How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework

Abstract

Close-to-community (CTC) providers have been identified as a key cadre to progress universal health coverage and address inequities in health service provision due to their embedded position within communities. CTC providers both work within, and are subject to, the gender norms at community level but may also have the potential to alter them. This paper synthesises current evidence on gender and CTC providers and the services they deliver. This study uses a two-stage exploratory approach drawing upon qualitative research from the six countries (Bangladesh, Indonesia, Ethiopia, Kenya, Malawi, Mozambique) that were part of the REACHOUT consortium. This research took place from 2013 to 2014. This was followed by systematic review that took place from January-September 2017, using critical interpretive synthesis methodology. This review included 58 papers from the literature. The resulting findings from both stages informed the development of a conceptual framework. We present the holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, influence of family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. We present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities. Gender roles and relations shape CTC provider experiences across multiple levels of the health system. To strengthen the equity and efficiency of CTC programmes gender dynamics should be considered by policymakers and implementers during both the conceptualisation and implementation of CTC programmes.

Our son is ‘our asset, future, and bank’: exploring gender-related factors influencing adherence to advice and treatment-seeking guidance following hospital discharge among infants and young children in Bangladesh

“…Previous studies have shown that support and encouragement by family members and supervisors is an important motivating factor for CHWs [44], assisting them to gain con dence in interacting with men and in negotiating work-related challenges [46]. These ndings suggest a gender sensitization program is required not only for health facilities, but also for households that CHWs visit, and for household members of the CHWs themselves.…”

­­­Opportunities for gender transformative approaches in a community-based drowning reduction program in Bangladesh

“…The program appeared to have acceptability in the view of communities who were generally supportive of hiring community women as Anchal Maas and Assistants and were also ready to accept some changes in their access to resources and mobility in return for their good work. As most community health workers in rural health programs in LMICs are women, being cognisant of gender attitudes and roles ensures that these workers are supported and retained (9,44,45). Declarations…”

Gender Equity and Norms in Health Programs: Learnings from a Drowning Reduction Program in Bangladesh

“…Community-based health programs often employ women, engage a wide range of stakeholders, and build close relationships with communities, and are able to in uence gendered attitudes and norms relating to employment and mobility. These in turn affect health outcomes of individuals (8)(9)(10)(11).…”

“…There is a lack of differential data and analysis on how health programs impact gender-based factors, including of drowning prevention programs (12,13). Program effects on gender-based differences in mobility privileges, power relationships between community members and expectations on behaviour need to be measured to understand how they in uence these health outcomes (1,9). For example, previous research has shown that negative perceptions towards women's economic empowerment may lead to higher rates of domestic violence on working women (14), but if programs do not evaluate these outcomes, they will remain invisible.…”

“…Techniques such as effective engagement and provision of incentives to support women's employment, mobility and involvement in decision making have been effective in improving women's autonomy and hence access to healthcare and information for themselves and their families (9,10,(16)(17)(18).…”