Country-level gender inequality is associated with structural differences in the brains of women and men.

Gender inequality across the world has been associated with a higher risk to mental health problems and lower academic achievement in women compared to men. We also know that the brain is shaped by nurturing and adverse socio-environmental experiences. Therefore, unequal exposure to harsher conditions for women compared to men in gender-unequal countries might be reflected in differences in their brain structure, and this could be the neural mechanism partly explaining women's worse outcomes in gender-unequal countries. We examined this through a random-effects meta-analysis on cortical thickness and surface area differences between adult healthy men and women, including a meta-regression in which country-level gender inequality acted as an explanatory variable for the observed differences. A total of 139 samples from 29 different countries, totaling 7,876 MRI scans, were included. Thickness of the right hemisphere, and particularly the right caudal anterior cingulate, right medial orbitofrontal, and left lateral occipital cortex, presented no differences or even thicker regional cortices in women compared to men in gender-equal countries, reversing to thinner cortices in countries with greater gender inequality. These results point to the potentially hazardous effect of gender inequality on women's brains and provide initial evidence for neuroscience-informed policies for gender equality.

Why We Should Stop Trying to Fix Women: How Context Shapes and Constrains Women's Career Trajectories.

In this review we examine two classes of interventions designed to achieve workplace gender equality: (a) those designed to boost motivations and ambition, such as those that aim to attract more women into roles where they are underrepresented; and (b) those that try to provide women with needed abilities to achieve these positions. While such initiatives are generally well meaning, they tend to be based upon (and reinforce) stereotypes of what women lack. Such a deficit model leads to interventions that attempt to "fix" women rather than address the structural factors that are the root of gender inequalities. We provide a critical appraisal of the literature to establish an evidence base for why fixing women is unlikely to be successful. As an alternative, we focus on understanding how organizational context and culture maintain these inequalities by looking at how they shape and constrain (a) women's motivations and ambitions, and (b) the expression and interpretation of their skills and attributes. In doing so, we seek to shift the interventional focus from women themselves to the systems and structures in which they are embedded.

Hiring women into senior leadership positions is associated with a reduction in gender stereotypes in organizational language.

Women continue to be underrepresented in leadership positions. This underrepresentation is at least partly driven by gender stereotypes that associate men, but not women, with achievement-oriented, agentic traits (e.g., assertive and decisive). These stereotypes are expressed and perpetuated in language, with women being described in less agentic terms than men. The present research suggests that appointing women to the top tiers of management can mitigate these deep-rooted stereotypes that are expressed in language. We use natural language processing techniques to analyze over 43,000 documents containing 1.23 billion words, finding that hiring female chief executive officers and board members is associated with changes in organizations' use of language, such that the semantic meaning of being a woman becomes more similar to the semantic meaning of agency. In other words, hiring women into leadership positions helps to associate women with characteristics that are critical for leadership success. Importantly, our findings suggest that changing organizational language through increasing female representation might provide a path for women to break out of the double bind: when female leaders are appointed into positions of power, women are more strongly associated with the positive aspects of agency (e.g., independent and confident) in language but not at the cost of a reduced association with communality (e.g., kind and caring). Taken together, our findings suggest that female representation is not merely an end, but also a means to systemically change insidious gender stereotypes and overcome the trade-off between women being perceived as either competent or likeable.

Chronic frames of social inequality: How mainstream media frame race, gender, and wealth inequality.

How social inequality is described­as advantage or disadvantage­critically shapes individuals' responses to it [e.g., B. S. Lowery, R. M. Chow, J. R. Crosby, J. Exp. Soc. Psychol. 45, 375­378, 2009]. As such, it is important to document how people, in fact, choose to describe inequality. In a corpus of 18,349 newspaper articles (study 1), in 764 hand-coded news media publications (study 2), and in a preregistered experiment of 566 lay participants (study 3), we document the presence of chronic frames of race, gender, and wealth inequality. Specifically, race and gender inequalities are more likely to be framed as subordinate groups' disadvantages than as dominant groups' advantages, and wealth inequality is more likely to be described with no frame (followed by dominant group advantage, then subordinate group disadvantage). Supplemental lexicon-based text analyses in studies 1 and 2, survey results in study 3, and a preregistered experiment (study 4; N = 578) provide evidence that the differences in chronic frames are related to the perceived legitimacy of the inequality, with race and gender inequalities perceived as less legitimate than wealth inequality. The presence of such chronic frames and their association with perceived legitimacy may be mechanisms underlying the systematic inattention to White individuals' and men's advantages, and the disadvantages of the working class.

Pragmatic bias impedes women's access to political leadership.

Progress toward gender equality is thwarted by the underrepresentation of women in political leadership, even as most Americans report they would vote for women candidates. Here, we hypothesize that women candidates are often disadvantaged by pragmatic bias, a tendency to withhold support for members of groups for whom success is perceived to be difficult or impossible to achieve. Across six studies (N = 7,895), we test whether pragmatic bias impedes women's access to a highly significant political leadership position-the US presidency. In two surveys, 2020 Democratic primary voters perceived women candidates to be less electable, and these beliefs were correlated with lower intentions to vote for women candidates (Studies 1 and 2). Voters identified many reasons women would be less electable than men, including others' unwillingness to vote for women, biased media coverage, and higher requirements to prove themselves. We next tested interventions to reduce pragmatic bias. Merely correcting misperceptions of Americans' reported readiness for a woman president did not increase intentions to vote for a woman (Study 3). However, across three experiments (including one preregistered on a nationally representative sample), presenting evidence that women earn as much support as men in US general elections increased Democratic primary voters' intentions to vote for women presidential candidates, an effect driven by heightened perceptions of these candidates' electability (Studies 4 to 6). These findings highlight that social change efforts can be thwarted by people's sense of what is possible, but this may be overcome by credibly signaling others' willingness to act collectively.

Gender-diverse teams produce more novel and higher-impact scientific ideas.

Science's changing demographics raise new questions about research team diversity and research outcomes. We study mixed-gender research teams, examining 6.6 million papers published across the medical sciences since 2000 and establishing several core findings. First, the fraction of publications by mixed-gender teams has grown rapidly, yet mixed-gender teams continue to be underrepresented compared to the expectations of a null model. Second, despite their underrepresentation, the publications of mixed-gender teams are substantially more novel and impactful than the publications of same-gender teams of equivalent size. Third, the greater the gender balance on a team, the better the team scores on these performance measures. Fourth, these patterns generalize across medical subfields. Finally, the novelty and impact advantages seen with mixed-gender teams persist when considering numerous controls and potential related features, including fixed effects for the individual researchers, team structures, and network positioning, suggesting that a team's gender balance is an underrecognized yet powerful correlate of novel and impactful scientific discoveries.

Gender inequality and utilization of ART: an international cross-sectional and longitudinal analysis.

STUDY QUESTION: What is the association between a country's level of gender equality and access to ART, as measured through ART utilization? SUMMARY ANSWER: ART utilization is associated with a country's level of gender equality even after controlling for the level of development. WHAT IS KNOWN ALREADY: Although gender equality is recognized as an important determinant of population health, its association with fertility care, a highly gendered condition, has not been explored. STUDY DESIGN, SIZE, DURATION: A longitudinal cross-national analysis of ART utilization in 69 countries during 2002-2014 was carried out. PARTICPANTS/MATERIALS, SETTING, METHODS: The Gender Inequality Index (GII), Human Development Index (HDI), and their component indicators were modelled against ART utilization using univariate regression models as well as mixed-effects regression methods (adjusted for country, time, and economic/human development) with multiple imputation to account for missing data. MAIN RESULTS AND THE ROLE OF CHANCE: ART utilization is associated with the GII. In an HDI-adjusted analysis, a one standard deviation decrease in the GII (towards greater equality) is associated with a 59% increase in ART utilization. Gross national income per capita, the maternal mortality ratio, and female parliamentary representation were the index components most predictive of ART utilization. LIMITATIONS, REASONS FOR CAUTION: Only ART was used rather than all infertility treatments (including less costly and non-invasive treatments such as ovulation induction). This was a country-level analysis and the results cannot be generalized to smaller groups. Not all modelled variables were available for each country across 2002-2014. WIDER IMPLICATIONS OF THE FINDINGS: Access to fertility care is central to women's sexual and reproductive health, to women's rights, and to human rights. As gender equality improves, so does access to ART. This relation is likely to be reinforcing and bi-directional, with progress towards global, equitable access to fertility care also improving women's status and participation in societies. STUDY FUNDING/COMPETING INTEREST(S): External funding was not provided for this study. G.D.A. declares consulting fees from Labcorp and CooperSurgical. G.D.A. is the founder and CEO of Advanced Reproductive Care, Inc., as well as the Chair of the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) and the World Endometriosis Research Foundation, both of which are unpaid roles. G.M.C. is an ICMART Board Representative, which is an unpaid role, and no payments are received from ICMART to UNSW, Sydney, or to G.M.C. to undertake this study. O.F., S.D., F.Z.-H., and E.K. report no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

The brother's penalty: Boy preference and girls' health in rural China.

This paper identifies the health penalty experienced by girls due to having a brother from endogenous sibling gender composition. We propose a girls-to-girls comparison strategy and rule out the confounding effect from the sibship size, birth interval, and birth order. Employing an instrumental variable approach and data from the Chinese Family Panel Studies, we find that girls with a brother are demonstrably shorter and report poorer health. This "brother's penalty" manifests even prenatally. Alternative explanations, such as birth order disadvantages, are carefully addressed and ruled out. The results hold even after excluding gender-neutral ethnic minorities. This observed penalty is likely attributed to unequal resource allocation within families and potential parental neglect. This penalty is amplified in families with lower income and maternal education, implying resource constraints contribute to gender discrimination. Our findings highlight the importance of addressing intrafamily gender bias for ensuring equal opportunities and health outcomes. Clinical trial registration: Not applicable.

Gender inequality and burden of orofacial clefts in the Eastern Mediterranean region: findings from global burden of disease study 1990-2019.

BACKGROUND: Gender inequality may be associated with the burden of orofacial clefts (OFCs), particularly in low-and middle-income countries (LMICs). To investigate the OFCs' burden and its association with gender inequality in the Eastern Mediterranean region (EMR). METHODS: Country-specific data on the OFCs' prevalence and Disability-Adjusted Life Years (DALYs) from 1990 to 2019 were gathered from the Global Burden of Disease database by age and gender. Estimated annual percentage change (EAPCs) was used to investigate the OFCs' trends. The association of the Gender Inequality Index (GII) with prevalence and DALY rates was determined using multiple linear regression. Human Development Index (HDI), Socio-Demographic Index (SDI), and Gross Domestic Product (GDP) were also considered as potential confounders. RESULTS: In 2019, the overall regional OFCs' prevalence and DALYs (per 100,000 person-years) were 93.84 and 9.68, respectively. During the 1990-2019 period, there was a decrease in prevalence (EAPC = -0.05%), demonstrating a consistent trend across genders. Moreover, within the same timeframe, DALYs also declined (EAPC = -2.10%), with a more pronounced reduction observed among females. Gender differences were observed in age-specific prevalence rates (p-value = 0.015). GII was associated with DALYs (ßmale= -0.42, p-value = 0.1; ßfemale = 0.48, p-value = 0.036) and prevalence (ßmale= -1.86, p-value < 0.001, ßfemale= -2.07, p-value < 0.001). CONCLUSIONS: Despite a declining prevalence, the burden of OFCs remained notably significant in the EMR. Gender inequality is associated with the burden of OFCs in the Eastern Mediterranean region. Countries in the region should establish comprehensive public policies to mitigate gender inequalities in healthcare services available for OFCs.

Pre- and post-COVID-19 gender trends in authorship for paediatric radiology articles worldwide: a systematic review.

BACKGROUND: Gender inequalities in academic medicine persist despite progress over the past decade. Evidence-based targeted interventions are needed to reduce gender inequalities. OBJECTIVE: This systematic review aimed to investigate the impact of COVID-19 on gender trends in authorship of paediatric radiology research worldwide. MATERIALS AND METHODS: This prospectively registered, PRISMA-compliant systematic review searched the following databases: PubMed, MEDLINE, Web of Science, and Scopus from January 1, 2018, to May 29, 2023, with no restrictions on country of origin. Screening and data extraction occurred independently and in duplicate. Gender of first, last, and corresponding authors were determined using an artificial intelligence-powered, validated, multinational database ( www.genderize.io ). Two time periods were categorised according to the Johns Hopkins Center for Systems Science and Engineering: pre-COVID (prior to March 2020) and peak and post-COVID (March 2020 onwards). One-sample binomial testing was used to analyse proportion of authorship based on gender. Categorical variables were described as frequencies and percentages, and compared using testing chi-square or Fisher exact testing, with a threshold of P<0.05 representing statistical significance. RESULTS: In total, 922 articles were included with 39 countries represented. A statistically significant difference in authorship based on gender persisted during the peak and post-COVID time period (March 2020 onwards) where women represented a statistically significant lower proportion of last (35.5%) and corresponding (42.7%) authors (P<0.001, P=0.001, respectively). Statistically significant differences for first authors were not found in either period (P=0.08 and P=0.48). CONCLUSION: This study identifies differences in gender trends for authorship in paediatric radiology research worldwide. Future efforts to increase authorship by women are needed.

Gender inequities in the online dissemination of scholars' work.

Unbiased science dissemination has the potential to alleviate some of the known gender disparities in academia by exposing female scholars' work to other scientists and the public. And yet, we lack comprehensive understanding of the relationship between gender and science dissemination online. Our large-scale analyses, encompassing half a million scholars, revealed that female scholars' work is mentioned less frequently than male scholars' work in all research areas. When exploring the characteristics associated with online success, we found that the impact of prior work, social capital, and gendered tie formation in coauthorship networks are linked with online success for men, but not for women-even in the areas with the highest female representation. These results suggest that while men's scientific impact and collaboration networks are associated with higher visibility online, there are no universally identifiable facets associated with success for women. Our comprehensive empirical evidence indicates that the gender gap in online science dissemination is coupled with a lack of understanding the characteristics that are linked with female scholars' success, which might hinder efforts to close the gender gap in visibility.

Gender role beliefs and adolescent pregnancy in Colombia: findings from the 2015 DHS survey.

This study investigated the association between gender role beliefs and the prevalence and likelihood of experiencing pregnancy among 8525 young women and girls aged 13-19 years in Colombia. The primary outcome of interest was adolescent pregnancy. Retrospective cross-sectional analysis utilised data from the 2015 Demographic and Health Survey (DHS) in Colombia, which included an add-on questionnaire on gender relations. Our analysis measured both pregnancy prevalence and pregnancy likelihood in relation to gender role beliefs. With one exception, young women who disagreed with traditionally conforming gender roles had a lower prevalence of pregnancy and were less likely to experience pregnancy than those who agreed with them. The highest likelihood of pregnancy prevalence and likelihood was found among those who agreed with statements suggesting male dominance and those who agreed with women's homemaking responsibilities. The greater the adherence to traditionally conforming gender role beliefs, the higher the likelihood of experiencing pregnancy during adolescence. Girls' and young women's adherence to traditional gender role beliefs appeared to be a risk factor for adolescent pregnancy. Our findings support Colombia's current sex education policies and practices within the framework of gender equity, and evidence the link between gender equity and girls' and young women's reproductive health.

"You feel like you're fairly disadvantaged with an advert over your head saying 'in final years of reproduction'": social egg freezing, dating and the (unequal) politics of reproductive ageing.

Recent decades have seen an increasing gap occurring between the 'desired' and 'actual' family size of middle-class and professional women. This situation of 'unrealised fertility' and 'incomplete families' carries implications at a population, but also couple and individual level. This paper explores how middle-class professional women make decisions about partnering and parenthood and how these are shaped by a contemporary neoliberal feminist discourse which articulates the possibility of 'having it all' through engagement in careful life planning, appropriate self-investment, and by drawing on new technologies of reproductive biomedicine. Informed by semi-structured interviews with UK and US women conducted at two different points in time, it explores how they approach and experience the process of relationship formation in the face of age-related fertility decline. It also examines how the use of social egg freezing shape their romantic and family building expectations but also their interactions with (potential) partners. In doing so, it explores how gendered cultural dating scripts and unequal gender power relations shape the formation and progression of intimate relationships in a manner which can disempower women as they age. It therefore questions whether egg freezing may be the 'great equaliser' that some have hoped.

Decoding worldwide efficiency: Linking government spending, corruption, gender inequality, and renewable energy practices.

Countries have become increasingly concerned about the impact of their activities and their alignment with sustainable development goals. Consequently, it is necessary to examine their performance efficiency in a unified manner, accounting for economic, environmental, and social variables. A country's performance efficiency is defined as the ratio of observed output to frontier output, given the country's productive resources. In this paper, we use the frontier technique of Data envelopment analysis (DEA) to estimate the frontier output. The objective of this study is to assess the performance efficiency of 111 worldwide countries and to examine whether gender inequality, the share of renewable energy consumption, the government control of corruption and government expenditure on education could explain differences in performance. We employed the non-parametric DEA model using three inputs (capital, labor, and primary energy consumption) and one output (GDP). We also considered an additional output (CO2 emissions); however, the results were identical to the one output model because CO2 emissions and primary energy consumption are highly correlated (0.96). We find that there is a negative impact of gender inequality, a positive impact of the share of renewable energy consumption and government control of corruption on performance efficiency. Our results also indicate that reducing CO2 emissions required transitioning towards renewable energy and using the energy efficiently. However, we did not find a positive relationship between government expenditures on education and country efficiency.

Case-study: A wicked way to address family violence in a regional setting in Western Australia.

ISSUE ADDRESSED: Communication tools have long been used to address complex social policy problems, known as wicked problems, in communities around the world. However, the challenge has remained, how do we measure the impact of social change with communication for development (C4D)? Evaluators recommend utilising evaluation tools that take a wider systems-based approach to assist in the evaluation of C4D projects. Health Communication Resources (HCR) Inc., a health promotion charity that supports C4D projects around the world, aimed to trial a tool to assist evaluation of a project addressing gender inequality, an underlying driver of family violence in the community. METHODS: WickedLab's tool for systemic change was utilised to assist the evaluation of the complex adaptive system. The research team mapped the system that existed in Geraldton working towards addressing the wicked problem of gender inequality. RESULTS: Mapping the system highlighted how integral C4D actions were in maintaining and strengthening the system as it works together towards gender equality in the community. CONCLUSION: A systems-based approach can strengthen evaluation and demonstrates the role C4D projects play in addressing wicked problems in a defined location. SO WHAT?: WickedLab's tool for systemic change provides significant potential for the evaluation of other health promotion and communication for development projects.

Sexual violence in conflicts: the shadow pandemic. A review of controversial issues.

This article explores the persistent and deeply troubling issue of conflict-related sexual violence (CRSV) throughout history and in contemporary conflicts. It examines the roots of wartime sexual violence in wartime, the evolving international legal framework for the protection of civilians, and the emergence of concerns about the protection of women and girls from such violence. The article delves into controversial aspects, including competing theories to explain CRSV, the challenges in obtaining accurate data on its prevalence, and the often-overlooked issue of CRSV against men and boys. It also addresses the cultural and societal factors that perpetuate CRSV and the long-lasting consequences on survivors. The article concludes by underscoring the importance of comprehensive care for survivors and the need to tackle the deep-seated causes of this violence, including gender inequality.

Development of the Gender Roles and Male Provision Expectations Scale.

Existing composite measures assess the extent to which women and men support masculinity ideals concerning the expectation that men should provide for their partners and families. In many contexts across sub-Saharan Africa, the male provider role is taken as given. This core masculinity tenet may be associated with related gender role expectations that result in increasing young women's risk of HIV, especially within the context of transactional sex relationships. Extant literature points to five domains potentially associated with male provider role expectations: male authority, men's sexual decision-making control, women's sexual agency, women's economic dependence, and love. The goal of this study was to develop the Gender Roles and Male Provision Expectations (GRMPE) scale toward understanding whether beliefs attached to male provider role expectations increase HIV risk. We developed the GRMPE across three research phases with young women (ages 15-24) in Central Uganda that (1) used qualitative data to refine domains and develop scale items; (2) cognitively tested the refined items; and (3) pilot tested a 26-item scale across five domains with 108 young women. Using confirmatory factor analyses, we retained 15 items across four factors, corresponding to the domains of male authority, sexual decision-making, women's sexual agency, and love; which we then modeled as indicators in a single second-order factor model. The GRMPE demonstrated initial reliability and validity, and tests of criterion validity found significant associations with known HIV risk behaviors. The GRMPE scale shows promise for better examining the determinants of HIV risk and assessing gender norm change interventions.

Unequal Duties and Unequal Retirement: Decomposing the Women's Labor Force Decline in Postreform China.

The gender gap in labor force participation (LFP) in China has grown over the last 30 years, despite substantial advances in women's education and economic development. Previous research has identified gender discrimination and work-family conflicts as two key explanations for the gap, both of which have risen since the start of China's economic reform in 1978. Using multiple waves of the national census and household panel data from China, this research shows that one overlooked mechanism widening the LFP gender gap lies in the institutional constraints that require women to retire earlier than men. This research also demonstrates how the impact of women's early retirement on the LFP gender gap has been exacerbated by two societal-level changes: (1) population aging, which increased the share of women who reached the retirement age; and (2) economic development, which increased the number of women entering nonfarming occupations and, hence, the gender-based retirement system. These findings suggest that without significant revisions to China's retirement system, the LFP gender gap will continue to expand as the population ages and economic development proceeds.

Systemic structural gender discrimination and inequality in the health workforce: theoretical lenses for gender analysis, multi-country evidence and implications for implementation and HRH policy.

This commentary brings together theory, evidence and lessons from 15 years of gender and HRH analyses conducted in health systems in six WHO regions to address selected data-related aspects of WHO's 2016 Global HRH Strategy and 2022 Working for Health Action Plan. It considers useful theoretical lenses, multi-country evidence and implications for implementation and HRH policy. Systemic, structural gender discrimination and inequality encompass widespread but often masked or invisible patterns of gendered practices, interactions, relations and the social, economic or cultural background conditions that are entrenched in the processes and structures of health systems (such as health education and employment institutions) that can create or perpetuate disadvantage for some members of a marginalized group relative to other groups in society or organizations. Context-specific sex- and age-disaggregated and gender-descriptive data on HRH systems' dysfunctions are needed to enable HRH policy planners and managers to anticipate bottlenecks to health workforce entry, flows and exit or retention. Multi-method approaches using ethnographic techniques reveal rich contextual detail. Accountability requires that gender and HRH analyses measure SDGs 3, 4, 5 and 8 targets and indicators. To achieve gender equality in paid work, women also need to achieve equality in unpaid work, underscoring the importance of SDG target 5.4. HRH policies based on principles of substantive equality and nondiscrimination are effective in countering gender discrimination and inequality. HRH leaders and managers can make the use of gender and HRH evidence a priority in developing transformational policy that changes the actual conditions and terms of health workers' lives and work for the better. Knowledge translation and intersectoral coalition-building are also critical to effectiveness and accountability. These will contribute to social progress, equity and the realization of human rights, and expand the health care workforce. Global HRH strategy objectives and UHC and SDG goals will more likely be realized.

"I stretch them out as long as possible:" U.S. women's experiences of menstrual product insecurity during the COVID-19 pandemic.

BACKGROUND: A growing body of evidence highlights how the COVID-19 pandemic has exacerbated gender inequalities in the US. This resulted in women being more vulnerable to economic insecurity and decreases in their overall well-being. One relevant issue that has been less explored is that of women's menstrual health experiences, including how inconsistent access to menstrual products may negatively impact their daily lives. METHODS: This qualitative study, conducted from March through May 2021, utilized in-depth interviews that were nested within a national prospective cohort study. The interviews (n = 25) were conducted with a sub-sample of cis-gender women living across the US who had reported challenges accessing products during the first year of the pandemic. The interviews sought to understand the barriers that contributed to experiencing menstrual product insecurity, and related coping mechanisms. Malterud's 'systematic text condensation', an inductive thematic analysis method, was utilized to analyze the qualitative transcripts. RESULTS: Respondents came from 17 different states across the U.S. Three key themes were identified: financial and physical barriers existed to consistent menstrual product access; a range of coping strategies in response to menstrual product insecurity, including dependence on makeshift and poorer quality materials; and heightened experiences of menstrual-related anxiety and shame, especially regarding the disclosure of their menstruating status to others as a result of inadequate menstrual leak protection. CONCLUSIONS: Addressing menstrual product insecurity is a critical step for ensuring that all people who menstruate can attain their most basic menstrual health needs. Key recommendations for mitigating the impact of menstrual product insecurity require national and state-level policy reform, such as the inclusion of menstrual products in existing safety net basic needs programs, and the reframing of menstrual products as essential items. Improved education and advocacy are needed to combat menstrual stigma.