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”
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Web
references:
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