Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies

Background: Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge. Methods: We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention. Results: We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW’s partner; and 4) the CHW’s patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes. Conclusions: This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities. Gender norms can vary depending on many factors including cultural norms, ethnic groupings, the laws and history of a country, whether primarily a rural or urban setting, and socio-economic status. Generally speaking, gender norms in Uganda and Kenya can be characterized as patriarchal, where men are typically are viewed as the head of the household, are the primary property owners, hold positions of power and social privilege, and predominate in political offices and other decision-making roles in society [28]. The study was conducted in Kenya and Uganda; two low-to-middle income countries located in East Africa. The population in these sub-Saharan African countries is relatively young, with approximately 65 and 77% of Kenya’s and Uganda’s population being 25 years of age or younger, respectively [29, 30]. The majority of the population cannot afford to pay for health care, the poor are less likely to utilize health services when they are ill, and wide disparities in utilization exist between geographical regions and between urban and rural areas [31]. Many individuals and households in the region experience social and health inequalities in relation to accessing basic services such as health care, water and sanitation, food, and decent housing [29, 30]. Access to primary healthcare services is a challenge either because of distance to facilities or economic barriers. In spite of efforts to increase access to health services at the community level, wide disparities in utilization exist between geographical regions and between urban and rural areas with urban areas having more access to basic services than rural areas [31]. In Uganda for example, the rural-urban divide is reflected in the maternal and newborn health indicators where coverage of skilled attendance at birth is 52% in rural areas, compared to 89% in urban areas [32]. In addressing these health gaps, the government of Uganda through the Ministries of Health introduced a community strategy that emphasized the need for CHWs (locally referred to as Village Health Teams) not only in rural areas but also in urban centres [33]. The Kenyan government also introduced CHWs into the healthcare system with the goal of making primary healthcare services accessible to all, specifically those in underserved communities [34, 35]. For this study, we drew our participants from CHWs that were involved with four health social enterprises in Nairobi county (Kenya), Kampala, Masaka, and Bukomansimbi districts (Uganda). In Nairobi, the participants were CHWs working in an urban informal settlement where healthcare provisioning is extremely limited, poorly resourced, and difficult to access, making the extended reach of CHWs important. Over 35% of Kenyans are currently living in urban areas, and 75% of people in urban areas live in informal settlements [29, 34]. These communities are characterised by high levels of poverty, insecurity, and inadequate access to basic social services and amenities. In Uganda, Kampala district was selected to represent the urban population with similar characteristics. Masaka and Bukomansimbi districts of Uganda represented rural communities where food crop agriculture is the main economic activity. Masaka has a rich cultural heritage with diversity of ethnicities of about 40 ethnic groups, although the majority are Baganda, and most of the tribes practice the Baganda culture [30]. To understand how health social enterprises in Africa can contribute to greater health outcomes and gender equality by addressing gender-based constraints for CHWs, we designed a study to answer the following research question: What are the key gender-based constraints and strategies for CHWs working with social enterprises in Africa and where are they found? To answer this question, we designed an in-depth qualitative study that would conduct key informant interviews and focus groups with four health social enterprises in Africa using CHWs. Qualitative studies are suitable for understanding social issues including gender norms and related constraints and opportunities [36]. We primarily focused on the organizational level of analysis (the health social enterprise), however our qualitative approach also allowed us to consider the individual level of analysis of CHWs and the social and economic context in which the CHWs and health social enterprises were embedded. Our qualitative approach was problem-driven, and oriented to explaining phenomena in a complex social environment [37]. Our research approach was primarily inductive, especially during the earlier phases of data gathering and analysis, but also included deduction as we consulted the literature on gender issues and CHWs. To understand gender issues and constraints in the work of CHWs working with health social enterprises, we selected four organizations for our study, which were sampled to cover diversity in terms of countries of operation, whether they worked primarily in rural or urban areas, whether CHWs operated primarily door-to-door or were based in a clinic, and whether organizations worked with only women or worked with male and female CHWs (see Table 1). The four organizations selected were BRAC Uganda, Access Afya, Healthy Entrepreneurs, and LifeNet International. Sampled Health Social Enterprises in Africa working with CHWs We began by reviewing the research literature [3] as well as the leading gender analysis frameworks and tools [38]. We then conducted 36 key informant interviews and 21 focus group discussions in Uganda and Kenya (for a total of 175 individuals: 106 women and 69 men). Data were collected between March 2016 and May 2019 which allowed for sufficient time to become familiar with the organizations, the health systems, and the gender norms in the regions of Uganda and Kenya where they operated. Data were collected in Kampala, Nkoni, and Bukomansimbi in Uganda and Nairobi in Kenya. The timeline, locations, and types of data collected is illustrated in Table 2. Data Collection Timeline 6 – 1 female – 5 males 8 – 3 females – 5 males 7 – 7 females 4 – 3 females – 1 male 5 – 4 females – 1 male 6 – 4 females – 2 males 1 – 5 females 3 – 5 female CHWs – 5 male partners – 5 female patients 4 – 7 female CHWs – 4 male CHWs – 4 male partners – 6 female patients 3 – 11 female CHWs – 11 male partners – 7 female patients 2 – 6 female CHWs – 4 male partners 3 – 12 female CHWs – 6 male CHWs – 6 male partners 2 – 9 female CHWs – 7 male partners 3 − 5 female CHWs – 5 male partners – 5 female patients Interview data were collected face-to-face during in-person visits attended by at least one coauthor, although typically all three coauthors were present. Interviewees were purposively selected from the four organizations we studied (including founders, executive directors, CHW supervisors, front line workers, and senior leaders). Additional expert interviews were carried out with practitioners, researchers, and experts from other local organizations knowledgeable about gender issues and community health workers. To elicit the most valuable interview data, we struck a balance between a structured process with predetermined interview questions and embracing deviations initiated by the interviewees on topics relevant to our exploration. We made every effort to be fully present with interviewees, attentive to verbal and non-verbal cues, and sensitive to cultural norms during interviews and focus groups. We took efforts to establish a relaxed and comfortable setting for our interviewees to encourage openness and reflection [39]. Interviews ranged from 30 to 90 min. For the focus group discussions, seven were with female CHWs, two with male CHWs, seven with the male partners of female CHWs, and five with patients of CHWs (mixed gender). During this time, the coauthors also observed participants social interactions including relationships and dynamics between men and women. As the study progressed, groups were focused on filling remaining gaps in our understanding. Focus groups were conducted either directly in English or through a translator in a local language. All qualitative data were recorded, transcribed, and coded in light of the research question [40]. An example focus group and interview discussion guide is included in Additional file 1 Annex 1. Focus groups ranged from one to 2½ hours. In analyzing the data from interviews and focus groups we also stayed open to understanding the impacts of gender on other non-CHW employees, such as clinical assistants, clinical officers, and managers. Data was gathered and analyzed iteratively as the study progressed and we triangulated between interviews, focus groups, and the literature to enhance the reliability and trustworthiness of the findings [41]. The systematic use of iteration and triangulation was aimed at discovering the social norms related to gender and related constraints that CHWs faced, and strategies suggested to address them. As interview and focus group data were collected, we began coding for gender-related constraints that CHWs faced, strategies to overcome the constraints and the conceptual ‘location’ where the issues were situated. We used both deductive and inductive coding. Our deductive coding started with some predefined codes related to our research question. These codes included: gender-based constraint and strategy to overcome constraint. We used inductive coding to understand the ‘locations’ of where we were finding gender issues (e.g. between the CHW and her partner, etc.) as well as to categorize gender-based constraints that CHWs faced and strategies to address them. Codes were weighted and organized hierarchically based on the perceived importance assigned to the particular gender issue at hand. Perceived importance and the structuring of the codes and their underlying themes was determined through discussions between coauthors. Analysis and collection proceeded iteratively as data was gathered over the 3 years of the study. As we progressed, our themes and categories became progressively clearer until our framework and findings became finalized. During the data collection and analysis process the emerging themes and categories were cross-checked between interview data, focus group data, and related findings in the literature. The multiple sources of data allowed for triangulation and corroboration which served to enhance the validity of the findings. We presented early versions of our emerging framework and findings to key interviewees to guard against premature conclusions as a result of human information-processing biases [42]. The coding of our data into constructs and a framework was done by hand. We aimed to code at various levels of abstraction, while remaining grounded in the data. We split or consolidated the lists of constraints and strategies and the constructs that comprised the framework until further data gathering and analysis continued to fit our models without need for further refinement. To maximize the reliability of our categories, constructs and framework, the analysis and coding process included ongoing conversations between authors and the construction of diagrams and tables to organize and represent the data [43]. During the process of coming to the final version of our framework and categories of constraints and strategies we searched for what we believed was, on balance, the findings that best fit the data [44]. We continued our refinement of our framework and categories until the model and lists became stabilized and new data and analysis no longer resulted in refinements or changes.