Empowering women: participatory approaches in women's health and development projects

Strategies for Sustained Empowerment of Community Health Workers: A Qualitative Analysis of the Comprehensive Rural Health Project in Jamkhed, India

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India-an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes-selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs' credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

"Real men don't": constructions of masculinity and inadvertent harm in public health interventions

Research shows that constraining aspects of male gender norms negatively influence both women's and men's health. Messaging that draws on norms of masculinity in health programming has been shown to improve both women's and men's health, but some types of public health messaging (e.g., Man Up Monday, a media campaign to prevent the spread of sexually transmitted infections) can reify harmful aspects of hegemonic masculinity that programs are working to change. We critically assess the deployment of hegemonic male norms in the Man Up Monday campaign. We draw on ethical paradigms in public health to challenge programs that reinforce harmful aspects of gender norms and suggest the use of gender-transformative interventions that challenge constraining masculine norms and have been shown to have a positive effect on health behaviors.

Breast-cancer screening with trained volunteers in a rural area of Sudan: a pilot study

BACKGROUND

Breast cancer has a low cure rate in low-income and middle-income countries because patients often present with late-stage disease that has metastasised to other organs. We assessed whether the implementation of a cancer awareness and breast examination programme that uses local, volunteer women could increase the early detection of breast cancer in a rural area of sub-Saharan Africa.

METHODS

We did this pilot study in two counties in Gezira State, Sudan. We chose Keremet (56 villages) as the experimental county and Abugota (79 villages) as the control county. Female volunteers from villages in Keremet were trained in the detection of breast abnormalities. When trained, volunteers visited households in their village and screened women aged 18 years or older for breast abnormalities, referring women with suspected breast cancer for medical diagnosis and, if necessary, treatment at the district hospital. We also ran a cancer awareness programme for both men and women in study villages. Villages in the control population received no intervention. This study is ongoing.

FINDINGS

Between Jan 1, 2010, and Oct 10, 2012, 10 309 (70%) of 14 788 women in Keremet were screened. 138 women were identified as having breast abnormalities and were referred to the district hospital for diagnosis and treatment. 20 of these women did not report to the hospital. Of the 118 women who did report, 101 were diagnosed with benign lesions, eight with carcinoma in situ, and nine had malignant disease. After treatment, 12 of the 17 women with either carcinoma in situ or malignant disease (four had early breast cancer and eight had ductal carcinoma in situ) were disease-free and had a good prognosis. In the control villages, only four women reported to the centre: one was found to have a benign lesion while three were diagnosed with advanced disease.

INTERPRETATION

Our findings show that a screening programme using local volunteers can increase the detection of breast cancer in asymptomatic women in low-income rural communities. These findings can inform policy-makers' decisions in the design of cancer control programmes in Sudan and other similar areas in sub-Saharan Africa.

FUNDING

Sudan National Cancer Institute.

Women front and center: the opportunities of involving women in participatory health research worldwide

Participatory research involving communities, especially women, is increasingly recognized as a valuable and scientifically sound approach to improve the relevance of a study, the accuracy of data collection and interpretation, the adherence to study procedures, and the likelihood of adopting any resulting intervention. This approach has interdisciplinary roots dating back more than half a century. Although widely used in community-based conservation and development projects worldwide, international public health research has yet to fully embrace this inclusive approach, which requires the sharing of power with research participants and a more involved relationship building process with communities. In return, the gap between publication and public action can be narrowed because ownership of the research process by an empowered community can lay the foundation for an accelerated implementation of interventions tailored to community needs and based on research results. This article draws on the professional experiences of the authors as well as published examples of international participatory health research with women. Factors critical for the success of participatory research are discussed, including attention to initial planning, early community involvement, conceptual clarity, defined community benefits, and joint interpretation of results, as well as translation to action. It includes common challenges and strategies to overcome them, such as conflict resolution and data ownership.

Finding a way: Afghan women's experience in community participation

Community participation is embedded in primary health care and is key to improving the health and well-being of communities. The concept has not, however, been well studied particularly from the perspective of community members who participate. This article describes findings from qualitative interviews with five Afghan refugee women to explore their experience and the meaning of community participation. From data analysis, two themes emerged: Becoming active encompasses their stories of home, flight, resettlement, learning, and coming together; and being active reflects what they are doing and why they are doing it. Nascent themes and questions that need further elucidation are also discussed.

Health promotion for childbearing women in Rubanda, Uganda

A train-the-trainer intervention, based on the World Health Organization's Safe Motherhood Initiative, was successful in changing some health beliefs and health practices among village men and women of childbearing age in a remote area of Uganda. Specifically, more villagers reported attending postpartum care and beginning prenatal care earlier in pregnancy. Some beliefs were not changed (eg, belief in bewitchment), but some beliefs (eg, use of herbal medicines during labor) were not as widely held as a result of this cost-effective and easily sustainable program.

The quality of life of families of female-headed households in Botswana: a secondary analysis of case studies

Previous studies note a positive relationship between female-headed households (FHHs) and poverty in urban and rural areas of Botswana. To explore this further, data were collected from 7 FHHs through participant observation and open-ended interviews. A secondary analysis of data described the quality of life (QOL) of members of the households according to one's ability to meet basic human needs (food, water, shelter, safety, and health). FHHs ranged in age from 40-91 years, with family size ranging from 1-11 members. Monthly income for 6 of the 7 families was 30 dollars (U.S.) per month or less. Physical living environments were overcrowded, with poorly maintained latrines and unsafe refuse disposal. Family illnesses included hypertension, cataracts, mental illness, knee pain, ringworm, leg sores, and tonsillitis. Health risk behaviours included unprotected sex, alcohol abuse, and breastfeeding among potentially HIV positive mothers. Although Botswana claims rapidly rising levels of national income after independence, the QOL of FHHs remains poor. We suggest that, to alleviate poverty, governments in developing African countries should explore strategies that effectively target families headed by women.

Man works from sun to sun, but woman's work is never done: insights on research and policy

Gender equity and equality in health and human development are key national and international goals. To achieve these goals, the androcentric definition of work needs to be addressed. The current definition is driven by the globalized capitalistic model, which equates "work" with generating income or the production of goods. Indeed, employment in the formal labor force has become the de facto definition of work. Women's work, unpaid and reflecting the gendered role of caring for others, does not fit the economic mold and is, therefore, devalued. The health and social welfare sectors rely heavily on the unremunerated work of women to reduce their budgets, ignoring the unequal burden of care shouldered by women worldwide. Research on women's health has also been hampered by the dichotomous nature of work as employment. Changing the definition of work to value explicitly women's work could significantly impact social, health, and research policies.

Women's health in a rural setting in societal transition in Ethiopia

There are reports indicating a worsening of women's health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of women's status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty.

Health promotion and risk reduction in Malawi, Africa, village women

OBJECTIVE

A train-the-trainer intervention was evaluated in which village leaders in Malawi, Africa, taught other villagers how to improve their health.

DESIGN

Health knowledge and reported health practices were compared before and after the educational intervention in 15 villages in Chimutu, Malawi, Africa.

SETTING

Surveys were completed by trained data gatherers in the village setting.

PATIENTS/PARTICIPANTS

All men and women of childbearing age who were present in the village when data collection occurred were asked to participate. There were 187 participants in the preintervention survey and 175 participants in the postintervention survey.

INTERVENTION

Seventy-six village women were trained, using low literacy techniques, to provide content on health promotion and risk reduction in pregnancy. Over 20,000 persons have received at least one health teaching session from the village trainers.

RESULTS

The intervention resulted in reported changes in prenatal and postpartum care and in more births occurring in the hospital or clinic. Some positive nutritional changes were reported, although few changes in beliefs about use of herbal medicines or about the use of witchcraft were reported.

CONCLUSIONS

A train-the-trainer approach is a sustainable intervention that appears to have positive benefits on the health of village women living in Malawi, Africa.

Applying medical anthropology in the control of infectious disease

This paper focuses on two roles of anthropology in the control of infectious disease. The first is in identifying and describing concerns and understandings of disease, including local knowledge of cause and treatment relevant to disease control. The second is in translating these local concerns into appropriate health interventions, for example, by providing information to be incorporated in education and communication strategies for disease control. Problems arise in control programmes with competing knowledge and value systems. Anthropology's role conventionally has been in the translation of local concepts of illness and treatment, and the adaptation of biomedical knowledge to fit local aetiologies. Medical anthropology plays an important role in examining the local context of disease diagnosis, treatment and prevention, and the structural as well as conceptual barriers to improved health status. National (and international) public health goals which respect local priorities are uncommon, and generic health goals rarely coincide with specific country and community needs. The success of interventions and control programmes is moderated by local priorities and conditions, and sustainable interventions need to acknowledge and address country-specific social, economic and political circumstances.