Health

18 10 2016

Research in Gender and Ethics (RinGs): Building Stronger Health Systems at #HSR2016

A summary of RinGs’ events and sessions at #HSR2016

18 October 2016

RinGs’ is excited to announce our involvement at the Fourth Global Symposium on Health Systems Research, held in Vancouver from 14-18 November 2016. Our events include a skills-building session on how to do gender analysis in health systems research, presentations and posters focusing on gender, ethics, and intersectionality, and a gender networking mixer.

See below for a summary of events and sessions that we are involved in:

Monday 14 November

8:00-12:00

How to do gender analysis in health systems research

Location: Meeting room 1600, Simon Fraser University at Harbour Centre, 515 West Hastings St

Health systems are not gender neutral; yet, health systems research (HSR) often fails to sufficiently consider gender as a social relation. The aim of this participatory session is to provide those interested in HSR with an introduction about how to conduct gender analysis within HSR.

Wednesday 16 November

11:00-12:30

Building resilient and responsive health systems in fragile and conflict affected contexts: equity, rights and gender

Location: Meeting room 19

This panel will share and update an e-resource on gender, equity and resilient health systems in fragile and conflict affected contexts. BuildingBackBetter.org analyses health system engagement in fragile contexts, and shows that such engagement can and should promote gender equitable health systems.

14:00-15:30

Disability, equity and rights: sharing intersectional approaches to building responsive, resilient and inclusive health systems

Location: Meeting room 12

Power and prejudice: how does inequity play out in the institutions and processes of health systems research?

Location: Meeting room 13

Too often inequities in terms of gender, age, class, sexuality, ethnicity, nationality within research systems, organisations and institutions are not the subject of enquiry. In this session we will interrogate these issues and formulate strategies to overcome the abuse of power and prejudice that hampers health systems research.

17:30-20:00

Gender Networking Meet & Greet

Location: P2B Bistro & Bar, Pinnacle Hotel Harbourfront, 1133 W Hastings St

Research in Gender and Ethics (RinGs): Building Stronger Health Systems, in conjunction with Women in Global Health, is hosting a gender networking meet and greet at the Fourth Global Symposium on Health Systems Research. If you work on gender and health systems, or are interested in the topic, please come and join us! All are welcome!

Thursday 17 November

12:30-14:00

Poster: How gender roles and relations affect health workers’ training opportunities and career progression in rural Zimbabwe: Implications for equitable health systems.

Location: Abstract ID: 2247, Poster #: GE-ip31

E-Poster: Why aren’t women rising to the top? The gendered factors that affect women’s professional progression in the Cambodian health sector

Location: Abstract ID: 2025, Screen #: 1

Friday 18 November

10:30-12:00

Ethics and equity in health systems research collaborations and conduct

Location: Meeting room 9

This session brings together innovative presentations that develop new concepts and approaches for incorporating ethical values and human rights considerations into health system operations (e.g. service delivery, governance, monitoring and evaluation). The ethical value of health justice is a common theme. Presentations in this session rely on a range of methodologies, including applied philosophy, photovoice, focus groups, interviews, and surveys, to develop these approaches, and draw on diverse experiences such as those of community health workers in Uganda and local government and civil society in India. Together they showcase ways to go forward for health care providers, policymakers, and implementers of family planning programs.

13:30-15:00

Integrating ethical values and human rights concerns into health system operations

Location: Meeting room 9

This session brings together multiple cutting-edge presentations on the ethics of health systems research, applying the specific lenses of gender, power, and health justice to the topic. It will explore how health equity can be promoted through research practice and consortia governance. It will consider how gender and power relationships/dynamics shape the ethical issues that arise and the translation of ethical requirements into practice during the conduct of health systems research. The ethical guidance presented in this session draws from political philosophy, the outputs of dialogue-based methods, and multiple case studies from the African context.

Other

E-Poster: Are women of Indian Sundarbans living in the Dark? A gender analysis of eye health in the Indian Sundarbans for responsive health systems

Location: HSG website

For more information e-mail RinGs.RPC@gmail.com

14 10 2016

Gender & Health System Leadership: Increasing Women’s Representation at the Top

This blog explores strategies to increase representation of women in health system leadership

Radhika Arora, Esther Nakkazi and Rosemary Morgan

14 October 2016

Women make up the bulk of the healthcare workforce but so few are in the top leadership roles. The role of women in leadership, or rather the lack of women in leadership positions and its impact on health policies, is indeed one which we must continue to question. What are the implications of having so few women at the top? How do we encourage the representation of women at the top? And, if more women were in healthcare leadership positions would we have better policies, remuneration and better long-term improvements in the sector?

The majority of health workers in lower tiered positions, such as within primary health care provision, are women. Despite women making up a significant proportion of health care workers, they are grossly underrepresented in leadership positions across the world. This is not unique to the health sector. In the corporate world, for example, the report on The State of Women in Healthcare: 2015 indicates that only 4% of CEOs are women.

Greater participation of women at the leadership level has been shown to result in policies which enhance the position and rights of women. For instance, Rwanda which has the highest level of women parliamentarians of any country, has also over the years invested in policies on ending violence and discrimination, investing more in health services, and investing more in improving women’s participation in the workforce. In the case of Rwanda, the participation of women at the political level went way beyond the 30% quota instilled in 2003. Contrast this to the Kurdistan Region of Iraq, where a study revealed that women constitute only 3% of leadership positions. This raises the question of the need for, and role of, quotas for women at the leadership level.

Encouraging women’s representation through quotas?

Deliberate efforts like putting quotas, reservations, and affirmative action to ensure participation of people from marginalized, vulnerable or less vocal sections of the populations could encourage more women’s participation at multiple levels of policymaking and the workforce. But do they really work? Are quotas a legitimate way to reach equilibrium and ensure at best some form of equal representation at the top? While quotas might ensure that more women have a seat, do they actually increase women’s meaningful and effective participation? If not, what is needed alongside quotas to ensure women’s meaningful and effective participation?

While a quota system may provide a way to encourage women’s representation at the leadership level, it is only a short-term solution. If women’s participation at the top is going to be meaningful and effective, longer-term strategies are needed to transform the unequal gender norms, roles, relations which perpetuate and reinforce gender inequities within the health system and inhibit women’s participation at the leadership level.

Increasing women’s value within the health system

Community health workers –the cornerstone of early primary health service programs, and for many people their only contact with the health system – are largely women. Women who take on this position often do so for little or no pay. Even as one acknowledges the role of the female community worker, we wonder if they would be better paid and organized if the majority of the workforce were men? Studies have found, however, that even within the same occupation (including those that are female dominated) not only are women promoted less frequently than men, but they also earn less. Gender inequities within the health system are a reflection of gender inequity within society. Gender pay inequity can therefore been seen as a reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important or worthwhile, and their role has health workers is no exception. As we usher in the Social Development Goals, we should strive to progressively change the value placed on women’s work and role within the health system, and offer equal opportunities and compensation to reflect this.

Minimizing gender bias within the health system

The issue of women’s role within the health system is becoming increasingly important, especially as we start to see a feminization of the medical workforce. In many countries, for example, the number of medical graduates are increasingly female. It will be interesting to see if the feminization of the health workforce translates to the top – as more women enter the health workforce will this be reflected at the leadership level? This is unlikely if we do not first minimize gender bias within the health system (and society more generally), which devalues women’s work, leads to lower compensation, and means that less women are given the opportunity to advance within their career.

Minimizing gender bias within the health system “requires systematic approaches to building awareness and transforming values among service providers,” along with developing policies and strategies to remove barriers to women’s career advancement and ability to engage in leadership roles. Women make up a large majority of the health care profession – it is time that they are recognized for their contribution and adequately represented at the top.

Note: This was an online discussion from 14 Emerging Voices. Over the past few weeks we engaged in a discussion on gender in health systems research with a few members of the new cohort of emerging voices. One of the most visible themes to have emerged from the discussions, and also perhaps an instinctive reaction of health system practitioners was the gender [here mostly in the context of the female sex] within the context of human resources for health and human resources in general. We present reflections on the issue of leadership and HRH from our discussions here.

This blog was originally posted on the IHP website.

Photo Credit: Edith Thaulo Head Nurse of Tisungane Clinic at Zomba, Travis Lupick

About the Authors:

Radhika Arora is an EV 2012 & ITM MPH alumnus.
Esther Nakkazi is a freelance science and technology reporter, a blogger at Uganda ScieGirl and a media trainer. She has mentored African science journalists in the World Federation of Science Journalists project. Follow her on twitter @Nakkazi. She is the 2016 Journalist in Residence Fellow at the Institute of Tropical Medicine in Antwerp, Belgium.
Rosemary Morgan is an Assistant Scientist at the Johns Hopkins Bloomberg School of Public Health

how_to_do_gender_in_hsr_skills-building_session

12 10 2016

How to do gender analysis in health systems research skills-building session at #HSR2016

Coming to the Fourth Global Symposium on Health Systems Research? Join us at our skills-building session on how to do gender analysis in HSR!

12 October 2016

Attending the Fourth Global Symposium on Health Systems Research?

Learn how to incorporate gender analysis into your health systems research!

Date: Monday 14 November

Time: 8:00am-12:00pm

Location: Meeting Room 1600, Simon Fraser University at Harbour Centre, 515 West Hastings Street, Vancouver BC

Session Info:

Gender analysis is important for all health systems research (HSR) and there are multiple ways in which it can be incorporated, all of which will help to strengthen research processes, evidence and recommendations.

Run by Research in Gender and Ethics (RinGs): Building Stronger Health Systems, this skills-building session will use participatory exercises to outline what gender analysis is, how gender power relations affect individuals in health systems, and how gender analysis can be incorporated into HSR.

During the session, participants will explore the use of gender frameworks and gender analysis questions to incorporate gender analysis into HSR, as well as consider the extent to which HSR outcomes can progressively transform gender power relations in health systems, or at least do not further exacerbate them.

Interested in learning more about gender and HSR? Come and join us!

For more information e-mail RinGs.RPC@gmail.com

12 10 2016

Gender Networking Meet & Greet at #HSR2016

Attending the Fourth Global Symposium on Health Systems Research? Interested in gender and HSR? Join us for a networking event!

12 October 2016

Coming to the Fourth Global Symposium on Health Systems Research?

Interested in Gender and Health Systems?

Want to meet other likeminded people?

Join us for a Gender Networking Event!

Event Details:

Gender equity is a global health priority. Academics, researchers and policy makers—across generations and regions are realizing the need for addressing gender within health systems research. In the spirit of inspiring and fostering collaboration among the emerging and current global health leaders to address gender in global health, we are hosting a networking social event for interested and like-minded HSR attendees.

Research in Gender and Ethics (RinGs): Building Stronger Health Systems, in conjunction with Women in Global Health, are hosting a gender networking meet and greet at the Fourth Global Symposium on Health Systems Research. If you work on gender and health systems, or are interested in the topic, please come and join us! All are welcome!

Date: Wednesday 16 November 2016

Time: 17:30-20:00

Location: P2B Bistro & Bar, Pinnacle Hotel Harbourfront, 1133 W Hastings Street

*There will be a cash bar available for those who would like a drink or pre-dinner snacks.

For more information e-mail RinGs.RPC@gmail.com

Women in Global Health (WGH) is a global movement that brings together all genders and backgrounds to achieve gender equality in global health leadership. We believe that everyone has the right to attain equal levels of participation in leadership and decision-making regardless of gender. WGH creates a platform for discussions and collaborative space for leadership, facilitates specific education and training, garners support and commitment from the global community, and demands change for Gender Transformative Leadership.

RinGs brings together three health systems focused Research Programme Consortia (RPC): Future Health Systems, ReBUILD and RESYST in a partnership to galvanise gender and ethics analysis in health systems research.

27 09 2016

Why are maternal health outcomes worse for migrant women in Masindi, Uganda?

This blog post discusses barriers to internal migrant’s access and utilisation of maternal and new born care services in Masindi, Uganda.

Richard Mangwi Ayiasi, Alice Jean Mangwi, Ann Kiiza, Christopher Garimoi Orach – Makerere University, School of Public Health

27 September 2016

Globally, 298,000 women die due to pregnancy related causes each year and half of these occur in Africa. In Uganda, maternal mortality has marginally reduced from 526/100,000 to 435/100,000 livebirths between 2001 and 2011. The presence of a skilled attendant during the entire continuum of care for maternal and new born care has great potential to reduce maternal and new born morbidities and mortality.

In 2013, an intervention to mobilize communities in Masindi, Uganda for maternal and new born health was introduced and the results showed marked improvement in utilization of maternal health services such as antenatal care and health facility delivery. However, non-indigenous populations were found to use maternal health services less compared to the indigenous populations. The non-indigenous population are mainly from the West Nile region of Arua and Nebbi. This group of people provide a cheap source of labour for the sugar plantation and sugar factory in Kinyala. This study could not adequately explain why migrants were using maternal health services less.

Poverty, educational level, distance from health facility and costs of transport to and from health facility are recognized as barriers to access. Cultural and traditional practices have also been recognized as reasons for high maternal and neonatal mortality. Most data comes from general populations, without disaggregating barriers in access for different groups.

The aim of this study was to gain a deeper understanding of internal migrant’s low access and utilisation of maternal and new born care services in Masindi, Uganda. Key barriers to access are discussed below.

Barriers to access maternal and new born services

Lack of financial resources: Low-income levels for men and women and high delivery costs appeared to be a common reason for low utilisation of delivery services. Women said they relied on crops in the gardens and when it is planting, weeding or harvest times, they do not have money enough to procure essential requirements for delivery:

“Our major problem has been money, you may start experiencing labour and you fail to transport yourself to the hospital, even our husbands don’t have proper jobs. This alone has made women to sit back and deliver at home, if there is money every woman will want to deliver in health centre.” (Respondent 1, FGD 2).

The cost of delivery care is expensive and requires buying the essential items required for delivery. The cost of 20,000 shillings required for a ‘mama kit’ for delivery is considered to be high and the expense is sometimes considered unnecessary by the women since they can even use old materials of cloth for receiving the baby:

“When you go to the health centre to deliver they tell you to prepare with delivery items like mama kit and new things like clothes, basin. As said earlier delivery comes with a lot of demands, what demands? They tell you to buy mama kit, cotton wool, kavera, gloves, yet to raise money as transport is a problem for our husbands yet that small transport to take you to the health facility cannot be raised, many of us are used to giving birth at home now, someone will say let me save this money for other things, even I use it as transport many other things are not bought, at home even without these things you can give birth…, on an old ‘kitenge’ you can deliver, in the health centre nurses will just chase you.”(Respondent 5, FGD 2)

Social beliefs: Community members perceive it to be cowardly behaviour for a woman to rush for care at the health facility during childbirth. Endurance of labour pains is considered a sign of a strong woman and delivering without the help of a second party is received as a heroic action:

“Here the moment you move on to seek care from the health unit the community members insult you by calling you a coward and saying that you are only married because of the bed service but for other issues you are not a woman.”(Respondent 5, FGD 4)

In order to fulfil the community norm of being a resilient woman, some women do not inform their husbands on time about labour, and instead keeps quiet until labour pains intensify. It is only when they are about to reach the second stage of labour that they communicate to their husbands, usually by such a time they are about to deliver within the next thirty minutes. One respondent said, for example, that she went on normally with her house chores and garden activities for the entire day until the labour pains were strong and she soon delivered.

Neglect by health workers: Neglect by health workers was a common complaint by respondents. Some of the male respondents explained that their partners are treated in a manner that they feel is degrading:

“Nurses on many occasions abuse the women that they are stupid and do not know anything to do with deliveries coupled with that is lack of attention for example recently a woman was to deliver she came to the health unit with a helper, on reaching the health unit no one gave her attention not until the helper decided to take her home but she ended up delivering on their way back, this made bad record of the health centre.” (Respondent 7, male FGD)

Respondents were strongly convinced that the main reason for neglect, discrimination and mistreatment by health workers is related to their ethnic differences. The women explain that when they reach the health facility health workers first identify their ethnicity by looking through their names or their ability to speak the local dialect. Sometimes a simple greeting in the local dialect is used as a ‘screening tool’ to separate indigenous from migrant population:

“For example I am a Lugbara, another mother is an Alur and then a Munyoro mother. If a nurse came and asked us in Runyoro only one mother will reply, those who do not answer back in the language will be abandoned, the Munyoro mother will be attended to first. At that moment, you will automatically know that she was picked because of tribe, you become timid, they will even start barking at you because you cannot explain your problems, even when nurses talk, you don’t understand.” (Respondent 1, FGD 1 women group)

Neglect by health workers is perceived to be an indirect means of demanding informal payments from the women. Informal payments influence the health workers to adjust their reception from being rude to be being very caring:

“The nurses asked me for money…they said if I don’t have money they will not help me, they asked for 20,000 which I said I did not have, one of them said I should give 15,000… they started working on me very fast as soon as my husband paid the money.” (Respondent 5, FGD 1 women group)

The problem of informal payments is so critical that women who do not provide the money demanded are denied access to care. One woman, for example, witnessed a migrant woman get off the delivery bed because she could not afford the fee.

Education: Level of education was also seen to influence the type of treatment women received at health facilities. Some women believed that having a higher educational level reduced the risk of discrimination by health workers. However, some respondents argued that indigenous women with lower education levels are treated better compared to immigrants of the same low education level meaning that lower education level alone could not adequately explain their mistreatment:

“It is not education but I think it is because we are from far, because even uneducated Banyoro are attended to very well.” (Respondent 1, FGD 1 women group).

Lack of male involvement: The responsibility of care during pregnancy, labour and childcare has been relegated to the women to the extent that women are held responsible if something goes wrong with the pregnancy. Women are expected to purchase all the requirements needed for delivery. While for the men their responsibility in pregnancy is to buy items for the new born baby, remind their spouses about antenatal care. A minority of the men and women agreed that few men fully support women throughout pregnancy, labour and childcare. Some men are reported to take concern about their sick spouse and even arrange for transport and escort them to the health centre. Others purchase all the requirements needed for delivery and provide special feeding for their spouses

Conclusion

There are a number of barriers to access to maternity care among migrant women in Masindi, Uganda. These barriers can be addressed at two levels. At the household level, there should be deliberate efforts to engage with men to support their partners during pregnancy and childbirth for example, by saving money and preparing for transport to the health facility in case of antenatal care and delivery. At the district level, there is need for district local managers together with district health managers to create a dialogue platform in which communication barriers and the mistreatment of migrant women can be addressed in the health sector.

21 09 2016

Mainstreaming gender into PMTCT guidelines in Tanzania

This blog explores the gender content of key PMTCT policy documents and discusses how this area could be strengthened.

Tumaini Nyamhanga, Muhimbili University of Health and Allied Sciences, Tanzania

21 September 2016

In Tanzania, the prevention of mother to child transmission of HIV (PMTCT) is a health sector priority, but there is very little information on how well gender mainstreamed in relation to national PMTCT guidelines. Mainstreaming gender into PMTCT programming is expected to lead to increased coverage, efficiency, and effectiveness of services, contributing towards a reduction of child and maternal illness and death.

Addressing gender concerns includes taking measures that address gender-related barriers to accessing PMTCT services and adhering to the advice given in those services. Gendered challenges include:

Unequal ownership of resources between men and women (women not going or going late to PMTCT clinic due to lack of fare; or women being unable to make appropriate decisions due to financial constraints);
Unequal decision making power in sexual relationships, contraceptive use, and in choosing infant feeding options.

Our research assessed the gender content of key policy documents in order to better understand how this area could be strengthened.

Fom unequal to transformative – the Gender Responsive Assessment Scale

In order to analyse the gender content of PMTCT policy and practice in Tanzania five PMTCT guidelines were assessed to identify and extract any content on gender and assessed according to their compatibility with the WHO Gender Responsive Assessment Scale (GRAS). The GRAS divides gender responsiveness into 5 levels:

Level 1 – gender unequal – contains content which perpetuates gender inequality by reinforcing unbalanced norms, roles and relations.
Level 2 – gender blind – contains content which ignores gender norms, roles and relations. The content of such documents, for example, ignores differences in opportunities and resource allocation for women and men.
Level 3 – gender sensitive – contains content which indicates awareness of the impact of gender norms, roles, and relations, but no remedial actions are developed.
Level 4 – gender specific – contains content which goes beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV.
Level 5 – gender transformative – contains content which includes ways to transform harmful gender norms, roles and relations. Such documents contain strategies to foster progressive changes in power relationships between women and men.

What did we find?

Gender is mentioned: Gender-related issues are mentioned in all of the guidelines, indicating some degree of gender responsiveness. The level of gender responsiveness of PMTCT policy documents, however, varies, with some graded at GRAS level 3 (gender sensitive), and others at GRAS level 4 (gender specific). None of the reviewed policy documents could be graded as gender transformative. Gender sensitive policies included the National Scale up Plan for The Prevention of Mother to Child Transmission of HIV and Paediatric HIV Care and Treatment, 2009-2013, The National Guidelines for Comprehensive Care Services for Prevention of Mother to Child Transmission of HIV and Keeping Mothers Alive (2013), and the National Communication Strategy for the Elimination of Mother to Child Transmission of HIV (2014 – 2017). These documents have sections acknowledging the influence of gender on PMTCT, but lack sections on remedial measures. And when statements do consider gender, they are often too general to offer effective guidance.

Policies rated at GRAS level four went beyond indicating gender awareness to also state measures for addressing specific concerns of women and men and addressing gender inequity. This was the case only for the National Training Refresher Package: Services for Comprehensive Care and Prevention of Mother-to-Child Transmission, Participant Manual, 2013.

But policies do not set out to transform gender relations: While the policy documents indicate recognition of gender inequality in decision-making and access to resources as a barrier to accessing PMTCT services by women, no attempt is made to transform harmful gender norms, roles, or relations. For example, the policy documents do not include actions to transform norms around masculinity that discourage men from seeking care, taking an HIV test, or accompanying their partners to PMTCT clinics.

And they haven’t mainstreamed gender: Overall, gender was not mainstreamed into any of the documents in the sense that gender was not considered in all key sections. For example, gender was not integrated into the documents’ goals and objectives or the strategies. As a result, while the documents were responsive to gender at different degrees, gender was not effectively mainstreamed throughout the entire document.

Conclusion

Although gender is often one of the guiding principles of the introductory chapters of key PMTCT guidelines in Tanzania, gender is not mainstreamed and document goals, objectives, and strategies do not incorporate gender considerations. Most policy documents are gender sensitive, that is, they indicate gender awareness without stating remedial measures. This might be explained by the fact that in the design stage of a policy or strategy, gender is handled as an “add on” ” in order to fulfil certain requirements, rather than being made an integral part of the entire policy.

Overall, this study revealed limited integration of gender concerns (less or lack of attention on the disadvantageous position of women in terms of inequality in ownership of resources, power imbalance in decision making, asymmetrical division of roles, and masculine norms that distance men from maternal and child care) in PMTCT guidelines. Revision of guidelines to mainstream gender is greatly needed if PMTCT services are to effectively contribute towards a reduction of child and maternal morbidity and mortality in Tanzania.

19 09 2016

Strengthening male involvement in prevention of mother-to-child transmission of HIV in Enugu State, Nigeria

This blog explores the extent of male involvement in PMTCT in Enugu state, Nigeria and its effects on women’s access to and use of PMTCT services.

Nkoli Ezumah, Chinyere Mbachu,Obinna Onwujekwe, Ifeanyi Chikezie, Ogo Ibe, Patricia Uju Agbawodikeizu & Kingsley Amadi, Health Policy Research Group, College of Medicine, University of Nigeria

19 September 2016

Nigeria has the second highest HIV prevalence in Sub-Saharan Africa and the risk of mother-to-child transmission of HIV in children below the age of 15 is between 25-40% . In 2010, the Nigerian government committed to achieving a 50% reduction in mother-to-child transmission of HIV and 50% improvement in HIV counselling and testing.

Prevention of mother-to-child transmission (PMTCT) services offered to women in Nigeria include: ante-natal care, basic information about HIV transmission and prevention; HIV counselling and testing; prevention of unintended pregnancy; and antiretroviral treatment. Efforts to improve uptake of PMTCT have been hindered by the lopsided focus on medical interventions and neglect of the social factors that contribute to mother-to-child transmission . In particular, lack of male involvement is considered a key challenge to the uptake of PMTCT services.

Our research explored the extent of male involvement in PMTCT in Enugu state, Nigeria and its effects on women’s access to and use of PMTCT services. The findings showed that only a few men accompanied their wives to antenatal care. Men’s attendance with their partners to educational sessions on prevention of unintended pregnancies and HIV counselling and testing was also reported to be low. Women were said to come for their antiretroviral treatments alone and on some occasions would also collect medicine for their partners.

Factors affecting men’s participation in PMTCT

Factors which contributed to the limited participation of men in PMTCT included individual and relationship factors, gendered community norms and expectations, and health system factors.

Individual and relationship factors

Individual and relationship factors, included: time constraints, poor spousal communication, and non-disclosure of status to one’s partner.

“The reason why it is difficult for men to participate in PMTCT services is just because of time. Because the work men do, keep them busy, like if a man is a driver, he will not be at home at the time his wife may want to go and access the PMTCT services. So, time is the main problem we have”(P8 FGD Male support Group Nsukka).

“Most of them will confide in you, “my husband is negative, he doesn’t know I’m going to this place; please, I don’t want him to know”. That is what they will tell you. And others will tell you, I am positive, I don’t know about my husband” (Health worker 2, at Facility A)

“…Because maybe, he has no clear knowledge of what the woman is passing through, the issue of PMTCT, the need to assist her during that period. If he has clear knowledge of the situation, definitely he will make time to accompany her” (P1 FGD Male support group Enugu).

“Well, I have never asked him to accompany me” (Female HIV client 3 at Facility B)

Gendered community norms

Gendered community norms and expectations included: pregnancy being perceived as a woman’s responsibility, male dominance in household decision making, and ridiculing of men who accompany women to ante-natal care visits.

“…What happens to men all the time is that they feel that family planning is always for the women… that it is the women that need such services…that is why I don’t follow my wife to go for it” (P6, FGD male support group, Nsukka).

“They see it as a woman’s work to go for her PMTCT service especially this ANC” (Health worker 3 at Facility B)

“For the man, it will look as if the woman now rules him” (P3, FGD Female support group Nsukka)

Health system factors

Health system factors included: ante-natal care services that were only woman-centred, unwelcoming attitudes of health workers to men who accompany their partners, and that appointments for anti-retroviral treatment for partners were scheduled separately (meaning separate visits to the health care centre).

“The attitude of the nurses at times contributes a lot to why some don’t like to follow their wives for antenatal.” (P2, FGD Male support group Enugu)

“We designed it (ante-natal care, PMTCT, post-natal care) in such a way that men are excluded here.” (Health worker 4 at Facility A)

“The date of appointment differs. Because my wife will be coming next week and my own falls today. So, there is no way we can come together” (P3, FGD, male support group, Nsukka).

Effects of male involvement (or lack of) on access and use of PMTCT by women

The perceived benefits of male partner participation in PMTCT included: male partners understanding and accepting the programme, women being more free to access the programme, reduction of the effects of male dominance on access to and uptake of PMTCT, male partners being better positioned to support their female partners emotionally and financially, couples being more able to work together towards preventing unintended pregnancies, and the promotion of adherence to treatment.

“So what I think that men do which is cultural for us is to ensure that the woman has the means of transportation to the clinic. And that is precisely the same thing that those whose wives are HIV infected do. The key male involvement in PMTCT is trying to understand that this woman needs to take her drugs everyday whether they are concordant positive, or discordant” (Health worker 4 at facility A)

“… I receive my ART drugs in the same facility with my wife. And I normally make sure every morning, at 8 o’clock, I take the drug, my wife takes hers too, and in the night we take our drugs at the same time” (P5 FGD Male support group Enugu)

Lack of men’s involvement in PMTCT was found to contribute to: difficulty in breastfeeding properly or as recommended for a HIV positive woman, difficulty with keeping to scheduled ante-natal care appointments, inability to discuss outcome of counselling visits, inability to discuss prevention of unwanted pregnancies, and poor adherence to antiretroviral treatment.

Conclusion

The findings of this study have highlighted various factors that affect men’s effective involvement in PMTCT services. As the constraints identified within this study have implications for successful implementation of PMTCT services in Nigeria, policy measures need to be put in place to deal with these constraints if effective up take of PMTCT services is to be achieved.

Interview been conducted in a rural area - China

14 09 2016

Gender analysis of family care for the elderly: evidence from Beijing, China

This blog discusses differences in receiving family care among the elderly in China.

Dr Hao Xiaoning and Liu Tianyang, China National Health Development Research Center

14 September 2016

Care giving within households is the foundation of health systems, especially for the elderly population in China where 98.1% of the elderly rely on daily care provided by family members, and only 1.9% rely on care from professionals and society welfare institutions. Because of the lack of well functioning long-term care programs, as well as the historical filial piety tradition, (the belief that adult children have the responsibility to support their parents), Chinese elderly prefer to rely on family members in their last years of life.

Caregivers and care receivers are the two major components of the Chinese family care system. Caregivers include: mates, sons, daughters, sons in law, and daughters in law. There are many papers discussing the gender difference of caregivers for the elderly in China. Kadoya and Yin’s study, for example, indicated that compared with daughters, sons (and their wives) were more likely to be primary caregivers for parents, consistent with historical tradition. Other studies have shown that daughters played a more important role in caring for parents. There are few studies, however, which analyze the gender difference in the care received by the elderly.

This study aimed to explore differences in receiving family care among the elderly, and to examine the risk factors affecting care received. The study was divided into two parts: the first part was a quantitative analysis of survey data, which aimed to explore gender difference in receiving family care among the elderly, and to examine the risk factors affecting care received. The second part consisted of qualitative semi-structured interviews within several households, which aimed to explore the opinions of elders and their children regarding family informal care within households. The findings help to provide a picture of the elderly family care situation and contribute to improving policy and public attention on gender equity within households in taking care of the elderly.

Care received by the elderly

The quantitative study was a cross-sectional study extracted from the results of the Health and Social Support of Elderly Project, which was conducted in three districts in Beijing in 2013. A group of 924 elders were included in the study. The data gathered were stored and analyzed using SPSS 19. A Mann-Whitney U test was conducted comparing mean hours of care received by elderly by gender. Descriptive analysis was also conducted for subgroups who did not receive any care in the last week. Binary logistic regression was used to examine the relationship between care received by elderly and different variables, including gender.

The results showed that elders received an average of 16.49 hours of care in the preceding week; men received an average of 15.57 hours, while women received an average of 17.39 hours. On average females received two more caring hours from children compared to males. 26.8% of the elderly did not receive any care from their children in the last week. There was no significant difference in the hours of care elderly received between male and female (p>0.1). The logistic regression showed that gender was not a significant determinant of the proportion of elders who received six hours or more of care in the preceding week; however, age, monthly income, and health status significantly affected the care received by the elderly.

For the qualitative component, 18 households (including elders and one of their children) were interviewed regarding family informal care. Nine households were from urban areas (Haidian District) and nine were from rural areas (Miyun district). Only households with elderly parents more than 60 years old were included. A customized semi-structured interview guide for elderly parents and their adult children was developed. For parents, the questions included “Do you think you received less care from children than your mate?” and “Among the children, who give you the most care? And what’s the reason for it”, etc. For the adult children, the questions included “Do you think you make more effort in taking care of parents than your siblings? And what’s the reason for it?” etc.

Results showed that a traditional supporting system was still mainstream in rural areas, however, there was a transition underway in urban areas. All of the nine rural elders interviewed were cohabiting with their children while only one of the nine urban elders was cohabiting with children. In rural areas, the traditional norm of “bring up sons to support parents in their old age” was still well accepted; sons and daughters-in-law were still the core force in supporting parents. On the contrary, in urban areas, eight out of nine elders thought that daughters were more reliable than sons, and daughters provided more hours of care compared to sons and daughters-in-law.

Factors affecting care received

Factors affecting the family care received by the elderly included: age, income, education, health status, and number of children.

Age played a role in whether or not care was received. People aged 70-79 years received the most care. Those who were younger (60-69 years) often did not receive any care from their children in the preceding week.
Among the elderly who received care, men had 4000 Yuan or more monthly income, while women had less than 1999 Yuan monthly income. Overall, elderly people with a monthly income of more than 4000 Yuan were less likely to receive care from their children. This may be due to the fact that richer elderly parents have more freedom in choosing care from the outside, rather than relying on the help and assistance of their children.
Elderly men who received care had a higher percentage of secondary and tertiary education, while most of the women who received care were illiterate and had only primary education.
Health status was significantly associated with the care received by elderly. Compared with healthy elders, those living with chronic disease were more likely to get more than six hours of care from their children in the preceding week. Those who were healthier were less likely to receive care.
Elderly people who only had one child received the most care in the preceding week, while those with two or more children were less likely to receive care.
Despite the fact that elderly women had more care-related needs and fewer resources, there was no significant difference between men and women in the care received.

Conclusion

In conclusion, male and female elders did not differ in the care received from their family in urban areas in Beijing, and gender was not found to be a risk factor affecting the hours of family care received by the elderly. Factors affecting care received included age, income, education, health status, and number of children. Traditional filial piety was under transition, and a large amount of the elders could not get family care from their children.

Unpaid elderly care is an important part of the health system and better understanding who provides and receives care is important in terms of identifying weaknesses and gaps in provision and responding with social policy. Due to the transition away from a traditional filial piety system, social welfare systems, such as long-term care insurance and professional care institutions in China should be strengthened so that the elderly could receive the care they need.

Photo caption: Interview being conducted in rural area, 2016

13 09 2016

Male involvement in the National Health Insurance Fund (NHIF/KfW) prepaid insurance card for pregnant women in Pangani District, Tanzania

This blog discusses factors associated with male involvement in access and use of health services in Tanzania and identifies strategies that can be used to increase male involvement.

Tani Kassimu, August Kuwawenaruwa, Jitihada Baraka, Fatuma Manzi, – IFAKARA Health Institute, Tanzania

13 September 2016

In Tanzania, estimates from 2010 show a maternal mortality ratio (MMR) of 454 maternal deaths per 100,000 live births. For every 1,000 live births in Tanzania, four or five women died of pregnancy-related causes. Reasons for low usage of maternal care are complex, including shortage of resources, long distances to services, high costs and low capacity to provide services.

Gender analyses suggests that maternal mortality is linked to a wide range of factors in women’s lives, including the value placed by women and by their families and communities on women’s health, women’s economic position, their access to education and information, and their capacity to make autonomous decisions. ‘Gender exclusion’, in this case the exclusion of men in planning or implementing interventions, can be a major barrier to achieving improved maternal and child health.

Health insurance, maternal health and gender

In 2010, the National Health Insurance Fund (NHIF) of Tanzania piloted a programme aimed at improving maternal and child health through the provision of insurance coverage to poor families. The pilot programme used the NHIF platform to support and strengthen expansion of social health insurance coverage to the informal sectors by providing free maternal and child health insurance cards named NHIF/KfW prepaid insurance card to poor pregnant women and their newborns in selected regions of Tanga and Mbeya.

Our study sought to understand male involvement in the implementation of a National Health Insurance Fund (NHIF/KfW) for pregnant women in Pangani District, Tanzania. It examined the factors associated with male involvement or lack of involvement in access and use of health services and identify the strategies that can be used to increase male involvement.

Male involvement in the implementation of NHIF/KfW prepaid insurance card

Men were involved in the implementation of NHIF/KfW prepaid insurance card scheme in various ways: during its design; inauguration; registration; and in community sensitization at the village level and health facilities.

Health System Factors: At the health care facilities, women are encouraged to attend with their partners during antenatal visits. This is to ensure they are all tested together for HIV, as well as educated on how to take care of the pregnancy and prepare for delivery. Participants often stated that while men increasingly go with their wives for first ANC and tests for a number of diseases together, they were not always told about the insurance programme while at the facility:

“Things have changed because few years back when you are pregnant you can come alone for health checkups and start ANC services, but nowadays to have a test or even to be registered, you have to come with your husband…” (FGD – women at Pangani Hospital)

“We were told whenever we come to clinic each one has to come with the partner to be tested, I came with him…we were examined but we were not told about the NHIF/KfW insurance programme…” (FGD – women at Mwera Health Centre)

Economic Factors: Maternal and child health care services should be free of charge as per the health care policy. However, in many cases families and partners incur costs related to transport and purchase of supplies. During the implementation of the project, the costs related to the service provision to the women and the family were borne by the programme. This encouraged male involvement because they were sure that they wouldn’t pay for extras at the point of provision:

“Nowadays he has changed, when you fall sick he asks you to go to the facility as he knows it’s free…he cannot say I don’t have to go because we do not have money…if I wouldn’t have gone with him the first day he could not knows…” (FGD – women at Pangani Hospital)

Social Norms: Women had a different views with regard to men’s involvement in the provision of reproductive and child health care services. It is not a usual thing to see a man accompanying the partner as well as carrying a baby to the hospital:

“But just saying a man carrying the baby with happiness….how many are they…you are lucky if you are accompanied by your partner to hospital…in reality I haven’t…“ (FGD – women at Mwera HC)

In addition, a number of women claimed that they did not involve men directly when they went for ANC services and registered for programme because men were at work. This reflects the perception that the role of men in the community is to work and that women should care for the family.

Strategies to increase male involvement

Participants identified strategies to improve male involvement in the implementation of NHIF/KfW prepaid insurance card in Pangani District.

Communication between partners: Communication between partners was one of the ways to increase their men’s involvement. Some of the men who have been involved in the programme are now responsible in taking their children to the health facility for growth monitoring and even when they are sick:

“When you tell a man that I am sick, he will ask you to go to the health facility, you will go and get services …when the child falls sick he will take him to the doctor and when prescribed he will go to find the drugs if they are not available at facilities…” (FGD – women at Mwera HC)

Use of village meetings: In the villages, there are routine meetings every three months. During the meeting, participants discuss various topics and make decisions together for the betterment of the whole community. Health care providers and Community Health Fund (CHF) coordinators can use such meetings to educate/sensitize the community; however, at times doctors are given time to talk at the end of the meetings specifically during the any other business session:

“We suggest that during the village meetings doctors should be given priority to speak as s/he, as they emphasize on health issues men will get to learn, as we usually come with the kids every day to the facility….” (FGD – women at Mwera HC)

Education: Men pointed out that one of the strategies to increase their participation is through education, as they will gain more knowledge about health care services and whatever has been happening in the facilities:

“Your wife goes to clinic while you just go to the farm…. it’s wrong……most of the time we are supposed to accompany our partners and get to know whatever is happening….…there is low awareness….…it’s good whenever people are being sensitized, or as the village chairman calls for a meeting and inform the community whatever is happening…”(FGD – men at Mwera Village)

Conclusion

Programme implementation together with other factors such as health system factors, economic factors and social norms act as facilitators and barriers in terms of male partner involvement in the implementation of the NHIF/KfW insurance programme. Largely these factors were complex and interrelated. Improvement in the health care provision and community sensitization of the importance of male partner involvement in the implementation of maternal and child health care programmes needs to be prioritised in order to improve their participation and mitigate the effect of socio-economic and cultural factors.

Researchers and community health workers

04 08 2016

Training Community Health Workers during Photovoice Research on Gender and Ethics in Health Systems

This blog discusses the use of photovoice to explore issues related to gender and ethics within the health system in Uganda.

Dr. David Musoke and Charles Ssemugabo, Makerere University School of Public Health, Uganda

04 August 2016

Gender and ethics are important aspects of the health system in terms of human resources and health seeking decision making in the community. Women are more affected by inequalities in the health system because of various reasons, including their health seeking behaviours sometimes being influenced by their spouses. Additionally, there are ethical concerns regarding the practice of Community Health Workers (CHWs) related to their work, such as responsibility in delivery of care, respect and equity.

CHWs play a big role in supporting the health system as the first contact for health service provision in the community, especially in the rural areas in Uganda. They are community volunteers who serve their communities and carry out health promotion and social mobilization activities, including treatment of childhood illnesses such as malaria, pneumonia and diarrhoea.

Several studies have been done among CHWs worldwide and in Uganda. However, minimal literature exists on gender and ethical issues that they face in execution of their work. In addition, in most studies concerning CHWs, their involvement in the various stages of the research process has been minimal. Our study employed photovoice, which is a community based participatory research methodology that involves taking pictures of aspects and experiences within the community which are shared with others. These photographs are later discussed among the research group to generate ideas pertinent to the study theme. In order to orient CHWs before photography, a training was held in order to inform their decisions in taking photos related to the research. The aim of the research was to explore issues of gender and ethics among CHWs in rural Wakiso district, Uganda.

The training, which involved 10 CHWs, was participatory with CHWs sharing their understanding of gender and ethics, and some of the related issues they face in their work. The one-day training had 3 sessions. In the first session, CHWs were introduced to the study focus (gender and ethics), photovoice methodology and research principles (including the ethics of taking photographs). Generally, the CHWs showed a good understanding of gender and ethics related to their work by identifying key issues related to the study themes such as their roles based on gender, and ethical challenges faced in their work.

During the second session, participants were asked to share their experiences on gender and ethics in relation to their work. Among the issues raised were female CHWs occasionally being vulnerable to sexual advances by men, women’s societal role in community is to do house work, and male CHWs finding it easier than their female counterparts to traverse villages to visit homes and provide health education. Regarding ethics, issues mentioned included ensuring equity in service provision without discrimination of any form, attending refresher courses whenever possible to get adequate knowledge and skills required in their work, and using CHWs manuals to guide them while carrying out their work.

In the third and last session, CHWs were trained on the use and care of cameras for use in the photovoice research. During this session, each member was given a camera. Among the issues taught included taking photos, charging the cameras, and how to protect them. The training was an opportunity for the researchers to ensure the CHWs understood the design and themes of the study so as to enable them take photos for subsequent discussion as part of the research.

In conclusion, the training held among the CHWs was important for them to appreciate the use of photography in research as well as get acquainted with the study focus of gender and ethics. This was necessary for the CHWs so as to be able to carry out the photography assignment as part of the photovoice research. This research is expected to establish gender related roles of CHWs as well as ethical issues they face in their work so as to inform the design and implementation of future programmes to ensure communities maximally benefit from their services.