The use of social network analysis to conduct gender analysis in health systems research

On 8 September 2015, RinGs held a cross-RPC webinar on “How to do gender analysis within health systems research” for members from Future Health Systems, ReBUILD, and RESYST.

A female participant from South Africa asked if we know of any studies within the gender literature that use social network analysis to uncover and understand who is important, who has power, who has influence, etc? In-depth interviews are great at identifying the obvious but I wonder if social network analysis has been used to uncover “hidden” or “soft” influence and power in health systems research? 

In response to this question, another member offered the following thoughts:

There are several related bodies of research which have touched on some component of this question (e.g. social networks in healthcare organizations, gender in organizations, or social networks and gender in health-seeking behaviour at community level) but we are not aware of any studies that combine all components and use social network analysis to explore gender and power within health care organizations and systems in low-income settings. (If you do – please let us know!)

Some gender studies certainly identify the importance of social relations in institutions even if not using a social network approach. Indeed, institutional gender audits seek to understand the existing distribution of power and resources in organizations and can offer extremely valuable formative data. All of these different bodies of literature (and many more!) provide useful methods, theories and lessons to draw from. Some examples are given at the end to provide a very brief snapshot of what they contribute. (There is also a connection between complexity theory and social network analysis, which has been explored in health care organizations, but that is not explored here.) The first key point is that, as with any research study, the design and data collection methods should always be chosen to fit and answer the overarching research questions, and not the other way round.

Social network studies are, by their nature, concerned with influence and power because a key focus of network studies is to understand the resources and directional influences that flow through and between social ties – whether at household, community or institutional levels – and to understand how these affect behaviour, choices, opportunities. Resources such as information, financial or practical help, introductions to useful others, or opportunities for exerting influence or getting promotion. The role of power, in turns of who knows who, who has access to or controls resources, and decision-making power, is therefore implicit in all network studies but whether researchers have sought to explicitly tease out this aspect in regards to gender relations and inequalities is another matter and depends on the research questions being asked.

The examples of social network studies given below, and what they manage to achieve, or not, through the methods used demonstrate that the key issue to consider, if wanting to use a social network approach to understand gender and power in health care institutions, is that a multi-faceted approach is needed in terms of both methods and theory. Designing a social network study needs careful consideration and some understanding of the limitations of available approaches. Mixed methods are essential.

The focus of most social network enquiry has been, and continues to be, on assessing the structure of social relations (which produce the famous sociogram diagrams of interconnectedness when, and only when, whole network data is collected). Structural measures can tell us a lot about things such as the similarity, or not, between people, who holds power through influence, multiplexity, and reciprocity amongst a network. Ultimately, however, structural data alone leaves both authors and readers hypothesizing about the meaning of findings. In addition to structure, the other two sets of characteristics important to understanding networks are the content and function of relationships, and these require good qualitative methods, which could be in-depth interviewing or/and a range of participatory methods. These together help paint a much more complete and rich picture of what social networks exist and what role they play in the phenomenon of interest.

It is also the case that different approaches for asking people about their network ties actually elicit different responses, i.e. different names and networks. This is clearly a major issue since it will directly affect a study’s findings. Many social network studies gather network information by asking people proxy questions about their network ties (for example: “Please name # people you talk to when … your child is ill / there is an emergency / to make decisions about XYZ, etc). Responses from interviewees will invariably depend on how the respondent interprets the question. It is possible that studies on institutional networks (rather than personal networks) might be easier to capture because there are clearer boundaries around the networks of interest. Overall, though, different qualitative approaches, including observation, can greatly enhance the capturing of network ties. In fact, almost all of the classic studies that have shaped the development of social network research have used mixed methods, many of them privileging qualitative data. Combining types of data does bring tensions about how to read and analyse the supposed factual, deductive data that comes from social network interviews compared with the more inductive data that comes from qualitative methods with respondents.

But the world is rapidly changing and it would be remiss to not mention the role of telephones, email and social media as important shapers of social networks everywhere in the world, and also as social spaces which produce large amounts of network data. These are clearly communication channels which need to be explored when asking people about their social ties – including people working in health systems in LMICs. (There are also several rapidly growing areas of research that explore all kinds of personal and professional networks online, including patient health networks, but this falls outside of our area of interest here.)

Lastly, interpretation of findings from network data also benefit from existing theory, which is especially important when exploring questions around gender power relations.

This all paints social network analysis as a very complicated type of research, and one which requires a great deal of time. Social network interviews can take several hours to complete, in addition to any formative or follow-up qualitative interviews. Indeed, the project of social network research could continue for years, given the expansive nature of people’s networks. We must acknowledge, therefore, that not everything can be measured or captured at the same time. Smaller network studies are possible – as the literature demonstrates – but researchers need to be clear of the limitations of their studies and make these clear to readers of their work.

Below are some other related areas of research which offer potentially stimulating ideas if curious about developing a social network study of gender and power in health systems. The papers listed here are not suggested because they are “best of” or even comprehensive, but purely offered as examples to stimulate thinking.

Gender and institutions. Even without a social network approach, gender and power within institutions – whether at the level of household, community or health system – and how these interact to affect various outcomes in development processes have been the focus of a number of studies. Naila Kabeer’s early work on gender and institutions, and how to make policy and planning processes more gender aware, provides a good starting point, as well as Deniz Kandyoti’s work on bargaining. Plus the many studies that have conducted institutional gender audits. The literature on bargaining and gender relations by people such as Bina Agarwal and Amartya Sen also offers relevant questions which might be used to explore gender issues within institutions, or even to interpret institutional network findings – depending on the purpose of the research. These ideas updated and framed through current approaches to institutional analysis – such as the application of complexity theory to health care organizations – could prove very fruitful.

An additional area of research to explore is that on gender, or women’s networks, in the workplace, or women’s professional networks, of which there are a large number of studies based in high-income countries. There are also studies of women’s informal work networks in low-income settings, which forces us to consider the interesting differences between networks in a so-called ‘professional’ health care workplace, such as a policy-making health department, versus those networks which exist at the lower levels of the health system: the nurses and community health workers working at the coalface.

Examples:

• Kabeer, N. and Subrahmanian, R. (1996). Institutions, relations and outcomes: framework and tools for gender-aware planning. IDS Discussion Paper 357. Brighton: Institute of Development Studies.
• Kandyoti, D. (1988). Bargaining with patriarchy. Gender & Society, Vol.2, No.3, pp.274-290.
• McGuire, G.M. (2002). Gender, race and the shadow structure. A study of informal networks and inequality in a work organization. Gender & Society, Vol.16, no.3, pp.303-322.
• Multiple frameworks (& studies) on conducting institutional gender audits produced by and for various aid agencies.

Network studies of health care organizations or of intra-organizational networks have been around for some time and pre-date the study and application of complexity theory in understanding health service organization and public management. To the best of our knowledge, all of these are based in high-income countries and explore the role of social networks in the spread of innovations, and in governance and management structures, in order to assess their role in policy-making or health care effectiveness. Whilst power is considered as part of this work, gender is not (yet).

Examples:

• Ferlie E., Fitzgerald L., Wood M., Hawkins C. 2005. The non-spread of innovations: the mediating role of professionals. Academy of Management Journal, 48(1): 117–134.
• Ferlie, E., L. Fitzgerald, G. McGivern, S. Dopson and M. Exworthy. 2010. ‘Networks in health care: a comparative study of their management, impact and performance’. Report for the National Institute for Health Research Service Delivery and Organisation Programme. London: King’s College London.
• Tasselli, S. 2014. Social networks of professionals in health care organizations. A review. Medical Care Research and Review, Vol 71, no. 6, pp. 619-660.

Social networks and health-seeking. There have been a number of studies exploring the role of social ties in health-seeking behaviour in LMICs, which inevitably highlight women’s roles in this area and the gendered nature of household bargaining, but all focus on the community level rather than the health service delivery side, especially for children’s health. The only exceptions are those studies which capture the ties that users of health services have, or develop, within the health system itself and therefore demonstrate the alternative interface between user and provider where ‘community’ segues into health system, and vice verse.

The point of sharing these is to show the more common use of social network approaches to health care and not because the methods used might prove relevant in a health systems study. The diverse methods used in these studies do highlight many of the limitations of social network studies when only structural measures are taken and proxy designations are used to capture someone’s network ties. The narrative review by Richards and colleagues is added because it provides an overview of these types of studies, identifies social networks as a common theme and provides some useful gender theory for interpretation.

Examples:

• Adams, A.M., Madhavan, S. and Simon, D. (2002). Women’s social networks and child survival in Mali. Social Science and Medicine, 54, pp. 165-178.
• Andrzejewski, C.S., Reed, H.E. and White, M.J. (2009). Does where you live influence what you know? Community effects on health knowledge in Ghana. Health and Place, Vol.15, pp. 228-238.
• Friend-du Preez, N.; Cameron, N.; Griffiths, P. (2008). Stuips, spuits and prophet ropes: the treatment of Abantu childhood illnesses in urban South Africa. Social Science and Medicine; 68(2), pp. 343-51.
• Gayen, K. and Raeside, R. (2007). Social networks, normative influence and health delivery in rural Bangladesh. Social Science and Medicine, Vol.65, pp. 900-914.
• Richards, E., Theobald, S., George, A., Kim, J.C., Jehan, K. and Tolhurst, R. 2013. Going beyond the surface: gendered intra-household bargaining as a social determinant of child health and nutrition in low and middle-income countries. Social Science & Medicine, Vol.95, pp. 24-33.

The ideas in this work are taken from the author’s unpublished PhD thesis on the role of social networks in the management of children’s health and illness in urban slums, based in Kenya.

Julie Evans works in applied public health research and practice in low income countries, and is based out of Baltimore, MD. She has a PhD in Public Health from the London School of Hygiene and Tropical Medicine, and an MPA in public sector management in low-income and fragile contexts.