Saturday, June 2, 2012

health conditions of women-gender studies


Introduction
It based on information relating to health promoting, seeking and utilization behavior and the factors determining these behaviors. All such behaviors occur within some institutional structure such as family, community or the health care services. The factors determining the health behaviors may be seen in various contexts: physical, socio-economic, cultural and political. Therefore, the utilization of a health care system, public or private, formal or non-formal, may depend on socio-demographic factors, social structures, level of education, cultural beliefs and practices, gender discrimination, status of women, economic and political systems environmental conditions, and the disease pattern and health care system itself. A main driver for the health seeking behavior is the organization of the health care system. In many health care systems, there is tension between the public and the private health Strategic policy formation in all health care systems should be sector. The private health sector tends to serve the affluent; thus the public sector resources should be freed for the poor. A dynamic cooperation, either formal or informal, between the two sectors is a must but the private sector is rarely taken into account in health planning scenarios. The public and private sector may complement or substitute for each other. There are very often resource mixes with doctors working in the public sector also establishing their own private practice. Features of the service outlet and confidence in the service provider also play a major role in decision making about the choice of health facility.
Background
The health status of women in Pakistan is directly linked to women's low social status. Pakistan's poor position internationally is seen in UNDP's Gender related Development Index (GDI) 2000, where Pakistan currently ranks 135 out of 174 countries. On the Gender Empowerment Measurement (GEM) 1999, Pakistan ranked 100 out of the 102 countries measured. In terms of health status, the figures are galling. Some 30,000 women die each year due to complications of pregnancy, and 10 times more women develop life-long, pregnancy-related disability. Rural women's health is generally poorest due to the lack of health facilities and skilled health providers. For example, the maternal mortality ratio in predominantly rural Baluchistan is 800 maternal deaths to 100,000 live births, compared to the national average of 340 per 100,000.
The untimely death or disability of a woman, a tragedy in itself, adversely affects the health of her children, household productivity and the national economy. About 25 percent of children are born with low birth weight due to maternal problems. Ten percent of children do not reach their first birthday. High fertility, with an average of six children per woman, has resulted in high population growth of three percent per annum. Consequently, improving women's reproductive health through the use of contraceptives and spacing of children will not only improve women's health but also reduce population growth and allow women more time to pursue economic activities.
There are also marked differences between the health status of women and men in Pakistan. For example, malnutrition is a major public health problem in Pakistan that disproportionately affects women and girls. More girls than boys die between the ages of 1 and 4; in fact the female mortality rate here is 12 percent higher than for boys. This is a direct consequence of the lower social status accorded to women and girls, who as a result tend to eat less and face additional barriers when accessing health care. Women, girls and infants most often die of common communicable diseases such as tuberculosis, diarrhea, pneumonia and tetanus, which could have been easily prevented and treated. The high prevalence of communicable diseases and malnutrition is not only related to poor living conditions, but also to the lower social status of women and girls. In addition, because of social stigma and gender norms, as many as fifty percent of women suffer from recurrent reproductive tract infections.
Consequently, poor women's health in Pakistan is as much a social as medical problem. Underlying factors here are the lack of awareness of, and attention to, women's health needs; women's lower education and social status; and social constraints on women and girls, including the practice of seclusion.
Women’s autonomy
Men play a paramount role in determining the health needs of a woman. Since men are decision makers and in control of all the resources, they decide when and where woman should seek health care. Women suffering from an illness report less frequently for health care seeking as compared to men. The low Downloaded from jpubhealth.oxfordjournals.org by guest on May 12, 2011 status of women prevents them from recognizing and voicing their concerns about health needs. Women are usually not allowed to visit a health facility or health care provider alone or to make the decision to spend money on health care. Thus women generally cannot access health care in emergency situations. This certainly has severe repercussions on health in particular and self-respect in general of the women and their children. Despite the fact that women are often the primary care givers in the family, they have been deprived of the basic health information and holistic health services. In Pakistan, having a subjugated position in the family, women and children need to seek the permission of head of the household or the men in the family to go to health services. Women are socially dependent on men and lack of economic control reinforces her dependency.17 The community and the family as institutions have always undermined her prestige and recognition in the household care. The prevailing system of values preserves the segregation of sexes and confinement of the women to her home. Education of women can bring respect, social liberty and decision making authority in household chores.
Economic factors
The economic polarization within the society and lack of social Security system make the poor more vulnerable in terms of affordability and choice of health provider. Poverty not only excludes people from the benefits of health care system but also restricts them from participating in decisions that affect their health, resulting in greater health inequalities. Possession of household items, cattle, agricultural land and type of residence signify not only the socio economic status but also give a picture of livelihood of a family. In most of the developing countries of south Asia region, it has been observed that magnitude of household out of pocket expenditure on health is at times as high as 80 per cent of the total amount spent on health care per annum. Economic ability to utilize health services has not been very different in Pakistan. For health expenditure in Pakistan, 76 per cent goes out of pocket. This factor also determines the ability of a person or a family as a whole to satisfy their need(s) for health care. Cost has undoubtedly been a major barrier in seeking appropriate health care in Pakistan. Not only the consultation fee or the expenditure incurred on medicines count but also the fare spent to reach the facility and hence the total amount spent for treatment turns out to be cumbersome. Consequently, household economics limit the choice and opportunity of health seeking.

Physical accessibility
Access to a primary health care facility is projected as a basic social right. Dissatisfaction with primary care services in either sector leads many people to health care shop or to jump to higher level hospitals for primary care, leading to considerable inefficiency and loss of control over efficacy and quality of services. In developing countries including Pakistan, the effect of distance on service use becomes stronger when combined with the dearth of transportation and with poor roads, which contributes towards increase costs of visits. Availability of the transport, physical distance of the facility and time taken to reach the facility undoubtedly influence the health seeking behavior and health services utilization. The distance separating patients and clients from the nearest health facility has been remarked as an important barrier to use, particularly in rural areas. The long distance has even been a disincentive to seek care especially in case of women who would need somebody to accompany. As a result, the factor of distance gets strongly adhered to other factors such as availability of transport, total cost of one round trip and women’s restricted mobility.


Health services and disease pattern
The under-utilization of the health services in public sector has been almost a universal phenomenon in developing countries. On the other hand, the private sector has flourished everywhere because it focuses mainly on ‘public health goods’ such as antenatal care, immunization, and family planning services, treatment for tuberculosis, malaria and sexually transmitted infections. Still higher is the pattern of use of private sector allopathic health facilities. This high use is attributed mostly to issues of acceptability such as easy access, shorter waiting time, longer or flexible opening hours, better availability of staff and drugs, better attitude and more confidentiality in socially stigmatized diseases. However, in private hospitals and outlets, the quality of services, the responsiveness and discipline of the provider has been questionable. Client-perceived quality of services and confidence in the health provider affect the health service utilization. Also whether medicine is provided by the health care facility or has to be bought from the bazaar has an effect. In Pakistan, the public health sector by and large has been underused due to insufficient focus on prevention and promotion of health, excessive centralization of management, political interference, lack of openness, weak human resource development, lack of integration, and lack of healthy public policy. The low use of MCH centers, dispensaries and BHUs in Pakistan is discouraging. It may be due to lack of health education, non-availability of drugs and low literacy rate in rural areas. The communication factor also creates a barrier due to differences of language or cultural gaps and it can also affect the choice of a specific health provider or otherwise.  The type of symptoms experienced for the illness and the number of days of illness are major determinants of health seeking Behavior and choice of care provider. In case of a mild single symptom such as fever, home remedies or folk prescriptions are used, whereas with multiple symptoms and longer period of illness, biomedical health provider is more likely to be consulted. Traditional beliefs tend to be intertwined with peculiarities of the illness itself and a variety of circumstantial and social factors. This complexity is reflected in the health seeking behavior, including the use of home-prescriptions, delay in seeking bio-medical treatment and non-compliance with treatment and with referral advice.

women’s mental health:

In Pakistan, societal attitudes and norms, as well as cultural practices (Karo Kari, exchange marriages, dowry, etc.), play a vital role in women's mental health. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, represent major issues and stressors. Such practices in Pakistan have created the extreme marginalization of women in numerous spheres of life, which has had an adverse psychological impact. Violence against women has become one of the acceptable means whereby men exercise their culturally constructed right to control women. Still, compared to other South Asian countries, Pakistani women are relatively better off than their counterparts.
Keywords: Pakistan, women's mental health, cultural practices, honor-killing, stove-burns, violence.
 The women's movement in Pakistan in the last 50 years has been largely class bound. Its front line marchers voiced their concerns about issues mainly related to the urban-middle class woman. It is only in the last few years that rural women's issues like 'Karo Kari' (honor killing) and rape have been brought to light. Feudal/tribal laws of disinheritance, forced marriages and violence against women (acid-throwing, stove-burning homicide and nose-cutting) in the name of honor are being condemned by non-governmental organizations and human rights activists in the cities. Still a vast majority of the women in the rural areas and urban slums are unaware of the development debates.
The urban Pakistani women in many aspects are almost at par with the women of developed countries. In the rural scenario, the picture is entirely different. It is archaic, brutal and clearly oppressive. These trends often seep into the urban lives of women through migratory movements of rural population, which has yet to adjust to urban ways.
At the societal level, restricted mobility for women affects their education and work/job opportunities. This adds to the already fewer educational facilities for women. Sexual harassment at home, at work and in the society has reached its peak. Lack of awareness or denial of its existence adds to further confine women to the sanctity of their homes. Violence against women further adds to restriction of mobility and pursuance of education and job, thereby lowering prospects of women's empowerment in society.
At the family level, birth of a baby boy is rejoiced and celebrated, while a baby girl is mourned and is a source of guilt and despair in many families. Boys are given priority over girls for better food, care and education. Subservient behavior is promoted in females. Early marriage (child-brides), Watta Satta (exchange marriages), dowry and Walwar (bride price) are common. Divorcees and widows are isolated and considered 'bad omens', being victims of both male and female rejection especially in villages. Marriage quite often leads to wife-battering, conflict with spouse, conflict with in-laws, dowry deaths, stove burns, suicide/homicide and acid burns to disfigure a woman in revenge.

Physical Underdevelopment

A major consequence of girls' nutritional deprivation in early childhood and adolescence is their failure to achieve full growth potential. A majority of girls from low income families reach adolescence about 12-15 cms shorter than their well-to-do peers in the same society (Rohde, 1987). The National Nutrition Monitoring Bureau's data on Indian women's heights and weights show that between 12 and 23 percent of 20-24 year-old women in the different states surveyed had heights below 145 cms; and between 15 and 29 percent had weights below 38 kg (NNMB, 1980). The percentages were even higher among younger girls - Girls who bear a child before the close of the adolescent growth spurt may remain physically underdeveloped and hence are at greater risk of obstetric complications, obstructed labor or maternal death, as well as of bearing low birth weight infants. During pregnancy, women's access to food is often restricted through the taboos and rituals observed in traditional Pakistani households. Besides low maternal pre-pregnancy weights and inadequate weight gains during pregnancy, low birth weights are also related to low hemoglobin levels, so that the high prevalence of anemia adds to the negative outcomes of childbearing.

High Maternal Mortality

In developing countries overall, maternal mortality accounts for some 25% of deaths in women of childbearing age, compared with 1% in the U.S. Worldwide, WHO has estimated that 250 women die every four hours due to problems associated with childbirth. The aggregate national maternal mortality rates are estimated to be around 600 per 100,000 live births in Pakistan, respectively High maternal mortality in Pakistan is a reflection of women's under nutrition, poor health status and high fertility. Poverty, low rates of female literacy, and poor access to or utilization of health services are some of the underlying factors. Several common causes of maternal deaths are related to malnutrition, particularly to anemia, while other serious causes, such as toxemia and septicemia, reflect the inadequate health care available to women in the ante-natal, intranasal, and post-natal periods (see below). Some research in India found that for each maternal death there were 16.5 cases of illness related to pregnancy and childbirth, most of which would go unattended.
VIOLENCE AGAINST WOMEN:
Women are confined to abusive relationships and lack the ability to escape their captors due to social and cultural pressures. Parents do not encourage their daughters to return home for fear of being stigmatized as a divorcee, which tantamount to being a social pariah. Moreover, if a woman leaves her husband, her parents have to repay him to compensate his loss. Cultural attitudes towards female chastity and male honor serve to justify violence against women.
Violence against women is very common in Pakistan. The violation of women's rights, the discrimination and injustice are obvious in many cases. A United Nations research study found that 50% of the women in Pakistan are physically battered and 90% are mentally and verbally abused by their men. A study by Women's Division on "Battered Housewives in Pakistan" reveals that domestic violence takes place in approximately 80% of the households. More recently the Human Rights Commission report states that 400 cases of domestic violence are reported each year and half of the victims die.
Battering or "domestic violence" or intimate partner abuse is generally part of the patterns of abusive behavior and control rather than an isolated act of physical aggression. Partner abuse can take a variety of forms, including physical violence, assault such as slaps, kicks, hits and beatings, psychological abuse, constant belittling, intimidation, humiliation and coercive sex. It frequently can include controlling behavior such as isolating women from family and friends, monitoring her movements and restricting her access to resources. Physical violence in intimate relationship is almost always accompanied by psychological abuse and in one-third to one-half of cases by sexual abuse.
A woman's response to abuse is often limited by the options available to her. Women constantly cite reasons to remain in abusive relationship: fear of retribution, lack of other means of economic support, concern for the children, emotional dependence, lack of support from family and friends and the abiding hope that the husband may change one day. In Pakistan divorce continues to be a taboo and the fear of social stigma prevents women from reaching out for help. About 70% of abused women have never told anyone about the abuse.
The psychological consequences of abuse are more severe than its physical effects. The experience of abuse erodes women's self-esteem and puts them at a greater risk for a number of mental disorders like depression, post-traumatic stress disorder, suicide, and alcohol and drug abuse. Children who witness marital violence face increased risk for emotional and behavioral problems, including anxiety, depression, poor school performance, low self-esteem, nightmares and disobedience.

PSYCHIATRIC ILLNESS IN PAKISTANI WOMEN:
A large study at Jinnah Post Graduate Medical Center, Karachi back in early 1990s showed that twice as many women as men sought psychiatric care and that most of these women were between 20s and mid 40s.
Another 5-year survey (1992-1996) at the University Psychiatry Department in Karachi (Agha Khan University/Hospital) showed that out of 212 patients receiving psychotherapy, 65% were women, 72% being married. The consultation stimuli were conflict with spouse and in-laws. Interestingly, 50% of these women had no psychiatric diagnosis and were labeled as 'distressed women'. 28% of women suffered from depression or anxiety, 5-7% had personality or adjustment disorders and 17% had other disorders.
The 'distressed women' were aged between20 to 45. Most of them had a bachelor's degree and had arranged marriage relationships for 4-25 years with 2-3 kids, and the majority worked outside home (running small business, teaching or unpaid charitable community work or involved in voluntary work). Their symptoms were palpitations, headaches, choking feelings, sinking heart, hearing weakness and numb feet.
A study on stress and psychological disorders in Hindukush mountain of North West Frontier Province of Pakistan showed a prevalence of depression and anxiety of 46% in women compared to 15% in men.
A study on suicidal patients showed that the majority of the patients were married women. The major source of suffer was conflict with husband (80%) and conflict with in-laws (43%).
A four-year survey of psychiatric outpatients at a private clinic in Karachi found that two thirds of the patients were females and 60% of these females had a mood disorder. 70% of them were victims of violence (domestic violence, assault, sexual harassment and rape) and 80% had marital or family conflicts.

CONCLUSIONS
Health care providers can play a key role. They must recognize victims of violence and help them by referring to legal aid, counselors and non-governmental organizations. They can prevent serious conditions and fatal repercussions. However, many doctors/nurses do not ask women about the experience with violence and are not prepared to respond to the needs of the victims.
A variety of norms and beliefs are particularly powerful perpetrators of violence against women. These include the notions that men are inherently superior to women, that it is appropriate for men to discipline women, and that women's sexual behavior is linked to male honor. Nobody is expected to intervene on behalf of the victim as such issues are considered private matters to be resolved by the immediate parties themselves.
Programs designed to change these beliefs must encourage people to discuss rather than antagonize or alienate them by appearing to 'demonize' men. A good tool is to encourage people to develop new norms by using techniques such as plays on TV and theatre.

To develop rational policy to provide efficient, effective, acceptable, cost-effective, affordable and accessible services, we need to understand the drivers of health seeking behavior of the population in an increasingly pluralistic health care system. This relates both to public as well as private sectors.. Health providers also need to be sensitized more towards the needs of the clients especially the women to improve interpersonal communication. People marked with debt, dependence and disease are those who deserve more universal support to achieve quality of life, health and well being in order to be able to compare them with the rest of the world. Introducing a ‘self care system’ in the community which includes early detection of danger signs in diarrhea, malaria, pneumonia and issues like family planning and personal hygiene could form a package of health education for any community setting. This should address the problem of self-medication to some extent. Patient education regarding drug use and its hazards has also been advocated since long ago. Public health awareness programs should be organized for mothers as components of public health efforts intended to help mothers understand the disease process and difference between favorable and unfavorable health practices. This would enhance the mothers’ understanding of disease process and importance of preventive measures for a better family health. With this complex and pervasive picture of health system utilization and health seeking behavior in Pakistan, it is highly desirable to reduce the polarization in health system use by introducing more client centered approach, employing more female health workers, supportive and improved working and living conditions of health personnel, and a convivial ambiance at health service outlets. Extra financial incentives offered to public sector staff not only will help in retaining them but will also motivate them to deliver quality services State regulatory mechanisms and continuing education and training for the providers seem imperative. A comprehensive health care system has to focus on the 66 per cent of rural people who are the poorest of the poor and who become visible only when programmers are signed with international donors. A more coordinated effort in designing behavioral health promotion campaigns through inter-sectoral collaboration focusing more on disadvantaged segments of the population (i.e. women, children and elderly would be step towards improvement).
Pakistani women are relatively better off than their counterparts in other developing countries of South Asia. However, fundamental changes are required to improve their quality of life. It is imperative that constructive steps be taken to implement women friendly laws and opportunity be provided for cross-cultural learning. Strategies should be devised to enhance the status of women as useful members of the society. This should go a long way to improving the lives and mental health of these, hitherto "children of a lesser God".



            “If a health service is to work, it must start from what users need”
References
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8. National Commission on the Status of Women.
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Web references:
·         http://www.who.int..
·         www.google.com
·         www.wikipedia.com

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