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Introduction:
There are an
extremely wide range of factors that influence whether or not a
woman seeks and obtains quality care from modern health-care
facilities. The obstacles that women face are much "more than a
problem of distance" and a lack of financial resources to cover
the cost of care and transportation (although these are
certainly important factors). Literature in this area tends to
distinguish between "access to care" and "quality of care."
Quality-of-care research usually centers on the experiences of
those who have managed to gain access to modern health services,
but the individuals who choose not to use services, or who are
unable to do so, are not addressed. However, female clients may
consider access to care to be integrally linked to quality of
care; conversely, services considered to be of poor quality will
not be used. Therefore, barriers that influence whether or not a
woman is able to gain access to services will be addressed, as
will factors that influence the quality of care provided to
women at the point of service delivery.
Recognition of illness
Before a woman
decides to seek care, she must be able to recognize the signs
and symptoms that indicate the need for care. However, a lack of
educational opportunities and poor understanding of
health-related matters mean that many women are not familiar
with different diseases and their presentation. For example,
some women assume that "vaginal discharge is a natural part of
being a woman" or think that back pain is normal because they
have suffered from it for as long as they can remember. How many
girls and women in the world still suffer from poverty of
education, information, and knowledge?
As a result of cultural restrictions and
taboos, women may be unable to interpret signs of illness,
particularly as they relate to the genitals.
Competing demands
Even if a woman
notices symptoms of illness, she may completely ignore these
signs because of other competing demands. Women may believe that
they cannot afford the "luxury" to take time out to visit a
health centre or to have a period of incapacity because this
would represent time and effort lost to other essential and
possibly more important, activities such as child care, food
production, and paid employment. Generally, mothers say that
they are busy, that they are not able to come [to the health
centre], that they have to travel or that they are traders. They
also say that their business nourishes the whole family and they
cannot neglect all the children just for one.
The hours when
health clinics are open may not be sensitive to the gender
division of labour and the timing of women's work. Women's work
patterns should therefore be considered when setting clinic
hours. To increase the chances of working women receiving care,
health services might also be established where women work, such
as at factories. Other family or community members rarely assume
women's essential tasks when they are ill. Women therefore
continue to perform necessary activities that are difficult to
defer. Because women do not take off enough time to care for
their health, it usually takes them longer to fully recover from
illness or disease. The amount of time that a woman stays in
hospital (if she has to go) can be significantly shorter than
the amount of time taken by a man, and a woman invariably
returns to her work, both inside and outside the home, before
she is fully recovered.
Women's health is not a priority
Women in
developing countries tend to place the health and well-being of
their families, especially children, as a priority over their
own health and, consequently, do not seek medical care for
themselves. Furthermore, male children tend to be given superior
access to care compared with female children. The general low
status of women, and their internalization of this status,
results in the marginalization of women's physical,
psychological, and emotional needs. Women are less likely than
men to consult modern health services, wait longer than men to
seek treatment when ill, are reluctant to spend limited
resources on their own needs, and often cope with illness by
self-treatment, by consulting traditional healers, or by simply
living with the condition and its resulting discomfort Because
of their heavy household duties, women cannot afford to be sick
themselves. It would be useful to discover how many ailments
exist among women but never receive attention from the medical
profession.
Women need to be
broadly educated about the importance of regular health care for
themselves, as well as for their children. The role of
self-esteem, an important factor that affects whether or not
women seek care for their own health, should be considered when
educational health programs are implemented. Because women tend
to place great importance on their children, it may be useful to
present messages that instill the notion that it is important
that a woman be healthy to maintain her child's health.
Lack of support
Social support
from others, such as relatives, friends, and neighbors can play
an important role in fostering the physical and psychological
health of and can greatly influence the health-seeking behavior
of women. Less importance may be placed on the health of female
members of the household, compared with male members, and,
consequently, a woman's illness may receive little attention
from others. Although men are strongly pressured by other family
members, particularly from mothers and wives, to seek treatment,
women are unlikely to receive such encouragement -- "a woman's
role is to nurse, not to be nursed."
The true extent of
some women's health problems may be completely underestimated by
society. Because some very serious illnesses and conditions may
not be properly acknowledged by society for example, cancer,
AIDS, physical disabilities, chronic fatigue, and depression,
women with such problems may not be assigned "a legitimate sick
status." If a woman's illness is not identified as being
authentic, it is doubtful that she will receive support from
family members and the wider community to seek care.
Shame and embarrassment
Shame and
embarrassment can lead to reluctance on the part of women to
share disease conditions with family members and health and this
may prevent them from reporting to health services for the
diagnosis and treatment of illnesses. A reluctance to tell
others is particularly acute in the case of illnesses with
genital or urinary involvement. There is considerable stigma
associated with STDs because these diseases are associated with
sexual deviance. It is not surprising that women are very
concerned about the consequences of detection and the
possibility of being ostracized by their family and community.
Women who have been victims of violence and abuse may be very
unwilling to seek medical care because they are reluctant to
draw attention to their situation.
Fear of illness
Some women express
concern that diseases would be discovered during check-ups and
they said "they would rather not know [about them]." Woman may
be concerned that she might have "cancer of the uterus" and she
would "rather not know" because her "mother-in-law died of
cancer of the uterus" and her "sister-in-law left behind five
children, she died of cancer of the uterus." The inclusion of
blood tests in regular check-ups may lead to similar concerns.
Apathy and depression
Women who suffer
from psychological conditions, such as depression, may have a
complete sense of apathy toward their own health care. Although
psychological conditions often have a biological component, the
particularly harsh living conditions of many women, including
poverty, high stress, isolation, and an absence of social
support, may work together to produce a state of depression or
apathy. The inability of some women to express their problems
may adversely affect their psychological health. For other
women, childhood experiences of violence, including rape or
incest, may be factors related to their apathy or depression.
Access to health facilities
People should be
able to receive reliable care close to where they live. However,
health facilities are often poorly distributed, and health
personnel and financial resources tend to be concentrated in
urban hospitals. In rural areas where the vast majority of women
in the developing world live, are less likely to have adequate
health services. Difficulties in reaching health facilities, as
a result of distances, lack of transportation, or poor roads,
are well-documented impediments to care. In rural areas, the
common mode of transportation for women is walking (or
occasionally a bicycle or a bullock-cart). If an ill woman wants
to visit a health centre, she may have to walk very long
distances. If her child is ill, she may have to walk several
kilometers with the sick child strapped on her back. These long
distances often mean that women only visit clinics when their
health, or the health of their child, has reached a critical
stage. Clients who are farther away are less likely to have a
good understanding or an exposure to the services provided by
the facility. Greater familiarity can bring with it higher
levels of acceptability.
Restrictions on mobility
Cultural norms
that restrict the movements of women in some societies can
prevent women from consulting health services. In rural areas of
India and Pakistan, for example, females are not allowed to
travel long distances alone. A male member of the family, even
the youngest brother or son, is required to accompany a woman.
This limits the distance women can travel alone to seek health
care. To get around this barrier to care, it has been suggested
that "elderly widows of secure honour and status might be
trained as health workers to visit women in domestic seclusion."
A woman-centered strategy would require additional measures such
as encouraging female community nurses to visit homes,
especially those in communities where women are in seclusion,
for case detection and management as part of the program to
control malaria.
Access to financial resources
Lack of access to
resources to cover transport, service, and treatment costs is
another barrier to care. Women generally lack control of
financial resources (often scarce) and therefore cannot, or will
not, divert them for their own health. Given the limitations on
women's earnings in both formal and informal employment, and
their complete exclusion from the cash economy in some cases,
the extent to which poor women, particularly those who head
households, can afford expenditures [associated with health
care] is questionable. Because they are financially dependent on
husbands or relatives women rely on male household members to
pay the costs associated with health services. Men usually have
the ultimate financial decision-making power about whether or
not a family member can go to a health.
Sex and maturity of the health worker
In many poor
countries, the primary health-care worker is male. The lack of
female health-care providers is another deterrent that prevents
women from reporting to health services, particularly for
illnesses involving the genitals and those causing physical
deformities. When female clients do see male providers, shyness
and reservation, especially concerning sexual health matters,
can make it nearly impossible to establish a good client
provider relationship.
Culturally sensitive services
Health care for
women must be culturally acceptable; otherwise women may
underutilize existing health services. It has been discovered
that there are many differences between the traditional and
western systems in their practices and beliefs related to
prenatal care, labour, and delivery. Indigenous women are
reluctant to attend hospitals for deliveries because of
drawbacks inherent in the modern health-care system. Indigenous
women preferred to deliver their babies at home because they
could take local help in labour, they could be attended by their
relatives and husband, they could walk around, they could be
wrapped up warmly and wear their own clothes, they were not
shaved or cut, and they were able to deliver vertically,
squatting on their haunches. At the western-based hospital,
however, nothing could be consumed, they were attended by
strangers, they could not walk around during labour, they were
undressed and given a hospital gown, the hospital was cold, an
episiotomy was mandatory, and they had to deliver horizontally
in the gynecological position.
Medical and
hospital practices should ensure that they are culturally
acceptable to the people who are intended to use them. Health
services should adapt their working methods to accommodate
traditional practices that are not detrimental to women's
health. Although cultural norms and values must be respected, at
some point it may be necessary for the health sector to
challenge beliefs and practices that are harmful to women's
health.
Poor quality of care
Women's decisions
to seek care are influenced by their judgments about the nature
and quality of health services. If women lack confidence in the
available services, they generally do not use them. Women are
often reluctant to use local health services because they
believe, often correctly, that these services are poor. As a
result, tertiary-level facilities are often seriously
overcrowded because women consider them to be more effective and
seek them out, despite the distances. Many women have had poor
personal experiences with health services, and their health is
compromised by their reluctance to return to such services.
Women's health-seeking behavior is also influenced by negative
stories relayed to them by relatives and neighbors about the
care they received. Women with positive attitudes to the staff
at the health centre were almost three times more likely to
deliver their children with the assistance of a trained person
compared with those with negative attitudes. Certain sources of
information, such as friends and relatives, can be particularly
credible to women who were making health-related decisions.
Women commonly complain that they are not provided with
sufficient information. It is generally believed that female
clients place great emphasis on interpersonal relationships.
Research findings, however, have highlighted a general lack of
sensitivity on the part of providers in their dealings with
clients. The doctor should not scold one for taking the child
[who is] dirty because if she goes for an emergency, she's not
going to be thinking that she should wash him beforehand.
Health workers who
are from the same community as the people being served may have
better success and provide better care than those from outside
the community because they share a common cultural background
and common experiences. Likewise, those who totally immerse
themselves in a community may gain the trust and respect of the
people being served -- crucial elements to good health care.
Good interpersonal
care requires sufficient time on the part of the provider. Many
physicians, however, reportedly do not provide enough time to
let women talk about how or what they feel. Women should have
the opportunity to discuss various psychosocial factors related
to their health and well-being. In this way, they can learn
about the relationship between the illness and disease and their
lives as women, workers, mothers, and wives.
School curricula,
including medical and health education curricula, must address
gender issues and the specific health needs of women. The basic
training and refresher training courses of all health providers
need reorientation to place health in the context of unequal
gender status, and to provide women's perspectives on their
needs and experiences.
Women are
frustrated and discouraged when they travel great distances to
the health centre by foot only to discover that the health
worker is not there or that there is only one person available
who has to treat many, and is therefore unable to provide
adequate service and attention to individual clients. Time of
access for clients at some health facilities may be limited to
only a fraction of the official 8 hours. Because health-care
providers often receive little compensation for their work in
public clinics, they may spend part of the working day at a
private clinic to make extra money. Providers in developing
countries usually face numerous constraints that affect the
quality of care they are able to provide. They tend to be
overworked and underpaid, and health centers are invariably
understaffed and underfinanced. As a result, they complain of
having neither the time nor the energy to provide long
explanations and high-quality care to their clients.
Ensuring the
availability of essential supplies, equipment, and medication is
a necessary requirement for good quality health care. However,
there are often serious deficiencies in this. The lack of
integration of health services is another key factor that
influences women's health-seeking behavior and the quality of
care received. In many countries, different types of health
services (such as prenatal care, family planning, immunizations)
are not integrated, and they may even be offered on different
days. Women are therefore forced to return repeatedly to a
clinic to receive care for their various health needs as well as
the needs of their children. Given the heavy workloads and
limited personal time available to women, strategies aimed at
combining several health services at convenient times to meet
women's needs should to be fully.
(reviewed
from books on health from International Development Research
Centre: www.idrc.ca)
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