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The health needs of women, and the constraints to meeting those needs, take a heavy toll on women. Most could be prevented or substantially reduced, however, through improved interventions based on more comprehensive, gender-disaggregated, interdisciplinary research.

-- Michael Paolisso and Joanne Leslie, International Centre for Research on Women, Washington, DC, USA (see Paolisso and Leslie 1995, p. 62)

Barriers to research

Various obstacles hinder the adoption of a gender perspective in health research. There is sometimes a lack of institutional and financial support for gender and health research, and many researchers lack the necessary research tools. In some cases, recent publications, good research, and bibliographies are difficult to access. In Latin America, researchers have difficulty obtaining resources in the Spanish language. The dearth of health research that incorporates a gender perspective, for example, in tropical disease research and the study of occupational health and safety, represents another barrier to research. There is also a need for in-depth training with regard to methodologies, techniques, and specific instruments for studying gender dimensions and for some form of a "checklist" that could be followed to ensure that research is gender-sensitive.

Beyond these barriers, it can take great efforts to overcome a "masculine-oriented perspective" (Lange et al. 1994). For example, Ilta Lange, in her research on health monitors in Santiago, Chile, found that masculine language dominated the research process. The Spanish word "monitores" was always used, instead of "monitoras," the feminine version of the word. Although all the health monitors studied were women, Lange said researchers persisted in using the masculine form of the word.

Finally, community resistance to certain types of research can also be an obstacle. Pino et al. (1994) reported that parents and teachers in Santiago, Chile, tried to prevent research that involved the study of adolescents and early sexual behaviour. Such barriers must be overcome. Research in this area is needed to help design sound programs and policies aimed at reducing the number of unwanted pregnancies and the incidence of sexually transmitted diseases, including AIDS, among adolescents.

A gender perspective

A gender perspective cannot simply be added to a study as an afterthought. It must be fully integrated into the research protocol as it is conceived, carried out, analyzed, and disseminated. A gender perspective also involves much more than sex disaggregation. At the very least, however, "sex should be a variable taken into account in ... studies, even where understanding sex differences as such are not inherent to the study objectives" (Vlassoff 1994, p. 1256). The existing lack of sex-disaggregated data and information hinders the ability of decision-makers to develop effective women's health programs and policies.

In addition to providing information on the sex of respondents and why they were selected, studies should furnish information "on the social structural and cultural context in the society under investigation" (Vlassoff 1994, p. 1257). Ideally, health research should address differential female and male roles; responsibilities; knowledge bases; positions and status within society; attitudes and perception; access to and use of resources and information; and participation in decision-making; as well as social codes and attitudes governing female and male behaviour.

Because women and men often have different roles and responsibilities, their "environmental life spaces" within and outside the home can be quite different. The impact of these differing environments on health should be addressed.

Interdisciplinary research teams, which, for example, include researchers with medical backgrounds and social scientists, may facilitate the adoption of a gender perspective. It is impossible for any single discipline or type of specialist to "have the requisite expertise to identify the critical socio-biomedical factors determining women's health risks and needs" (Paolisso and Leslie 1995, p. 55). However, interdisciplinary teams are not always feasible because of insufficient resources. Because of this constraint, cross-disciplinary training, for example, highlighting social science issues and techniques in the medical school curriculum, and vice versa, is increasingly being carried out. However, researchers with scientific and medical backgrounds, even without social science training, can learn to look at their data from a new perspective. As human beings, medical researchers can uncover the human dimension and carry out social science research.

The challenge is to find ways of ensuring that health studies are designed to take into account all the determinants of health and disease in any society so that gender differentials become visible to policymakers.

-- Dzodzi Tsikata, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Ghana

Where does a man or a woman, a girl or a boy, a female baby or a male baby, stand 24 hours of the day? Men's and women's life spaces are different and this may lead to differential exposure to diseases and illnesses, including tropical diseases. This is tied to the gender division of labour. For example, who does the animal herding? Who picks up the cow dung? Who slaughters the animals? Who cleans the clothes and utensils in the river? Researchers could look at how many hours members of the population being studied spend each day at the office, in the field, at home, and so on. How often is the population exposed to certain hazards? If the community lives near a toxic waste dump, which community members -- men, women, or children -- are at home all day and most exposed to the dump?

-- Vivienne Wee, Centre for Environment, Gender and Development (ENGENDER), Singapore

Having a gender perspective means being aware of, and accounting for, the plethora of gender-related factors that may affect the collection of research data. Researchers should be aware, for example, that women may have different notions of health and illness than men. Women, and in particular, poor women, may take a certain amount of aches and pain for granted. They may not report backaches as a health problem because they have a high threshold of pain, and view them as normal. "Women tend to suffer in silence ... the threshold of illness recognized by the society on the illness-health continuum is so high for women that they endure so much in order not to disrupt household organization" (Okojie 1994, p. 1237).

It may be extremely difficult for researchers to gather information that reflects the true state of affairs for women because, in some cultures, women may be reticent to speak their minds, particularly if men are around. Male heads of households may wish to speak "on behalf of women," even about subject matters that are particularly important to women. Researchers therefore need to ensure that women are able to speak for themselves. As Irene Luppi (1994) reported: "[With] the presence of husbands during the interviews, ... interviewers had to [cope with] the difficulties such presence presented when, for example, the husband would correct or censor the interviewee's answers, or would ask the interviewer to erase some answers, or would [say] that 'It'd be better that I answer cos' I know better.'"

The sex of the researcher is another important issue to be considered. In some societies, women are forbidden to open their doors to unknown males and this could result in the systematic skipping of women (Manderson 1994). Even if a male researcher is able to access both sexes, girls and women can feel uncomfortable being interviewed by a man and may resist answering his questions. They may feel greater ease expressing themselves with other women, particular concerning sensitive issues like sexuality. In her study of women and AIDS, Strebel (1993) reported that the use of female researchers helped to create a sense of shared experience, especially related to sexual matters and men's treatment of women. For evaluative purposes, study reports should be sure to identify whether the research team was made up of men, women, or a combination of both sexes.

The timing of interviews must also build in an appreciation of gender differences. Respondents may or may not be available to be interviewed given gender-differentiated roles and responsibilities. For example, in an agricultural community, the sample is likely to be skewed if interviews are conducted when most women are at work in the fields.

Participatory research methods are increasingly gaining acceptance and respect, and those methods tend to have a more feminist perspective because they tend to value everyone's opinion and give opportunity for everyone to speak.

-- Eva M. Rathgeber, International Development Research Centre, Regional Office for Eastern and Southern Africa, Nairobi, Kenya

A potential methodological problem relates to the possible discrepancies between what women say they do, and what they actually do. For example, although women may be aware of what they should be doing to stay healthy, for various reasons, they may be unable to carry out desired health practices. If an interviewer asks, "what do you do when ...?" women may report what they believe is "the right answer" (that is, what they should be doing, not what they actually do). When looking at household nutritional practices, for example, women, as the designated "family caregivers," could be embarrassed to tell researchers about the difficulties they have in providing their children with nutritious and adequate foods. Researchers therefore need to find ways to learn about the gap between desired intentions and actual practices. It may be helpful to ask questions such as: "What are the difficulties that you face in carrying out what you know should be done?"

In the area of sexuality, women may be reluctant to be truthful with interviewers because of socialized gender expectations. When researching adolescent sexual activity, for example, the extent to which a respondent is truthful about this subject matter is related to the social acceptability of her or his conduct, which is largely conditioned by gender. Even if researchers take all steps necessary to ensure confidentiality and anonymity, results may still be affected by gender-differentiated societal expectations concerning premarital sex.

Researchers should ensure that the research topic is of concern to the community being studied. Women's voices need to be heard. Perspectives of women from the community should be included throughout the research process -- community women should be involved in defining priorities for research, creating ethical guidelines and standards, creating and implementing the research design, and analyzing the results. Researchers from the Health Research and Consultancy Centre in Ecuador, for example, followed a model of participatory research in which the women helped administer questionnaires about their living and working conditions, health problems, and access to health care (Breilh 1994). Researchers should also be sensitive to the demands they place on women and ensure that the women are properly compensated for their time and efforts. To learn more about women's health needs, researchers can also draw on the expertise of groups who work closely with women and are likely to represent women's perspectives.

At the end of each focus group discussion, women spoke about how marvellous it was to have the opportunity to talk about issues that are usually ignored. After each discussion we gave the women information and answers to questions that had arisen during the discussion. This gave them useful knowledge and dealt with many of their anxieties. We promised to come back to them when we finished the research so that they could hear what other women had to say. Women expressed delight at this opportunity because they are so removed from the experiences of other women. This example illustrates how the research process can be enjoyable and beneficial to the "researched."

-- Barbara Klugman, Women's Health Project, University of Witwatersrand, Johannesburg, South Africa (see Klugman 1994)

The researched population should also be fully informed of the results of the research. Women who participate in research should emerge from that interaction more conscious of their world and, thus, better able to act upon it (Klugman 1994). Many researchers in the past have exploited community members without giving back to the community. As remarked by Violeta Lopez-Gonzaga: "Many have received their PhD and reaped honours because of the time and labour sacrificed by community members, without empowering the people being studied." Strebel (1993) noted, however, that attempts to provide results to research participants were not always successful. She asserts that creative ways are needed to get research findings to connect with the immediate needs of participants.

Qualitative research

Many commentators have emphasized the importance of qualitative research techniques -- such as key informants, focus-group discussions, and in-depth interviews -- to provide a multidimensional view of social situations. In Women in Development: Perspectives from the Nairobi Conference, Ellis (1986, p. 138) comments:

The qualitative approach helps us to understand people as they interact in various social contexts and to define social reality from their own experience, perspective and meaning rather than from that of the researcher alone .... It raises hitherto unasked questions, the answers to which afford deeper and sharper insights into how and why people participate as they do in a variety of social processes.

Also, according to Simmons and Elias (1994, p. 6):

Qualitative methods, using primarily observational techniques and a variety of in-depth interviewing approaches, produce contextual or holistic explanations for a smaller number of cases, with an emphasis on meaning rather than the frequency of social phenomena.

Chiarella (1994) outlined five advantages of qualitative research: it is flexible, and allows for the development of the concept and model throughout the investigation; the data gathered need not always prove preconceived hypotheses or theories; it provides the possibility of investigating essential elements and people as a whole, not as variables; it rejects pre-established prejudices and beliefs and attempts to see facts or processes as if they were occurring for the first time; and the integration of data can be carried out from the point of view of the informants themselves. This last point is important because the way people talk about their lives is significant. "The language they use and the connections they make reveal the world that they see and in which they act" (Gilligan 1982, p. 2).

Several researchers have reported fascinating research results stemming from qualitative methods. Chiarella (1994), for example, obtained a wealth of qualitative information concerning why some indigenous women in Bolivia were reluctant to use western-based health-care services. Through qualitative techniques, researchers from Myanmar identified traditional customs and cultural beliefs toward pregnancy, explored the perceptions of married couples about pregnancy, and investigated the advantages and disadvantages of antenatal care (Win May et al. 1995). A study of the psychosocial determinants that influence the use of maternal and child-health services in areas of extreme poverty in Montevideo, Uruguay, had an initial qualitative stage aimed at learning more about the variables, indicators, and categories associated with the use or nonuse of health services (Bonino 1994). Individual and collective interviews were held with women in the area, as well as with health personnel, and a rich collection of information was gathered that would not have been obtained through quantitative methods.

Focus groups have many advantages. To begin with, focus groups can serve to reduce the potential power differential that may occur in one-on-one interviews. Focus groups, which have more participants than facilitators, allow conversations or discussions to occur among participants with only occasional direction from the facilitator. The facilitator, in effect, moves into the background, and any perceived difference in status or power between participants and the facilitator tends to be minimized. Focus groups can also serve to bring women together who share similar day-to-day life experiences. In the process of sharing their stories, the women themselves probe, challenge, and share information in greater depth than can usually be fostered in a single interview.

-- Thicumporn Kuyyakanond, Northeast Centre for AIDS Prevention and Care, Khon Kaen University, Thailand

The research question should determine whether qualitative or quantitative techniques, or a combination of both approaches, are used. Quantitative approaches, such as representative surveys, emphasize coverage and the ability to generalize to larger populations. Triangulation, the combination of various methodologies in the study of the same phenomenon, is useful for validating results and for providing different insights into a selected subject area.

Action research

There is a need for more action-oriented research that is integrally linked to social change. Research should have an action component that is identified by the subjects of the research themselves and is aimed at having an impact on women's health status. It is not enough to simply ask questions and analyze problems in the traditional research style. Instead, researchers must "actively use their knowledge and skill to act and to bring about change in national policies and programmes" (Ellis 1986, p. 142). Indeed, according to Ellis (1986, p. 139), "any research done simply for its own sake and/or for the benefit of the researcher is oppressive and exploitative of those who are being researched."

International conferences will continue to be held year after year, while the lot of poor women and their communities remains bleak. It is not enough to assemble experts to lament these ills. It is important to act, to become alert, and to deliberate no longer. Change must happen at the local level where people make daily decisions that shape their lives and those of their children.

-- Yianna Lambrou, International Development Research Centre, Ottawa, Canada (see Conway and Lambrou 1995)

State-of-the-art research data on women's health issues is often not integrated into public policy and health interventions. Atai-Okei (1994, pp. 205-206), for example, expressed frustration concerning the extent to which health research has failed to reach the local populations that it is meant to serve. Results from research are often not "put into practice in ... hospitals or in rural medical clinics."

Information obtained as a result of research must serve to empower women, and the communities to which the research applies, to foster the process of change (AbouZahr 1994, p. 6).

All research on women's perceptions and needs in health should be designed and implemented with the express objective of developing interventions arising from the analysis of research results. Such interventions should be applied to extend health-care services into the community, improve the quality of health care available to women, and have an impact on women's health status.

Although there have been a number of health conferences, seminars, and workshops organized in the name of women's health in Uganda, little has been accomplished to date in terms of measurable improvement in the status of women's health or in the accessibility of health care to women.

-- Hellen Rose Atai-Okei, Ateki Women Development Association, Kampala, Uganda

In addition to developing interventions, research results should inform public policies concerning health. However, many attempts by researchers to educate policymakers about the need to plan programs aimed at improving women's health and well-being "seem to have fallen on deaf ears" (Atai-Okei 1994). Violetta Lopez-Gonzaga (1995) has urged researchers to take that extra step and translate their "200-page documents that will just sit of the shelf for years" into "2-page documents that are useful to policymakers." Developing nations, she said, cannot afford to do research "just for the sake of it."

In her paper "WID, WAD, GAD," Rathgeber (1990b) states:

The challenge of articulating the findings of ... research projects into viable, broad-based societal development plans and programs still remains to be met. To achieve this end, there is a particularly strong need for more effective communication and interaction among researchers, national and international policymakers, and donor agency representatives.

The results from two recent United Nations conferences represent major victories for women in the battle to ensure that women's concerns are integrated into policymaking. At the International Conference on Population and Development (September 1994, Cairo), women's groups from all over the world were successful in getting their message across that the population issue should be understood not as an isolated phenomenon, but in the larger framework of women's health and reproductive rights. Their success in placing women's concerns onto the international agenda resulted in a groundbreaking plan of action that stressed that if women are empowered to control their own reproductive lives, they will choose to have fewer children. In this regard, the plan of action stressed the importance of giving women equal participation in politics and public life and the need for initiatives to eliminate gender discrimination in the workplace as well as other forms of economic inequality, such as limits on a woman's ability to obtain credit, hold property, or receive an inheritance (un 1994).

Likewise, despite intimidation and harassment from Chinese officials, women at the Fourth World Conference on Women (September 1995, Beijing) hammered out a 150-page Declaration and Platform for Action that built on the gains made at Cairo. In the weeks and months preceding the conference, activists were concerned that China's attempts to limit the participation of international nongovernmental delegates would set back important achievements made by women (Broadbent 1995). Indeed, as many as 10 000 women fromNGOS who wished to participate in the conference were denied visas, and many others were prohibited from fully taking part. Despite the poor handling by China of the conference, women from around the world were able to turn the conference around.

The program of action stemming from the ICPD [International Conference on Population and Development] stressed the importance of the advancement of gender equity, the empowerment of women, the elimination of all kinds of violence against women, and the importance of the ability of women to control their own fertility. The rights of women are an inalienable, integral, and indivisible part of universal human rights.

-- Trinidad S. Osteria, De La Salle University, Manila, Philippines

The final declaration forcefully denounced violence, domestic battering, and sexual harassment, and condemned rape as an instrument of war; it upheld women's sexual and childbearing rights by denouncing forced sterilization, forced intimacy by spouses, and forced abortions; and it championed women's economic empowerment by calling for women's access to financial resources and banking credit. Women's health issues were linked to human rights, and a broad approach to women's health was taken that emphasizes social and gender determinants as well as a wide range of conditions that negatively affect women's health (in addition to sexual and reproductive health concerns). Furthermore, women from the governmental conference and parallel NGO forum returned to their home countries committed to making the declaration a reality.

Workshop initiatives

The workshops identified research gaps and produced recommendations for further research in the area of gender, health, and sustainable development. In addition, to help bring about changes in programs and policies related to women's health, two action-oriented initiatives were developed.

Caribbean research agenda

At the workshop in the English-speaking Caribbean, a research agenda was formulated to outline priorities for research on gender, health, and sustainable development. Recommendations for research addressed a number of priority issues including poverty, violence, nutrition and chronic diseases, work-related health issues, and factors affecting the compliance and use of services. Key policy issues were also outlined. These recommendations were presented to the following key executing agencies: governments and their ministries, the Caribbean Development Cooperation Committee, the Caribbean Community Secretariat, the Commonwealth Caribbean Medical Research Council, the Organization of Eastern Caribbean States Secretariat, the Pan American Health Organization and the World Health Organization, the International Development Research Centre, and the University of the West Indies.

The Asia and Pacific Women's Health Network

A highly ambitious action-oriented initiative was developed at the workshop in Singapore. A regional research and action network for women's health was launched. The objectives of the Asia and Pacific Women's Health Network are threefold:

• To address fundamental gaps in knowledge about women's health at all stages of the life cycle;

• To promote gender-sensitive health policies, research, and care delivery; and

• To empower women in the articulation of their own health needs and their capacity to provide health care for themselves and for others.

At its most basic level, the network will serve as a clearinghouse for information on women's health and coordinate regional health research and activities that have a focus on women. At a more advanced level, the network will seek to bring together a critical mass of convergent effort on a comprehensive range of women's health issues to improve the health and well-being of women of the region. The network will give special attention to health issues that have resulted from the rapid economic development of the countries in the region. The network will bring together practitioners, policymakers, researchers, managers, and business interests in the region to address the fundamental gaps in knowledge about women's health issues, to access services at all levels, and to initiate innovative gender-sensitive programs.

A secretariat, based for the time being at ENGENDER,³ will coordinate activities and disseminate information through these activities:

• Information gathering and information sharing: building databases, coordinating and producing a network newsletter, showcasing success stories and lessons learned, and developing and managing an electronic bulletin board;

• Research: coordinating transnational research activities;

• Advocacy and coordination of strategies: coordinating advocacy of policymakers at the international, regional, and national levels;

• Training and education: developing training modules about gender sensitization and sharing training materials and modules that can be translated, popularized, and tailored to local needs; and

• Facilitation of funding.

Task forces were formed on several issues: occupational health; AIDS; osteoporosis; environmental health; health-care systems; tropical parasitic diseases; reproductive health; and women against tobacco. Furthermore, strategy-based task forces were also proposed on: women's empowerment and participation; sustainable mechanisms of development; community-based research; policy advocacy; and communications and information dissemination.

³ENGENDER is the Centre for Environment, Gender and Development, an NGO based in Singapore that jointly hosted the workshop with IDRC.

Documento(s) 5 de 13