Documento(s) 11 de 13

Now that we know more about women than ever before, and have identified the major problems they face, what can we do to accelerate actions which we know will alleviate unnecessary suffering and death? Among the large number of areas that need to be addressed, how can we choose the critical few that will make the greatest difference in the lives and health of many? How can we effectively involve women themselves in this process?

-- A. El Bindari Hammand, Global Commission on Women's Health, WHO, Geneva, Switzerland

One of the objectives of the four IDRC-sponsored workshops on gender, health, and sustainable development was to translate the insights shared by participants into recommendations for future research to promote health and welfare for all. There is a definite need for further interdisciplinary research on various aspects of women's health. This research must fully integrate a gender perspective into the research protocol as it is conceived, carried out, analyzed, and disseminated. The dearth of health research that incorporates a gender perspective hinders the ability of decision-makers to design, plan, monitor, and evaluate effective women's health policies and programs.

Although each region faces unique concerns, common issues and problems clearly emerge. Researchers and organizations from around the world can achieve significant advancements in research on women's health by working cooperatively to consolidate experiences and results. It is hoped that this publication will inspire more collaborative work and networking among researchers working in the biomedical and social science fields.

Several priority research questions need to be explored in health studies. These questions should be tailored to the particular community or communities being studied, and the health implications of these questions should be explored. Key research questions have been divided into seven categories that broadly correspond to the chapters in this book: general issues, nutrition, education, AIDS, the working environment, tropical diseases, and barriers to quality health care. Many of these questions have been discussed in their respective chapters.

General issues

• What are women's priority health concerns? What importance do women give to nonreproductive health issues? For example, how are tropical diseases and health issues associated with women's work perceived by women?

• How can the perspectives of women be incorporated into all stages of research, as well as interventions? How can women's viewpoints be fully integrated into the decision-making process in health policy?

• To what extent do policies and programs undertaken outside the health sector, aimed at improving the quality of women's lives (such as savings and credit programs and literacy courses), also lead to health improvements for women?

• What programs and policies will help to discourage harmful attitudes and practices against women, including son preference, female genital mutilation, violence, and discrimination against girls and women in educational opportunities and food allocation?

• What measures can be taken to empower women with regard to their own health? Would the formation of women's groups, where women can come together and talk openly about their problems, lead to increased self-esteem and to greater confidence to take control of their health and well-being?

• What obstacles hinder the adoption of a gender perspective in health research, and how can the obstacles be overcome?

• What strategies might help increase the number of female biomedical and social scientists working in women's health?

Education

• What educational opportunities do women and men, girls and boys, receive? How does the community or communities being studied view the education of girls? How does poverty of education affect women's health and well-being?

• To what extent does a woman's level of education influence her decision-making power on health-related matters within the family and the community?

• What are the links between women's education and opportunities in the work force? What types of subjects are women and men encouraged to study?

• How can families and communities be encouraged to place more emphasis on the education of girls?

Nutrition

• Is there any difference between the nutritional intake of girls and boys, women and men? Who eats first and last? Who eats the most and least?

• What factors affect gender-differentiated nutritional levels? How can the discrimination against women's access to food that exists in some societies be overcome?

• Who decides on what crops to cultivate, who farms them, and who gets the money for the produce?

• Do women suffer from specific health problems, such as fatigue, night blindness, bone deformities, and stunting, that result from nutritional deficiencies?

• Who decides how much money is to be spent on food and what sorts of foods should be bought?

• Who prepares the food? What is the health status of the family member who prepares the food?

• What factors lead to the high rate of nutrition-related diseases among Caribbean women and how can they be overcome?

• How does environmental degradation affect family nutritional levels? Where environmental degradation makes it difficult to obtain adequate food, does this have a greater impact on women, as family food providers?

AIDS

• To what extent do women and men suffer from AIDS?

• Is there a physiological basis to the susceptibility of HIV infection in women, particularly among young women and postmenopausal women?

• What factors increase the risk of HIV infection among young women (pressures to be sexually active at an early age, sexual relations with older men, lack of decision-making power)? What strategies could be used to delay the entry of females into sexual activity? How can young women gain greater control over how, when, and with whom they have sexual intercourse?

• Will effective education programs tailored to adolescents girls and boys, both in and out of school, on a wide range of sexual and reproductive health issues, including STD and HIV prevention, lead to a decrease in STD and HIV infection rates among adolescents? How can the restrictions that in some societies prevent adolescents, particularly young women, from access to information on sexuality, contraception, and disease prevention be overcome?

• Why do women with AIDS have a poorer prognosis than men? Is this related to biological differences? What role do other factors play (later diagnosis for women, less access to health services, lack of social support, and poor knowledge of early HIV symptoms)?

• What strategies might increase the diagnosis and treatment of stds in women and men? How can the shame, embarrassment, and stigma associated with stds, especially among women, be challenged? If STD services were offered in private consultations in conjunction with primary health care and family-planning services, would this increase the chances of women reporting for stds? Would screening for asymptomatic STD infections in women in family-planning clinics lead to increased diagnosis? Would the inclusion of high quality, gender-sensitive instruction on stds in the professional training of health providers lead to greater diagnosis of stds among women?

• How do women and men believe that a HIV infection is acquired? How can misperceptions about HIV and AIDS be effectively clarified? (For example, women and men need to be informed that married men or those in steady relationships can expose their partners to HIV and that monogamous women can be at risk; that some men are bisexual and can expose their partners to HIV risk; that AIDS is not restricted to homosexuals, prostitutes, and drug users; that an HIV-infected individual can look "healthy"; and that there is a latency period of about 6 months between the time of infection and a positive HIV test).

• Are women able to ask their partners to use condoms? Who decides whether or not to use condoms? How do women and men feel about condoms? Are condoms widely available?

• How can women be empowered to take control of their bodies? Would assertiveness-training programs and initiatives aimed at building women's self-esteem improve women's ability to determine the conditions under which sexual intercourse occurs? Can group counseling help women deal with these issues?

• If community women were trained in AIDS-prevention measures and encouraged to visit their neighbours to discuss these issues face-to-face, would this be an effective AIDS-prevention strategy?

• Would the creation of an HIV-prevention method that women could control (that would not require partner awareness, compliance, or action) lead to decreased HIV transmission to women?

• Does a desire for children influence condom use? Would women and men be more likely to use an HIV-prevention method that would let sperm pass unharmed (and therefore permit conception)?

• What policies and programs can be designed and implemented to encourage men to take greater responsibility for AIDS prevention? How can condoms be made more acceptable to men? Would the use of male workers in condom distribution campaigns lead to greater male acceptance of condoms?

• How can strategies for AIDS education be tailored to the needs poor women, women with low literacy levels, and women from different cultural backgrounds? Do radio and newspaper messages effectively reach women? Are creative educational approaches (such as packaging prevention messages in soap operas and community dramas) effective?

• How can communication barriers between women and men on matters related to sexuality be reduced? How can women and men be motivated to openly discuss extramarital sex, the risks of contracting stds, and the need for condom use?

• How are women and men who are living with AIDS treated by their families and the community at large?

• How can the legal and customary inheritance practices in some societies be changed to allow women the right of ownership to their husbands' property when he dies?

• To what extent do women and men turn to prostitution as a source of income?

• Are certain women in society more likely to get stds (and AIDS) than others? To what extent do race and class variables intersect with gender?

• Would an increase in the economic autonomy of women -- by, for example, changing laws that perpetuate women's economic dependence on men by denying them the right to independent property ownership or tenancy, or prohibiting access to certain forms of employment or financial credit -- lead to an increase in the ability of women to demand safer sex?

• How can harmful cultural practices that increase HIV risk for women and generally endanger women's health (such as female genital mutilation and vaginal drying) be stopped?

• To what extent are women and men encouraged by society to engage in extramarital sex? How can traditional practices and rituals in which women and men are permitted to have extramarital sexual contact (which carries the risk of STD transmission) be challenged?

• Are women and men exposed to sexual violence? Would enforced laws against rape and sexual violence decrease the incidence of sexual violence against women as well as the risk of AIDS?

• Would messages targeted and tailored to male bisexuals and their partners lead to a decreased risk of AIDS among women?

The working environment

• What constitutes women's work and men's work? How do the differentiated life spaces of women and men and their gender-determined roles and responsibilities affect their health? Who works at a fast pace? Who experiences sexual harassment? Who handles heavy weights? Who works in positions of authority and decision-making? Who works on assembly lines? Who works shift work? Who has repetitive and monotonous work? Who performs rapid and repetitive hand movements?

• What measures can be taken to ensure that women's "invisible work" is properly measured and that the health risks associated with women's work in the informal sector are properly addressed?

• What are the potential health risks associated with women's agricultural work? What are the health risks to women from excessive pesticide use?

• What policies and programs will help ensure that women are properly informed of the ill-effects associated with agrochemicals and provided with protective clothing and masks?

• Would improvements in the general status of women's health and well-being (such as better nutrition and more rest) improve their ability to cope with detrimental health conditions associated with the workplace?

• What are the psychological health effects associated with the common characteristics of women's work (monotonous, repetitive tasks, a lack of control over the external environment, little opportunity for communication with others, and minimal decision-making and creativity)?

• How can increased recognition be achieved for women's role as health providers within the formal health-care system? How do we ensure that female health providers are not exploited and that their work is fully recognized? How can the working conditions of female health workers be improved?

• What are the health hazards associated with women's work in the industrial sector of developing nations, particularly in the rapidly expanding free-trade and export-producing zones? How do the forces of globalization and increased international trade affect the working conditions and health standards of female workers in developing nations? How can these forces best be dealt with?

• What is a woman's daily activity pattern? Who cares for children when they are sick? Who ensures the provision of safe and abundant water? Who obtains fuel and prepares the food? Who maintains the kitchen garden? To what extent do the competing demands placed on women (paid work outside the home and childrearing and household management) create physical and mental stress?

• What measures and technologies might serve to lessen the daily burden of women's domestic responsibilities (perhaps water pumps for people of shorter physical stature)? How can other family members be encouraged to support women with their childcare and household responsibilities?

• What are the working conditions and specific health concerns of homeworkers?

• What are the health implications of carrying water over long distances in heavy containers for many years? To what extent are women and men exposed to indoor air pollution, and how does this affect health? How can these health risks be minimized?

• To what extent can modifications to home cooking and heating facilities -- such as stove design, ventilation design, and fuel type -- reduce women's exposure to the detrimental effects of indoor air pollution?

• Do the effects of environmental degradation have similar consequences on the health and livelihoods of women and men?

• What are women's hours of work and leisure compared with those of men? How does minimal discretionary time affect health?

• How is women's work valued, compared with men's work? What are women's income levels compared with men's? What types of activities do women and men perform without financial compensation? To what extent do wage levels influence the health status of women and men?

• What factors compound or mitigate poverty and poor health within female-headed households?

• What steps can be taken to ensure that adequate occupational health and safety standards, and enforcement measures, are put into place with regard to the risks associated with women's work? What strategies will ensure that protective legislation is not used to justify discriminatory labour practices and keep women out of better paying jobs? How can we ensure that other legislation aimed at protecting women (such as maternity-leave benefits) does not end up depressing their wages or discouraging their employment?

• To what extent are women's jobs, compared with men's, supported by unions? What percentage of union representatives are women and men? How can the representation of women in trade unions be increased? How can union representatives be encouraged to make the health concerns of women a priority?

• Do women and men work within a contractual situation? Is their work covered by health and social-security protection? In the case of a work-related illness, who pays for medical care? Can medical leave be taken?

• What steps can be taken to effectively extend the protection of labour and social security laws to part-time, temporary jobs and seasonal and homebased workers?

• How can we ensure that workers are properly educated about the hazards associated with their work?

• To what extent can organizations of women workers play a role in pressuring for better wages and working conditions and reducing occupational risks?

Tropical diseases

• What is the effect of sex on the susceptibility and intensity of infection and progression of disease? How do factors such as pregnancy, the generally poor nutritional status of women, and intercurrent infections influence disease susceptibility in women?

• To what extent do women's and men's gender-differentiated "life spaces" influence their exposure to tropical diseases? What sociocultural factors (such as clothing patterns and religious practices) predispose women and men to tropical diseases and what practices safeguard women and men? Would the mapping of women's and men's culturally prescribed and gender-differentiated responsibilities and activities lead to more effective interventions to prevent and control tropical diseases among women and men?

• Are women living in poorer socioeconomic conditions (such as with poor housing and lack of adequate hygiene practices) disproportionately affected by tropical diseases?

• How are women and men differentially affected by the stigmatizing effect of tropical diseases? What are the social and psychological effects (anxiety and depression) of disfigurement for women? What are the implications for women and men when diseases are believed to be sexually transmitted? How can health services be made more aware of the stigmas associated with the disfigurement and disability that result from some tropical diseases, especially for women?

• To what extent do women have access to diagnosis and treatment for tropical diseases? Are personnel and facilities for the detection, documentation, and treatment of tropical diseases available for women who attend health-care clinics?

• What is the impact on women when other family members are ill? To what extent do women feel they are the sole or principal caretakers of the family? Who diagnoses family illnesses? Who cares for the sick? Who accompanies sick family members to the health centre? How can men be encouraged to take more responsibility for caring for the sick?

• What sort of support and resources should be provided for those involved formally or informally in the care of sick and dying individuals?

• To what extent does a woman's illness impact on other family members? What are the effects of a woman's illness on children, for example, its effects on absenteeism, drop-out rates, and learning outcomes of school-age girls?

• Who is responsible for assuring that disease-control interventions are carried out? For example, who is responsible for reimpregnating bednets every 6 months? Who is responsible for maintaining household sanitation practices?

• Because the ultimate success and effectiveness of interventions may depend on the participation of women, what steps can be taken to ensure that women are involved in disease-control interventions? At the same time, what strategies might lead to a more equitable distribution of family roles? How can health interventions be designed to eliminate gender bias and to take into account the disproportionate demands that child-rearing, household duties, and income-generating activities make on women's time? Would the targeting of messages about family health to both women and men, rather than solely to women (which perpetuates the idea that family health is primarily or exclusively the responsibility of women) be helpful? How can men be encouraged to take a more active role in creating and maintaining a healthy home environment, rather than leaving the entire responsibility to women?

• Do women and men properly understand the causes, symptoms, transmission routes, and prevention and treatment strategies for tropical diseases?

• What role do men and other family members play in decision-making about health-related practices?

• To what extent do health interventions targeted at women lead to changes in health-related practices and beliefs among other family members?

• How do we ensure that the considerable health-related knowledge and expertise of women, which is related to their role as health providers in the formal health-care sector and in the community and home, is fully acknowledged? If women, the major users of health services, were consulted during the conceptualization of health-care policies and programs, would this lead to health gains for women and men?

Barriers to quality health care

• What factors prevent women from knowing and understanding their bodies? Can women openly discuss health issues? Would greater education on health-related matters increase the ability of women to recognize the signs and symptoms of illness? How can cultural restrictions and taboos that prevent women from understanding issues related to their reproductive and sexual health best be dealt with?

• What are women's time-use patterns for their health and personal needs? Given women's busy lives and the competing demands on their time, what strategies might make it easier for women to visit modern health services? Would it be helpful to change the hours when clinics are open (perhaps opening clinics in the evening) to accommodate women's work schedules? If health services were offered where women work, would this increase the opportunity for women to receive care?

• What are the attitudes of society to women who are ill? Who looks after women when they are sick, and who accompanies them to health services? What do women feel that they can expect in terms of men's support? How can other family members be encouraged to help women with their tasks so women can have enough time to fully recover from illness?

• How do women prioritize health compared with other social, economic, environmental, and political concerns? How do women prioritize their health compared with the health of their children and other family members?

• What health problems do women consider to be serious and not serious? How many ailments exist among women and never receive medical assistance? How can we instill in women the importance of making their own health care a priority? Because women tend to place great importance on their children, would messages that emphasize the notion that women must take care of their health to maintain their child's health be persuasive? Would strategies aimed at improving women's self-esteem lead to their increased use of health services?

• Who are the significant others that participate in decision-making regarding women's access to health care? If women were encouraged to go to health centres when they were ill, would this improve the chance of them going? How can family members and the community at large be encouraged to support women's health?

• What are the stigmatizing diseases and conditions in the community? How can health services be more sensitive to the shame and embarrassment felt by women with regard to stigmatizing diseases and illnesses?

• What psychological barriers (such as depression, apathy, and fear) prevent women from accessing care and how can they be reduced?

• How far do people have to travel to reach a health centre? How can health services be made more physically accessible to women? Would mobile health clinics and the provision of transportation improve the accessibility of health services?

• What is the extent of women's physical mobility outside the home compared with men's? How can the cultural restrictions on women's mobility in some societies be overcome? If elderly widows of secure honour and status were trained as health workers to visit women in domestic seclusion, would this improve access to care for women whose mobility is restricted?

• How much, if anything, does it cost to use the health centre? Is there a cost associated with transportation to the health centre? What sorts of schemes of payment are suitable to women? What are women's means for the purchase of drugs? Which family member(s) decides whether the costs associated with health are worthwhile?

• Who are the health practitioners who provide care to the community or communities being studied? What is the sex of the health worker? Do women feel comfortable visiting this provider? What does the wider community think of the health worker and clinic? Is there a difference in quality of care if the provider belongs to the community being served?

• Would the availability of female providers increase the liklihood that women would go to modern health services? Given the reluctance of women to see male providers in some societies, how can more female providers, especially mature women, be recruited, particularly for sexual health issues?

• How can we ensure that health care for women is culturally acceptable? At the same time, what is the best way to challenge beliefs and practices that are harmful to women's health and well-being?

• To what extent would integrated services (such as tropical disease, family planning, reproductive health, and pediatric services) lead to improvements in the quality of care delivered to women? If health services for women were available when they presented their children for care, would this improve the chances of women seeking care for themselves?

• How can we ensure that women with low levels of education and lower socioeconomic positions receive high-quality information and counseling and care from providers?

• What sources of information (such as friends and relatives) are particularly credible to women when making health-related decisions?

• How can health-education messages be provided in a way that is useful and easily understood by rural women?

• What level of sensitivity to gender issues exists among health providers? Are providers knowledgeable about women's health concerns? Do providers treat women as persons in their own right, or as nurturers and the bearers of children?

• How can the quality of care provided to women be improved given the constraints faced by providers (such as overwork, low pay, and many clients)?

• What quality of care elements are important to women (for example, privacy, nonjudgemental attitudes, and sufficient time with provider)?

• Who do women consult for health care, at what stage of illness, and for what conditions? What type of health facilities do women consult first? Why do women sometimes prefer traditional healers? What are the aspects of healers that make them attractive to women?

• What strategies could be used to improve interpersonal relationships between female patients and health providers?

• How and to what extent can training in interpersonal and communication skills, counseling, and the use of a gender perspective that emphasizes sensitive and respectful care lead to a change in the attitudes and behaviour of health-care providers?

Documento(s) 11 de 13