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In this paper we argue the importance of including gender and sexually diverse populations in policy development towards a more inclusive form of health promotion. We emphasize the need to address the broad health and wellbeing issues and needs of LGBT people, rather than exclusively using an illness-based focus such as HIV/AIDS. We critically examine the limitations of population health, the social determinants of health (SDOH), and public health goals, in light of the lack of recognition of gender and sexually diverse individuals and communities. By first acknowledging the unique health and social care needs of LGBT people, then employing anti-oppressive, critical and intersectional analyses we offer recommendations for how to make population health perspectives, public health goals, and the design of public health promotion policy more inclusive of gender and sexual diversity. In health promotion research and practice, representation matters. It matters which populations are being targeted for health promotion interventions and for what purposes, and it matters which populations are being overlooked. In Canada, current health promotion policy is informed by population health and social determinants of health (SDOH) perspectives, as demonstrated by Public Health Goals for Canada. With Canada's multicultural makeup comes the challenge of ensuring that diverse populations are equitably and effectively recognized in public health and health promotion policy.

Background

Most studies into social determinants of health conducted in Spain based on data from health surveys have focused on social class inequalities. This paper aims to review the progressive incorporation of gender perspective and sex differences into health surveys in Spain, and to suggest design, data collection and analytical proposals as well as to make policy proposals.

Methods

Changes introduced into health surveys in Spain since 1995 to incorporate gender perspective are examined, and proposals for the future are made, which would permit the analysis of differences in health between women and men as a result of biology or because of gender inequalities.

Results

The introduction of gender perspective in health surveys requires the incorporation of questions related to family setting and reproductive work, workplace and society in general to detect gender differences and inequalities (for example, domestic work, intimate partner violence, discrimination, contract type or working hours). Health indicators reflecting differential morbidity and taking into account the different lifecycle stages must also be incorporated. Analyses ought to be disaggregated by sex and interpretation of results must consider the complex theoretical frameworks explaining the differences in health between men and women based on sex differences and those related to gender.

Conclusions

Analysis of survey data ought to consider the impact of social, political and cultural constructs of each society. Any significant modification in procedures for collection of data relevant to the study of gender will require systematic coordination between institutions generating the data and researchers who are trained in and sensitive to the topic.

Objectives

To provide a framework for epidemiological research on work and health that combines classic occupational epidemiology and the consideration of work in a structural perspective focused on gender inequalities in health.

Methods

Gaps and limitations in classic occupational epidemiology, when considered from a gender perspective, are described. Limitations in research on work related gender inequalities in health are identified. Finally, some recommendations for future research are proposed.

Results

Classic occupational epidemiology has paid less attention to women's problems than men's. Research into work related gender inequalities in health has rarely considered either social class or the impact of family demands on men's health. In addition, it has rarely taken into account the potential interactions between gender, social class, employment status and family roles and the differences in social determinants of health according to the health indicator analysed.

Conclusions

Occupational epidemiology should consider the role of sex and gender in examining exposures and associated health problems. Variables should be used that capture the specific work environments and health conditions of both sexes. The analysis of work and health from a gender perspective should take into account the complex interactions between gender, family roles, employment status and social class.

Social capital and health research has emerged as a focus of contemporary behavioral epidemiology, while intervention research is seeking more effective measures to increase health protective behaviors and decrease health-risk behaviors. In this review we explored current literature on social capital and health outcomes at the micro-, mesa-, and macro-levels with a particular emphasis on research that incorporates a social capital framework, and adolescent and young adult engagement in risk behaviors. These data indicate that across a broad range of socio-cultural and economic contexts, social capital can affect individuals' risk for negative health outcomes and their engagement in risk behaviors. Further research is needed which should focus on differentiating and measuring positive and negative social capital within both mainstream and alternative social networks, assessing how social constructions of gender, ethnicity, and race – within specific cultural contexts – mediate the relationship between social capital and risk and/or protective behaviors. This new research should integrate the existing research within historical socioeconomic and political conditions. In addition, social capital scales need to be developed to be both culturally and developmentally appropriate for use with adolescents living in a diversity of settings. Despite the proliferation of social capital research, the concept remains underutilized in both assessment and intervention development for adolescents' and young adults' engagement in risk behaviors and their associated short- and long-term poor health outcomes.

Health inequities are related to social determinants based on gender, socioeconomic status, ethnicity, race, living in a specific geographic region, or having a specific health condition. Such inequities were reviewed for blindness and visual impairment by searching for studies on the subject in PubMed from 2000 to 2011 in the English and Spanish languages. The goal of this article is to provide a current review in understanding how inequities based specifically on the aforementioned social determinants on health influence the prevalence of visual impairment and blindness. With regards to gender inequality, women have a higher prevalence of visual impairment and blindness, which cannot be only reasoned based on age or access to service. Socioeconomic status measured as higher income, higher educational status, or non-manual occupational social class was inversely associated with prevalence of blindness or visual impairment. Ethnicity and race were associated with visual impairment and blindness, although there is general confusion over this socioeconomic position determinant. Geographic inequalities and visual impairment were related to income (of the region, nation or continent), living in a rural area, and an association with socioeconomic and political context was suggested. While inequalities related to blindness and visual impairment have rarely been specifically addressed in research, there is still evidence of the association of social determinants and prevalence of blindness and visual impairment. Additional research should be done on the associations with intermediary determinants and socioeconomic and political context.

In order to promote the concept that old age is a dynamic stage of one’s life and that it should be regarded as an achievement—and not a disaster—for both, individuals and for societies, the World Health Organization launched in 2002 the Active Ageing Policy Framework in which Active Ageing is defined as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age”.

Active ageing depends on a variety of influences or determinants that surround individuals, families and nations. They include material conditions as well as social factors that affect individual types of behaviour and feelings. All of these factors, and the interactions between them, play an important role in affecting how well individuals age. These determinants—namely: personal; physical environment; social; economic; behavioural and; access to health and social services within a background that emphasizes the importance of the cross-cutting influences of culture and gender—have to be understood from a life course perspective that recognizes that older persons are not a homogeneous group and that individual diversity increases with age.

Because active ageing is a lifelong process an age-friendly approach is not just ‘elderly friendly’: it benefits all age groups. From theory to practice the translation of the Active Ageing Framework required ways to demonstrate its applicability on the ground. Accordingly, WHO embarked on two parallel projects which will be described in detail at the Bridging Knowledge Conference:

1. Age friendly Primary Health Care (PHC)

The ultimate aim of health and social services should be that individuals can live for as long as possible enjoying the highest possible level of functional capacity for the longest possible period of time in their own communities. For that to happen it is essential to re-think the way Primary Health Care is conceived and delivered worldwide. Population ageing is happening within a background of rapid social change, a shift from infectious to chronic diseases and rising health care costs. Yet PHC is by and large not responding to these trends. In response to this, WHO developed over a period of five years a project involving 14 countries focused on how to make Primary Health Care Centres more age friendly. The ultimate aim of this project, developed over three consecutive stages, was to make available worldwide a toolkit on how to make a PHC facility more responsive to ageing. Its specific objectives were: to minimize the barriers to care; to promote age friendly attitudes and services; to ensure comprehensiveness of community based health care services; to increase geriatric knowledge and skills of community-based health care staff and; to support coordination and linkages with other community-based groups, services, and family.

2. Age friendly cities

The WHO age-friendly cities global project (AFC-GP) was launched in 2005. In March 2006 a core group of cities met in Vancouver to finalize the project protocol and within the next few months WHO and its partners from 33 cities from 22 countries implemented the qualitative research that led to the WHO Age friendly Cities Guide launched in 1 October 2007.

This project was conceived within the context of three major global trends shaping the 21st century: ageing; urbanization and globalization. The world is ageing fast, is increasingly more urbanized and more than ever before boundaries are becoming blurred, the world more globalized. It is also a practical application of the main call from the International Plan of Action of Ageing agreed by all nations at the World Assembly on Ageing, Madrid 2002 requesting ‘bottom up approaches’. Thus, the project is based on qualitative research asking older people themselves to identify the issues, concerns and recommendations for improving the environment in which they live around eight main domains: 1. outdoor spaces and buildings; 2. transportation; 3. housing; 4. social participation; 5. respect and social inclusion; 6. civic participation and employment; 7. communication and information; and 8. community support and health services.

Details of both projects can be found on: http://www.who.int/ageing/en

Background

Few research projects have analyzed how social determinants of health impact cities in North Africa. The sustained growth in these countries has nevertheless proven to exacerbate health disparities and create many social and economic inequalities. This strategic analysis examines selected social determinants of health in a major urban centre of Tunisia, identifies the most influential stakeholders able to influence equity/inequity, and reviews the accomplishments and need for action to foster health equity.

Methods

This analysis was performed through a literature review and participatory research methods that included focus groups discussions and interview with key informants.

Results

Access to health care, changes in lifestyles, housing issues and gender-related inequities are prime, socially-determined elements that affect health in Ariana.

Conclusion

Recognition of emerging health issues is needed along with improved inter and intrasectoral coordination among stakeholders. The community-participatory approach used in this paper proved to be a useful scoping technique for this setting. A similar methodology could be used by other researchers as a first step toward health equity action at a city level.

Background

The objective of the paper is to compare population health in the United States (US) and Canada. Although the two countries are very similar in many ways, there are potentially important differences in the levels of social and economic inequality and the organization and financing of and access to health care in the two countries.

Methods

Data are from the Joint Canada/United States Survey of Health 2002/03. The Health Utilities Index Mark 3 (HUI3) was used to measure overall health-related quality of life (HRQL). Mean HUI3 scores were compared, adjusting for major determinants of health, including body mass index, smoking, education, gender, race, and income. In addition, estimates of life expectancy were compared. Finally, mean HUI3 scores by age and gender and Canadian and US life tables were used to estimate health-adjusted life expectancy (HALE).

Results

Life expectancy in Canada is higher than in the US. For those < 40 years, there were no differences in HRQL between the US and Canada. For the 40+ group, HRQL appears to be higher in Canada. The results comparing the white-only population in both countries were very similar. For a 19-year-old, HALE was 52.0 years in Canada and 49.3 in the US.

Conclusions

The population of Canada appears to be substantially healthier than the US population with respect to life expectancy, HRQL, and HALE. Factors that account for the difference may include access to health care over the full life span (universal health insurance) and lower levels of social and economic inequality, especially among the elderly.

This study examined gender differences in the associations between affection- and status-related stressors encountered in the first half of life and physical and mental health problems later on. Based on the theory of Social Production Functions (SPF) two hypotheses have been formulated, which were tested in a representative sample of 446 men and 514 women (aged 40–79). Main outcome measures were number of chronic somatic diseases and level of psychological distress. As expected, regression analyses showed no gender differences in the associations between affection-related stressors and physical and mental health problems later on. In contrast, but as also expected, status-related stressors encountered in the first half of life were associated with later physical and mental health for men only. It is concluded that the gender differences in the associations between earlier social stressors and later health problems may be more complex than the common assumption that men are only affected by status stress and women only by affection stress. This study contributes to the knowledge on gender differences concerning the link between social stress and health, and it indicates that social experiences encountered earlier in life are of importance for being healthy and happy in later life.

Understanding social inequalities in health is of great importance; it provides the conceptual frame for investigating the social factors that affect health, together with empirical evidence for improving population health. Individual and socioeconomic data, disease related conditions and self rated health (SRH) ratings were collected from a representative sample of 1,000 participants in order to study health inequalities in Greece. 20.8% of men and 37.2% of women reported poor health status. Significant inequalities in SRH were observed. Strong associations of poor SRH with gender, age, insurance coverage and chronic diseases were identified. Social insurance scheme captured partly the effects of educational level, income and residence area in SRH in multivariate analysis. Respondents under chronic treatment and those suffering from cardiovascular, musculoskeletal and neurological/psychiatric disorders exhibited the highest risk of reporting poor SRH. Our findings provide decision-makers with insights into how to manage health inequalities by prioritizing preventive measures and consequently, progress towards the fair distribution of healthcare resources.

Background

Sex and gender sensitive inquiry is critical in pharmaceutical policy due to the sector's historical connection with women's health issues and due to the confluence of biological, social, political, and economic factors that shape the development, promotion, use, and effects of medicinal treatments. A growing number of research bodies internationally have issued laws, guidance or encouragement to support conducting sex and gender based analysis (SGBA) in all health related research.

Methods

In order to investigate the degree to which attempts to mainstream SGBA have translated into actual research practices in the field of pharmaceutical policy, we employed methods of literature scoping and mapping. A random sample of English-language pharmaceutical policy research articles published in 2008 and indexed in MEDLINE was analysed according to: 1) use of sex and gender related language, 2) application of sex and gender related concepts, and 3) level of SGBA employed.

Results

Two thirds of the articles (67%) in our sample made no mention of sex or gender. Similarly, 69% did not contain any sex or gender related content whatsoever. Of those that did contain some sex or gender content, the majority focused on sex. Only 2 of the 85 pharmaceutical policy articles reviewed for this study were primarily focused on sex or gender issues; both of these were review articles. Eighty-one percent of the articles in our study contained no SGBA, functioning instead at a sex-blind or gender-neutral level, even though the majority of these (86%) were focused on topics with sex or gender aspects.

Conclusions

Despite pharmaceutical policy's long entwinement with issues of sex and gender, and the emergence of international guidelines for the inclusion of SGBA in health research, the community of pharmaceutical policy researchers has not internalized, or "mainstreamed," the practice. Increased application of SGBA is, in most cases, not only appropriate for the topics under investigation, but well within the reach of today's pharmaceutical policy researchers.

The purpose of this study was to determine the combined effects of gender and levels of social support on 1-year functional health outcomes in older persons diagnosed with heart failure (HF). Persons ≥ 65 years of age with an acute HF exacerbation (164 females; 271 males) were enrolled and followed for a year. Participants completed baseline and 12-month questionnaires containing clinical and demographic descriptive information and validated self-report measures of: (1) physical functioning (Medical Outcome Study [MOS] SF12 and Kansas City Cardiomyopathy Questionnaire [KCCQ]) and (2) social support (MOS- Social Support Survey). Women were more likely to be single, widowed or divorced, living alone and earning less annual income. At baseline, women reported significantly lower support and physical function scores. However, at 1 year there were no significant gender differences in the proportion of men or women who experienced clinically meaningful functional decline or death across the year of follow-up. In multivariable modeling, men with lower levels of social support were more likely to experience functional decline. This was not the case for women. Our findings suggest that gender-directed strategies to promote optimization of function for both men and women living with HF in their community are warranted.

Cardiovascular disease is the largest killer of women internationally and women often suffer inferior outcomes following an acute cardiac event as compared to men. A gendered approach to investigating cardiovascular disease in women incorporates the unique social, cultural, and economic circumstances that being a woman brings to the health encounter. The multiple roles enacted by many women may be important factors in this health discrepancy. In order to more fully understand the impact of the roles of women on health, a questionnaire was administered to participants of the Heart Awareness for Women group cardiac rehabilitation program which assessed women's role perceptions followed by discussions. We found that caregiving can be both positive and negative. It gives a sense of purpose, meaning, and community connection as well as burden and conflict. Emphasis must be placed on promoting strategies in women to achieve a balance between caregiving responsibilities and prioritisation of cardiovascular health.

Study objective

To examine the Canadian origins of the Lalonde Report and its impact on British and American health promotion activities.

Design:

A brief history of the development of key Canadian documents and their use by politicians and public health activists in the United Kingdom and United States.

Setting:

This paper focuses on the impact of the Canadian model on Canada, the United Kingdom and United States.

Main results:

This paper argues that internal political and economic forces are as important as international trends in determining healthcare policy initiatives.

Conclusions:

In the 1970s all the English‐speaking developed nations were facing deficits as curative costs rose. Adopting health promotion policies permitted them to shift responsibility back to local governments and individuals while limiting their expenditures. Health and community activists, however, used this concept to broaden their focus to include the social, economic and political determinants of health and thus reinvented public health discourse and practice for the 21st century.

Background

Men and women have different patterns of health. These differences between the sexes present a challenge to the field of public health. The question why women experience more health problems than men despite their longevity has been discussed extensively, with both social and biological theories being offered as plausible explanations. In this article, we focus on how gender equality in a partnership might be associated with the respondents' perceptions of health.

Methods

This study was a cross-sectional survey with 1400 respondents. We measured gender equality using two different measures: 1) a self-reported gender equality index, and 2) a self-perceived gender equality question. The aim of comparison of the self-reported gender equality index with the self-perceived gender equality question was to reveal possible disagreements between the normative discourse on gender equality and daily practice in couple relationships. We then evaluated the association with health, measured as self-rated health (SRH). With SRH dichotomized into 'good' and 'poor', logistic regression was used to assess factors associated with the outcome. For the comparison between the self-reported gender equality index and self-perceived gender equality, kappa statistics were used.

Results

Associations between gender equality and health found in this study vary with the type of gender equality measurement. Overall, we found little agreement between the self-reported gender equality index and self-perceived gender equality. Further, the patterns of agreement between self-perceived and self-reported gender equality were quite different for men and women: men perceived greater gender equality than they reported in the index, while women perceived less gender equality than they reported. The associations to health were depending on gender equality measurement used.

Conclusions

Men and women perceive and report gender equality differently. This means that it is necessary not only to be conscious of the methods and measurements used to quantify men's and women's opinions of gender equality, but also to be aware of the implications for health outcomes.

Background

Long-term recipients of social assistance face barriers to social and economic inclusion, and have poorer health and more limited opportunities for improving their health than many other groups in the population. During recent decades there have been changes in Swedish social policy, with cutbacks in public benefits and a re-emphasis on means-tested policies. In this context, it is important to investigate the necessary conditions for social workers to offer social assistance and services, as well as the mediating role of social workers between public policies and their clients. Swedish social services aim to promote social inclusion by strengthening the individual´s own resources. We investigated the issues that arise when providing social services to long-term social assistance clients within the framework of resilience, which focuses on the processes leading to positive functioning in adverse conditions.

Methods

Interviews were conducted with 23 social workers in Stockholm and analysed by qualitative content analysis.

Results

The main theme to emerge from the interviews concerned the constraints that the social workers faced in providing social services to social assistance clients. The first subtheme focused on dilemmas in the interaction between social workers and clients resulting from the dual role of exercising authority and supporting and building trust with clients. Working conditions of social workers also played a crucial role. The second subtheme addressed the impact of the societal context, such as labour market opportunities and coordination between authorities.

Conclusions

Overall, we found that social workers to a great extent tried to find individual solutions to structural problems. To provide resilience-enhancing social services to long-term social assistance clients with varying obstacles and needs requires a constructive working environment, supportive societal structures and inter-sectoral cooperation between different authorities.

In this study, the authors focused on older adults in Beijing with three objectives: to examine gender differences in functional health and mortality at the end of a five-year study period, controlling for initial functional health; to determine the extent to which these differences were a function of exposure versus vulnerability to risk factors; and to analyze the relative importance of social, economic, and psychological risk factors in explaining gender differences. The results show that women were more likely to survive and to be functionally dependent at follow-up compared with men among those functionally independent at baseline. No significant differences among those who were initially dependent were apparent. Differential vulnerability to risk factors, more so than exposure, explained the variation in health outcomes across gender. Smoking, a lack of formal education, a lack of health insurance, a low sense of control, stressful events, and rural living played large roles in explaining the differences.

Public service advertisements have been used by many in hopes of "selling" good health behaviors. But selling good behavior--even if it could be done more effectively--is not the best goal for using mass media to prevent health problems. Personal behavior is only part of what determines health status. Social conditions and the physical environment are important determinants of health that are usually ignored by health promotion advertising. Public service advertising may be doing more harm than good if it is diverting attention from more effective socially based health promotion strategies. Counter-ads are one communications strategy that could be used to promote a broader responsibility for rectifying health problems. In the tradition of advocacy advertising directly promoting policy rather than products, counter-ads promote views consistent with a public health perspective. Counter-ads set the agenda for health issues, conferring status on policy-oriented strategies for addressing health problems. The primary purpose of counter-ads is to challenge the dominant view that public health problems reflect personal health habits. They are controversial because they place health issues in a social and political context. Advertising strategies for health promotion range over a spectrum from individually oriented public service advertising to socially oriented counter-advertising. The recent anti-tobacco campaign from the California Department of Health Services represents advertisements across the spectrum. Counter-ads that focus on a politically controversial definition for health problems are an appropriate and necessary alternative to public service advertising.

The design and analysis of research may cause systematic gender dependent errors to be produced in results because of gender insensitivity or androcentrism. Gender bias in research could be defined as a systematically erroneous gender dependent approach related to social construct, which incorrectly regards women and men as similar/different.

Most gender bias can be found in the context of discovery (development of hypotheses), but it has also been found in the context of justification (methodological process), which must be improved. In fact, one of the main effects of gender bias in research is partial or incorrect knowledge in the results, which are systematically different from the real values.

This paper discusses some forms of conceptual and methodological bias that may affect women's health. It proposes a framework to analyse gender bias in the design and analysis of research carried out on women's and men's health problems, and on specific women's health issues.

Using examples, the framework aims to show the different theoretical perspectives in a social or clinical research context where forms of selection, measurement and confounding bias are produced as a result of gender insensitivity. Finally, this paper underlines the importance of re‐examining results so that they may be reinterpreted to produce new gender based knowledge.

Background

The role of gender differences in Health Related Quality Life (HRQL) in coronary patients is controversial, so understanding the specific determinants of HRQL in men and women might be of clinical importance. The aim of this study was to know the gender differences in the evolution of HRQL at 3 and 6 months after a coronary event, and to identify the key clinical, demographic and psychological characteristics of each gender associated with these changes.

Methods

A follow-up study was carried out, and 175 patients (112 men and 63 women) with acute myocardial infarction (AMI) or unstable angina were studied. The SF-36v1 health questionnaire was used to assess HRQL, and the GHQ-28 (General Health Questionnaire) to measure mental health during follow-up. To study the variables related to changes in HRQL, generalized estimating equation (GEE) models were performed.

Results

Follow-up data were available for 55 men and 25 women at 3 months, and for 35 men and 12 women at 6 months. Observations included: a) Revascularization was performed later in women. b) The frequency of rehospitalization between months 3 and 6 of follow-up was higher in women c) Women had lower baseline scores in the SF-36. d) Men had progressed favourably in most of the physical dimensions of the SF-36 at 6 months, while at the same time women's scores had only improved for Physical Component Summary, Role Physical and Social Functioning; e) the variables determining the decrease in HRQL in men were: worse mental health and angina frequency; and in women: worse mental health, history of the disease, revascularization, and angina frequency.

Conclusions

There are differences in the evolution of HRQL, between men and women after a coronary attack. Mental health is the determinant most frequently associated with HRQL in both genders. However, other clinical determinants of HRQL differed with gender, emphasizing the importance of individualizing the intervention and the content of rehabilitation programs. Likewise, the recognition and treatment of mental disorders in these patients could be crucial.

Background

The use of medicine is an important part of any health care process and the improvement of health status of any population. While some medicines are legitimately prescribed by practitioners, others take drugs not prescribed by practitioners when they suffer from illness or injuries. The effect of such actions on the health of individuals cannot be overlooked. Even though majority of health policies in developing countries have focused on chronic diseases and the functioning of health systems, abuse of drugs or medicines is a serious population health problem that deserves equal attention. The objectives of the current study are to examine the social and economic dimensions of the use of non-prescription medicines and to determine the effect it has on self-assessed health of individuals.

Methods

The study employs data from the second Integrated Household Survey of Malawi with a sample of 2506 individuals who reported an incidence of illness or injury over the past two weeks before the survey. Regression analysis is conducted at two levels, first is a probit model to identify socio-economic factors that influence the use of non-prescription medicine. The second step uses an ordered probit to model the effect of the use of non-prescription medicines on self-assessed health of individuals.

Results

Results from the probit model show that availability of a health facility in the community negatively affects the use of non-prescription medicines. Age of the individual and the total household health expenditure relate to higher use of non-prescription medicine. Results from the ordered probit model shows that individuals who used non-prescription medicines were likely to report lower categories of self-assessed health.

Conclusions

While policy makers need to engage in public campaign to educate the population on the health risks posed by the use of non-prescription medicines, attention also has to be paid to the social and economic characteristics of the population. Efforts to provide health facilities in communities where they do not exist and improve existing ones will be a crucial step in reducing the use of non-prescription medicines.

Gender is a significant determinant of health, yet the choice of topic for research, as well as the methodology, analysis, and interpretation, are often insensitive to the biologic, psychologic, social, economic, and cultural differences between men and women. Family medicine researchers could study a broad range of gender-related topics; such research could lead to improved family medicine.

In 2005 women represented approximately half of all 190 million international migrants worldwide. This paper addresses the need to integrate a gender perspective into epidemiological studies on migration and health, outlines conceptual gaps and discusses some methodological problems. We mainly consider the international voluntary migrant. Women may emigrate as wives or as workers in a labour market in which they face double segregation, both as migrants and as women. We highlight migrant women's heightened vulnerability to situations of violence, as well as important gaps in our knowledge of the possible differential health effects of factors such as poverty, unemployment, social networks and support, discrimination, health behaviours and use of services. We provide an overview of the problems of characterising migrant populations in the health information systems, and of possible biases in the health effects caused by failure to take the triple dimension of gender, social class and ethnicity into account.

Background

In Pakistan, where gendered norms restrict women's mobility, female community health workers (CHWs) provide doorstep primary health services to home-bound women. The program has not achieved optimal functioning. One reason, I argue, may be that the CHWs are unable to make home visits because they have to operate within the same gender system that necessitated their appointment in the first place. Ethnographic research shows that women’s mobility in Pakistan is determined not so much by physical geography as by social geography (the analysis of social phenomena in space). Irrespective of physical location, the presence of biradaria members (extended family) creates a socially acceptable ‘inside space’ to which women are limited. The presence of a non-biradari person, especially a man, transforms any space into an ‘outside space’, forbidden space. This study aims to understand how these cultural norms affect CHWs’ home-visit rates and the quality of services delivered.

Design

Data will be collected in district Attock, Punjab. Twenty randomly selected CHWs will first be interviewed to explore their experiences of delivering doorstep services in the context of gendered norms that promote women's seclusion. Each CHW will be requested to draw a map of her catchment area using social mapping techniques. These maps will be used to survey women of reproductive age to assess variations in the CHW's home visitation rates and quality of family planning services provided. A sample size of 760 households (38 per CHW) is estimated to have the power to detect, with 95% confidence, households the CHWs do not visit. To explore the role of the larger community in shaping the CHWs mobility experiences, 25 community members will be interviewed and five CHWs observed as they conduct their home visits. The survey data will be merged with the maps to demonstrate if any disjunctures exist between CHWs’ social geography and physical geography. Furthermore, the impacts these geographies have on home visitation rates and quality of services delivered will be explored.

Discussion

The study will provide generic and theoretical insights into how the CHW program policies and operations can improve working conditions to facilitate the work of female staff in order to ultimately provide high-quality services.

Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion—increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)—that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.