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

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.

'I was thinking we would be spoon-fed': Community co-researchers' perceptions of individual empowerment in participatory health research in Swaziland

Empowerment is an influential concept in global public health. Current theoretical models, which were developed in resource-rich countries, conceptualise individual-level empowerment as a process (or outcome) of developing positive self-perceptions, critical thinking expertise and new behaviours. They neglect the social and structural aspects that were central to early conceptualisations of empowerment, and may be culturally biased. My aim was to elucidate lay-people in Swaziland's perspectives about individual-level empowerment. Twenty-one focus group discussions with lay-community 'co-researchers' were collected longitudinally over 14 months of a participatory health research process. Findings generated using interpretive analysis of epiphanies highlighted the salience of socio-historic context, in limiting the co-researchers' expectations and experiences, and shaping their perceptions, of empowerment. The findings demonstrate that the co-researchers perceived: working independently and collaboratively; developing new perceptions of others, and technical (health and research) expertise; using expertise to take action; and accessing material resources were important aspects of empowerment. They indicate that individual-level empowerment models utilised in global public health might be enhanced by incorporating social and structural dimensions. These dimensions are needed to capture the relations and interactions which mediate socially excluded people's agency to access the social and material resources needed to secure their right to health.

Limits and opportunities to community health worker empowerment: A multi-country comparative study

BACKGROUND

In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience.

METHODS

We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used.

RESULTS

CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact.

CONCLUSIONS

While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.

Understanding the agency of home-based care volunteers: establishing identity and negotiating space in AIDS-home-based care in rural KwaZulu-Natal, South Africa

In traditional Zulu communities, caregiving is rooted in compassionate and hardworking personal identity precepts and the traditional identity expectations of women. Home-based-care volunteerism in the community represents the performance of this identity. Data from a series of interviews with 15 home-based care volunteers (HBCVs), in a rural community in KwaZulu-Natal Province, South Africa, is used to illustrate how HBCVs promote the notion of women as paid home-based caregivers, with a recognised space in the care and support system regarding HIV and AIDS. Home-based-care volunteering also represents the attempt by women to be seen, heard and recognised in the hope that it will lead to self-improvement and the improvement of their families. Volunteer motivations vary from altruism, to volunteering as a means to be recognised and increasing the chances of self-improvement. We propose that home-based-care volunteering may be viewed as a form of agency in response to a lack of recognition, support and acknowledgement for AIDS caregivers and their patients. The continued lack of support for HBCVs over a long period undermines the work and the basis of the HBCVs' identity or the aspects of identity on which the motivation for the work is based.

Can local communities 'sustain' HIV/AIDS programmes? A South African example

Globally, there is a renewed interest in building the local sustainability of HIV/AIDS programmes to ensure that once funders withdraw, local communities can sustain programmes. While the 'local sustainability assumption' is widespread, little research has assessed this. In this article, we assess the sustainability of the Entabeni Project, a community-based intervention that sought to build women's local leadership and capacity to respond to HIV/AIDS through a group of volunteer carers, 3 years after external support was withdrawn. Overall, the sustainability of the Entabeni Project was limited. The wider social and political context undermined volunteer carers' sense that they could affect change, with little external support for them from government and NGOs, who struggled to engage with local community organizations. At the community level, some church leaders and community members recognized the important role of health volunteers, many continued to devalue the work of the carers, especially once there was no external organization to support and validate their work. Within the health volunteer group, despite extensive efforts to change dynamics, it remained dominated by a local male leader who denied others active participation while lacking the skills to meaningfully lead the project. Our case study suggests that the local-sustainability assumption is wishful thinking. Small-scale local projects are unlikely to be able to challenge the broader social and political dynamics hindering their sustainability without meaningful external support.

Community group membership and stigmatising attitudes towards people living with HIV in Eastern Zimbabwe

Stigmatising attitudes towards people living with HIV and AIDS (PLHIV) are hampering attempts to control HIV epidemics in sub-Saharan African countries. This study measures the effect of social capital, in the form of local community groups, in reducing stigma and tests a new explanatory framework for the association between community group membership and less stigmatising attitudes. Prospective data on membership of a wide range of different community groups and stigmatising attitudes (being unwilling to care for a relative with AIDS), collected from a general population cohort of 5,253 men and women aged 15–54 years in eastern Zimbabwe between 2003 and 2008 were analysed using multivariable logistic regression. 36 % of respondents were members of community groups throughout the study period. Individuals in community groups were less likely to express stigmatising attitudes towards PLHIV—3.4 versus 9.5 % (adjusted odds ratio = 0.46, p < 0.001). Discussions of care for PLHIV within groups, improved knowledge about AIDS, greater exposure to PLHIV, and increased uptake of HIV testing and counselling did not account for the association. Further work is needed to identify the mechanisms through which community participation can reduce stigma. Nevertheless, these findings suggest that promoting well-informed discussions about HIV within pre-existing community groups and involving these groups in stigma reduction programmes could be effective means of reducing stigma at the grassroots level.

From rhetoric to reality? Putting HIV and AIDS rights talk into practice in a South African rural community

Whilst international rhetoric on HIV and AIDS frequently invokes discourses of human rights to inspire and guide action, translating universal rights talk into practice in specific settings remains a challenge. Community mobilisation is often strategy of choice. We present a case study of the Entabeni Project in South Africa--in which a foreign-funded NGO sought to work with female health volunteers in a deep rural community to increase their access to two HIV-relevant rights: women's rights (especially gender equality) and rights to health (especially access to HIV- and AIDS-related services). Whilst the project had short-term health-related successes, it was less successful in implementing a gender empowerment agenda. The concept of women's rights had no purchase with women who had little interest in directly challenging male power, foregrounding the fight against poverty as their main preoccupation. The area's traditional chief and gatekeeper insisted the project should remain 'apolitical'. Project funders prioritised 'numbers reached' over a gender empowerment orientation. In the absence of (1) a marginalised group who are willing to assert their rights; and (2) a context where powerful people are willing to support these claims, 'rights' may be a blunt tool for HIV-related work with women in deeply oppressive and remote rural communities beyond the reach of international treaties and urban-based activist movements.