan womenand girls before the Taliban returned to power in late
2021. Gallup surveys in the years leading up to thisshowed women were struggling to afford food andshelter, few felt safe, and most saw their lives getting
worse with every passing year.

A record-high 96% of Afghan women evaluatedtheir lives so poorly — rating their current andfuture lives less than a 4 on a scale of zero to 10— that they could be considered suffering on theLife Evaluation Index.82

While the pandemic prevented Hologic and Gallupfrom surveying in Afghanistan in 2020, male andfemale Afghan interviewers returned to the field to
conduct in-person polls in August and September 2021
— as the Taliban retook control and the U.S. withdrew.80
The interviewers found unprecedented misery.81

Many men found themselves in a similar situation,with 92% in the suffering category. However, 2021
marked the first time that more women than men wereclassified this way, which bears close watching in theyears to come.

Preventive Care: Testing rates are low to nonexistent among Afghan women.
At the time of the survey, Afghanistan’s healthcare
system was on the verge of collapse and essential
health facilities, medications and vaccinations were
scarce. In the first half of 2021, the Taliban’s attacks
on healthcare facilities left 26 damaged and 12 healthworkers dead.83

Relatively few Afghan women reported getting tested
for high blood pressure, diabetes, cancer or STDs/
STIs in the 12 months prior, which helps explain why thecountry’s score of 13 on the Preventive Care dimension
is so far below the global average of 19.

CHART 17:

Preventive Care Testing for Afghan Women in 2021

23%

High bloodpressure

0%
Cancer14%
Diabetes

13%

STDs/STIs

80 Teams of husbands and wives and brothers and sisters traveled together to satisfy the Taliban rule that banned women from traveling more than 48 miles
without a mahram or male guardian. Female interviewers surveyed female respondents and male interviewers surveyed male respondents.
81

Reinhart, R. J. (2022, July 16). Suffering Reaches Unprecedented Levels in Afghanistan. Gallup.com. https://news.gallup.com/poll/391406/suffering-reachesunprecedented-levels-afghanistan.aspx

82 Gallup, Inc. (2021, April 8). Understanding How Gallup Uses the Cantril Scale. Gallup.com. https://news.gallup.com/poll/122453/Understanding-Gallup-UsesCantril-Scale.aspx
83 Awan, Usman & Malik, Wasif & Afzal, Muhammad & Ahmed, Haroon & Zahoor, Sarmad. (2022). War-torn Afghanistan and cancer care: where to focus?. The
Lancet Oncology. 23. 562-563. 10.1016/S1470-2045(22)00192-9

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Notably, no Afghan women — zero respondents —said they had been tested for any type of cancer inthe past year.
But even if women had been tested for cancer, cancer
treatment is not readily available in most of the country.
Just one hospital in Kabul bears the treatment burden
for the entire country, which had a population of morethan 39 million in 2021.84, 85
However, the fact that women in Afghanistan were notgetting medical tests does not mean that women do notvalue annual care visits with healthcare professionals.

Seventy-one percent of Afghan women said they
believe in the value of checkups with a healthcare
professional and 61% said they went to a healthcare
professional in the past 12 months.
Access to these professionals will remain a challenge:
In 2020, roughly one in three Afghans had no accessto a functional health center within two hours of theirhome, according to the UN Office for the Coordinationof Humanitarian Affairs.86 With travel restrictions
imposed by the Taliban on women traveling more than
48 miles without a male guardian, women may feel
discouraged from seeking care.87

Emotional Health: Negative emotions hit a record high.
Although 2021 was the first year Hologic and Gallup could conduct the Hologic Global Women’s Health Index
in Afghanistan, Gallup has been tracking Afghans’ emotions since 2008. Worry, stress, anger and sadness
unsurprisingly soared to record levels among women and men in Afghanistan in 2021.
Like men, overwhelming numbers of Afghan women reported feeling worried (85%), stressed (83%), sad (78%)
and angry (62%) the day before the survey. However, women reported these emotions much more than men —particularly in regard to anger and sadness.
CHART 18:

Negative Emotions in Afghanistan by Gender% Women% Men

Gender gap (pct. pts.)

-7

85

-9

78

83

-17

74

-16

78
61

62
46

Worry

StressSadnessAnger

84 Awan, Usman & Malik, Wasif & Afzal, Muhammad & Ahmed, Haroon & Zahoor, Sarmad. (2022). War-torn Afghanistan and cancer care: where to focus?. The
Lancet Oncology. 23. 562-563. 10.1016/S1470-2045(22)00192-9
85 World Bank. (2022.). Population, total - Afghanistan. The World Bank Data. https://data.worldbank.org/indicator/SP.POP.TOTL?locations=AF
86 Devi, S. (2020). Access to health care under threat in Afghanistan. The Lancet, 395(10242). https://doi.org/10.1016/s0140-6736(20)31447-1
87 France 24. (2021, December 26). Taliban bans women from travelling longer distances unless with male relative. France 24. https://www.france24.com/en/asiapacific/20211226-taliban-say-no-trips-for-afghan-women-unless-escorted-by-male-relative73

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GWHI_Global_Section2_072922_kn_hs asic Needs: Record numbers of Afghan women are struggling to afford
Bfood and shelter.
The Taliban’s takeover in late 2021 made an existing
problem in Afghanistan — the ability to afford food —even worse.
By March 2022, an estimated 95% of Afghans
did not have enough to eat or enough moneyfor food.88

Gallup surveys before the Taliban regained control
showed Afghans had been struggling for years toafford food — and women more so than men since2017. At the time of the survey in 2021, a record-high
86% of women and 76% of men said there weretimes when they could not afford food that they ortheir families needed. Women also disproportionately
struggled more than men to afford shelter.

CHART 19:

Basic Needs in Afghanistan by Gender% Women% Men

Gender gap (pct. pts.)

-10

86

-8

76
64

Not enough money for food56

Not enough money for shelter

88 United Nations. (2022, March 18). Afghanistan: Food insecurity and malnutrition threaten ‘an entire generation’. UN News. https://news.un.org/en/
story/2022/03/1113982?

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C OU N T RY I N C R I S I S S P OT L I G H T

India
India’s second wave of COVID-19 overwhelmed thecountry’s health system. In several cities and states,
hospitals turned patients away and crematoriums
ran out of space.89 While hundreds of millions ofIndians suffered, marginalized groups, including
women and girls, were at higher risk because of theirsocioeconomic status, cultural norms, and because
they were often on the front lines as caregivers athome and in the health and service sectors.90

The results suggest the second year of the pandemic
exacted a toll on Indian women’s physical andmental health.91
Indian women’s score on the overall Index
declined 14 points to 44 — the biggest drop for any
country in the world. India showed sharp declines
in every dimension except Preventive Care —which was already one of the lowest in the world.

Hologic and Gallup conducted the 2021 Hologic Global
Women’s Health Index on the heels of India’s deadly
second wave, after Indian states started to emerge
from another round of lockdowns.

89 Samarasekera, U. (2021). India grapples with second wave of COVID-19. The Lancet Microbe, 2(6). https://doi.org/10.1016/s2666-5247(21)00123-3
90 UN Women. (2021, July 27). Your questions answered: Women and COVID-19 in India. https://www.unwomen.org/en/news/stories/2021/7/faq-women-and-covid19-in-india
91 Switching from telephone to in-person surveys in India between 2020 and 2021 may account for some of this effect, but given the extent of the changes fromyear to year, it does not account for all of the effect.

A woman talks about her health experiences with the team fromthe Hologic Global Women’s Health Index video project.
New Delhi, India

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Emotional Health: Negative emotions flare in India.
Indian women suffered the biggest decline in
Emotional Health of any country that Hologic and
Gallup surveyed in 2021, with the score dropping from79 to 53 in the span of a year.
Negative emotions soared in India between 2020 and
2021, with double-digit increases in all four negative

emotions: worry, anger, sadness and stress. Majorities
of Indian women said they felt sadness and worry
during much of the previous day.
Women carried more of the emotional burden in 2021
compared with the previous year, when they were lesslikely than men to report feeling stress and worry.

CHART 20:

Negative Emotions in India% 2020% 2021

Change from 2020 to 2021 (pct. pts.)

+29
+34

59

53

+21

+20

42
34

30
13

Worry

77

StressThe Hologic Global Women’s Health Index | Global Report

19

Sadness

22

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Conclusions From the 2021 Hologic
Global Women’s Health Index
While the results from the 2020 Hologic Global
Women’s Health Index offered a sobering accountof the state of women’s health worldwide, theresults from the 2021 Index sound an alarm.
Despite hopes that the COVID-19 pandemic would beover in 2021, disruptions to essential health services
would end, and women’s health situations would start
to improve, the findings from the 2021 Index suggest
the situation may be even more urgent now than it was
during the first year of the pandemic.
Globally, the Index shows most women’s healthsituations did not improve in 2021 and the healthsituations for many women who were alreadyvulnerable worsened. The gap in the overall Indexscore between women in high-income and low-income
economies nearly doubled in the span of a year, while
the gap between women in urban and rural areas
stretched twice as wide. Less-educated women fell
further behind, while higher-educated women had
slightly better health outcomes in 2021.

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Worldwide, women also lost ground in four out of thefive dimensions of their health as they struggled more
to afford the basics, they felt less safe, their emotional
health suffered and they experienced more pain thanin the previous year. Preventive care continued toremain the weakest of all dimensions. Women were
not screened or tested for deadly diseases any morein the second year of the pandemic than they were in
the first.
With so much of the world in crisis and headed in
the wrong direction on women’s health, frameworks
like the Index become even more critical tools forpolicymakers and leaders as they seek pathways
to a healthier future for women. Women are thecornerstones of families, societies and economies. To
help the world correct its course — and move forward— Hologic and Gallup will be monitoring the world’s
progress on women’s health for at least the next six
years. Hologic looks forward to working with andengaging global partners in the pursuit of better healthfor women.

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Index Scores byCountry and Territory
Rank

80

Country/Territory

Hologic Global Women’s
Health Index

1

Taiwan, Province of China

70

2

Latvia69

3Austria67

4

Denmark

67

5

Estonia66

6

Switzerland

66

7

Germany

66

8Czech Republic

659

Israel65

10Norway65

11Singapore

64

12

Sweden

63

13

Japan

63

14

China

63

15

New Zealand63

16

Netherlands

63

17

Finland

62

18

South Korea

62

19

Mauritius

62

20

Australia

61

21

Malaysia

61

22

Iceland

61

23

United States of America

61

24

Lithuania

61

25

Hong Kong, S.A.R. of China

61

26

Belgium

61

27

France61

28

Saudi Arabia

61

29

Poland60

30

United Kingdom of Great Britain and Northern Ireland60

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Index Scores by Country and Territory( CON TI N UED)

81

Hologic Global Women’s
Health Index

Rank

Country/Territory

31

Kazakhstan

60

32

Slovenia

60

33

Kosovo60

34

Ireland60

35

United Arab Emirates

59

36

Spain

59

37

Croatia59

38

Slovakia

59

39

Portugal

58

40

Italy

57

41

Uruguay57

42

Hungary

57

43

Indonesia

56

44

Uzbekistan

56

45

Malta

56

46

Thailand

56

47

Paraguay

56

48

Canada56

49

Vietnam

56

50

Republic of Moldova

56

51

Romania56

52

Tajikistan

55

53

Chile

55

54

Greece55

55

South Africa

55

56

Costa Rica

55

57

Cyprus55

58

Bulgaria

55

59

Serbia54

60

Argentina

54

61

Kyrgyzstan

54

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Index Scores by Country and Territory( CON TI N UED)

82

Hologic Global Women’s
Health Index

Rank

Country/Territory

62

North Macedonia

54

63

Algeria

53

64

Mexico52

65

Russian Federation

52

66

Bosnia and Herzegovina

52

67

Nicaragua

51

68

Lao People’s Democratic Republic

51

69

Mongolia

51

70

Ghana

51

71

Albania

51

72

Kenya

50

73

Iran

50

74

Namibia50

75

Panama50

76

Tanzania

49

77

El Salvador

49

78

Ukraine

49

79

Jamaica

49

80

Sri Lanka

49

81

Zimbabwe

49

82

Zambia49

83

Honduras

48

84

Pakistan

48

85

Tunisia

48

86

Dominican Republic

48

87

Nepal

47

88

Georgia

47

89

Egypt

47

90

Myanmar46

91

Senegal46

92

Nigeria46

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Index Scores by Country and Territory( CON TI N UED)

83

Hologic Global Women’s
Health Index

Rank

Country/Territory

93

Philippines

45

94

Mozambique

45

95

Armenia45

96

Cambodia

45

97

Jordan45

98

Morocco44

99

Burkina Faso

44

100

Colombia

44

10 1

Bolivia

44

102

Cameroon

44

103

Uganda44

10 4

Brazil44

105

Malawi

44

106

Bangladesh

43

107

Mali

42

108

Ivory Coast

42

109

India

41

11 0

Sierra Leone

41

111

Iraq

41

112

Guinea

41

11 3

Gabon

40

11 4

Peru

40

11 5

Ecuador

40

11 6

Benin

40

117

Togo

40

118

Lebanon40

11 9

Türkiye40

1 20

Venezuela

39

1 21

Republic of the Congo

38

122

Afghanistan

22

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AP P E N DI X 1

About the 2021 Hologic Global
Women’s Health Index

The goal of the Hologic Global Women’s Health Index is to contribute to extending the life expectancy of womenaround the world and improving their quality of life. The ultimate outcome of the partnership with Gallup is to create
a global measure to track progress in key aspects of women’s health and well-being that informs change to improve
women’s health in the future.
The Gallup World Poll has collected data since 2005 in more than 160 countries and territories and over 140
languages. To consistently and accurately collect data on the same indicators from a wide range of respondents
in different countries and territories, questions are rigorously tested to ensure clarity and precision so that they areeasily translated, well understood and interpreted across cultures.

Why an Index?
An Index provides the opportunity to summarize the multidimensional construct we are measuring —factors contributing to women’s health — in an easy-to-interpret way. This produces a tool to assess
progress over time and captures the interest of both the public and policymakers. This means that it will beeasier to communicate complex ideas and promote accountability.
It is important to clearly communicate what the Index captures to not oversimplify complex issues andtopics and to avoid overstating policy conclusions. We are transparent with our methodology and what theIndex does and does not measure, including the weighting process used to combine the variables.

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Development of the Hologic Global Women’s Health Index
1

Theoretical framework development

In consultation with a wide and growing list of experts,
Hologic and Gallup set out to understand which key
metrics would be most salient to a women-reported
Index of health at the national level.
The World Health Organization (WHO) listed the top
10 issues for women’s health 20 years after countries
signed pledges in the 1995 Beijing Declaration andPlatform for Action, adding that women still face many
health problems, which we must recommit to address(Bustreo, 2015).
These included:• cancer• reproductive health• maternal health• HIV• sexually transmitted diseases (STDs) and sexuallytransmitted infections (STIs)• violence against women• mental health• noncommunicable diseases• age-related issues (teenage pregnancies; older

women may have fewer pensions and benefits,less access to healthcare and social services, andgreater risk of poverty, compounded by the morewidespread health challenges associated with
old age)

An additional list put forth by the WHO in 2020 indicates
top health checks for women, which include: bloodpressure, blood glucose tests, body mass index, bonedensity screening, breast cancer detection, colon cancer
detection, dental checkups, lipid profile checks andscreening for cervical cancer (Pap smears and HPV
testing) (WHO, 2020).

While not all of these issues can accurately be measured
in a non-epidemiological social science survey, they
convey that women’s health is a combination of physical,
social, economic and political factors (culture, poverty,
discrimination, violence, system of provision of healthservices, geographical location, etc.).
This process of working with experts and existingknowledge sources identified three key objectivesof the survey:
1) Capture knowledge, attitudes and behaviors(KAB model) related to health, which is a common
framework for health surveys across many culturesand languages (Bhattacharya et al., 2018; Fan etal., 2018; Mustafa et al., 2008; Okobia et al., 2006;
Zhang et al., 2020).
2) Focus on female-specific health issues:a. prenatal health, pregnancy and deliveryb. health consequences of gender-based
violence: sexual and physical violencec. increasingly common causes of death:heart and lung disease, cervical, lung andbreast cancer, and obesityd. aging-related and noncommunicablediseases, which are increasing while
infectious diseases are decreasing —making preventive care essential
3) Bring attention to actionable areas to increase

female longevity:a. increasing years of education to improve thelife expectancy, independence and earning
power of womenb. reducing domestic violence, sexual assault
and femicidec. diagnosing conditions early so they are
effectively treated and having services toprovide care on an ongoing basisd. decreasing neonatal and infant mortality, as
well as maternal mortality

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2

Indicator and data selection

The Gallup World Poll already includes items that cover general health and quality of life, opinions of general health,safety and victimization, food and shelter insecurity, and emotional health and well-being. Because the Gallup World
Poll creates nationally representative samples in each country, the survey is intended for both male and female
respondents. Accordingly, the survey questions should be as broadly applicable as possible.
Building on these existing items, Gallup and Hologic developed the following module to field starting in 2020.
These items were cognitively tested in seven countries: Nigeria (Yoruba and English), Kyrgyzstan (Russian), Vietnam(Vietnamese), United States (English), United Kingdom (English), Peru (Spanish) and Tunisia (Arabic). This process
helped refine the final survey questionnaire and ensured that questions are well interpreted and understood acrossdifferent countries, cultures and languages.
These questions are also discussed in greater detail in the subsequent section.

Hologic Survey Module Included in the Gallup World Poll
Topic

Question

Why It Matters

Value ofpreventive care

• Do you think going to a healthcare

Knowledge and attitudes toward preventive healthcare
are the first two dimensions of “knowledge, attitudes andbehaviors theory” (KAB). KAB is a health behavior theory ofchange wherein the change in human behavior is divided into
three successive processes, namely, acquisition of the rightknowledge, generation of attitudes and adoption of behaviors(or practices) (Bhattacharya et al., 2018; Fan et al., 2018; Mustafa
et al., 2008; Okobia et al., 2006; Zhang et al., 2020).

Experience ofpreventive care

• In the past 12 months, have

Knowledge and attitudes need to lead to concrete behaviors,
which are shaped by individual and social barriers.

• To the best of your knowledge,• Heart disease is the leading cause of death in both men andprofessional, such as a medical
doctor or a nurse, at least once
every 12 months for a checkup,
can help people improve theirhealth, or not?

you talked to a healthcare
professional, such as a medical
doctor or nurse, about yourown health?

were you tested for any of thefollowing in the past 12 months?
[High blood pressure, cancer,
diabetes, STDs/STIs]?

women (CDC, 2020b).

• Men and women are susceptible to different types of cancer,
and testing is crucial to early diagnosis and increasing theodds of successful treatment (CDC, 2020a).

• Obesity and diabetes-related diseases are a growing concern
around the world and are associated with heart disease, as
well as increased incidence of certain cancers (CDC, 2021b).

• STDs/STIs have an outsized impact on women’s reproductive
health and fertility (compared to men) (CDC, 2021a).

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TopicQuestion

Why It Matters

Prenatal care

• Do you think most pregnant

Perceptions of the quality of prenatal care are lacking in
global statistics — a critical dimension of women’s healthcare
experiences throughout their lives.

• How many children do you,

A woman’s age of first pregnancy and number of children havea strong relationship with years of education, employability,
household income, time available to manage personal health,mental health, etc. (PRB, 2011; UNFPA, 2021; UNICEF, 2021;
World Bank, 2021).

women in the city or area where
you live receive high-quality
healthcare during theirpregnancies, or not?

Pregnancy

personally, have?

• How old were you the first time
you were pregnant?

Domestic violence87

Now I would like to ask you aquestion regarding domestic
violence. Domestic violence can bephysical, psychological, or involve
sexual acts done to someone
against their will by a person they
live with. In your opinion, is domestic
violence a widespread problem in[country name], or not?

The Hologic Global Women’s Health Index | Global Report

Perceptions of widespread domestic violence can vary
for different groups (e.g., men vs. women). In addition, thepsychological burden of believing domestic violence iswidespread could be tied to negative well-being outcomes.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix1_072522_kn

Value of Preventive Care
Do you think going to a healthcare professional, such as a medical doctor or a nurse, at least once every
12 months for a checkup, can help people improve their health, or not?

Rationale
Preventive health screenings and yearly primary care consultations have been found to significantly increase life expectancy,
particularly among the 30- to 75-year-old age group, but recommendations vary greatly depending on the disease, level ofresources in the community and gender.
The framing of this item specifically addresses people’s knowledge and attitudes (“do you think”) toward preventive care andprovides a specific time frame (“at least once every 12 months”) to aid with recall.
The question is also framed neutrally and the final clause “or not” allows respondents to answer based on personal opinions,
reducing the chance of social desirability bias as much as possible. This framing may appear odd in English, but Gallup has foundit to be highly successful in reducing acquiescence bias, especially in other languages.

Implications• Inform where preventive care is not occurring systematically.
• Earlier detection of chronic illnesses and deadly diseases helps decrease mortality rates. Many of the top risk factors leading
to illness and premature death can be prevented.

• Reduced medical expense through early detection.
Experience of Preventive CareIn the past 12 months, have you talked to a healthcare professional, such as a medical doctor or nurse,
about your own health?

Rationale
This item is a follow-up to the previous question about knowledge and attitudes and seeks to uncover whether respondents havetaken action to seek annual preventive care (behavior or practice).
The concept of a visit to a healthcare professional is described in simple and broad terms (“have you talked to a healthcare
professional […] about your own health”) to capture unscheduled, informal consultations as well as annual health examinations.
The question echoes the specific timeframe used in the previous question (“the past 12 months”) to aid with recall and yield more
precise responses.
The question also defines who is considered a medical professional. In some countries, a nurse may be considered “less than”
a doctor and therefore their checkup and medical advice could be given less credence. Specifying who is considered a medical
professional also helps eliminate any informal sources of health advice, such as local healers or family members credited withhealth knowledge, especially in countries with less access to medical infrastructure.

Implications• Highlight potential differences and service inequities between populations.
• Educate the public regarding personal care behaviors.

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Experience of Preventive Care (continued)
To the best of your knowledge, were you tested for any of the following in the past 12 months? [High bloodpressure, cancer, diabetes, STDs/STIs]?

Rationale
The framing of this question lets us survey participants on four different issues using a common stem, which makes the overall
time involved in asking the questions shorter and allows respondents to move through the battery quickly, reducing the overall
cognitive burden of the survey.
The item is being framed as a yes/no question to simplify the process of answering.
In addition, the inclusion of STDs/STIs — a highly sensitive topic — occurs at the end of the list to allow respondents to gain
confidence in answering questions about less sensitive diseases before disclosing their answer.
The question provides a specific timeframe to aid with recall and precision in the responses.
The diseases themselves are described in the simplest terms possible and translated into local languages using the commonlyused terminology.
Following the question about discussing health with a healthcare professional, the four types of specific screenings were chosenbecause they include the most frequent, fastest-growing and/or most damaging diseases for women:• Heart disease is the leading cause of death in both men and women (CDC, 2020b).
• Cancer is the second-leading cause of death globally and was responsible for an estimated 10 million deaths in 2020.
Globally, about one in six deaths is due to cancer (CDC, 2020a; WHO, 2021c).

• Obesity and diabetes-related diseases are a growing concern around the world and are associated with heart disease, as
well as increased incidence of certain cancers (CDC, 2021b; WHO, 2021b, 2021).

• STDs/STIs have an outsized, potentially devastating impact on women’s reproductive health and fertility (compared with men)
(CDC, 2021a).

Implications• Earlier detection of chronic illnesses and deadly diseases helps decrease mortality rates.
• Underscores the importance of understanding the role of annual screenings in improving health and curtailing expenses.
• The COVID-19 pandemic may have an amplifier effect on already worrying trends:- Between 2000 and 2016, there was a 5% increase in premature mortality from diabetes (WHO, 2021).
- Diabetes is one of the fastest-growing health challenges of the 21st century, with the number of adults living withdiabetes having more than tripled over the past 20 years (IDF, 2019).

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Maternal Care
Do you think most pregnant women in the city or area where you live receive high-quality healthcare
during their pregnancies, or not?

Rationale
Perceptions of the quality of maternal care are lacking in global statistics. This item is inviting an opinion of prenatal care based on
personal experience and knowledge of local institutions.
The geographical delimitation to the local vicinity (“city or area where you live”) helps respondents express an opinion more
confidently since they are more likely to know about the situation locally rather than in their region or country.
By asking about “most pregnant women,” respondents are encouraged to consider a broad majority of women, regardless of theirsocioeconomic status and beyond their own social circle.

Implications• Most maternal deaths are preventable with timely management by a skilled healthcare professional working in a supportive
environment (WHO, 2021a).

• Every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth. Ninety-fourpercent of all maternal deaths occur in low- and lower-middle income countries (WHO, 2019).

• Maternal conditions are the top cause of mortality among girls aged 15 to 19 globally (UNICEF, 2021). Adolescent pregnancy iscommon and high risk for the neonate and mother.

Pregnancy
How many children do you, personally, have?
How old were you the first time you were pregnant? [Question only asked of female respondents who
said they had children in the previous question.]

Rationale
A lot can be learned about a woman and her socioeconomic status through her age at her first pregnancy and her number ofchildren. A woman’s age at first pregnancy and number of children can impact her overall health, number of years of education,
employability, household income, time available to manage personal health and mental health. (PRB, 2011; UNFPA, 2021; UNICEF,
2021; WHO, 2020; World Bank, 2021).
Notably, the question about the age at first pregnancy is the only question asked only of women in the survey as part of theHologic survey module.
The questions are extremely simple, allowing respondents to answer accurately and easily.

Implications• Adolescent mothers (aged 10 to 19 years) face higher risks of eclampsia, puerperal endometritis and systemic infections than
women aged 20 to 24 years, and babies of adolescent mothers face higher risks of low birth weight, preterm delivery andsevere neonatal conditions (UNFPA, 2021; WHO, 2020).

• Adolescent pregnancy takes an enormous toll on a girl’s education and income-earning potential and longevity. Many girls
who become pregnant are pressured or forced to drop out of school. Leaving school jeopardizes a girl’s future economic
prospects and excludes her from other opportunities in life (UNFPA, 2021).

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Domestic Violence
Now I would like to ask you a question regarding domestic violence. Domestic violence can be physical,
psychological, or involve sexual acts done to someone against their will by a person they live with.
In your opinion, is domestic violence a widespread problem in [country name], or not?

Rationale
Domestic violence has dramatic health and safety consequences for women of all socioeconomic backgrounds around theworld. The belief that domestic violence is widespread and thus negatively affects health and safety could potentially lead to thedeconstruction of harmful norms, such as victim-blaming, and could optimistically lead to a cultural awakening, as seen during the#MeToo movement. Cultural movements and grassroots initiatives focusing on domestic violence can be strong forces in callingfor social and legislative change, putting pressure on leaders to act.
This question allows respondents to express their view on the incidence of domestic violence without having to discuss their own
victimization or that of loved ones.
The item intentionally asks how “widespread” the problem is, rather than how “serious” or “important,” given that the question ofgravity elicited high levels of agreement due to desirability bias during cognitive testing.
Answers to this question framed at the national level may be based on personal contact with domestic abusers and survivors, butalso on awareness of the national debate on the issue.

Implications• Domestic violence against women is a major public health and education problem globally and can damage physical, mental
and financial well-being (UNFPA, 2021; UNHCR, 2021; WHO, 2021d; World Bank, 2019).

• Across their lifetime, one in three women — around 736 million — are subjected to physical or sexual violence by an

intimate partner or sexual violence from a non-partner, a number that has remained largely unchanged over the past decade(WHO, 2021).

• The WHO lists a series of commitments countries can honor to reduce violence against women and girls:- sound gender transformative policies, from policies on childcare to equal pay, and laws that support gender equality- a strengthened health system response that ensures access to survivor-centered care and referral to other services
as needed- school and educational interventions to challenge discriminatory attitudes and beliefs, including comprehensive
sexuality education- a targeted investment in sustainable and effective evidence-based prevention strategies at local, national, regional andglobal levels- strengthening data collection and investing in high-quality surveys on violence against women and improving

measurement of the different forms of violence experienced by women, including those who are most marginalized(WHO, 2021)• The provision of assistance, including in humanitarian settings and to mitigate secondary impacts of the COVID-19 pandemic,
such as food insecurity and gender-based violence (National Security Directive (sec 2. (b)(iii)(B))).

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Determining the Dimensions of Health and Calculating the Hologic
Global Women’s Health Index
Approaching analysis in Year 2 of the Index
In the second year of fielding the Index, researchers replicated the process to test for robustness in the Year 1
analysis and to confirm that the assumptions from Year 1 remained true. We found that assumptions remained valid,
and the process of calculating the Index is described in more detail in the following sections.
The Year 2 analysis result shows that:• All the selected variables used for Index creation cluster in the same way as Year 1. That is, the Year 2 Index ismade up of the same five sub-indexes and each sub-index includes the same elements as Year 1.

• The weights associated with each dimension calculated based on Year 2 data are within 2% from theircorresponding values of Year 1. The changes are minor, allowing one to directly compare the Index score
between Year 1 and Year 2.

Factor analysis
The Gallup and Hologic research team initially hypothesized that 18 items would be usable for the Index.

Items Considered for Inclusion in the Hologic Global Women’s Health Index92
Topic

Question

Attitudes andbehaviors regarding
preventive care

• Do you think going to a healthcare professional, such as a medical doctor or a nurse, at least once
every 12 months for a checkup, can help people improve their health, or not?

• In the past 12 months, have you talked to a healthcare professional, such as a medical doctor or
nurse, about your own health?

• To the best of your knowledge, were you tested for any of the following in the past 12 months?
[High blood pressure, cancer, diabetes, STDs/STIs]?

Domestic violence• Now I would like to ask you a question regarding domestic violence. Domestic violence can bephysical, psychological, or involve sexual acts done to someone against their will by a person they
live with. In your opinion, is domestic violence a widespread problem in [country name], or not?

• Do you feel safe walking alone at night in the city or area where you live?
Access to quality
maternal care andpersonal experienceof childbirth• Do you think most pregnant women in the city or area where you live receive high-quality healthcare

General quality
healthcare access• In the city or area where you live, are you satisfied or dissatisfied with the availability of quality

during their pregnancies, or not?

• How many children do you, personally, have?
• How old were you the first time you were pregnant?

healthcare?

92 Items marked in blue are from the Hologic World Poll module in 2020. All other items are Gallup historical items collected since 2005.

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TopicQuestion

Food and shelter
accessibility• Have there been times in the past 12 months when you did not have enough money to buy food thatyou or your family needed?

• Have there been times in the past 12 months when you did not have enough money to provide
adequate shelter or housing for you and your family?

Overall health(quality of life,
daily pain levels)• Do you have any health problems that prevent you from doing any of the things people your age

Emotional
well-being issues• Did you experience the following feelings during a lot of the day yesterday? How about worry?
• Did you experience the following feelings during a lot of the day yesterday? How about sadness?
• Did you experience the following feelings during a lot of the day yesterday? How about stress?
• Did you experience the following feelings during a lot of the day yesterday? How about anger?
• Life Evaluation Index (Struggling, Suffering, Thriving)normally can do?

• Did you experience the following feelings during a lot of the day yesterday? How about
physical pain?

In preparation for running a factor analysis of the listed items, the following two tests were used to check correlationand sampling adequacy:• Bartlett Test: If the p-value is less than 0.05, this shows the significance of the test and indicates a factor analysis
may be useful for our dataset.

• Kaiser-Meyer-Olkin Test: If the test score is above 0.8, it indicates the sample is adequate for factor analysis.
Tetrachoric correlation (instead of Pearson’s correlation) was used to measure the association between variables
since all variables are binary.

• After testing, the following variables were dropped:- Two items — the questions about the number of children and age of first pregnancy — were excluded due toscaling and issues with directionality.

- The question regarding whether going to a healthcare professional improves health was excluded due tolow variance (87% of women globally answered in the affirmative).

Researchers then used factor analysis to determine which factors emerged and which items were mosthighly loaded.

• Factor analysis is limited to female respondents only since we are trying to predict the health and safety statusof women, rather than the general population. Female cases without missing values in the selected items were
included in the analysis.

• Before running factor analysis, many of the variables were recoded.
• The question regarding domestic violence and the Life Evaluation Index were dropped due to not being highly
loaded (with factor loadings above 0.4) on any factor.

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A statistically good factor analysis solution was achieved by setting the number of factors to five and using “Varimax”
rotation (orthogonal). The eigenvalues of all five factors are greater than one. The eigenvalue is used to measure
the amount of variance of variables that a factor explains. The logic is that only factors that explain at least the sameamount of variance as a single variable are worth keeping.

• Factor 1 is about preventive care, including having been tested for high blood pressure, cancer, diabetes
and STDs/STIs.

• Factor 2 is about emotional issues, including experiencing worry, sadness, stress and anger for a lot of the dayprior (all items reverse scored).

• Factor 3 is about health and safety, including receiving high-quality care during pregnancy, satisfaction withquality healthcare in general and feeling safe walking alone at night.

• Factor 4 is about basic needs, including having trouble affording food and shelter in the past 12 months (all items
reverse scored).

• Factor 5 is about individual health, including having health problems and experiencing pain for a lot of the dayprior (all items reverse scored).

The extracted five factors explain 61.4% of the total variance of the selected items for Year 1.

3

Missing data

Given the global nature of the Gallup World Poll, all national surveys are subject to the relevant government
approvals and restrictions.
The following exclusions apply:• Saudi Arabia: Values are missing for the question regarding testing for STDs/STIs.
• Iran: Values are missing for the question regarding testing for STDs/STIs.
To achieve a valid score, a respondent needs to answer “Yes” or “No” to at least three of the four items for factor 1,
three of the four items for factor 2, two of the three items for factor 3, two of the three items for factor 4 and two of
the two items for factor 5.

4

Rounding

The numbers in the Hologic Global Women’s Health Index use many observations and are calculated first to theinfinite decimal place. Then, to display the scores, they are rounded to the nearest whole number.

• To calculate a country’s rank, Hologic and Gallup researchers use the full score with multiple digits to avoid ties.
- If two countries have a score of 56 but one is 56.1 and one is 56.4, the country with 56.4 has a higher rank.
• However, to calculate change the standard way, scores are rounded first, then subtracted.
- If a country has a rounded final score of 54 in 2020 and a score of 52 in 2021, the change will be 54-52,
or a decrease of 2.

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Differences in Countries Surveyed in 2021
Additionally, in 2021 there were differences in the countries that were surveyed. The differences are listed in thefollowing table.
Year Wave

Global Coverage

Number of Countries

2020

93%

116

New Countries

Less Countries

Baseline

Baseline

Afghanistan

Montenegro

Armenia

Bahrain

Honduras

Ethiopia

Malawi

2021

94%

122

Mozambique
PanamaSierra Leone
Singapore
Togo

Countries Included in the 2021 Hologic Global Women’s Health Index

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5Weighting and aggregation approach

Each sub-index score is calculated for each factor by taking the simple average of its corresponding recoded
items. The Hologic Global Women’s Health Index score is calculated by taking a weighted sum of the five sub-index
scores, with weights proportional to each factor’s eigenvalue (amount of variance of variables that a factor explains).
The weights are shown in Figure 1.
FIGURE 1:

Index Weights Based on Eigenvalues
1.0

0.12

0.9

0.15
0.8

0.16

0.7

0.6

0.28

0.5

0.4

0.3

0.29
0.2

0.1

0.0
Preventive Care

96

Emotional Health

Opinions of
Health and Safety

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6Data normalization

Variables were recoded for inclusion in the Hologic Global Women’s Health Index as follows:
For a list of variable codes, please see Section 9: Survey module.

• TEST_FOR_HBP: set to 1 if H4A. = 1, 0 if H4A. = 2 OR H3. = 2, NA for any other value.
• TEST_FOR_CANCER: set to 1 if H4B. = 1, 0 if H4B. = 2 OR H3. = 2, NA for any other value.
• TEST_FOR_DIABETES: set to 1 if H4C. = 1, 0 if H4C. = 2 OR H3. = 2, NA for any other value.
• TEST_FOR_STD: set to 1 if H4D. = 1, 0 if H4D. = 2 OR H3. = 2, NA for any other value.
• WORRY_REVERSE: set to 1 if WP69 = 2, 0 if WP69 = 1, NA for any other value.
• SADNESS_REVERSE: set to 1 if WP70 = 2, 0 if WP70 = 1, NA for any other value.
• STRESS_REVERSE: set to 1 if WP71 = 2, 0 if WP71 = 1, NA for any other value.
• ANGER_REVERSE: set to 1 if WP74 = 2, 0 if WP74 = 1, NA for any other value.
• WELL_RESTED: set to 1 if WP60 = 1, 0 if WP60 = 2, NA for any other value.
• TREATED_WITH_RESPECT: set to 1 if WP61 = 1, 0 if WP61 = 2, NA for any other value.
• SMILE_LAUGH: set to 1 if WP63 = 1, 0 if WP63 = 2, NA for any other value.
• LEARN_SOMETHING: set to 1 if WP65 = 1, 0 if WP65 = 2, NA for any other value.
• ENJOYMENT: set to 1 if WP67 = 1, 0 if WP67 = 2, NA for any other value.
• PREGNANT_HEALTHCARE: set to 1 if H2. = 1, 0 if H2. = 2, NA for any other value.
• QUALITY_HEALTHCARE: set to 1 if WP97 = 1, 0 if WP97 = 2, NA for any other value.
• SAFE_NIGHT_WALKING: set to 1 if WP113 = 1, 0 if WP113 = 2, NA for any other value.
• NO_FOOD_REVERSE: set to 1 if WP40 = 2, 0 if WP40 = 1, NA for any other value.
• NO_SHELTER_REVERSE: set to 1 if WP43 = 2, 0 if WP43 = 1, NA for any other value.
• HEALTH_PROBLEM_REVERSE: set to 1 if WP23 = 2, 0 if WP23 = 1, NA for any other value.
• PHYSICAL_PAIN_REVERSE: set to 1 if WP68 = 2, 0 if WP68 = 1, NA for any other value.
• CHECKUP_IMPROVE_HEALTH: set to 1 if H1. = 1, 0 if H1. = 2, NA for any other value.
• DOMESTIC_VIOLENCE: set to 1 if H7. = 1, 0 if H7. = 2, NA for any other value.
• LIFE_THRIVING: set to 1 if INDEX_LE = “Thriving”, 0 if INDEX_LE = “Struggling” or “Suffering”, NA for any other value.

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7Multivariate analysis

To understand the interactions of the individual dimensions and their relationship to health outcomes, the Gallup andHologic research team ran correlations among the variables and regression analysis using life expectancy as thedependent variable.
Correlations reveal low collinearity between the individual dimensions. In addition, all the dimensions and GDP 2019are relatively highly correlated with the life expectancy of women.
The regression analysis reveals that the five factors of the Hologic Global Women’s Health Index explain 86% of thefemale life expectancy at birth at the country level.

Basic Needs

GDP Per Capita

Female Life Expectancy at Birth

Preventive Care

Individual Health

Emotional Health

Opinions of Health and Safety

Correlation Table

Hologic Global Women's Health Index 2021

FIGURE 2:

1.0

Opinions of Health and Safety

0.8
Emotional Health

0.6
0.4

Individual Health0.2

Preventive Care

0.0
Female Life Expectancy at Birth

-0.2
-0.4

GDP Per Capita

Hologic Global Women's Health Index 2021

-0.6
-0.8

Basic Needs

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Regression Analysis
Call: lm(formula = Life_expectancy_at_birth_years_Female ~ Preventive Care + Emotional Health +Opinions on Health and Safety + Basic Needs + Individual Health, data = df_sub, weights = df_sub$weight)
Dependent variable: Female life expectancy at birth
Regression output for female life expectancy at birth
Variable

p-value

Coefficient

Preventive Care

(3.843)13.265***

Emotional Health(5.671)-26.255***

Opinions of Health and Safety(3.095)0.585

Basic Needs(2.890)17.313***

Individual Health(4.927)20.681***

Constant(1.529)64.134***

Observations = 119
R2 = 0.803
Adjusted R2 = 0.795
Residual Std. Error = 5,697,204.000 (df = 113)
F Statistic = 92.335*** (df = 5; 113)
Note: *p<0.1; **p<0.05; ***p<0.01

8Relationship with other measures

Adding to the relationships that the Hologic Global Women’s Health Index has with a woman’s life expectancy atbirth, as well as a country’s GDP per capita, researchers tested the following Sustainable Development Goals (SDGs):• SDG 1.1
- population pushed below a relative poverty line by household health expenditures(60% of median daily per capita consumption or income) (%)• SDG 2.2
- prevalence of anemia in pregnant women (aged 15 to 49) (%)• SDG 3.1.1- maternal mortality ratio (MMR) (per 100,000 live births)• SDG 3.1.2- births attended by skilled health personnel (%)• SDG 3.8.1- universal health service coverage (UHC)• SDG 5.2
- proportion of ever-partnered women and girls aged 15 to 49 years subjected to physical and/or sexual
violence by a current or former intimate partner in the previous 12 months- proportion of ever-partnered women and girls aged 15 to 49 years subjected to physical and/or sexual
violence by a current or former intimate partner in their lifetime99

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FIGURE 3:

Pearson Correlation Coefficients
Dark Magenta = Strong Negative Relationship (-0.7 to -1)
Light Magenta = Negative Relationship (-.3 to -.7)
Light Teal = Positive Relationship (.3 to .7)

Individual 2021

Healthcare Professional(12 month)

Domestic Violence

Access to HQ Pregnancy
Healthcare

High = Bad

Basic 2021

_

0.68

0.44

0.24

0.46

0.77

0.50

0.65

0.20

0.41

-0.23

-0.15

-0.23

-0.18

-0.08

-0.27

-0.17

-0.01

-0.20

SDG 2.2(anemia in pregnancy)

_

-0.64

-0.56

-0.24

-0.32

-0.69

-0.48

-0.69

-0.31

-0.28

SDG 3.1.1
(MMR)

_

-0.59

-0.36

-0.30

-0.38

-0.63

-0.41

-0.52

-0.10

-0.28

SDG 3.1.2(skilled health at birth)

+

0.53

0.43

0.25

0.24

0.58

0.38

0.51

0.20

0.17

SDG 3.8.1
(UHC)

+

0.72

0.47

0.33

0.46

0.75

0.58

0.67

0.17

0.43

_

-0.69

-0.32

-0.41

-0.52

-0.71

-0.47

-0.53

-0.09

-0.45

_

-0.54

-0.10

-0.42

-0.43

-0.55

-0.40

-0.32

0.05

-0.34

SDG 5.2(domestic violence
past 12 months)
SDG 5.2(domestic violence
lifetime)

100

High = Good

Opinions 2021

SDG 1.1(poverty from health)+Emotional 2021

Female Life
Expectancy at Birth

Preventive 2021

Predicted
RelationshipWith Women’s
HealthHGWHI 2021

Dark Teal = Strong Positive Relationship (.7 to 1)

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9Additional analysis

Going to a Healthcare Professional
As a part of the module on attitudes and behaviors regarding preventive care, Hologic and Gallup asked women
globally the question:“In the past 12 months, have you talked to a healthcare professional, such as a medical doctor or nurse,
about your own health?”
This question measures whether a woman has seen or spoken to a healthcare professional in the last year.
Annual visits with a healthcare professional are sometimes referred to as physicals, annuals, wellness visits,
preventive visits, health evaluations or general medical examinations. Annual visits to a healthcare professional are
standard recommendations for individuals over the age of 65 (Jin, 2022). While there is a debate between academics
and medical professionals about the recommendation that every individual should go to a healthcare professional
annually, most sources agree that people younger than age 65 should go to a healthcare professional every one
to three years, and that after age 65 it is best to do so annually (ODPHP, 2021; WHA, 2022; Neumann et al., 2009;
Gee, 2012).
As an example, in the United States, the Office of Disease Prevention and Health Promotion (ODPHP) recommends
an annual appointment with a healthcare professional. Likewise, Australian health services declare women shouldschedule routine health checks (Department of Health AUS).
The argument for going to a healthcare professional annually, even when an individual is well, boils down tothree categories:• Preventive medicine: Routine medical visits lead to early detection of disease.
- detection- early treatment- up to date with vaccines• Education: The value of spending time with a trusted healthcare professional is that it can empower women to
maintain a healthy lifestyle.

- ability — knowing how to live a healthy lifestyle- ownership — having enough information to make informed decisions about health• Relationship with a healthcare professional: Building a trusted relationship with a healthcare professional canmake it easier for people to share sensitive but important information in the future.

- trust between patient and healthcare professional- healthcare professional’s understanding of patient’s family history and health background- healthcare professional is better equipped to notice changes and monitor health101

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Bottom Line: The argument for routine general health checks is associated with increased chronic
disease recognition and treatment, risk factor control, preventive service uptake, and improved
patient-reported outcomes.
However, never has there been a globally representative study of the relationship between women going to ahealthcare professional and its association with other country economic indicators like GDP per capita and life
expectancy at birth, as well as significant predictors of a woman’s life, such as her income, her ability to meet her
basic needs and her individual health.
Gallup and Hologic tested two hypotheses:• Hypothesis 1: At the country level, when more women (per 100) go to a healthcare professional annually, thatcountry also has better health outcomes measured by life expectancy at birth.

• Hypothesis 2: Individual-level indicators of a woman’s basic needs (measured by her ability to afford food andshelter), her individual health (measured by experienced health problems and pain), and her access to quality
healthcare (measured by high-quality pregnancy care in her area) are also related to the likelihood that she
would have been to a healthcare professional in the past 12 months.

PART 1:
Researchers at Gallup and Hologic tested this hypothesis by running a country-level regression:
Going to a healthcare professional is related to a woman’s life expectancy at birth.
Call: lm(formula = Female Life Expectancy ~ Go to HCP + GDPpc, data = dataframe)
Residuals:
Min

1Q

Median3QMax-2.1428

0.49392.71908.3049Estimate

Std. Errort value

Pr (>|t|)(Intercept)

6.363e+01

1.941e+00

32.778<2e-16 ***Went to healthcare professional

1.727e+01

3.222e+00

5.361

4.32e-07***

GDP per capita

1.365e-04

2.622e-05

5.207

8.49e-07***-11.3803
Coefficients:

Signif. codes: 0 ‘***’ 0.001 ‘**’ 0.01 ‘*’ 0.05 ‘.’ 0.1 ‘ ’ 1
Residual standard error: 4.577 on 115 degrees of freedom (4 observations deleted due to missingness)
Multiple R-squared: 0.5338, Adjusted R-squared: 0.5256
F-statistic: 65.83 on 2 and 115 DF, p-value: <2.2e-16
As a note: We are limited by the data publicly available — Gallup researchers used the WHO’s most recent estimate,which is from 2019 (over time, the average life expectancy variable is stable and is a slow-moving measure) and does
not have country/region estimates for Taiwan, Hong Kong or Kosovo.

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To further test this hypothesis, researchers compared the means of the WHO projected life expectancy for women
who said they went to a healthcare professional in the past 12 months with women who said they did not go to ahealthcare professional. Any answers of “don’t know” or “refused” were excluded from the analysis.
In 2021, the weighted average life expectancy at birth for women who answered “yes” to going to a healthcare
professional was 77.7 years, while the weighted average for women who answered “no” was 75.6 years. When
women are included from both the 2020 and 2021 surveys, the results were very similar: 77.8 vs. 75.8. With an nsize of 126,085, this is a significant difference (using a design-based t-test to test the difference in means) with ap-value <0.001.
Design-based t-test
data: WHO_F_LE_At_Birth ~ as.factor (Go_Doc)t = 31.289, df = 242045, p-value < 2.2e-16
Alternative hypothesis: true difference in mean is not equal to 0
95 percent confidence interval: 1.683989 1.909062
Sample estimates: difference in mean 1.796526

PART 2:
Logistic regression:
Dependent variable: Did a woman go to a healthcare professional in the last 12 months?
Across both years, about two in three women went to a healthcare professional in the past 12 months.
Using two years of data collected in over 120 countries with more than 1 million women, researchers ran a logistic
regression to see how a certain factor of having enough money for food and shelter, a woman’s opinions of heraccess to high-quality pregnancy care, as well as her individual experiences of health problems and pain, relate to
the likelihood that a woman had been to a healthcare professional in the last 12 months.
Dependent variable: Went to a healthcare professional in the past 12 months
Variable

Odds Ratio

t-value

GDP per capita

1.00

t = 39.002***

Have enough money for food

1.290

t = 15.956***

Have enough money for shelter

1.106

t = 6.104***

High-quality pregnancy care

1.482

t = 27.944***

Have a health problem

1.656

t = 28.697***

Feel pain ‘yesterday’

1.238

t = 14.153***

Constant

0.872

t = -8.285***

Observations = 112,313
Log Likelihood = -67,319.720
Akaike Inf. Crit = 134,653.400
Note: *p<0.1; **p<0.05; ***p<0.01

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Controlling for the country a woman lives in and GDP per capita, Gallup researchers found there was a significant
relationship between our predictor variables and a woman going to a healthcare professional.
The model itself had a good fit — with the Chi-squared probability < 0.001.
Independent variables (odds ratio and their 95% confidence intervals):• Access to food (OR = 1.290, 95% CI [1.25 - 1.33]) (***Controlling for her country’s GDP per capita — which had

another significant relationship): If a woman has enough money to access food, she is 1.29 times (29%) more
likely to have been to a healthcare professional.

• Access to shelter (OR = 1.106, 95% CI [1.07 - 1.14]) (***Controlling for her country’s GDP per capita — which had

another significant relationship): When a woman has enough money to access shelter, she is 1.11 times (11%) more
likely to have been to a healthcare professional.

• Access to high-quality pregnancy care (OR = 1.482, 95% CI = [1.44 - 1.52]): When a woman believes that she hasaccess to high-quality pregnancy care, she is about 1.48 times (48%) more likely to have been to a healthcare
professional in the past 12 months.

• Pain (OR = 1.238, 95% CI = [ 1.20 - 1.28]): When a woman answers that she experienced pain a lot of the day
before, she is 1.23 times (23%) more likely to have been to a healthcare professional in the past 12 months.

• Health problems (OR = 1.244, CI = [1.60 - 1.71]): When a woman has health problems that prevent her from doing

things people her age usually do, she is 1.244 times (24%) more likely to have been to a healthcare professionalin the past 12 months.

Analysis Discussion and Implications
The analysis of the relationship between going to a healthcare professional in the past year and country-level life
expectancy at birth picks up a bi-directional relationship that reflects the complexities of the health of an individual.
Life expectancy at birth is closely related to each individual dimension of health that the Hologic Global Women’s
Health Index measures and going to a healthcare professional is also related to the dimensions. For example,
researchers found within the dimension of Basic Needs, women who are able to afford food for themselves andtheir families are more likely to have been to a healthcare professional by 29 percentage points. The ability toafford food is also positively associated with longer life expectancy at birth. This analysis does not disentangle
these associations.
Additionally, macro-economic factors relate to both a woman’s life expectancy at birth and her likelihood of having
been to a healthcare professional. Researchers found that women who go to a healthcare professional have thepotential for better life expectancy outcomes, even when accounting for country-level GDP per capita. At the sametime, we see a significant relationship between going to a healthcare professional annually and a country’s GDP
per capita. It is important to understand that there are many layers in the analysis that relate to a woman going to ahealthcare professional as well as her country’s life expectancy at birth. Many of the layers also interact with each of
the other dimensions of health. Hologic and Gallup will continue to explore this relationship, both in 2020 and 2021
data and as they collect data in future years.

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10Survey module

H1	Do you think going to a healthcare professional, such as a medical doctor or a nurse, atleast once every 12 months for a checkup, can help people improve their health, or not?
Yes

No

(DK)

(Refused)

1

2

8

9

H2	Do you think most pregnant women in the city or area where you live receive high-quality
healthcare during their pregnancies, or not?
Yes

No

(DK)

(Refused)

1

2

8

9

H3	In the past 12 months, have you talked to a healthcare professional, such as a medical
doctor or nurse, about your own health?
Yes

No

(DK)

(Refused)

1

2

8

9

(If code 1 in H3., Continue;
Otherwise, Skip to H5.)

H4	To the best of your knowledge, were you tested for any of the following in the past 12
months? (Read items)

Yes

No

(DK)

(Refused)

H4A. High blood pressure

1

2

8

9

H4B. Cancer

1

2

8

9

H4C. Diabetes

1

2

8

9

H4D. Sexually transmitted diseases or infections

1

2

8

9

H5	How many children do you, personally, have? (Interviewer: Respondent should include
all children even if they are now adults or have died.)

Circle One Response

105

Write in:___________________________

None

00

97+

97

(DK)

98

(Refused)99

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(If [respondent is a woman and has children], Continue;
Otherwise, Skip to Read before H7.)

H6	How old were you the first time you were pregnant? (Open-ended and code actual age)
Circle One Response
Write in:___________________________

96+

96

(Never pregnant/has only adopted children or stepchildren)

97

(DK)

98

(Refused)99

Now I would like to ask you a question regarding domestic violence. Domestic violence can be physical,
psychological, or involve sexual acts done to someone against their will by a person they live with.

H7	In your opinion, is domestic violence a widespread problem in [Country], or not?

106

Yes

No

(DK)

(Refused)

1

2

8

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References in This Section
Bhattacharya, S., Thakur, J. S., & Singh, A. (2018). Knowledge attitude, and practice regarding dietary salt intake
among urban slum population of North India. Journal of Family Medicine and Primary Care, 7(3), 526–530.
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Bustreo, F. (2015, February 20). Ten top issues for women’s health. World Health Organization.
https://www.who.int/news-room/commentaries/detail/ten-top-issues-for-women’s-healthCDC. (2020a, July 29). How to Prevent Cancer or Find It Early. Centers for Disease Control and Prevention.
https://www.cdc.gov/cancer/dcpc/prevention/index.htm
CDC. (2020b, September 8). Heart Disease Facts. Centers for Disease Control and Prevention.
https://www.cdc.gov/heartdisease/facts.htm
CDC. (2021a). How STDs Impact Women Differently From Men. Centers for Disease Control and Prevention.
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CDC. (2021b, March 22). Adult Obesity. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/
adult/causes.html
Dang, B.N., Westbrook, R.A., Njue, S.M. et al. Building trust and rapport early in the new doctor-patient relationship: alongitudinal qualitative study. BMC Med Educ 17, 32 (2017). https://doi.org/10.1186/s12909-017-0868-5
Fan, Y., Zhang, S., Li, Y., Li, Y., Zhang, T., Liu, W., & Jiang, H. (2018). Development and psychometric testing of theKnowledge, Attitudes and Practices (KAP) questionnaire among student Tuberculosis (TB) Patients (STBP-KAPQ) in
China. BMC Infectious Diseases, 18(1), 213. https://doi.org/10.1186/s12879-018-3122-9
Gee, R. E. (2012). Preventive Services for Women Under the Affordable Care Act. Obstetrics & Gynecology, 120(1).
https://doi.org/10.1097/aog.0b013e31825bd604
IDF. (2019). Worldwide toll of diabetes. International Diabetes Federation. https://diabetesatlas.org/#:~:text=537%20
million%20adults%20(20%2D79,2021%20%2D%201%20every%205%20seconds.
Jin, J. (2022, April 12). Routine checkups for adults. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2790936
Liss, D. T., Uchida, T., Wilkes, C. L., Radakrishnan, A., & Linder, J. A. (2021, June 8). General Health Checks in Primary
Adult Care: A Review. JAMA. https://jamanetwork.com/journals/jama/article-abstract/2780614
Mustafa, R., Afreen, U., & Hashmi, H. A. (2008). Contraceptive knowledge, attitude and practice among rural
women. Journal of College of Physicians and Surgeons Pakistan, 18(9), 542–545.
Neumann, P. J., & Cohen, J. T. (2009). Cost savings and cost-effectiveness of clinical preventive care. The Synthesis
project. Research synthesis report, (18), 48508.

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Office of Disease Prevention and Health Promotion. Get your well-woman visit every year. Health.gov/MyHealthfinder.
https://health.gov/myhealthfinder/healthy-living/sexual-health/get-your-well-woman-visit-every-year
Okobia, M. N., Bunker, C. H., Okonofua, F. E., & Osime, U. (2006). Knowledge, attitude and practice of Nigerian
women toward breast cancer: a cross-sectional study. World Journal of Surgical Oncology, 4(1), 1–9.
PRB. (2011, August 15). The Effect of Girls’ Education on Health Outcomes: Fact Sheet. PRB. https://www.prb.org/
resources/the-effect-of-girls-education-on-health-outcomes-fact-sheet/
UNFPA. (2021). Adolescent pregnancy. United Nations Population Fund. https://www.unfpa.org/adolescent-pregnancy
UNFPA. (2021). Gender-based violence. United Nations Population Fund. https://www.unfpa.org/gender-based-violence
UNHCR. (2021). Gender-based violence. The UN Refugee Agency. https://www.unhcr.org/gender-based-violence.html
UNICEF. (2021, May). Early childbearing. UNICEF. https://data.unicef.org/topic/child-health/adolescent-health/WHO. (2019, September 19). Maternal mortality. World Health Organization. https://www.who.int/news-room/factsheets/detail/maternal-mortality
WHO. (2020, January 31). Adolescent pregnancy. World Health Organization. https://www.who.int/news-room/factsheets/detail/adolescent-pregnancy
WHO. (2020, March 12). Top Health Checks for Women. World Health Organization. https://www.who.int/news-room/
photo-story/photo-story-detail/top-health-checks-for-women
WHO. (2021a). Maternal health. World Health Organization. https://www.who.int/health-topics/maternalhealth#tab=tab_1
WHO. (2021b). Obesity and overweight. World Health Organization. https://www.who.int/westernpacific/health-topics/
obesityWHO. (2021c, March 3). Cancer. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/cancer
WHO. (2021, March 9). Devastatingly pervasive: 1 in 3 women globally experience violence. World HealthOrganization. https://www.who.int/news/item/09-03-2021-devastatingly-pervasive-1-in-3-women-globallyexperience-violence
WHO. (2021d, March 9). Violence against women. World Health Organization. https://www.who.int/news-room/factsheets/detail/violence-against-women
WHO. (2021). Violence Against Women Prevalence Estimates, 2018. World Health Organization. https://www.who.int/
publications-detail-redirect/9789240022256
WHO. (2021, April 13). Diabetes. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/diabetes

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Women’s Health Alliance (WHA). (2022, March 7). How often should I schedule a well woman exam? Women’s HealthAlliance. https://womenshealthalliance.com/how-often-should-i-get-a-well-woman-exam/
World Bank. (2019, September 25). Gender-Based Violence (Violence Against Women and Girls). World Bank. https://www.worldbank.org/en/topic/socialsustainability/brief/violence-against-women-and-girls
World Bank. (2021). Adolescent fertility rate (births per 1,000 women ages 15-19). The World Bank Data.
https://data.worldbank.org/indicator/SP.ADO.TFRT
Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice
regarding COVID-19 among healthcare workers in Henan, China. Journal of Hospital Infection, 105(2), 183–187.

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AP P E N DI X 2

Hologic Global Women’s Health Index:
Methodology and Data Analysis

Introduction
The Hologic Global Women’s Health Index is the world’s most comprehensive, globally comparative survey about
women’s health. This appendix provides key methodological details related to the 2020 and 2021 surveys andfurther information about the data analysis presented in this report.

Methodology
The Hologic Global Women’s Health Index was included as a module within the Gallup World Poll in 2020 and 2021.
Since 2005, the World Poll has regularly surveyed people in more than 160 countries using mixed methods oftelephone and face-to-face interviewing. In a typical year, the poll results represent more than 95% of the world’s
population aged 15 and older, using randomly selected, nationally representative samples.

Data collection in 2020
2020 was far from a typical year. The unprecedented challenges presented by the COVID-19 pandemic forced
Gallup to pause its global data collection in March 2020 to thoroughly assess risk and prepare contingency plans forcollecting data. By May, the continued prevalence of COVID-19 made it clear there was too much risk of community
transmission to conduct face-to-face data collection in 2020.
Nonetheless, Gallup recognized the importance of finding a way to collect representative, high-quality data during
this critical period and prepared a contingency methodology. This new methodological approach was driven by
several key considerations, including the safety of Gallup World Poll interviewers and respondents and retaining highlevels of representativity.
Ultimately, the 2020 Hologic Global Women’s Health Index survey was conducted primarily by phone (via computerassisted telephone interviewing, or CATI) in nearly all of the 116 countries and territories — representing more than
93% of the global aged 15 and older population — with the exception of the Republic of the Congo, Mali, Pakistan
and Senegal. As a standard practice, Gallup and its partners complied with all government-issued guidance fromlocal authorities and took this guidance into account throughout the interviewing process, including following social
distancing measures for telephone interviews conducted in a call center (however, most CATI data collection was
done remotely).

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Changing modes in 2021
The Gallup World Poll returned to face-to-face interviewing in many countries in 2021 (see dataset details).
The change in mode is reflected in the design effect — thus, larger percentage differences are required forsignificant change.

Questionnaire Translation
The questionnaire was translated into the major conversational languages of each country and area (autonomous orsemi-autonomous regions or territories that are not recognized as sovereign states). The Hologic Global Women’s
Health Index was originally developed in English. From this starting point, Gallup translators produced several
major-language questionnaires in French, Spanish, Portuguese, Russian and Arabic (using one of the two translation
methods described below, as deemed appropriate by the Gallup World Poll Regional Directors).
Then, local language translations were performed from the major-language versions. For example, the Russian majorlanguage questionnaire was created first (translation from English to Russian), then translated from Russian into otherlanguages, such as Ukrainian, Kyrgyz and Uzbek. As a key component of quality assurance, one of the following two
methods was used in each country as an independent check of every questionnaire translation:
Method 1: Two independent translations are completed. An independent third party with some knowledge ofsurvey research methods adjudicates the differences. A professional translator translates the final version backinto the source language.
Method 2: A translator translates into the target language, and an independent translator back-translates into
the source language. An independent third party with knowledge of survey methods reviews and revises thetranslation as necessary.
Professional translators — experienced in translating survey questionnaires and who have typically worked for years
with Gallup’s local data collection network (local translators) — were selected. All translators received the same setof notes and guidance regarding the meaning of specific items. Interviewers were instructed to follow the interview
script and not to deviate from the translated language.

Interviewer Training and Quality Control
As a standard practice, Gallup and its data collection partners were mindful of complying with all government-issued
guidance from local authorities and took this guidance into account throughout the interviewing process, including
following social distancing measures for telephone interviews. Gallup selects and retains in-country partners basedon their experience in nationwide survey research studies in the mode that is typically appropriate for that country,
and Gallup continued to use data collection partners when fielding the Hologic Global Women’s Health Index.
Gallup conducted all training remotely using available technologies such as e-learning and video conferencing.
The changes were largely necessary to address the lack of telephone data collection experience, technical andinfrastructural limitations, and compressed timelines.

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Gallup provided a standardized training manual to assist the fieldwork
team with training and ensure consistency and structure.
Topics covered in training included:1Standards for conducting a quality interview• how to ask closed-ended questions• how to ask open-ended questions• rotation of survey questions or response options• how to follow or implement skip patterns• probing2

Respondent selection and disposition coding (i.e., recording the results ofeach contact)• within-household selection for those reached on landline and mobile in countries
where telephone coverage is low• coding practices for each telephone attempt• sample release and management
3

Recruitment and retention of interviewers and field quality control• characteristics of a successful interviewer/motivation for retention• requirements for setting up remote data collection• monitoring sample performance and interviewer productivity
Sampling and Data Collection Methodology
All samples were probability-based — meaning respondents were selected randomly — and nationally representativeof the aged 15 and older population. As all eligible landline exchanges and valid mobile service providers were
included, coverage area is an entire country, including rural areas. The sampling frame represents adults aged 15
and older with access to a phone (either landline or mobile). Gallup used random digit dialing (RDD) or a nationally
representative list of phone numbers.

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How the sample generation and selection process works
Gallup uses telephone surveys in countries where telephone coverage represents at least 80% of the
population or is the customary survey methodology. In countries where telephone interviewing is employed,
Gallup uses RDD or a nationally representative list of phone numbers. Telephone methodology is typical insuch areas as the U.S., Canada, Western Europe, Japan and Australia. Gallup purchases telephone samples
from various sample providers located in each region, including Sample Answers and Sample Solutions.
In the developing world, including much of Latin America, the former Soviet Union countries, nearly all ofAsia, the Middle East and Africa, Gallup uses an area frame design for face-to-face interviewing in randomly
selected households.
Face-to-face interviews are approximately one hour, while telephone interviews are about 30 minutes.
With some exceptions, all samples are probability based and nationally representative of the resident
population aged 15 and older. The coverage area is the entire country including rural areas, and thesampling frame represents the entire civilian, non-institutionalized adult population of the country. Exceptions
include areas where the safety of the interviewing staff is threatened and scarcely populated islands in somecountries. Sampling procedures include the following stages:• 1) Selecting primary sampling units (PSUs): In countries where Gallup conducts face-to-face surveys,

the first stage of sampling is the identification of PSUs, consisting of clusters of households. PSUs are
stratified by population size and/or geography and clustering is achieved through one or more stagesof sampling. Where population information is available, sample selection is based on probabilities
proportional to population size; otherwise, Gallup uses simple random sampling. In countries where
telephone interviewing is employed, Gallup uses RDD or a nationally representative list of phone
numbers. In select countries where cellphone penetration is high, Gallup uses a dual sampling frame.
Gallup makes at least three attempts to reach a person in each household.

• 2) Selecting households: Gallup uses random-route procedures to select sampled households. Unlessan outright refusal occurs, interviewers make up to three attempts to survey the sampled household.
To increase the probability of contact and completion, interviewers make attempts at different times ofthe day and, when possible, on different days. If the interviewer cannot obtain an interview at the initialsampled household, they use a simple substitution method.

• 3) Selecting respondents: In face-to-face and telephone methodologies, random respondent selectionis achieved by using either the latest birthday or the Kish grid method. In a few Middle Eastern andAsian countries, gender-matched interviewing is required, and probability sampling with quotas
is implemented during the final stage of selection. Gallup implements quality control proceduresto validate the selection of correct samples and that the interviewer selects the correct person ineach household.

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Response Rates
As is the case with Gallup World Poll surveys more generally, response rates for the Hologic Global Women’s HealthIndex varied considerably across countries. In general, response rates are lower in countries where interviewing is
conducted by telephone than in countries where interviewing is conducted in person. However, in many countries
and territories where telephone interviewing is used, response rates are comparable to those of other polling firms.
The Gallup World Poll does not publish individual country response rates.

Data Weighting
Data weighting is used to minimize bias in survey estimates and is intended for use in generating nationally
representative estimates within a country. The weighting procedure was formulated based on the sample design andperformed in multiple stages. Gallup constructed a probability weight factor (base weight) to account for selectionof telephone numbers from the respective frames and correct for unequal selection probabilities that result fromselecting one adult in landline households and for dual users coming from both the landline and mobile frame. For
instance, an individual in a five-person household will have a lower probability selection than someone who lives
alone, holding everything else equal. The data weighting process seeks to address this type of imbalance.
Next, the base weights were post-stratified to adjust for nonresponse (where selected respondents are neverreached or refuse to participate) and to match the weighted sample totals to known target population totals obtained
from country-level census data. Gallup made calibration adjustments for gender, age and, where reliable data wereavailable, education. In many nontraditional telephone countries, weights were also adjusted on an additional setof demographic factors, including employment status (whether employed for an employer/self or not employed),urbanicity, region or some combination of these factors. In general, countries with lower coverage of the target
population required a larger set of weighting variables than countries with a minimum amount of coverage error.
Where necessary, Gallup implemented procedures to limit or reduce the number and size of extreme samplingweights. This process was done in both stages of the data weighting process. In any given country, the unweighted
demographic profile (including but not limited to characteristics such as gender, age group, educational attainment
level, employment status and region) was compared against reliable statistics (typically census data from the national
government); Gallup also compared the final weighted sample to these statistics.
Finally, approximate study design effect and margin of error were calculated (calculations are presented in Table 1).
The design effect calculation reflects the influence of weighting on sampling variance compared to a simple random
sample of the same size.

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Sampling Error and Precision of Estimates
When interpreting survey results, all sample surveys are subject to various types of potential errors. For example,
errors may occur due to nonresponse (where selected respondents are never reached or refuse to participate),interviewer administration error (where a response can be mistyped or misinterpreted by the interviewer), or
incomplete or inaccurate answers from the respondent.
The sampling design employed in this study was used to produce unbiased estimates of the stated target population.
An unbiased sample will have the same characteristics and behaviors as those of the total population from which
it was drawn. In other words, with a properly drawn sample, we can make statements about the target population
within a specific range of certainty. Sampling errors can be estimated, and their measures can help interpret the final
data results. The size of such sampling errors depends largely on the number of interviews and the complexity of thesampling design.
The margin of error (MOE), or the level of precision used in estimating the unknown population proportion ‘P,’ can bederived based on the following formula:

MOE = 1.96 * √(P*(1-P)/n)where ‘n’ is the sample size (i.e., the number of completed surveys). Under the most conservative assumption (P =0.5), the MOE for a sample size of 1,000 will be 1.96 * √(0.25/1000) = 3.1 percentage points under the assumption of
simple random sampling.
Table 1 shows the size of the MOE associated with the 95% confidence interval for various sample sizes under theassumption of simple random sampling. They may be interpreted as indicating the approximate range (plus or minus
the figure shown) around the point estimate within which the results of repeated sampling in the same time period
could be expected to fall 95% of the time, assuming the same sampling procedures, interviewing process andquestionnaire.
For any given sample size, the estimated precision is lowest when P = 0.5 (or 50%). For example, the sample size
needed to ensure a sampling error (or half-width of confidence interval) of 0.05 at 95% confidence level is around400 cases when P = 0.5 (or 50%). A sample size of 300 will produce a sampling error close to 0.057 at 95% level ofsignificance when P = 0.5 (or 50%). With P = 0.4 (or 40%), a sample size of 300 will produce a sampling error of 0.056.
Table 1 shows estimated precision levels for different values of P and sample sizes under the assumption of simple
random sampling.

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TA B L E 1 :Margin of Error Associated With 95% Confidence Interval for Percentages for Entire Sample
or Subgroups, in Percentage Points
For Percentages Near
SampleSizes Near

5/95%
±

10/90%±

20/80%±

30/70%±

40/60%±

50/50%
±

400

2.1

2.9

3.9

4.5

4.8

4.9

500

1.9

2.6

3.5

4.0

4.3

4.4

600

1.7

2.4

3.2

3.7

3.9

4.0

800

1.5

2.1

2.8

3.2

3.4

3.5

1,000

1.4

1.9

2.5

2.8

3.0

3.1

1,500

1.1

1.5

2.0

2.3

2.5

2.5

2,000

.96

1.3

1.8

2.0

2.1

2.2

2,500

.85

1.2

1.6

1.8

2.0

2.0

3,000

.78

1.1

1.4

1.6

1.8

1.8

4,000

.68

.93

1.2

1.4

1.5

1.5

5,000

.60

.88

1.2

1.3

1.3

1.4

While the above table reflects precision assuming simple random sampling (i.e., respondents within a target
population have an equal probability of being selected for the survey), World Poll surveys rely on more complex
designs, even for telephone samples (which was the sole mode of data collection in 2020). In addition to design
complexities, data are weighted to correct for unequal probabilities of household selection and post-stratification
adjustments. This weighting process introduces a design effect that needs to be considered while computing thesampling error (or precision) of the estimates.
The design effect is defined as the ratio of the complex, design-based sample variance to the sample varianceobtained from a simple random sample of the same size. To calculate the precision of an estimate using the complex
sampling design with a design effect, one must multiply the precision under the assumption of simple random
sampling by the square root of the design effect associated with this estimate.

116

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GWHI_Global_Appendix2_073022_kn

In other words, the precision of an estimate (p) of an unknown population proportion ‘P’ may be approximated as:

Precision (p) = {SQRT (Deff)} × SE(p)where ‘Deff’ is the design effect associated with the estimate (p)SE(p) = SQRT{p*(1-p)/(n – 1)}
n = the unweighted sample size
For purposes of simplicity, an estimate of ‘Deff_wt’ is provided for each country, taking into consideration only thevariability of weights. A design effect of 1 means the effective sample size is the same as the nominal sample size,
which is 1,000 for most countries in the World Poll. For proportions close to 50%, a design effect of 2 reduces theeffective sample size by 50% or increases margin of error by 41% compared to a simple random sample size of 1,000.

Meaningful Change
Researchers developed a standardized definition of meaningful change in a country’s score from one year to thenext — a threshold of +/- 5 points. This definition allows researchers to establish best practice when comparing
country scores from year to year, while considering a country’s sample size and margin of error estimates (defined inTable 1).
A five-point change is the smallest, standard number where researchers can be certain that change cannot be
explained by sampling random fluctuations or by measurement error, no matter the percentage or the country’s
particular design effect. This number is defined as a meaningful change because, while complex survey sampling
methods to test for significant change were not individually applied (see example: Cohen, 198893), this is the upper
limit of change where researchers can be certain there is a statistically significant difference between the two groups.
Researchers seek to avoid confusion by setting this threshold, so in all instances, a change of +/- 5 or more points ishighlighted throughout the report.

93 Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). L. Erlbaum Associates.

117

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GWHI_Global_Appendix2_073022_kn

Hologic Global Women’s Health Index Country Dataset Details
TA B L E 2 :Country dataset details
Gallup Worldwide Research Data Collected From 2020 and 2021aThe design effect calculation reflects the weights and does not incorporate the intraclass correlation coefficients. Design effect calculation:n*(sum of squared weights)/[(sum of weights)*(sum of weights)]b

Margin of error is calculated around a proportion at the 95% confidence level. The maximum margin of error was calculated assuming a reported
percentage of 50% and takes into account the design effect. Margin of error calculation: √(0.25/N)*1.96*√(DE)

118

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages*Handheld data collection.

2020

Albania15.1

Sep 7 –
Oct 6, 2020

1,000

1.41

3.7

Mobile Telephone

Albanian

2020

Algeria15.1

Oct 9 –
Oct 24, 2020

1,016

1.56

3.8

Landline andMobile Telephone

Arabic2020

Argentina

15.1

Sep 7 –
Nov 20, 2020

1,000

1.93

4.3

Landline andMobile Telephone

Spanish2020

Australia

15.1

Feb 4 –
Mar 22, 2020

1,003

1.76

4.1

Landline andMobile Telephone

English2020

Austria

15.1

Aug 24 –Sep 19, 2020

1,000

1.68

4.0

Landline andMobile Telephone

GermanExclusions(Samples are nationally
representative unless
noted otherwise)

Includes only Bahrainis,
Arab expatriates andArabic, English non-Arabs who were able
to complete the interview in
Arabic or English.

2020

Bahrain15.1

Aug 6 –
Aug 23, 2020

1,009

1.61

3.9

Landlineand Mobile
Telephone

2020

Bangladesh

15.1

Oct 30 –Nov 28, 2020

1,013

2.43

4.8

MobileTelephone

Bengali

2020

Belgium

15.1

Aug 19 –Sep 19, 2020

1,005

1.33

3.6

Landlineand Mobile
TelephoneFrench,
Dutch

2020

Benin

15.1

Dec 11 –Dec 25, 2020

1,042

2.36

4.7

MobileTelephone

Bariba, Fon,
French2020

Bolivia

15.1

Sep 25 –Oct 28, 2020

1,001

1.84

4.2

MobileTelephone

Spanish2020

Bosnia andHerzegovina

15.1

Oct 16 –Nov 19, 2020

1,001

1.50

3.8

Landlineand Mobile
Telephone

Bosnian2020

Brazil15.1

Sep 10 –Nov 11, 2020

1,002

1.85

4.2

Landlineand Mobile
Telephone

Portuguese

2020

Bulgaria

15.1

Sep 17 –Nov 26, 2020

1,000

2.03

4.4

Landlineand Mobile
Telephone

BulgarianThe Hologic Global Women’s Health Index | Global Report© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Oct 23 –Nov 15, 2020

1,002

2.73

5.1

MobileTelephone

Khmer

2020

Cameroon

15.1

Sep 19 –Nov 8, 2020

1,000

2.63

5.0

MobileTelephoneFrench,English,Fulfulde

1,006

1.46

3.7

Landlineand Mobile
Telephone

English,French

1,000

1.52

3.8

Landlineand Mobile
Telephone

SpanishChineseLanguages

15.1

2.52

Mode ofInterviewing

Cambodia

1,007

Marginof Errorb

2020

DesignEffecta

Data Collection
Date

15.1

Number ofInterviews

Wave

Burkina Faso

Country

Data Collection
Year

119

2020

Feb 19 –Mar 4, 2021

4.9

MobileTelephone

Dioula,French,Fulfulde,
Moore

2020

Canada15.1

Aug 3 –
Sep 21, 2020

2020

Chile

15.1

Sep 11 –Nov 16, 2020

3,503

2.16

2.4

MobileTelephoneExclusions(Samples are nationally
representative unless
noted otherwise)

2020

China

15.1

Sep 8 –
Oct 28, 20202020

Colombia

15.1

Aug 21 –Oct 27, 2020

1,000

1.52

3.8

Landlineand Mobile
Telephone

Spanish2020

Congo,
Republicof the15.1

Dec 2 –
Dec 29, 2020

1,002

1.55

3.9

Face-to-Face(HH)*

French,Kituba,Lingala2020

Costa Rica

15.1

Sep 15, 2020
– Jan 4, 2021

1,000

1.67

4.0

Landlineand Mobile
Telephone

Spanish2020

Croatia

15.1

Sep 22 –Nov 2, 2020

1,002

1.77

4.1

Landlineand Mobile
Telephone

Croatian

2020

Cyprus15.1

Jul 20 –Sep 27, 2020

1,005

1.55

3.8

Landlineand Mobile
Telephone

Greek,English

2020

Czech
Republic

15.1

Oct 9 –
Nov 28, 2020

1,004

1.50

3.8

Landlineand Mobile
Telephone

Czech

2020

Denmark

15.1

Sep 14 –Oct 10, 2020

1,000

1.30

3.5

MobileTelephone

Danish

2020

Dominican
Republic

15.1

Sep 24 –Oct 23, 2020

1,000

1.63

4.0

Landlineand Mobile
Telephone

Spanish2020

Ecuador

15.1

Aug 26 –Oct 23, 2020

1,000

1.51

3.8

Landlineand Mobile
Telephone

Spanish

2020

Egypt

15.1

Oct 24 –Nov 12, 2020

1,002

2.00

4.4

Landlineand Mobile
TelephoneArabicThe Hologic Global Women’s Health Index | Global Report

Northwest Territories, Yukon
and Nunavut (representing
approximately 0.3% of theCanadian population) were
excluded.

Tibet was excluded from thesample. The excluded areas
represent less than 1% of the
population of China.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2020

El Salvador

15.1

Sep 23 –Nov 17, 2020

1,000

1.83

4.2

MobileTelephone

Spanish2020

Estonia15.1

Oct 14 –Nov 20, 2020

1,000

1.54

3.8

MobileTelephone

Estonian,
Russian

1,003

2.96

5.3

MobileTelephone

Amharic,
English,Oromo,
Tigrinya2020

Ethiopia15.1

Oct 5 –
Nov 1, 2020

2020

Finland

15.1

Mar 26 –May 13, 2020

1,000

1.42

3.7

MobileTelephone

Finnish,Swedish2020

France15.1

Sep 7 –
Oct 2, 2020

1,000

1.52

3.8

Landlineand Mobile
TelephoneFrench

2020

Gabon

15.1

Feb 19 –Mar 3, 2021

1,000

2.43

4.8

MobileTelephoneFrench, Fang

2020

Georgia

15.1

Sep 25 – Nov14, 2020

1,003

2.00

4.4

Landlineand Mobile
Telephone

Georgian,
Russian2020

Germany

15.1

Aug 24 – Sep
19, 2020

1,000

2.14

4.5

Landlineand Mobile
Telephone

German

2020

Ghana

15.1

Oct 2 –
Oct 30, 2020

1,000

2.19

4.6

MobileTelephone

English,Ewe, Twi

2020

Greece15.1

Sep 23 –Oct 24, 2020

1,002

1.88

4.2

Landlineand Mobile
Telephone

Greek

2020

Guinea15.1

Feb 19 –Mar 4, 2021

1,005

2.88

5.2

MobileTelephoneFrench,Malinke,
Pular,
Soussou

2020

Hungary

15.1

Oct 19 –Nov 17, 2020

1,001

1.83

4.2

Landlineand Mobile
Telephone

Hungarian2020

Hong Kong,
S.A.R. of
China

15.1

Sep 3 –
Nov 8, 2020

1,005

1.26

3.5

Landlineand Mobile
Telephone

Chinese2020

Iceland15.1

Aug 31 –Oct 12, 2020

501

1.49

5.3

Landlineand Mobile
Telephone

Icelandic

MobileTelephone

Assamese,
Bengali,
Gujarati,
Hindi,
Kannada,Malayalam,
Marathi,Odia,
Punjabi,
Tamil,
Telugu2020

120

Exclusions(Samples are nationally
representative unless
noted otherwise)

India

15.1

Dec 28, 2020
– Jan 26, 2021

3,103

3.53

3.3

The Hologic Global Women’s Health Index | Global Report

Excluded population living
in Northeast states andremote island.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

121Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2020

Indonesia

15.1

Oct 31, 2020
– Jan 13, 2021

1,062

2.43

4.7

MobileTelephoneBahasaIndonesia

2020

Iran

15.1

Aug 5 –
Aug 12, 2020

1,009

1.45

3.7

Landlineand Mobile
Telephone

Farsi

2020

Iraq

15.1

Nov 1 –
Nov 23, 2020

1,000

1.69

4.0

MobileTelephoneArabic,Kurdish2020

Ireland

15.1

Aug 17 –Sep 12, 2020

1,000

1.62

3.9

Landlineand Mobile
Telephone

English2020

Israel15.1

Sep 24 –Oct 19, 2020

1,057

1.38

3.5

Landlineand Mobile
Telephone

Hebrew,
Russian,Arabic

2020

Italy

15.1

Aug 24 –Sep 16, 2020

1,000

2.53

4.9

Landlineand Mobile
Telephone

Italian

2020

Ivory Coast

15.1

Dec 5 –
Dec 21, 2020

1,021

2.20

4.5

MobileTelephoneFrench,Dioula2020

Jamaica

15.1

Sep 24, 2020
– Jan 4, 2021

502

1.47

5.3

MobileTelephone

EnglishExclusions(Samples are nationally
representative unless
noted otherwise)

2020

Japan

15.1

Aug 7 –
Oct 8, 2020

1,016

1.22

3.4

Landlineand Mobile
TelephoneJapanese

2020

Jordan15.1

Nov 3 –
Nov 20, 2020

1,012

1.46

3.7

MobileTelephoneArabic2020

Kazakhstan

15.1

Nov 7 –
Dec 4, 2020

1,000

1.57

3.9

MobileTelephone

Russian,
Kazakh

2020

Kenya

15.1

Sep 30 – Nov6, 2020

1,008

1.99

4.4

MobileTelephone

English,Swahili[Kishwahili]

2020

Kosovo15.1

Oct 12 –Dec 12, 2020

1,000

1.73

4.1

MobileTelephone

Albanian,
Serbian

2020

Kyrgyzstan

15.1

Oct 27 –Nov 20, 2020

1,000

1.33

3.6

MobileTelephone

Kyrgyz,Russian

2020

Lao People’s
Democratic
Republic

15.1

Oct 28 –Nov 11, 2020

1,000

2.43

4.8

MobileTelephone

Lao

2020

Latvia15.1

Sep 10 –Oct 31, 2020

1,001

1.62

3.9

MobileTelephone

Latvian,Russian

2020

Lebanon

15.1

Oct 18 –Nov 26, 2020

1,050

1.33

3.5

Landlineand Mobile
TelephoneArabicThe Hologic Global Women’s Health Index | Global Report

Landline RDD, excluded
12 municipalities near the
nuclear power plant inFukushima. These areas
were designated as notto-call districts due to thedevastation from the 2011
disasters. The exclusion
represents less than 1% of the
population of Japan.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2020

Lithuania

15.1

Oct 8 –
Nov 26, 2020

1,002

1.93

4.3

MobileTelephone

Lithuanian

2020

Malta

15.1

Mar 8 –
Apr 24, 2020

1,001

1.46

3.7

Landlineand Mobile
Telephone

Maltese,English

15.1

Oct 27, 2020 –Jan 26, 2021

4.5

MobileTelephoneBahasaMalay,
Chinese,English2020

122

Malaysia

1,000

2.09

Exclusions(Samples are nationally
representative unless
noted otherwise)

2020

Mali

15.1

Dec 3 –
Dec 22, 2020

1,000

1.36

3.6

Face-to-Face(HH)*

French,Bambara2020

Mauritius

15.1

Jul 24 –Aug 27, 2020

1,000

1.69

4.0

Landlineand Mobile
Telephone

Creole,English,French2020

Mexico15.1

Sep 8 – Nov18, 2020

1,010

1.66

4.0

Landlineand Mobile
Telephone

Spanish2020

Moldova,
Republic of

15.1

Oct 7 –
Nov 16, 2020

1,000

1.63

4.0

MobileTelephone

Romanian/
Moldavian,Russian

2020

Mongolia

15.1

Nov 14 –Nov 30, 2020

1,000

1.58

3.9

MobileTelephone

Mongolian

2020

Montenegro

15.1

Oct 15 –Dec 25, 2020

1,004

1.74

4.1

Landlineand Mobile
TelephoneMontenegrin

2020

Morocco15.1

Oct 8 –
Nov 10, 2020

1,006

1.47

3.7

Landlineand Mobile
Telephone

MoroccanArabic2020

Myanmar15.1

Oct 29 –Dec 4, 2020

1,000

1.84

4.2

MobileTelephone

Myanmar,Burmese

1,000

1.76

4.1

MobileTelephone

English,Oshivambo,
Afrikaans,
Kwangali

2020

Namibia15.1

Oct 5 –
Nov 16, 2020

2020

Nepal

15.1

Oct 18 –Dec 4, 2020

1,000

2.59

5.0

MobileTelephone

Nepali

2020

Netherlands

15.1

Mar 11 –May 15, 2020

1,006

1.60

3.9

Landlineand Mobile
Telephone

Dutch

2020

New
Zealand15.1

Feb 17 –Mar 23, 2020

1,002

1.56

3.9

Landlineand Mobile
Telephone

EnglishThe Hologic Global Women’s Health Index | Global Report

The regions of Gao, Kidal,
Mopti and Tombouctou
were excluded because
of insecurity. Quartiersand villages with lessthan 50 inhabitants werealso excluded from thesample. The excluded areas
represent 23% of the total
population.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

123Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2020

Nicaragua

15.1

Nov 14 –Dec 28, 2020

1,002

2.06

4.4

MobileTelephone

SpanishExclusions(Samples are nationally
representative unless
noted otherwise)

1.96

4.3

MobileTelephone

English,Hausa,
Igbo, Pidgin
English,Yoruba2020

Nigeria

15.1

Sep 25 –Nov 2, 2020

2020

North
Macedonia

15.1

Nov 28 –Dec 17, 2020

1,003

1.44

3.7

Landlineand Mobile
Telephone

Macedonian,
Albanian

2020

Norway15.1

Mar 24 –May 4, 2020

1,000

1.47

3.8

Landlineand Mobile
Telephone

Norwegian

1,004

Did not include AJK, GilgitBaltistan. The excluded area
represents approximately 5%of the population. Gendermatched sampling was usedduring the final stage of
selection.

2020

Pakistan

15.1

Jan 2 –
Feb 5, 2021

1,000

1.56

3.9

Face-to-Face
(HH)*

Urdu

2020

Paraguay

15.1

Nov 28 –Dec 28, 2020

1,000

1.28

3.5

Landlineand Mobile
Telephone

Spanish

2020

Peru

15.1

Oct 29, 2020
– Jan 6, 2021

1,006

1.67

4.0

Landlineand Mobile
Telephone

Spanish2020

Philippines

15.1

Sep 14 –Oct 26, 2020

1,000

1.92

4.3

Landlineand Mobile
Telephone

Filipino,
Iluko,
Cebuano,Waray, Bicol

2020

Poland15.1

Sep 25 –Oct 24, 2020

1,010

1.74

4.1

Landlineand Mobile
Telephone

Polish2020

Portugal

15.1

Mar 20 –Apr 16, 2020

1,002

1.70

4.0

Landlineand Mobile
Telephone

Portuguese

2020

Romania15.1

Dec 5, 2020 –Jan 25, 2021

1,000

1.44

3.7

Landlineand Mobile
Telephone

Romanian

2020

RussianFederation

15.1

Aug 19, –Oct 2, 2020

2,022

1.68

2.8

Landlineand Mobile
Telephone

RussianArabic,English,Hindi, Urdu
French,
Wolof

2020

Saudi Arabia

15.1

Aug 9 –
Aug 27, 2020

1,043

1.80

4.1

Landlineand Mobile
Telephone2020

Senegal15.1

Dec 5 –
Dec 23, 2020

1,000

1.36

3.6

Face-to-Face(HH)*

The Hologic Global Women’s Health Index | Global Report

Includes Saudis, Arab
expatriates, and non-Arabs
who were able to complete
the interview in Arabic,
English, Urdu or Hindi.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

124Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2020

Serbia15.1

Sep 18 –Oct 25, 2020

1,002

1.63

4.0

Landlineand Mobile
Telephone

Serbian2020

Slovakia

15.1

Sep 9 –
Oct 9, 2020

1,001

1.51

3.8

Landlineand Mobile
Telephone

Hungarian,
Slovak

2020

Slovenia

15.1

Mar 13 –Apr 18, 2020

1,001

1.97

4.3

Landlineand Mobile
Telephone

Slovene

2020

South Africa

15.1

Oct 21 –Dec 12, 2020

1,019

1.91

4.2

MobileTelephone

Afrikaans,
English,Sotho,
Xhosa, Zulu

2020

South Korea

15.1

Aug 25 –Oct 7, 2020

1,005

1.32

3.6

Landlineand Mobile
Telephone

Korean

2020

Spain

15.1

Aug 24 –Sep 17, 2020

1,000

1.60

3.9

Landlineand Mobile
Telephone

Spanish2020

Sri Lanka

15.1

Oct 31 –Dec 5, 2020

1,000

1.91

4.3

MobileTelephone

Sinhala,
Tamil

2020

Sweden15.1

Mar 30 –Apr 29, 2020

1,000

1.41

3.7

Landlineand Mobile
Telephone

Swedish2020

Switzerland

15.1

Sep 7 –
Oct 9, 2020

1,000

1.79

4.1

Landlineand Mobile
Telephone

German,French,Italian

2020

Taiwan,Province of
China

15.1

Jul 9 –
Jul 31, 2020

1,000

1.54

3.8

Landlineand Mobile
Telephone

Chinese2020

Tajikistan

15.1

Nov 15 –Dec 7, 2020

1,000

1.89

4.3

MobileTelephone

Tajik

2020

Tanzania

15.1

Oct 6 –
Nov 8, 2020

1,001

2.56

5.0

MobileTelephone

Swahili[Kishwahili]

2020

Thailand

15.1

Oct 22 –Dec 7, 2020

1,000

2.39

4.8

MobileTelephone

Thai

2020

Tunisia15.1

Sep 19 –Oct 7, 2020

1,003

1.81

4.2

Landlineand Mobile
TelephoneArabic2020

Türkiye15.1

Oct 3 –
Oct 23, 2020

1,000

1.68

4.0

Landlineand Mobile
Telephone

Turkish2020

Uganda15.1

Oct 12 –Nov 8, 2020

1,016

2.35

4.7

MobileTelephone

Ateso,English,Luganda,Runyankole

2020

Ukraine15.1

Sep 20 –Oct 19, 2020

1,001

1.68

4.0

Landlineand Mobile
Telephone

Russian,
Ukrainian

The Hologic Global Women’s Health Index | Global Report

Exclusions(Samples are nationally
representative unless
noted otherwise)© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Languages

1,011

1.27

3.5

MobileTelephone2020

UnitedKingdom ofGreat Britain
and Northern
Ireland

15.1

Aug 17 –Sep 12, 2020

1,000

1.50

3.8

Landlineand Mobile
Telephone

English2020

UnitedStates ofAmerica

15.1

Mar 16 –May 8, 2020

1,007

1.67

4.0

Landlineand Mobile
Telephone

English,Spanish2020

Uruguay

15.1

Sep 24 –Nov 30, 2020

1,001

1.54

3.8

Landlineand Mobile
Telephone

Spanish2020

Uzbekistan

15.1

Oct 26 –Nov 21, 2020

1,000

1.82

4.2

Landlineand Mobile
Telephone

Uzbek,
Russian2020

Venezuela

15.1

Sep 19 –Nov 25, 2020

1,000

1.65

4.0

Landlineand Mobile
Telephone

Spanish2020

Vietnam

15.1

Dec 16, 2020
– Jan 8, 2021

1,000

2.15

4.5

MobileTelephone

Vietnamese

Marginof Errorb

Aug 9 –
Sep 7, 2020

DesignEffecta

15.1

Number ofInterviews

United ArabEmirates

Includes only Emiratis, Arab
expatriates and non-Arabs
who were able to complete
the interview in Arabic,
English, Urdu or Hindi.

Wave

2020

Arabic,English,Hindi, Urdu

Country

Mode ofInterviewing

Data Collection
Date

Data Collection
Year

125

Exclusions(Samples are nationally
representative unless
noted otherwise)

2020

Zambia15.1

Oct 4 –
Oct 28, 2020

1,026

1.81

4.1

MobileTelephone

Bemba,English,Lozi,
Nyanja,
Tonga

2020

Zimbabwe15.1

Sep 21 –Oct 24, 2020

1,004

1.81

4.2

MobileTelephone

English,Shona,
Ndebele2021

Afghanistan

16.2

Aug 8 –
Sep 27, 2021

1,002

1.60

3.9

Face-to-Face andFace-to-Face(HH)*

Dari, Pashto

Gender-matched sampling
was used during the final
stage of selection.
People living in remoteor difficult-to-access rural
areas were excluded. The
excluded area represents
approximately 2% of the
population.

2021

Albania

16.2

Jun 29 –Aug 27, 2021

1,000

1.65

4.0

Face-to-Face(HH)*

Albanian

2021

Algeria

16.4

Nov 6 –
Nov 23, 2021

1,003

1.85

4.2

MobileTelephoneArabic2021

Argentina

16.3

Oct 16, 2021 –Jan 31, 2022

1,003

2.51

4.9

Landlineand Mobile
Telephone

SpanishThe Hologic Global Women’s Health Index | Global Report© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Languages

Mode ofInterviewing

1.59

3.9

Face-to-Face(HH)*

Armenian

2021

Australia

16.4

Aug 23 –Oct 3, 2021

1,000

1.63

4.0

Landlineand Mobile
Telephone

English2021

Austria

16.4

Sep 6 –
Oct 1, 2021

1,000

1.53

3.8

Landlineand Mobile
Telephone

German2021

Bangladesh

16.2

Feb 27 –Mar 30, 2022

1,000

1.27

3.5

Face-to-Face(HH)*

Bengali

2021

Belgium

16.3

Nov 10 –Dec 30, 2021

1,012

1.32

3.5

Landlineand Mobile
TelephoneFrench,
Dutch

2021

Benin

16.2

Jul 26 –Aug 12, 2021

1,000

1.49

3.8

Face-to-Face(HH)*

Bariba, Fon,
French2021

Bolivia16.3

Sep 11 –Oct 20, 2021

1,000

2.14

4.5

MobileTelephone

Spanish2021

Bosnia andHerzegovina

16.3

Oct 2 –
Nov 8, 2021

1,000

1.81

4.2

Landlineand Mobile
Telephone

Bosnian

2021

Brazil16.3

Jul 21 –Sep 10, 2021

1,002

2.39

1.5

Landlineand Mobile
Telephone

Portuguese

2021

Bulgaria

16.4

Aug 13 –Sep 26, 2021

1,013

1.79

4.1

Landlineand Mobile
Telephone

BulgarianFace-to-Face(HH)*

Dioula,French,Fulfulde,
Moore

Some communities in the
East and Sahel regions
were excluded due tosecurity reasons. The areas
excluded represent 4% of the
population.

Khmer

Koh Kong, Stueng Treng,
Otdor Meanchey and Kep
provinces were excluded.
These excluded areas
represent approximately 3%of the population.

2021

Burkina Faso 16.2

Cambodia

16.2

Aug 16 –Sep 7, 2021

Aug 28 –Oct 5, 2021

1,000

1,000

1.51

1.95

Marginof Errorb

1,000

DesignEffecta

Aug 5 –
Dec 12, 2021

Number ofInterviews

16.2

Wave

Armenia

Country

2021

Settlements near territories
disputed with Azerbaijan
were not included for
insecurity reasons. The
excluded area represents
approximately 3% of the
population.

2021

126

Data Collection
Date

Data Collection
Year

Exclusions(Samples are nationally
representative unless
noted otherwise)

3.8

4.3

The Hologic Global Women’s Health Index | Global Report

Face-to-Face(HH)*© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

127

Cameroon

16.2

Jun 11 –Jul 4, 2021

1,007

1,000

Languages

Mode ofInterviewing

Marginof Errorb

DesignEffecta

Number ofInterviews

Data Collection
Date

Wave

Country

Data Collection
Year
2021

Exclusions(Samples are nationally
representative unless
noted otherwise)

3.8

Face-to-Face(HH)*

French,English,Fulfulde

Some arrondissements inthe Extreme North region,
the Northwest region and
the South West region were
excluded due to insecurity.
Neighborhoods with less than
50 households were also
excluded from the sampling.
The exclusion represents
20% of the total population.

1.39

3.6

Landlineand Mobile
Telephone

English,FrenchNorthwest Territories, Yukon
and Nunavut (representing
approximately 0.3% of theCanadian population) were
excluded.

1.49

2021

Canada16.3

Sep 3 –
Oct 26, 2021

2021

Chile

16.2

Aug 20 –Dec 22, 2021

1,000

1.52

3.8

Face-to-Face(HH)*

Spanish

2021

China

16.3

Nov 29, 2021
– Jan 4, 2022

3,500

2.66

2.7

MobileTelephone

Chinese2021

Colombia

16.4

Nov 5, 2021 –Jan 7, 2022

1,000

1.43

3.7

Landlineand Mobile
Telephone

Spanish2021

Congo,
Republicof the16.2

Jun 25 –Jul 21, 2021

1,000

1.62

3.9

Face-to-Face(HH)*

French,Kituba,Lingala2021

Costa Rica

16.3

Sep 23 –Nov 5, 2021

1,001

1.41

3.7

Landlineand Mobile
Telephone

Spanish2021

Croatia

16.3

Sep 30 –Nov 9, 2021

1,001

1.57

3.9

Landlineand Mobile
Telephone

Croatian

2021

Cyprus

16.3

Oct 5 –
Nov 17, 2021

1,019

2.11

4.5

Landlineand Mobile
Telephone

Greek,English

2021

Czech
Republic

16.4

Sep 1 –
Nov 16, 2021

1,003

1.58

3.9

Landlineand Mobile
Telephone

Czech

2021

Denmark

16.3

Sep 3 –
Oct 12, 2021

1,002

1.74

4.1

MobileTelephone

Danish2021

Dominican
Republic

16.2

Aug 1 –
Aug 30, 2021

1,000

1.32

3.6

Face-to-Face(HH)*

Spanish2021

Ecuador16.3

Oct 5 –
Dec 2, 2021

1,000

1.66

4.0

Landlineand Mobile
Telephone

SpanishThe Hologic Global Women’s Health Index | Global Report

Tibet was excluded from thesample. The excluded area
represents less than 1% of the
population.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

1,0031.53

3.8

Face-to-Face(HH)*

Arabic2021

El Salvador

16.2

Sep 22 –Nov 24, 2021

1,002

1.61

3.9

Face-to-Face(HH)*

Spanish2021

Estonia

16.4

Sep 9 –
Oct 16, 2021

1,001

1.53

3.8

MobileTelephone

Estonian,
Russian

2021

Finland

16.4

Aug 26 –Sep 28, 2021

1,006

1.37

3.6

MobileTelephone

Finnish2021

France16.4

Sep 6 –
Oct 5, 2021

1,000

1.53

3.8

Landlineand Mobile
TelephoneFrench

2021

Gabon

16.3

Nov 4 –
Nov 16, 2021

1,020

2.36

4.7

MobileTelephoneFrench,Fang

Marginof Errorb

Sep 4 –
Sep 28, 2021

DesignEffecta

16.2

Number ofInterviews

Egypt

Wave

2021

Frontier governorates(Matruh, Red Sea, New Valley,
North Sinai and South Sinai)
were excluded, as they are
remote and represent a small
proportion of the populationof the country. The excluded
areas represent less than 2%of the total population.

Country

Languages

Mode ofInterviewing

Data Collection
Date

Data Collection
Year

128

Exclusions(Samples are nationally
representative unless
noted otherwise)2021

Georgia

16.2

Jul 29 –Dec 5, 2021

1,000

1.42

3.7

Face-to-Face(HH)*

Georgian,
Russian

2021

Germany

16.4

Sep 6 –
Oct 2, 2021

1,000

2.44

4.8

Landlineand Mobile
Telephone

German

2021

Ghana

16.2

Jul 27 –Sep 11, 2021

1,000

1.48

3.8

Face-to-Face(HH)*

English,Ewe, Twi,
Dagbani,
Hausa

2021

Greece16.4

Aug 30 –Sep 24, 2021

1,009

2.03

4.4

Landlineand Mobile
Telephone

Greek

2021

Guinea16.2

Sep 4 –
Sep 27, 2021

1,000

1.40

3.8

Face-to-Face(HH)*

French,Malinke,
Pular,
Soussou

2021

Honduras

16.2

Sep 22 –Dec 21, 2021

1,000

1.98

4.4

Face-to-Face(HH)*

Spanish2021

Hong Kong,
S.A.R. of
China

16.3

Aug 18 –Nov 9, 2021

1,003

1.18

3.4

Landlineand Mobile
Telephone

ChineseThe Hologic Global Women’s Health Index | Global Report

South Ossetia and Abkhazia
were not included for thesafety of the interviewers.
In addition, very remotemountainous villages or thosewith less than 100 inhabitants
were also excluded. The
excluded areas represent
approximately 8% of the
population.

Localities with less than 100
inhabitants were excluded
from the sample. The
excluded areas represent
approximately 4% of the
population© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

129

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2021

Hungary

16.3

Nov 15 –Dec 17, 2021

1,003

1.90

4.3

Landlineand Mobile
Telephone

Hungarian

2021

Iceland16.3

Oct 5 –
Oct 31, 2021

502

1.38

5.1

Landlineand Mobile
Telephone

Icelandic

Exclusions(Samples are nationally
representative unless
noted otherwise)

2021

India

16.2

Jul 30 –Oct 18, 2021

3,000

1.34

2.1

Face-to-Face(HH)*

Assamese,
Bengali,
Gujarati,
Hindi,
Kannada,Malayalam,
Marathi,Odia,
Punjabi,
Tamil,
Telugu2021

Indonesia

16.2

Jul 7 –
Oct 15, 2021

1,062

1.42

3.6

Face-to-Face(HH)*

BahasaIndonesia

2021

Iran

16.4

Oct 8 –
Oct 14, 2021

1,005

1.31

3.5

Landlineand Mobile
Telephone

Farsi

2021

Iraq

16.2

Nov 1 –
Dec 9, 2021

1,012

1.66

4.0

Face-to-Face andFace-to-Face(HH)*

Arabic,Kurdish2021

Ireland16.3

Oct 18 –Nov 13, 2021

1,000

1.90

4.3

Landlineand Mobile
Telephone

English

1,000

1.16

3.3

Face-to-Face(HH)*

Hebrew,Arabic2021

Israel

16.2

Aug 15 –Nov 26, 2021

2021

Italy

16.4

Sep 6 –
Oct 2, 2021

1,000

2.59

5.0

Landlineand Mobile
Telephone

Italian

2021

Ivory Coast

16.2

Oct 28 –Nov 27, 2021

1,000

1.62

3.9

Face-to-Face(HH)*

French,Dioula2021

Jamaica

16.2

Sep 17 –Nov 24, 2021

502

1.36

5.1

Face-to-Face(HH)*

English

2021

Japan

16.3

Sep 29 –Dec 16, 2021

1,010

1.28

3.5

Landlineand Mobile
TelephoneJapanese

2021

Jordan16.3

Nov 8 – Dec
1, 2021

1,009

1.38

3.6

MobileTelephoneArabicThe Hologic Global Women’s Health Index | Global Report

Excluded population living inNortheast states and remoteislands, and Jammu andKashmir. The excluded areas
represent less than 10% of
the population.

The sample does not include
the area of East Jerusalem.
This area included in thesample of Palestinian
Territories.

For landline RDD, excluded
12 municipalities near the
nuclear power plant inFukushima. These areas
were designated as notto-call districts due to thedevastation from the 2011
disasters. The exclusion
represents less than 1% of the
population of Japan.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2021

Kazakhstan

16.2

Sep 3 –
Oct 19, 2021

1,000

1.46

3.8

Face-to-Face(HH)*

Russian,
Kazakh

2021

Kenya

16.2

Jun 19 –Jul 18, 2021

1,000

1.37

3.6

Face-to-Face(HH)*

English,Swahili[Kishwahili]

2021

Kosovo16.2

Jul 3 –
Oct 4, 2021

1,000

1.55

3.9

Face-to-Face(HH)*

Albanian,
Serbian

2021

Kyrgyzstan

16.2

Aug 26 –Oct 23, 2021

1,000

1.43

3.7

Face-to-Face(HH)*

Kyrgyz,Russian,
Uzbek

2021

Aug 30 –Dec 14, 2021

1,000

1.49

3.8

Face-to-Face
(HH)*

Lao

Excluded Xaisomboun
Province, Xayaboury Provinceand some communes thatare unreachable and/or havesecurity considerations. In
addition, during fieldwork,
Attapu and Houaphan
were also excluded due to
COVID-19 (red zones). The
excluded areas represent
approximately 14% of the
population.

2021

Latvia16.4

Oct 5 –
Nov 4, 2021

1,002

1.65

4.0

MobileTelephone

Latvian,Russian2021

Lebanon

16.4

Nov 24 –Dec 4, 2021

1,006

1.22

3.4

Landlineand Mobile
TelephoneArabic2021

Lithuania

16.3

Oct 20 –Dec 3, 2021

1,009

1.79

4.1

Landlineand Mobile
Telephone

Lithuanian

2021

Malawi16.2

Aug 2 –
Aug 13, 2021

1,000

1.42

3.7

Face-to-Face(HH)*

Chichewa,
English,TumbukaFace-to-Face(HH)*

BahasaMalay,
Chinese,EnglishLabuan and Putrajaya
were excluded due tolow population. The
excluded areas represent
approximately 1% of the
population.
The regions of Gao, Kidal,
Mopti and Tombouctou
were excluded because
of insecurity. Quartiersand villages with lessthan 50 inhabitants werealso excluded from thesample. The excluded areas
represent 23% of the total
population.

2021

130

Lao People's
Democratic 16.2
Republic

Exclusions(Samples are nationally
representative unless
noted otherwise)

Malaysia

16.3

Dec 17, 2021 –Jan 28, 2022

1,000

1.70

4.0

2021

Mali

16.2

Jul 15 –Aug 11, 2021

1,000

1.35

3.6

Face-to-Face(HH)*

French,Bambara

2021

Malta

16.3

Sep 14 –Nov 8, 2021

1,000

1.41

3.7

Landlineand Mobile
Telephone

Maltese,EnglishThe Hologic Global Women’s Health Index | Global Report© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2021

Mauritius

16.4

Aug 21 –Oct 14, 2021

1,000

1.90

4.3

Landlineand Mobile
Telephone

Creole,English,French2021

Mexico16.4

Nov 9, 2021 –Feb 1, 2022

1,003

1.86

4.2

Landlineand Mobile
Telephone

Spanish2021

Moldova,
Republic of

16.2

Jul 12 –Sep 10, 2021

1,000

1.25

3.5

Face-to-Face(HH)*

Romanian/
Moldavian,Russian

2021

Mongolia

16.2

Aug 20 –Oct 13, 2021

1,000

1.49

3.8

Face-to-Face(HH)*

Mongolian

2021

Morocco16.4

Nov 12 –Nov 28, 2021

1,004

1.75

4.1

MobileTelephone

MoroccanArabic2021

Mozambique 16.2

Oct 28 –Dec 16, 2021

1,000

1.87

4.2

Face-to-Face(HH)*

Portuguese,
Xichangana,Emakhuwa

2021

Myanmar16.3

Oct 9 –
Nov 11, 2021

1,000

2.01

4.4

MobileTelephone

Myanmar,Burmese2021

Namibia

16.2

Aug 29 –Oct 13, 2021

1,000

1.62

3.9

Face-to-Face(HH)*

English,Oshivambo,
Afrikaans

2021

Nepal

16.2

Sep 10 –Nov 19, 2021

1,000

1.45

3.7

Face-to-Face(HH)*

Nepali

Netherlands 16.4

Sep 6 –
Dec 3, 2021

1,000

1.57

3.9

Landlineand Mobile
Telephone

Dutch

2021

131

Exclusions(Samples are nationally
representative unless
noted otherwise)

2021

New
Zealand

16.4

Aug 16 –Sep 26, 2021

1,000

1.49

3.8

Landlineand Mobile
Telephone

English2021

Nicaragua

16.2

Sep 15 –Nov 23, 2021

1,007

1.62

3.9

Face-to-Face(HH)*

Spanish2021

Nigeria16.2

Jul 15 –Aug 20, 2021

1,000

1.91

4.3

Face-to-Face(HH)*

English,Hausa,
Igbo, Pidgin
English,Yoruba2021

North
Macedonia

16.3

Oct 22 –Dec 12, 2021

1,003

1.22

3.4

Landlineand Mobile
Telephone

Macedonian,
Albanian

2021

Norway16.3

Aug 31 –Oct 17, 2021

1,001

1.94

4.3

MobileTelephone

NorwegianThe Hologic Global Women’s Health Index | Global Report

Transnistria (Prednestrovie)
excluded for safety
of interviewers. The
excluded area represents
approximately 13% of the
population.

Cabo Delgado Province, as
well as a small number of
districts in other provinces,
was excluded due toinsecurity. The excluded
areas represent 11% of
population.

The states of Adamawa,
Borno and Yobe were
excluded for safety andsecurity reasons. Thesestates represent 7% of the
population.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Languages

Mode ofInterviewing

1.72

4.1

Face-to-Face
(HH)*

Urdu

2021

Panama16.2

Oct 4 –
Dec 17, 2021

1,002

1.64

4.0

Face-to-Face(HH)*

Spanish2021

Paraguay

16.2

Sep 1 –
Nov 11, 2021

1,000

1.37

3.6

Face-to-Face(HH)*

Spanish,Jopara

2021

Peru

16.2

Aug 22 –Oct 21, 2021

1,000

1.34

3.6

Face-to-Face(HH)*

Spanish

1,000

1.95

4.3

MobileTelephone

Filipino,
Iluko,
Cebuano,Bicol, Waray

Marginof Errorb

1,002

DesignEffecta

Oct 16 –Dec 14, 2021

Number ofInterviews

16.2

Wave

PakistanCountry2021

Did not include AJK, GilgitBaltistan. The excluded area
represents approximately 5%of the population. Gendermatched sampling was usedduring the final stage of
selection.

2021

Philippines

16.4

Aug 17 –Oct 13, 2021

2021

Poland

16.4

Aug 11 –Sep 8, 2021

1,006

1.43

3.7

Landlineand Mobile
Telephone

Polish2021

Portugal

16.3

Oct 8 –
Nov 8, 2021

1,002

1.74

4.1

Landlineand Mobile
Telephone

Portuguese2021

Romania

16.3

Sep 4 –
Oct 6, 2021

1,001

1.44

3.7

Landlineand Mobile
Telephone

Romanian

2021

RussianFederation

16.4

Aug 20, –Oct 25, 2021

2,000

1.49

2.7

Landlineand Mobile
Telephone

Russian

Saudi Arabia 16.3

Sep 5 –
Sep 20, 2021

1,019

2.02

4.4

Landlineand Mobile
TelephoneArabic,English,Hindi, Urdu

2021

2021

Senegal16.2

Aug 17 –Sep 9, 2021

1,000

1.49

3.8

Face-to-Face(HH)*

French,
Wolof

2021

Serbia16.3

Sep 29 –Dec 3, 2021

1,001

1.95

4.3

Landlineand Mobile
Telephone

SerbianSierra Leone 16.2

Jun 16 –Jul 19, 2021

1,001

1.46

3.7

Face-to-Face(HH)*

English,Krio, Mende

2021

2021

132

Data Collection
Date

Data Collection
Year

Exclusions(Samples are nationally
representative unless
noted otherwise)

Singapore

16.3

Nov 23, 2021
– Jan 17, 2022

1,000

1.24

3.4

The Hologic Global Women’s Health Index | Global Report

Face-to-Face(HH)*

English,ChineseIncludes Saudis, Arab
expatriates and non-Arabs
who were able to complete
the interview in Arabic,
English, Urdu or Hindi.

Twenty-eight of 55 Planning
Areas were excluded due tozero or small population size,accounting for less than 3%of the population. In addition,individuals living in private
condos or landed properties
were excluded, representing
approximately 20% ofhouseholds in Singapore.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

133

Data Collection
Year

Country

Wave

Data Collection
Date

Number ofInterviews

DesignEffectaMarginof Errorb

Mode ofInterviewing

Languages

2021

Slovakia

16.3

Sep 28 –Nov 6, 2021

1,005

1.51

3.8

Landlineand Mobile
Telephone

Hungarian,
Slovak

2021

Slovenia

16.3

Nov 10 –Dec 8, 2021

1,000

1.97

4.4

Landlineand Mobile
Telephone

Slovene

1,014

1.71

4.0

Face-to-Face(HH)*

Afrikaans,
English,Sotho,
Xhosa, Zulu

Exclusions(Samples are nationally
representative unless
noted otherwise)

2021

South Africa

16.2

Aug 6 –
Nov 8, 2021

2021

South Korea 16.3

Sep 8 –
Oct 31, 2021

1,011

1.59

3.9

Landlineand Mobile
Telephone

Korean

2021

Spain

16.3

Oct 18 –Nov 13, 2021

1,000

1.86

4.2

Landlineand Mobile
Telephone

Spanish2021

Sri Lanka

16.3

Nov 11 –Dec 28, 2021

1,005

2.47

4.9

MobileTelephone

Sinhala,
Tamil

2021

Sweden16.4

Aug 24 –Sep 29, 2021

1,002

1.53

3.8

Landlineand Mobile
Telephone

Swedish2021

Switzerland

16.4

Sep 6 –
Oct 6, 2021

1,000

1.60

3.9

Landlineand Mobile
Telephone

German,French,Italian

2021

Taiwan,Province of
China

16.3

Aug 16 –Sep 14, 2021

1,000

1.88

4.3

Landlineand Mobile
Telephone

Chinese2021

Tajikistan

16.2

Aug 18 –Oct 11, 2021

1,000

1.67

4.0

Face-to-Face
(HH)*

Tajik

2021

Tanzania

16.2

Aug 2 –
Aug 29, 2021

1,001

1.54

3.9

Face-to-Face(HH)*

Swahili[Kishwahili]

2021

Thailand

16.3

Oct 11 –Dec 1, 2021

1,017

2.03

4.4

MobileTelephone

Thai

2021

Togo

16.2

Sep 4 –
Sep 21, 2021

1,000

1.66

4.0

Face-to-Face(HH)*

French, Ewe

2021

Tunisia

16.2

Sep 24 –Oct 16, 2021

1,000

1.29

3.5

Face-to-Face(HH)*

Arabic2021

Türkiye16.3

Nov 24 –Dec 17, 2021

1,000

1.41

3.7

Landlineand Mobile
Telephone

Turkish2021

Uganda16.2

Sep 12 –Oct 5, 2021

1,000

1.46

3.7

Face-to-Face(HH)*

Ateso,English,Luganda,Runyankole

2021

Ukraine16.4

Sep 11 –Sep 28, 2021

1,000

1.80

4.2

Landlineand Mobile
Telephone

Russian,
Ukrainian

The Hologic Global Women’s Health Index | Global ReportThree districts in the Northregion were excluded for
security reasons: Kotido,
Moroto and Nakapiripirit. The
excluded areas represent 2%
or less of the population.

© 2022 Hologic, Inc. All rights expressly reserved.
GWHI_Global_Appendix2_073022_kn

Languages

1,000

1.41

3.7

MobileTelephone2021

UnitedKingdom ofGreat Britain 16.3
and Northern
IrelandOct 18 –Nov 12, 2021

1,000

1.47

3.8

Landlineand Mobile
Telephone

EnglishMarginof Errorb

Oct 19 –Nov 17, 2021

DesignEffecta

16.3

Number ofInterviews

United ArabEmirates

Includes only Emiratis, Arab
expatriates and non-Arabs
who were able to complete
the interview in Arabic,
English, Hindi or Urdu.

Wave

2021

Arabic,English,Hindi, Urdu

Country

Mode ofInterviewing

Data Collection
Date

Data Collection
Year

Exclusions(Samples are nationally
representative unless
noted otherwise)

2021

UnitedStates ofAmerica

16.3

Oct 5 –
Dec 27, 2021

1,007

1.61

3.9

Landlineand Mobile
Telephone

English,Spanish2021

Uruguay

16.2

Aug 24 –Nov 20, 2021

1,000

1.29

3.5

Face-to-Face(HH)*

Spanish2021

Uzbekistan

16.2

Aug 12 –Oct 6, 2021

1,000

1.65

4.0

Face-to-Face(HH)*

Uzbek,
Russian2021

Venezuela

16.3

Oct 4 –
Nov 24, 2021

1,000

1.72

4.1

Landlineand Mobile
Telephone

Spanish2021

Vietnam

16.3

Oct 14 –Nov 16, 2021

1,000

2.59

5.0

MobileTelephone

Vietnamese

2021

Zambia16.2

Aug 31 –Sep 28, 2021

1,000

1.54

3.9

Face-to-Face(HH)*

Bemba,English,Lozi,
Nyanja,
Tonga

2021

Zimbabwe

16.2

Jun 26 –Aug 8, 2021

1,000

1.40

3.7

Face-to-Face(HH)*

English,Shona,
NdebeleData Analysis Methodology
The analysis in this report sought to answer the critical research questions that motivated this study. In someinstances, this entailed reporting on the topline results for each country and area in the study; however, more
complex data analysis techniques often were required to better understand why and how attitudes toward scienceand health differed across the world or parts of the world, or within a certain population. This section explores theanalytical tools and techniques employed in this analysis.

Country Groupings
As the Hologic Global Women’s Health Index was fielded in 116 countries and territories in 2020 and 122 countries
and territories in 2021. The survey findings are often reported in various cross-national groupings to help illustrate theglobal variation of results without overburdening the reader by presenting data points from more than 120 different
countries and territories. The major types of country groupings used in this report are by country income breakdowns
described below.

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Presentation of Cross-Country Results
All results presented at a combined-country level — such as by region, country income level or at the overall (i.e.,‘global’) level — were weighted by the aged 15 and older population size of the countries included in the analysis.
This process gives more populated countries more weight than less populated countries.
For example, in 2020 China had the largest population of the 116 countries included in the Hologic Global Women’s
Health Index. China’s aged 15 and older population represented about 22% of the total 15 and older population
across the countries and areas surveyed, according to the national census figures Gallup used in its sampling andweighting processes. Thus, when presenting global estimates in this report, respondents from China were given agreater weight — corresponding to their share of the population — in determining the final calculation.

Standardization of Income, Education and Employment Groups
Personal information such as income, education and employment can be defined or measured differently acrosscountries, which can create challenges when attempting to compare cross-country results.
For this reason, the Hologic Global Women’s Health Index examined these characteristics using standardized
definitions of income and education (shown below) that have been developed by the Gallup World Poll. Additionally,
employment status was defined in a manner consistent with the Bureau of Labor Statistics in the United States.

Country income level
Countries were divided into four income groupings, as defined by the World Bank:
The World Bank updates its classifications annually on July 1 based on the GNI per capita in current USD of theprevious year.
In 2020 these categories were:• Low income: Gross national income (GNI) per capita of $1,035 or less (in 2019)• Lower-middle income: GNI per capita of $1,036 to $4,045• Upper-middle income: GNI per capita of $4,046 to $12,535• High income: GNI per capita above $12,535
In 2021 these categories were:• Low income: GNI per capita of $1,035 or less (in 2019)• Lower-middle income: GNI per capita of $1,046 to $4,095• Upper-middle income: GNI per capita of $4,096 to $12,695• High income: GNI per capita above $12,695
Note: The World Bank does not classify Venezuela in any of the categories. When the country averages arepresented at their country income level breaks, Venezuela is not included.

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Education
Countries have unique ways of classifying education levels, and these classifications need to be preserved during
data collection for weighting purposes. However, to make comparisons across countries by educational attainment,
consistent categories needed to be created. All education descriptions can be placed within three categories:
primary, secondary and tertiary. All responses regarding education were coded into their relevant category for
global comparison.

• Primary: Functional equivalent to completing primary education or lower secondary or less. This level is closest
to completing up to eight years of education. The exact definition will vary by country.

• Secondary: Functional equivalent to completing some secondary up to some tertiary education. This category
typically refers to individuals who have completed nine to 15 years of education but have not completed theequivalent of a bachelor’s degree. The exact definition will vary by country.

• Tertiary: Functional equivalent to completing four years of post-secondary tertiary education, or the equivalent ofa bachelor’s degree. This level typically refers to individuals who have completed approximately 16 or more yearsof education. The exact definition will vary by country.

Employment
Gallup classified respondents into one of six employment categories based on a respondent’s combination ofanswers to a series of questions about employment.

• Employed full time for an employer: A respondent is considered employed full time for an employer if they are
employed by an employer and work for this employer for at least 30 hours per week.

• Employed full time for self: Respondents are considered employed full time for themselves if they are selfemployed and work at least 30 hours per week.

• Employed part time, do not want to work full time: Respondents who work either for an employer or themselvesand do not work more than 30 hours per week at either job are categorized as employed part time. Additionally,
when asked, these respondents indicate that they do not want to work more than 30 hours per week.

• Employed part time, want to work full time: Respondents who work either for an employer or themselves and do
not work more than 30 hours per week at either job are categorized as employed part time. Additionally, when
asked, these respondents indicate that they do want to work more than 30 hours per week.

• Unemployed: A respondent is unemployed if they report not being employed in the last seven days, either for an
employer or themselves. The respondent must also report actively looking for a job in the past four weeks AND
being able to begin work in the last four weeks.

• Out of the workforce: Respondents who are out of the workforce, were not employed within the last sevendays either for an employer or themselves, are not looking for work, AND/OR are not available to start work.
Respondents may be full-time students, retired, disabled or homemakers; however, some respondents will not
fall into any of these scenarios.

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