Pakistan's health policy: appropriateness and relevance to women's health needs

The interface between national health policy and women's health needs is complex in developing countries like Pakistan. This paper aims to assess if Pakistan's national health policy 2001 is relevant and appropriate to women's health needs. Through review of existing data on women, a profile of women's health needs was developed which was transformed into framework of analysis. This framework indicates that Pakistani women's health needs are determined by gender disparities in health and health-related sectors. Comparison of national health policy with women's health needs framework reveals that although policy focuses on women's health through prioritization of gender equity, it is however addressed as an isolated theme without acknowledging the vital role gender inequalities in health and health-related sectors play in defining women's health needs. Moreover, gender equity is translated as provision of reproductive health services to married mothers, ignoring various critical overarching issues of women's life such as sexual abuse, violence, induced abortion, etc. Health systems strengthening strategies are though suggested but these fails to recognize main obstacles of utilization of healthcare services by women including non-availability of female healthcare providers and gender-based obstacles to healthcare utilization such as illiteracy, lack of empowerment to make decisions related to health, etc. In order to be relevant and appropriate to women's health needs the policy should: (1) use gender equity in health and health-related sectors as an approach to develop a healthy policy (2) expand the focus from reproductive health to life cycle approach to address all issues around women's life (3) strengthen health systems through creation of gender equity among all cadres of health providers (4) tailoring health interventions to counter gender-based obstacles to utilization of healthcare services and (5) dissemination interventions for behavior change.     

‘If she is a good woman …’ and ‘to be a real man …’: gender,risk and access to HIV services among key populations in Tajikistan

The HIV epidemic continues to grow in Tajikistan, especially among people who inject drugs, sex workers, men who have sex with men and incarcerated populations. Despite their susceptibility to HIV, members of these groups do not always have access to HIV prevention, testing and treatment. The purpose of this study was to identify and understand the gender constraints in accessing HIV services for key populations in Tajikistan. Using focus-group discussions and key-informant interviews the assessment team collected information from members of key populations and those who work with them. Several themes emerged from the data, including: low levels of HIV knowledge, gender constraints to condom use and safer drug use, gender constraints limit HIV testing opportunities, gender-based violence, stigma and discrimination, and the lack of female spaces in the HIV response. The results of this study show that there are well-defined gender norms in Tajikistan, and these gender norms influence key populations’ access to HIV services. Addressing these gender constraints may offer opportunities for more equitable access to HIV services in Tajikistan.     

Critical trajectories of female victims of gender violence: discourse analysis of women and staff professionals in Porto Alegre, Rio Grande do Sul State, Brazil

This qualitative study aims to describe the trajectories of female victims of gender violence in Porto Alegre, Rio Grande do Sul State, Brazil. The methodology included in-depth interviews with women and staff, attempting to map the critical paths of women when they made the decision to seek professional help. We interviewed 21 women victims of gender violence and 25 professionals, including law enforcement officials, health and social workers, and nongovernmental organizations. The women's trajectories in the services were mapped, identifying facilitating factors and obstacles in the process of breaking with gender violence. The victims reported: pressure by professional staff to return to their marriages and police inefficiency in providing protection. The discourse of law enforcement officials and health and social workers showed a range of different concepts regarding violence, medicalization of violence, and network fragmentation.     

Health Workers for Change: developing the initiative

This paper describes an intervention developed in South Africa for health workers at the health facility level, and designed to explore interpersonal relations among health workers and between health workers and female clients. Several participatory methods to explore the provider-client relationship were tested with health workers. Health workers identified many constraints to the provision of adequate health services and that these constraints affected their work in general and their relationship with women clients in particular. Constraints included inadequacies and inefficiencies in management and the lack of gender sensitivity training. The participatory approach was found to be acceptable to the participants and effective in exploring interpersonal relationships.     

The importance of gender in defining and improving quality of care: some conceptual issues

This paper discusses some conceptual underpinnings of research on gender and quality of health services and demonstrates the importance of training health professionals about how gender influences the health-illness-care process in men and women. It addresses the need to provide opportunities for health providers to understand how gender influences their own lives and work. It also describes the gendered nature of the health system itself, an aspect that is little understood and hence neglected in the training of health workers and the planning and provision of services. The paper demonstrates the need for interventions such as Health Workers for Change to sensitize health workers to the needs of female clients in particular, but also to their own constraints and challenges as health workers. It is also meant to stimulate further research into these issues, particularly among resource poor populations.     

Beijing and beyond: women's health and gender-based analysis in Canada.

On the tenth anniversary of the Fourth World Conference on Women, held in Beijing, this article evaluates Canada's progress in the area of women's health by critically examining the Women's Health Strategy. Introduced in 1999 by Health Canada, the Strategy is considered Canada's key response to its international commitments for promoting women's health and in particular for implementing a gender-based analysis in all programs, services, policies, and research. By reviewing each objective of the Strategy, the article illustrates the limited progress that has been made to date. It provides arguments for why and how all levels of government should work to improve their response to women's health in Canada and, specifically, how the Women's Health Strategy can be redesigned to be more effective in attending to the needs and concerns of all Canadian women.     

Changing gender roles and health impacts among female workers in export-processing industries in Sri Lanka

Since the economic liberalization in 1977, a large number of Sri Lankan women have entered the labour market and engaged in income-generating activities. Some women choose to travel abroad as domestic workers, while others choose to work in export-processing industries. This process has a profound impact on gender and gender roles in Sri Lanka. Young rural women have changed their traditional women's roles to become independent daughters, efficient factory workers and partially modernized women. Even though changing gender roles are identified as a positive impact of industrial work, the new social, cultural, and legal environments of industrial work have negative impacts on these women's lives. This paper explores health impacts of changing gender roles and practices of young rural women, focusing on the experiences of female workers in export-processing industries. Further, it contributes to the literature on gender and health, and on qualitative approaches within health geographic studies. A model is formulated to suggest a conceptual framework for studying women's health. The model describes the determinant factors of individual health status based on the question of who (personal attributes) does what (type of work) where (place), when and how (behaviours). These are also determinant factors of gender and gender roles of a society. The three types of health problems (reproductive, productive and mental health) of a woman, in this case a female industrial worker, are determined by her gender roles and practices associated with these roles.     

‘You already drank my beer,I can decide anything’: using structuration theory to explore the dynamics of alcohol use,gender-based violence and HIV risk among female sex workers in Tanzania

Abstract

Female sex workers experience high rates of gender-based violence and HIV. Alcohol has been shown to facilitate women’s risk of both gender-based violence and HIV; however, little research has explored how aspects of the sex work environment shape this risk. Drawing on structuration theory, this study explored how social conduct is patterned across time and space within the sex work environment to influence alcohol consumption, gender-based violence and HIV risk among female sex workers. Qualitative in-depth interviews were conducted with 24 female sex workers enrolled in an ongoing community randomised controlled trial of a combination HIV prevention intervention in Iringa, Tanzania. Data were analysed using both inductive and deductive approaches. Findings reveal how routine interactions between female sex workers and their clients occur at three moments of time and space during the sex exchange process to facilitate alcohol consumption and increase women’s risk of gender-based violence and HIV. Findings also highlight how sex workers utilise collective agency to address aspects of the sex work environment that place them at risk of alcohol abuse, gender-based violence and HIV. Implications for future interventions to prevent gender-based violence and HIV among female sex workers in Tanzania and similar contexts are discussed.     

Country watch: Brazil

The Health in Prostitution Project was launched in 1991 in Rio de Janeiro, Brazil. The project offers a multi-year training program of health education designed to both fight the stigmatization of and violence against commercial sex workers and enhance their self-esteem, self-determination, and access to civil rights. The project therefore promotes individual awareness while influencing public opinion and policies. At first, health agents were recruited among women and transvestites who work in street-based sex work. The program was then gradually expanded to include young male sex workers and other locations, such as private parlors, saunas, and escort services. People of all sexes and sexual orientation now comprise the health agent group. The program has a paid staff of five women, three young men, and three transvestites, and approximately 70 sex workers are trained annually. Basic training includes topics such as human sexuality, personal risk assessment, HIV/STD infection, negotiation of safer sex, and STD referral services. Year two training emphasizes reproductive and women's health issues, while year three courses prioritize street work methodologies. Theatrical performances, speaking English as a second language, and performing Bach flower therapy for clients take place during the fourth year. Program trainers include medical specialists, nurses, psychologists, health educators, lawyers, and university students. At least half of the 350 health agents trained thus far are estimated to be currently engaged in paid or voluntary prevention work. Two surveys with female sex workers in 1991 and 1993 found that reported regular condom use increased from 57% to 73%; the health agents are having an effect. The program is constantly evaluated and revised.     

Women's social position and health-seeking behaviors: is the health care system accessible and responsive in Pakistan?

To make the health care system more accessible and responsive to women particularly in developing countries, it is imperative to study the health-seeking behaviors and factors determining utilization of health care services. This study was carried out in close collaboration with Aga Khan Health Services, Pakistan (AKHSP) and the Health Department of Northern Areas of Pakistan. Key findings indicate that more than one-third of women did not know the cause of their reported illness. There is a median delay of 3 days before a consultation. Local women utilize AKHSP services far more than other health services due to the quality of services offered and the availability of female health staff. The perception of receiving the required treatment is lowest for government health services. Consulting faith healers is a common practice. Health education and health promotion campaigns are needed to change existing health-seeking behaviors among women. Social arrangements should be thoughtfully considered to make the health system more responsive. More female staff needs to be deployed in government health facilities. A public-private partnership seems to provide a means to strengthen the health care system and consequently to promote women's health.     

The lived experience of UK street-based sex workers and the health consequences: an exploratory study

The complex, difficult lives and subsequent health issues of street-based female sex workers are well documented. This paper explores the health needs of a group of sex workers in one geographical locality in the north-west of England. Interviews were conducted with a number of women currently engaged in sex work, with the aim of identifying factors maintaining them in this work and examining their experience of health and health-related services. A thematic analysis revealed considerable life circumstance complexity, with violence, drugs, alcohol and housing problems being prevalent factors. The combination of such factors compounds the likelihood of the women's social exclusion. Other themes related to the casual perception the women had of their own health needs, their generally poor experience of services and the demonstrable impact of one specific service in supporting a group so reluctant to engage. The study suggests poor understanding of the complex needs of street-based sex workers by both services and professionals, particularly a failure to engage with the reality of these women's lives and the factors that maintain them in this work.     

The health care system for female workers and its current status in Japan

In this paper we describe female workers' health care, the women's and maternal protection system within the Japanese legal system, the current status of female workers in Japan, and problems regarding methods of advancing health care and the women's or maternal protection system. Motherhood is respected in the workplace in Japan, and in order to provide an environment in which women can work and still bear and rear children with a sense of security, laws concerning maternal protection of female workers, and revisions in terms of the system have been made, and a new system has been in effect since the fiscal year of 1998. Nevertheless, gender discrimination against women and the disparagement of women, rooted in gender role stereotypes concerning the division of labor, remain firmly planted in the social environment and in long-established custom. Received: 20 February 2000 / Accepted: 10 June 2000     

RURAL AND URBAN FEMALE SECONDARY SCHOOL STUDENTS' ATTITUDES TOWARDS AND USE OF PRIMARY CARE SERVICES

ABSTRACT: In light of the current and ongoing threats to young women's health of unplanned pregnancy and sexually transmissible diseases (including HIV/AIDS), assured access to appropriate and sensitive health services is of paramount importance. In this article, the results of a recent Victorian study involving rural and urban female secondary school students on issues relating to sexual health are reported. Drawing upon the findings of an extensive self-report questionnaire, young women's attitudes towards and use of health services are presented with a particular focus upon the variations that exist between the rural and urban populations. Apart from issues associated with privacy, which were found to be more crucial to rural young women's decisions to seek medical care, this study found young women's concern about the attitudes of medical and non-medical staff alike, the atmosphere of surgery or clinic, and gender of doctor all to be important factors in their general use of health services, regardless of location.     

Doctors and nurses in outback Australia: living with bush initiatives

This qualitative in-depth study investigates the work and life experiences of 18 female doctors and nurses in remote Australia. The study begins to unravel some of the events and relationships in the women's lives that keep them working and living in remote areas. The study also examines social and working conditions that cause the women to leave, and concludes that action must be taken at both government and local levels to support female health professionals who work in remote locations. This may be achieved by the means of a health promotion action model to underpin such initiatives as the 1999 Commonwealth Government 'fly-in-fly-out' initiative, in which sessional female doctors provide women's health services in remote areas.     

An occupational health services initiative at a women's hospital in Kabul, Afghanistan

This article describes the process of developing targeted occupational health services for the health care workers in a women's hospital in Kabul, Afghanistan, as part of a larger project to establish an obstetrics and gynecology residency training program at the facility. The goal was to create a feasible and sustainable program to: (1) address basic health care needs impacting the ability of these Afghan health care workers to optimize learning opportunities; (2) decrease absenteeism due to illness; (3) decrease the likelihood of infectious disease transmission among staff, from staff to patients, and from patients to staff; (4) foster belief that a healthy and safe working environment is a basic right; (5) begin to collect preliminary health status indicators on health care workers in this employee population; and (6) serve as an adaptable program to expand to other Afghan health care workers.     

Female workers health: the case of a laundry at a sodium chlorate factory

This article presents a case study on working and health conditions of female workers and former workers in the laundry at a sodium chlorate plant. The women's main function was to wash uniforms of workmen who handled metallic mercury during production and maintenance. The aim of this study is to show the health effects of this work process by analyzing workplace conditions, evaluating clinical aspects in the women, and performing individual interviews in order to obtain more precise information based on their personal experience. The authors demonstrate how harmful this type of work is to the women workers' health, posing a serious risk for them in particular and workers' conditions in general in the factory. They also point out that most of what is known about women's occupational activity (in terms of its contents and risks), in addition to their specific problems and different diseases, may be disguised by gender relationships.     

Cisgender male and transgender female sex workers in South Africa: gender variant identities and narratives of exclusion

Sex workers are often perceived as possessing ‘deviant’ identities, contributing to their exclusion from health services. The literature on sex worker identities in relation to health has focused primarily on cisgender female sex workers as the ‘carriers of disease’, obscuring the experiences of cisgender male and transgender sex workers and the complexities their gender identities bring to understandings of stigma and exclusion. To address this gap, this study draws on 21 interviews with cisgender male and transgender female sex workers receiving services from the Sex Workers Education and Advocacy Taskforce in Cape Town, South Africa. Our findings suggest that the social identities imposed upon sex workers contribute to their exclusion from public, private, discursive and geographic spaces. While many transgender female sex workers described their identities using positive and empowered language, cisgender male sex workers frequently expressed shame and internalised stigma related to identities, which could be described as ‘less than masculine’. While many of those interviewed felt empowered by positive identities as transgender women, sex workers and sex worker-advocates, disempowerment and vulnerability were also linked to inappropriately masculinised and feminised identities. Understanding the links between gender identities and social exclusion is crucial to creating effective health interventions for both cisgender men and transgender women in sex work.     

Ethnic health workers in primary health care

Abstract: Ethnic health workers were employed to increase the access of communities of non-English-speaking background to health services, but their role has remained unclear in a national health system that has been criticised for being slow to respond to the needs of these communities. Interviews and a questionnaire were used to survey a convenience sample of 40 South Australian ethnic health, welfare and community workers and 17 supervisors about the important roles of ethnic health workers, how they should perform their roles and their ability to fulfil them. Interviews with 11 staff from the New South Wales Ethnic Health Worker Program then provided a broader perspective to the South Australian findings. High-priority roles were to provide help to solve immediate health problems. Roles included providing access as well as services. There were pressures on ethnic health workers to become service providers: clients from non-English-speaking backgrounds expected assistance with a wide range of problems, and mainstream staff lacked competence in meeting these needs. Ethnic health workers' involvement in needs assessment and health agency change was limited by these pressures, by ethnic health workers' separation from the work of mainstream staff and because systematic planning of services to non-English-speaking communities was lacking. The appropriate role for an ethnic health worker is as an access provider, with a greater emphasis on needs assessment and agency change. Agencies need to develop culturally appropriate service plans and training so that ethnic health workers and mainstream staff are better able to work together.     

Fitness for work in health care workers from the prospective of ethics, science and good practices

Fitness for work (FFW) is the final task of both risk assessment and health surveillance, aimed at protecting workers' health and working capacity. There are numerous specific concerns regarding health care workers. In particular: i) the frequent difficulty in determining at pre-employment/pre-placement examinations the specific task that the individual worker will perform; ii) the prevalence of female workers and the contemporary presence of numerous occupational risk factors that are a potential cause of harmful effects on women's reproductive health; iii) the progressive aging of the staff especially nurses; iv) the risk to third parties, with particular reference to the issues of biological risk and substance abuse, also in relation to shift work, fatigue and occupational stress; v) the increasing number of immigrant workers among support staff In such cases the occupational physician, respecting both ethical principles and regulations and with an appropriate balance between scientific evidence and the precautionary principle, should express a FFW judgment that allows both the adaptation of work to the worker and vice versa, as recommended by the World Health Organization (WHO) and the International Commission on Occupational Health (ICOH). Proper FFW judgment also permits the expected benefits to be achieved, not only for the workers but also for employers, companies and society.     

Working in the margins women's experiences of stress and occupational health problems in part-time and casual retail jobs

Women workers dominate the labor market of part-time and casual jobs in Canada and other industrialized countries, particularly in the retail trade and consumer services sector. However, research into the occupational health consequences of part-time and casual jobs for this large group of women workers is still in its early stages. Emerging evidence suggests that part-time and casual jobs contribute to stress and result in health problems for women. To learn about the impact of part-time and casual jobs on women's experiences of stress and their resulting physical and emotional health, we conducted interviews and focus groups with occupational health and safety union representatives and female workers in retail and consumer services. Results show that stress is a major occupational health problem for these women, due to the working conditions in part-time and casual jobs, the psychosocial work environment, and the gendered work environment in the retail trade and consumer services. Stress from part-time and casual jobs results in repetitive strain injuries, migraine headaches, and feelings of low self-esteem, low motivation, and job dissatisfaction for women. The disconcerting implication of our research is that part-time and casual employment comes at a cost for some women.