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Year : 2007  |  Volume : 20  |  Issue : 3  |  Page : 118

Gender Sensitization among Health Providers and Communities through Transformative Learning Tools: Experiences from Karachi, Pakistan

Health Systems Division, Department of Community Health Sciences, Aga Khan University, Pakistan

Date of Submission12-Sep-2007
Date of Web Publication19-Oct-2007

Correspondence Address:
B T Shaikh
Stadium Road, PO Box 3500, Karachi 74800
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Source of Support: None, Conflict of Interest: None

PMID: 18080960

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Context: Pakistan lags far behind most developing countries in women's health and gender equity. Appropriateness of health care services vis-à-vis the gender specific cultural norms that influence clients' needs are not very visible and are more difficult to monitor. Programs and services need to be sensitively designed to facilitate women's access to physical and social needs. This paper narrates the experience of working with health providers from public and private sectors, community, local government representatives and community-based organizations. Through transformative learning, this endeavour focused on initiating a process of sensitization on gender related health issues for women.
Approach: The initiative was primarily based on the use of the following two standardized tools: 'Health Workers for Change' for working with health providers and 'Initiating Women Empowerment for Health' for interacting with the community. Both tools focus primarily on women's health and social issues affecting their health status. The research methodology used was predominantly qualitative, using focus group discussions, participatory rural appraisal and interactive workshops.
Implications: This approach endeavours to sensitize the health service providers to the health needs of female clients and encourages behavioural changes. Simultaneously, it creates an opportunity to raise awareness among women and the community in general regarding appropriate health-seeking behaviour and the timely use of health services. The information collected is evidence for policy makers regarding the gender-based problems faced by women who are seeking health care and it suggests how to overcome these problems.

Keywords: gender, health system, health-seeking behaviour, participatory rural appraisal, Pakistan

How to cite this article:
Shaikh B T, Reza S, Afzal M, Rabbani F. Gender Sensitization among Health Providers and Communities through Transformative Learning Tools: Experiences from Karachi, Pakistan. Educ Health 2007;20:118

How to cite this URL:
Shaikh B T, Reza S, Afzal M, Rabbani F. Gender Sensitization among Health Providers and Communities through Transformative Learning Tools: Experiences from Karachi, Pakistan. Educ Health [serial online] 2007 [cited 2022 Oct 2];20:118. Available from:


“The most common language is neither English nor Spanish nor Hindi. The most common language is silence - the language of the world’s poor and marginalized women” (Indira Gandhi)

Women’s health is a mixture of physical, emotional, social, cultural and spiritual well-being (Paquette & Raine, 2004). Women in low income and developing countries have shorter life expectancies due to inequality in access and quality of health services (World Health Organization, 2002; Tinker, 2000). Therefore, investing in women’s health issues has become an international concern and an effective conduit (Pathmanathan et al., 2003). This paper narrates the experience of working with health providers from the public and private sectors, the community, local government representatives and community-based organizations. Through transformative learning, this endeavour focused on initiating a process of sensitization to gender-related health issues of women.

Pakistan is trying to cope with the significant challenge of developing an equitable and sustainable health care system that can address the basic and special needs of women who are in the reproductive age. In this context, Pakistan lags far behind most developing countries in women's health and gender equity, standing 107 out of 174 countries in the United Nations Development Programme (UNDP) Gender-related Development Index (GDI) and 71 out of 102 countries on Gender Empowerment Measurement (GEM). Only 35% of adult women are literate compared to 57% of men; 50% of girls are enrolled in primary schools, compared to 80% of boys (United Nations Development Programme, 2005; Sass & Ashford, 2002). Pakistan is one of the few countries in the world where men outnumber women (Government of Pakistan, 2000). This unfavourable ratio is mainly a consequence of the high mortality of young girls and women of child-bearing age - 340-500/100,000 live births (Islam & Aman, 2001; United Nations Population Fund, 2005). The contraceptive prevalence rate is 20% and the number of women receiving appropriate antenatal care is negligible (World Health Organization, 2005). Appropriateness of services vis-à-vis the gender specific cultural norms that influence clients’ needs are not very visible and are more difficult to monitor (Standing, 1997; Mumtaz et al., 2003). Health care systems are frequently tuned to treat patients on the basis of their biological construction, utterly ignoring their social construction, thereby perpetuating health inequities (Sen et al., 2002). In most parts of Pakistan, women are seen to endure ill health and suffer silently, accepting it as a burden of being a woman.

The purpose of our study was two-fold: firstly to sensitize the health service providers to the health needs of women clients and encourage behavioural change, and secondly to raise awareness among women and the community, in general, regarding appropriate health-seeking behaviour and timely use of health services.


The initiative was primarily based on the use of two standardized tools ‘Health Workers for Change’ (Malik et al., 2003) and ‘Initiating Women Empowerment for Health’ (Khan et al., 2003). The contents of both tools focus primarily on women’s health and social issues affecting their health status. The methodology followed was predominantly qualitative research using focus group discussions (FGDs), participatory rural appraisal (PRA) and interactive workshops. Main population groups in focus were the community women, men and the health care providers. The project used a purposive sampling in selecting health care providers and community members for the study. The reason for using purposive sampling was to include only trained health care providers and for the community to include only married adult men and women of reproductive age. One hundred health care providers participated in seven FGDs; and in 14 gender-specific FGDs, 100 men and 90 women participated. Extensive documentation was kept of all the activities and processes.

The tools

Health Workers for Change

Originally developed by WHO/UNDP/World Bank, this tool describes different exercises to assist health care providers in examining their position, status and role in the health care system and to relate the factors influencing their interaction with women clients. These exercises identify ways and means to improve both health care service and job satisfaction for health care providers, thus, changing their work attitude and professional behaviour while treating their clients, especially women.

Initiating Women Empowerment for Health

The second tool devised by the Department of Community Health Sciences, Aga Khan University, is a conceptual framework for understanding women’s health as an outcome of gender relations and self-image. Using Participatory Rural Appraisal (PRA) techniques, both women and men were facilitated in identifying the local perceptions of health and illness; in recognizing the gender relations affecting women’s health, their ability to implement changes in their lives and those of their families; and in acknowledging the health care giving role of women in a household.

Study setting

This whole endeavour was a unique opportunity where multiple stakeholders including community health workers, community-based organizations, non-governmental organizations, local government representatives and the researchers from academia interacted very closely to ‘brainstorm’ on the issues of women’s health. The study sites were two union councils of Gadap Town, which is an administratively distinct area of Karachi city district, predominantly rural with residents of sub-castes of Sindhi and Baluchi ethnicities. The majority of the population live in houses made of mud and wood, very few have concrete boundaries and cemented, wooden or thatched roofs. One household may consist of several families living within a boundary. Water supply, sanitation and sewage disposal is poor. Per capita income is around US$400 and the literacy level is 40% for both men and women (Government of Pakistan, 2000).

Ethical Considerations

The project team successfully sought the approval from the Aga Khan University Ethical Review Committee, which abides by international norms and regulations. Community elders and opinion leaders were given an orientation to the project and all participants were assured of confidentiality of information. Neither the names of the health providers nor the individuals were revealed and the participants (both community and health providers) were informed of the results.


Workshops with health care providers using ‘HEALTH WORKERS FOR CHANGE’

The health care providers represented the government employees, women health workers, private health care practitioners, traditional birth attendants, doctors, nurses, vaccinators, and dispensers. Seven workshops were held in all, in which almost 100 male and female health workers participated together. To explore and obtain information, different probes and exercises were used. ‘River of life’ was used to make out a representation of an individual’s life events up to the time, s/he became a health worker. Role plays, storytelling, brainstorming and group work were extensively used during the workshops. Their responses from all the workshops were noted and relevant themes were extracted (table 1).

Table 1: Selected responses from the workshops with health workers

1. Why am I a health worker?

Most of the health workers joined the profession, having realized the need for awareness on health in the community, particularly among women of reproductive age. The majority of the women became health providers to supplement the earnings of their families. The desire to serve humanity also influenced many to become a health worker. Becoming a health worker provided a platform for them to take a stand against women’s suppression and their restricted social mobility. Many opted for this profession because of their concerns about issues of maternal and child health in the community. They wanted to help educate community women on family planning and other family health matters. Several participants admitted that they were inspired by the work of other health workers, so they joined the Expanded Programme for Immunization (EPI) teams which eventually brought them permanent employment in the health department.

2. How do our clients see us?

The health providers reported that for common and minor problems, most community men and women consider them as the frontline caregivers. The community women trust the women health workers due to their availability and readiness to listen and solve their domestic problems. Concurrently, a negative image prevails with a common perception especially among men, that health workers are solely promoting family planning. Health providers who are unapproachable, unaffordable and not punctual are not respected by their community. This opinion is often related to the patient’s prior experience with health care and the medicines that were given.

3. Regarding status of women in our community

The health providers remarked that generally younger women play no role in decision-making of any kind in the family and it is the men and elder women of the family who mainly influence decisions, even regarding women’s personal health matters and family planning practices. Participants maintained that hardworking and overworked women are generally accepted and appreciated. Women are permitted to work if they give their earnings to their husbands. Even during pregnancy, a woman’s workload remains the same and is seldom relieved. So, those who are able to obtain some rest, cherish it. The joint family system further jeopardizes their status as women, where they have the least to say. The only situation where women have some autonomy is when they seek health care assistance and cross home boundaries on their own when visiting a doctor. Health providers pointed out that women’s reproductive health issues are neither a priority in most families, nor in the community at large.

4. Regarding the unmet needs of women

Women continue to work until delivery and ignore reproductive health needs, including antenatal check-ups. They are the last and least important person in the family when it comes to nutrition, especially in a joint family system. Moreover, health needs of an unmarried woman are resolved discreetly to avoid any spread of rumours and misconceptions in the community. Health providers reported that most women cannot get an education because there are no schools available within the locality. Most health providers affirmed the need and importance of financial stability in the lives of most community women. Women have unattended reproductive health needs and the adverse attitude of the community towards family planning is another hindrance in ensuring good health. Therefore, some women carry out family planning discreetly.

5. Regarding obstacles at work

Most of the respondents pointed out the unsatisfactory service structure and lack of efficient supervision of their work. They mentioned receiving theoretical trainings only, which do not serve to enhance their skills. The health providers are not appreciated by their supervisors or the community for their hard work. Shortage of staff in primary health care centres, particularly of a women doctors, is a major problem. Village health workers are not skilled enough to deal with reproductive health issues. Salaries are not disbursed in time which is extremely discouraging. The community loses its trust in their health providers when they are unable to provide them with the required medicines or carry out necessary checkups. Negative myths related to EPI campaigns also make the health workers’ tasks even more difficult. Last but not the least is poverty, which impedes patients from consulting a specialist.

6. Suggestions and recommendations to improve the situation

The respondents provided a number of suggestions which included deploying a woman doctor or midwife in health centres to facilitate women to access timely and appropriate health care. To deal more effectively with obstetric emergencies, an ambulance and a maternity home within the locality would be practical. Better administration in the existing primary health care centres would improve the current situation. Adequate logistics and timely disbursement of salaries was emphasized too. It was agreed by all to develop their understanding of the prevailing customs and rituals and remove the wrongly associated myths to promote better health care utilization.

Focus group discussions with community using ‘INITIATING WOMEN EMPOWERMENT FOR HEALTH’

A homogenous mix of married community men and women belonging to well off, middle and low income groups constituted the target group. In all, 14 focus group discussions (FGD) with 100 men and 90 women were conducted. The PRA techniques of Robert Chambers were used for various exercises (Chambers, 1992). An FGD guide was used for collecting the information Table 2).

Table 2: Selected responses from focus group discussions with the community

1. Livelihood, health and vulnerability

Most of the people are daily wage earners, agri-labourers, drivers, contractors or owners of small village shops. Nonetheless, women play an equal part as bread winners in the family, mostly working as agri-labourers, while some work as maids and some do embroidery and sewing. Poor women are worry-stricken and on the whole unhealthy individuals. An overpopulated house exerts many different kinds of pressures and tensions. Most women remain uneducated. They have no say in household affairs including their own marriage. Usually the availability of food in a poor household is dependent on the day’s earning, and at times, they have nothing to eat. In a large family, children’s health is not a priority for the parents. All the participants admitted that the poor class is the most vulnerable to illnesses. Yet, entertainment is a vital component in the lives of the community. The middle class comprises the government servants with a regular income and they do not harbour the fear of utter financial instability. They can afford three modest meals daily, and their children go to government schools. For health care, they can access a government hospital or a private one, when absolutely necessary. The rich are mostly businessmen, male landlords and factory owners and the women in this economic level are healthier, clean, satisfied individuals. They eat good nutritious meals and have enough time for physical rest while many are educated and socially active.

2. Workload

Women have a gigantic workload from sunrise to sunset and most of this work is done single-handedly, except in a few families, where work is shared among the women. In addition, women work as agri-labourers and maids. Men do realise the amount of work women do, but they hardly contribute to household chores.

3. Seasonal calendar for determining illnesses

Most women described generalized body aches as their main complaint. Anaemia is common among women and young girls. In addition to that, they suffer from muscular pain and numbness of the limbs during winter. Excessive dishwashing and laundry also cause dryness of hands throughout the year. Swelling in the hands, face and feet causes itching and burning. In the summer, they also suffer from occasional stomach-aches, malaria and diarrhoea. Hepatitis, diabetes, high and low blood-pressure, kidney stones, urinary tract infections, leucorrhoea, headache, etc. are found throughout the year. Men suffer from mouth ulcers and dental problems as a result of tobacco consumption, betel nuts and piper-leaf chewing.

4. Health-seeking behaviour

Identical patterns of health care seeking are followed dogmatically in all sections of the community. Almost all the women agreed that upon falling sick, they initially practise self-medication and home remedies. Self-medication continues until their persistent state of illness renders it absolutely necessary to visit a health care provider. In poor families, women’s health is not a priority and delay in consulting a trained health provider is common. General practitioners are eventually approached, but the delay in consulting a doctor may range from two days to two weeks. Some women deliberately delay their visit while others are forced to do so. For issues pertaining to reproductive health, most female patients take attendants along with them when visiting a doctor in a government health care facility. The community generally believes that unmarried girls have no maladies. So, if they ever have to receive any form of treatment, it is kept confidential. In fact, it is the elder woman of the family who decides when and which hospital to visit. Most men, too, recognized the limited support of the family. Economic constraints are of course another consideration. Health consultation charges and roundtrip fares can become cumbersome. Some women did admit openly that they visited a spiritual healer once a week, even if it cost several hundreds of rupees.

5. Institutions of power

According to the women, health care services are only available for common problems. For serious ailments, one has to visit a private hospital in the neighbouring village or the city hospital. In some of the villages, there are no doctors at all. In the absence of a woman doctor, traditional birth attendants carry out the examinations and deliveries. In the market, the pharmacies play a critical role dispensing various medicines at affordable rates over the counter. Even this decision is influenced by the elders of the family, especially the mother-in-law. Participants criticized the role of the government. In villages where a woman doctor is appointed, the community expressed its dissatisfaction about her services, punctuality and attitude.


Gender relations, differences in power and access to resources and changing expectations of appropriate gender roles and behaviours have a profound influence on patterns of health and illness (Walters, 2004). In our study, PRA sensitized the health workers about the fact that women do not enjoy a reasonable health status in their communities. Ironically, the entire health care system lacks gender sensitivity. Inadequate and improper client-provider interaction is a significant reason for poor performance of the health care system in the world (Douthwaite & Ward, 2005; Haddad et al., 2000). In our study, this is reflected in the respondents’ strong faith in spiritual healers, home remedies or alternative medicines (Shaikh & Hatcher, 2005a; Shaikh et al., 2004). Mainstream health providers ought to develop greater interaction with clients with improved quality of communication, greater sensitivity towards clients, particularly the women, and improve problem-solving skills (Correa-de-Arajou, 2004; Kettunen et al., 2001). Similar strategies have been proposed by the World Bank more than a decade ago and are still very much doable for the ultimate improvement in health indicators (World Bank, 1993). Over the years many studies have shown that gender of the provider is a point of contention in women’s health care seeking (Kroeger 1983; Shaikh & Hatcher, 2005b). Therefore, more female staff deployed to the health centres in Pakistan would definitely present a practical solution to this problem. Researchers must look into the determinants of women’s health behaviour and health-seeking behaviour, by comprehending their position, status and triple role in society (Standing, 2004). A participatory research approach in our study facilitated building a relaxed rapport with the community which was particularly needed for bringing up most sensitive issues and dealing with emotional upsets during the sessions. Female education retains a net effect on the use of maternal health service, independent of other women’s background characteristics, household’s socioeconomic status and access to health care services (Grown et al., 2005; Afsar & Younus, 2003). Moreover, family income, treatment cost and fare involved are the other genuine concerns of all families with low or even modest incomes (Chakraborty et al., 2003; Shaikh & Hatcher, 2005b).

The issue of safe motherhood requires working with concepts that could help understand the barriers to avail health services (Abou Zahr, 2003). Women’s health is influenced not only by the burden of living in material scarcity but also by the stigmatization and alienation they receive from the families, the health care system and the community (Reid & Tom, 2006). The overwhelming odds in the family and the community tend to hold women back from their legitimate right of seeking appropriate and timely health care. Our discussions with men left a realization in them about the family pressures placed on women and the consequences for their health. There is a definite need for mobilizing the community to extend full support and render its role for increasing awareness among women about health and appropriate utilization of health care services (Portela & Santarelli, 2003). Discussions with both men and women allowed them to take stock of what role different institutions of power play in a woman’s life.


To see the impact of our intervention aimed at sensitizing the community as well as the health providers, an in-depth, mixed method research study would be imperative. Meanwhile, programs and services need to be designed so as to facilitate women’s physical and social access. Women’s health is directly linked to women’s empowerment, augmenting their access and control over critical resources. This phenomenon demands the study of the determinants of women’s health-seeking behaviour. Therefore, more research on gender differences in access to health care and quality of health care would help in reorienting our health services. Moreover, such research would furnish evidence to lobby for health policies and programs to adequately address the inequalities between women and men in relation to their health. Consequently, an engendered system of health care would be the answer.


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