Introducing Health Workers for Change: from transformation theory to health systems in developing countries.

This introductory paper provides the theoretical basis behind the Health Workers for Change methodology, and the role of interactive, participatory learning approaches in promoting social change. The methodology has its origins in Latin America and Kenya, where participatory research methods have been used widely to raise social consciousness and promote change. The paper discusses the resistance of health institutions to participatory ways of learning and the reasons why this occurs. It also presents the logic for the subsequent papers in this special issue and provides a summary of their respective contributions.

An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool.

This paper presents the findings of a multi-centre study assessing the impact of Health Workers for Change (HWFC) workshops in seven different primary care sites, based on the common core protocol described in this paper. The paper discusses a common methodology used by the studies, consisting of a triangulation of qualitative and quantitative methods. Such methodologies are inherently complex as they require comparisons across systems, sites and procedures. The studies were conducted in six sites in Africa and one site in Argentina. Generally, the intervention resulted either in positive change or in no change, except in the area of staff relationships where conflicts were more frequent after the intervention than before. This may reflect a willingness to confront problems or contentious issues. Implementing the HWFC workshops improved provider-client relations, facility level functioning and aspects of staff interrelationships, and had some impact at the system level. All studies indicated that overall health system development is essential for improved service provision including quality of care. The findings also indicated that this intervention complemented and could assist health sector reform efforts and can play a role in sensitizing health workers to gender issues. The paper concludes with a discussion of the robustness of the methodology used in the studies.

Health Workers for Change as a health systems management and development tool.

In this paper we draw overall conclusions concerning the Health Workers for Change (HWFC) methodology as a management and health systems development tool. We examine how HWFC has contributed to an elucidation of the four main themes with which this special Issue is concerned, namely: the value of participatory training; the need for gender sensitivity in health services; the impact of the HWFC intervention on gender sensitivity and quality of care in health services; and the ability to replicate the HWFC intervention in a variety of cultural and geographical sites. The paper concludes that HWFC is a useful health systems development tool, discusses other applications of HWFC beyond those reported in this Issue and makes several recommendations concerning its future use.

Gender and the stigma of onchocercal skin disease in Africa.

This paper reports results from a multicenter study of gender differences in the stigma associated with onchocercal skin disease (OSD) in five African sites: Cameroon, Ghana, Nigeria (Awka and Ibadan) and Uganda. The studies used a common protocol to compare affected and unaffected respondents, that is, men and women with onchodermatitis in highly endemic areas and respondents from communities with low endemicity or no onchocerciasis. The methods were both quantitative and qualitative, allowing for the comparison of stigma scores and people's verbal descriptions of their experiences and attitudes. Questions to the unaffected were asked after providing them with photographs and short descriptions (vignettes) depicting typical cases. We found that stigma was expressed more openly by the unaffected, who perceived OSD as something foreign or removed from themselves, whereas the affected tended to deny that they experienced stigma as a result of the condition. Gender differences in stigma scores were not significantly different for men and women, but qualitative data revealed that stigma was experienced differently by men and women, and that men and women were affected by it in distinctive ways. Men were more concerned about the impact of the disease on sexual performance and economic prospects, whereas women expressed more concern about physical appearance and life chances, especially marriage. Similar trends were found in the different sites in the responses of affected and unaffected respondents, and differences between them, despite geographical and cultural variations.

Treatment-seeking behaviour for malaria: a typology based on endemicity and gender.

A main component of current malaria control strategies to reduce malaria-related mortality and severe morbidity is early diagnosis and treatment at peripheral health services such as village health posts and dispensaries. This strategy has been promoted mainly by sensitising the population with regard to the available service offered and by providing classical biomedical descriptions of symptoms and signs of malaria. This strategy represents important challenges for successful implementation and maintenance. Early treatment depends upon prompt recognition of symptoms and signs of malaria in the household, i.e. mainly by women. Early treatment also requires that appropriate health services and medication are accessible and used. In this paper we argue that the success of malaria control depends upon an approach that is gender-sensitive and takes into account the level of endemicity in a given setting. The level of endemicity determines which group of the population is at highest risk for infection, morbidity and mortality, and is strongly related to gender considerations. The paper develops a typology that combines the key factors of gender variables with epidemiological features. It consequently outlines an approach to community-based, effective malaria control tailored to a given endemic setting. Finally, we suggest that the proposed framework could be validated for its potential application to the control of other communicable diseases.

Incorporating gender in the anthropology of infectious diseases.

The paper focuses on key issues in research and control of infectious diseases and demonstrates the utility of combining a gender perspective with anthropological investigation both for understanding disease and for designing and evaluating interventions for its control. Based on a definition of gender as opposed to sex, it illustrates, with the help of a gender framework for tropical diseases, how this concept is applied. It argues that gender-sensitive research is essential to the understanding of the nature of the disease, its prevalence, distribution, determinants and consequences. Examples are taken from anthropological studies on infectious diseases, including research on urinary schistosomiasis, malaria, leprosy, leishmaniasis and onchocerciasis. How gender-sensitive qualitative research can guide the design and evaluation of appropriate interventions for the prevention and control of infectious diseases is also discussed.

Quality health care for women: a global challenge.

This paper discusses barriers to the provision of high quality care from the perspectives of the health system and female clients, and interventions that have been developed to overcome these barriers. These interventions are in the area of reproductive health, where most attention to women's health has focused; they consist mainly of assessment tools that can be used by peripheral health workers and rural women themselves. The paper argues that in nonreproductive health generally, there is a dearth of information on the biological and social determinants and consequences of infection and disease from a gender perspective. Recommendations are made for further research on quality of care and for practical interventions with application to women's health, both within and outside the reproductive context.

PIP: This paper considers problems of definition, measurement, and management of quality health care for women as well as barriers to quality of care, including information, access, and use barriers. It then describes a number of interventions supported by the World Health Organization designed to improve the quality of care provided and women's access to and use of health services. Interventions need to take into account the perspectives of both health workers and women, as well as the constraints they face in providing and receiving services, respectively. The authors broadly focus upon women's health, considering reproduction as well as other health concerns such as tropical diseases endemic to developing countries. They argue that in nonreproductive health, there is a general lack of information upon the biological and social determinants and consequences of infection and disease from a gender perspective. Recommendations are made for further research into the quality of care and for practical interventions with application to women's health, both within and outside of the reproductive context.

Filariasis in northern Ghana: some cultural beliefs and practices and their implications for disease control.

This article reports on how some endemic rural communities in northern Ghana perceive and manage lymphatic filariasis. The disease was mainly attributed to supernatural and spiritual factors. Except for a few instances of neglect, the community was generally caring towards people with the disease. Issues related to marriage, stigma, concealment and leadership are discussed. On the whole, the importance of social and cultural perceptions of a disease and its relevance to control cannot be over emphasized.

Double jeopardy: women and leprosy in India.

This article presents evidence from two states of India, Bihar and Maharashtra, on the process of "dehabilitation" among male and female leprosy patients, and suggests gender-sensitive interventions to address existing problems in leprosy control. While the study investigated a wide range of gender differences in the impact of leprosy, this article focuses on only two-marriage and family reactions. Important gender differences were apparent in the impact of the disease. While both men and women were negatively affected in terms of their family and marital lives, women suffered more isolation and rejection. Psychologically, women appeared more vulnerable because they were deprived of personal contact with others in the domestic environment where they were accustomed to receiving their greatest emotional rewards. Women reported that indifference to them by other family members, or seeming negation of their presence, caused them the greatest suffering. This underscores the importance of providing information to both leprosy patients and their families about the disease and its treatment, including the possibility of cure with MDT (multi-drug therapy) and of counselling family members about their crucial role in helping patients cope and recover. This support is even more critical for women, who often lack access to the variety of outside advice and assistance available to men. The evidence presented in the article demonstrates the importance of analysing leprosy from a gender perspective, not only because this approach helps to inform our understanding of the determinants and consequences of the disease, but also because it provides new insights for improved disease control.

PIP: As part of a larger study of gender differences in the stigmatization connected with leprosy in India as well as in its detection and treatment, this article presents data on the impact of leprosy on marriage and the family. A review of previous studies shows that women's immune responses to leprosy may be weakened by pregnancy, that congenital transmission is possible but rare, and that affected women may not receive counseling about risks of pregnancy or the side effects of the drugs they are given. The present study gathered data from 2495 inhabitants of Bihar and Maharashtra including 934 who were receiving treatment and living relatively normal lives (59% male), 300 members of their families, 1071 who had to leave home or a job (63% male), 100 who were rehabilitated (55% male), and 90 health workers treating the patients. Additional data were gathered from in-depth interviews and 25 case studies (13 males). The findings of this study, including the fact that the impact of leprosy was greater for women because they suffered more isolation and rejection than men, led to the following conclusions: 1) in order to improve early detection and treatment of women, they should be encouraged to seek treatment for any skin ailments; 2) leprosy workers should alleviate concerns about the efficacy of smaller pills and should counsel families about the importance of the medical regimen; 3) women should be counseled about the risks of pregnancy associated with leprosy and about the side effects of the drugs; 4) calendars and family members should be used to help patients follow their drug regimen; 5) leprosy workers should undergo gender sensitization, and more women should be recruited to examine women; and 6) the needs of children of leprosy patients should receive attention so they can have equal access to education, employment, and health care.

Gender inequalities in health in the Third World: uncharted ground.

Gender differences in health in developing countries have, until recently, received little attention from researchers, health programmes and international development efforts. This paper highlights several issues related to gender and health in the Third World on which information, especially of an empirical nature, is inadequate. These include certain health conditions and diseases for which gender differences remain largely uncharted, gender inequalities in the development of health and contraceptive technology, the lack of gender-sensitivity in the provision of health services, and gender inequalities in health policies, focusing mainly on structural adjustment. Questions urgently requiring research are identified and suggestions are made for improving the gender sensitivity of health policies and interventions.

Evaluating agency initiatives: building social science capability in tropical disease research.

In recent years, in an endeavour to increase social and economic research in tropical diseases, WHO/TDR has used a number of alternative models to develop social science research capability in countries endemic for the designated tropical diseases. These have included small grants schemes to encourage junior researchers to gain familiarity with the subject area and methods, and protocol development and methodology workshops, either for specific research topics (e.g. adolescent women's health; community perceptions of schistosomiasis) or for any topic of interest to the participants. Participants have included medical researchers, social science researchers, and interdisciplinary teams (e.g. a medical researcher and a collaborating social scientist). This paper develops a typology and critically analyses these alternative approaches to developing research capability, and assesses their effectiveness in terms of cost, short-term effectiveness, and sustainability of the initiative.

Gender, HIV and AIDS.

PIP: Gender refers to differences in behavior, cultural expectations, and the social roles of males and females within particular social structures. A gender approach to health and illness includes not only biological aspects, but also the social, cultural, and economic contexts of those affected. A gender approach to the impact of HIV and AIDS therefore must take into account female and male roles in terms of factors which affect the risk of exposure and infection, responsibility for preventive actions, responsibility for caring for people with AIDS, and access to health care and treatment. A gender analysis of health is concerned with the well-being of individuals as human beings with personal needs, priorities, and preferences within the context of everyday experience. The gender and tropical diseases framework incorporates the three following principal dimensions: economic/production, social reproduction, and personal. This framework applies to the impact of HIV and AIDS on men and women as described in the case presented in the text of a man and woman in Africa infected with HIV. The man became ill with what clinically appeared to be AIDS. He refused, however, to have his blood tested for the presence of antibodies to HIV and would not tell anyone, especially his family, about his condition. The ongoing illness crippled the man and his family financially, and ultimately killed him. After his death, his wife was confirmed HIV-seropositive. She now travels by bus to work and lies in bed despondent at night.^ieng

Reversing the flow: agricultural development and changing migration patterns in rural Maharashtra.

"In this paper we investigate the impact of rapid change from subsistence to irrigated farming [in Maharashtra, India,] and human dynamic responses to these changes from a longitudinal perspective (1975 to 1987). The study focuses on a single village, providing an in-depth and extensive analysis of both in and out-migration, characteristics of migrants, motivations for migration, experience at destination, and links with home areas, both social and economic.... The importance of migration, not only to the study village, but also to other rural areas from which in-migrants came, is also assessed." (SUMMARY IN FRE AND SPA)

Gender-related differences in the impact of tropical diseases on women: what do we know?

This paper explores the importance of gender differences in the impact of tropical diseases on women. Malaria and schistosomiasis are used as examples but most of the observations also apply to other diseases endemic to developing countries. The distinction between sex and gender is discussed and evidence of sex and gender differences in the determinants and consequences of malaria and schistosomiasis, particularly their economic, social and personal dimensions, is reviewed. Issues on which research and intervention studies are needed are identified.

PIP: We have limited knowledge about nonreproductive aspects of women's health in developing countries. We need to learn about these aspects t identify effective interventions to improve their health. Improved knowledge and effective interventions will allow women to actively participate in disease prevention and obtaining health care for their families and the larger society. This review of gender differences uses schistosomiasis and malaria as examples of the determinants and consequences of tropical diseases. Women, particularly poor women, basically do not know the signs and symptoms of the diseases and that these diseases risk their health. They do not realize that, when they are infected, they pose a threat to their children. Women tend to be at a greater risk of schistosomiasis than men because they have more contact with water. Since women in India spend the early evening hours around cooking fires and men sit outside, women are at a lower risk of malaria than men. In some countries, women cannot seek medical treatment for schistosomiasis or participate in morbidity surveys without the consent and/or the presence of their husbands. Health providers tend not to believe women's experience of symptoms, so the women question their own perceptions and knowledge base. When women take care of ill family members, their work days become longer, the work load becomes heavier, and they defer some chores. When women have a tropical disease, a female relative or neighbor cares for her but then is unable to complete her own duties. These effects, as well as the conflict between expected roles and physical limitations, exacerbate their stress and feelings of inadequacy. Women with schistosomiasis report their illness later than do men. Clinicians need to provide women accurate information through better communication techniques while considering their perception of illness. Improvement in provider-patient relations has the potential to empower women to be actively involved in disease prevention.

Gender and tropical diseases: a new research focus.

This paper examines the underlying assumptions that have led to a lack of attention to women's health, particularly in developing countries, beyond the context of their reproductive roles. It is argued that the peculiar nature of women' responsibilities both in economic production and within the family, may have a profound impact on the extent to which they are affected by tropical diseases and their responses to disease. It is suggested that the gender relations of health are of considerable significance in explaining the differential consequences of tropical disease on women, men and children. The paper proposes a framework for gender-sensitive research on this topic and suggests some new directions for research.

Social and economic factors and the control of lymphatic filariasis: a review.

Formal control programmes do not exist for lymphatic filariasis in much of the endemic world. The literature on the social, economic and clinical impacts of the disease is so sparse as to provide virtually no guidance on whether the disease should be accorded more importance in national or local public health programmes. This type of research is a major priority. Putting together what little is known about the socioeconomic determinants of filariasis with the fairly extensive experience in control leads to a finding that control programmes must be undertaken at the community level to be effective. Diethylcarbamazine (DEC) is a readily available and apparently safe drug that can be deployed successfully for community control. While research currently is exploring the potential for individuals to protect themselves with DEC or a newer drug, ivermectin, community-wide control is unlikely to be achieved in that way. Under some special circumstances, controlling the mosquito vectors may be sufficient to control the disease, and in other cases, it may complement chemotherapy, but in general, it cannot be relied upon as a primary measure. DEC may be used in a variety of regimens which vary in their cost, duration, incidence of side effects and degree of community participation. Some, including DEC-medicated salt, are particularly attractive alternatives for many filariasis-endemic areas. The search for less expensive, yet effective, control options must continue, and this requires research not only into the costs of the various options, but also into the determinants of community acceptance, compliance and participation.

New approaches to social and economic research on schistosomiasis in TDR (Special Programme for Research and Training in Tropical Diseases).

This paper describes new approaches to social and economic research being developed by the Social and Economic Research component of the Special Programme for Research and Training in Tropical Diseases of the World Health Organization. One of these is a study to assess the possibility of identifying high risk communities for urinary schistosomiasis through a "mailed" questionnaire approach distributed through an existing administrative system, thereby eliminating the need for face-to-face interviews by the research or disease control team. This approach, developed by the Swiss Tropical Institute in Ifakara, Tanzania, is currently being tested in seven other African countries. The paper also describes a change of emphasis of economic research on schistosomiasis, focusing on the intra-household effects of the disease on rural households, rather than, as previously done, studying the impact of the disease on the productivity of individual wage labourers. Other priorities involve the identification of epidemiological information needed for improved decision-making regarding acceptable treatment strategies in endemic areas with limited financial capacity, as well as research on how the adverse effects of economic development projects can be alleviated.