Gendered and racial experiences of moral distress: A scoping review.

AIM: To inform efforts to integrate gender and race into moral distress research, the review investigates if and how gender and racial analyses have been incorporated in such research. DESIGN: Scoping review. METHODS: The PRISMA (Preferred Reporting Items for Systematic and Meta-Analysis) Extension for Scoping Reviews was adopted. DATA SOURCES: Systematic literature search was conducted through PubMed, CINAHL and Web of Science databases. Boolean operators were used to identify moral distress literature which included gender and/or race data and published between 2012 and 2022. RESULTS: After screening and full-text review, 73 articles reporting on original moral distress research were included. Analysis was conducted on how gender and race were incorporated in research and interpretation of moral distress experiences among healthcare professionals. IMPACT: This study found that while there is an upward trend in including gender and race-disaggregated data in moral distress research, over half of such research did not conduct in-depth analysis of such data. Others only highlighted differential experiences such as moral distress levels of women vis-à-vis men. Only about 20% of publications interrogated how experiences of moral distress differed and/or explored factors behind their findings. CONCLUSION: There is a need to not only collect disaggregated data in moral distress research but also engage this data through gender and race-based analysis. Particularly, we highlight the need for intersectional analysis, which can elucidate how social identities and categories (such as gender and race) and structural inequalities (such as those sustained by sexism and racism) interact to influence moral experiences. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Moral distress as experienced by healthcare professionals is increasingly recognized as an important area of research with significant policy implications in the healthcare sector. This study offers insights for nuanced and targeted policy approaches. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Intersectional insights into racism and health: not just a question of identity.

Intersectionality is a useful tool to address health inequalities, by helping us understand and respond to the individual and group effects of converging systems of power. Intersectionality rejects the notion of inequalities being the result of single, distinct factors, and instead focuses on the relationships between overlapping processes that create inequities. In this Series paper, we use an intersectional approach to highlight the intersections of racism, xenophobia, and discrimination with other systems of oppression, how this affects health, and what can be done about it. We present five case studies from different global locations that outline different dimensions of discrimination based on caste, ethnicity and migration status, Indigeneity, religion, and skin colour. Although experiences are diverse, the case studies show commonalities in how discrimination operates to affect health and wellbeing: how historical factors and coloniality shape contemporary experiences of race and racism; how racism leads to separation and hierarchies across shifting lines of identity and privilege; how racism and discrimination are institutionalised at a systems level and are embedded in laws, regulations, practices, and health systems; how discrimination, minoritisation, and exclusion are racialised processes, influenced by visible factors and tacit knowledge; and how racism is a form of structural violence. These insights allow us to begin to articulate starting points for justice-based action that addresses root causes, engages beyond the health sector, and encourages transnational solidarity.

The intersection of biological sex and gender in adverse events following seasonal influenza vaccination in older adults.

BACKGROUND: Women/females report more adverse events (AE) following immunization than men/males for many vaccines, including the influenza and COVID-19 vaccines. This discrepancy is often dismissed as a reporting bias, yet the relative contributions of biological sex and gender are poorly understood. We investigated the roles of sex and gender in the rate of AE following administration of the high-dose seasonal influenza vaccine to older adults (≥ 75 years) using an AE questionnaire administered 5-8 days post-vaccination. Participant sex (male or female) was determined by self-report and a gender score questionnaire was used to assign participants to one of four gender categories (feminine, masculine, androgynous, or undifferentiated). Sex steroid hormones and inflammatory cytokines were measured in plasma samples collected prior to vaccination to generate hypotheses as to the biological mechanism underpinning the AE reported. RESULTS: A total of 423 vaccines were administered to 173 participants over four influenza seasons (2019-22) and gender data were available for 339 of these vaccinations (2020-22). At least one AE was reported following 105 vaccinations (25%), by 23 males and 82 females. The majority of AE occurred at the site of injection, were mild, and transient. The odds of experiencing an AE were 3-fold greater in females than males and decreased with age to a greater extent in females than males. The effects of gender, however, were not statistically significant, supporting a central role of biological sex in the occurrence of AE. In males, estradiol was significantly associated with IL-6 and with the probability of experiencing an AE. Both associations were absent in females, suggesting a sex-specific effect of estradiol on the occurrence of AE that supports the finding of a biological sex difference. CONCLUSIONS: These data support a larger role for biological sex than for gender in the occurrence of AE following influenza vaccination in older adults and provide an initial investigation of hormonal mechanisms that may mediate this sex difference. This study highlights the complexities of measuring gender and the importance of assessing AE separately for males and females to better understand how vaccination strategies can be tailored to different subsets of the population.

Double distress: women healthcare providers and moral distress during COVID-19.

Background: COVID-19 pandemic has led to heightened moral distress among healthcare providers. Despite evidence of gendered differences in experiences, there is limited feminist analysis of moral distress.Objectives: To identify types of moral distress among women healthcare providers during the COVID-19 pandemic; to explore how feminist political economy might be integrated into the study of moral distress.Research Design: This research draws on interviews and focus groups, the transcripts of which were analyzed using framework analysis.Research Participants and Context: 88 healthcare providers, based in British Columbia Canada, participated virtually.Ethical Considerations: The study received ethical approval from Simon Fraser University.Findings: Healthcare providers experienced moral dilemmas related to ability to provide quality and compassionate care while maintaining COVID-19 protocols. Moral constraints were exacerbated by staffing shortages and lack of access to PPE. Moral conflicts emerged when women tried to engage decision-makers to improve care, and moral uncertainty resulted from lack of clear and consistent information. At home, women experienced moral constraints related to inability to support children's education and wellbeing. Moral conflicts related to lack of flexible work environments and moral dilemmas developed between unpaid care responsibilities and COVID-19 risks. Women healthcare providers resisted moral residue and structural constraints by organizing for better working conditions, childcare, and access to PPE, engaging mental health support and drawing on professional pride.Discussion: COVID-19 has led to new and heightened experiences of moral distress among HCP in response to both paid and unpaid care work. While many of the experiences of moral distress at work were not explicitly gendered, implicit gender norms structured moral events. Women HCP had to take it upon themselves to organize, seek out resources, and resist moral residue.Conclusion: A feminist political economy lens illuminates how women healthcare providers faced and resisted a double layering of moral distress during the pandemic.

Association of Frailty, Age, and Biological Sex With Severe Acute Respiratory Syndrome Coronavirus 2 Messenger RNA Vaccine-Induced Immunity in Older Adults.

BACKGROUND: Male sex and old age are risk factors for severe coronavirus disease 2019, but the intersection of sex and aging on antibody responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines has not been characterized. METHODS: Plasma samples were collected from older adults (aged 75-98 years) before and after 3 doses of SARS-CoV-2 mRNA vaccination, and from younger adults (aged 18-74 years) post-dose 2, for comparison. Antibody binding to SARS-CoV-2 antigens (spike protein [S], S receptor-binding domain, and nucleocapsid), functional activity against S, and live-virus neutralization were measured against the vaccine virus and the Alpha, Delta, and Omicron variants of concern (VOCs). RESULTS: Vaccination induced greater antibody titers in older females than in older males, with both age and frailty associated with reduced antibody responses in males but not females. Responses declined significantly in the 6 months after the second dose. The third dose restored functional antibody responses and eliminated disparities caused by sex, age, and frailty in older adults. Responses to the VOCs, particularly the Omicron variant, were significantly reduced relative to the vaccine virus, with older males having lower titers to the VOCs than older females. Older adults had lower responses to the vaccine and VOC viruses than younger adults, with greater disparities in males than in females. CONCLUSIONS: Older and frail males may be more vulnerable to breakthrough infections owing to low antibody responses before receipt of a third vaccine dose. Promoting third dose coverage in older adults, especially males, is crucial to protecting this vulnerable population.

Scoping 'sex' and 'gender' in rehabilitation: (mis)representations and effects.

BACKGROUND: Researchers have highlighted a large-scale global unmet need for rehabilitation. While sex and gender have been shown to interact with each other and with other social and structural factors to influence health and wellbeing, less is known about how sex and gender shape rehabilitation participation and outcomes within health systems. METHODS: Using an intersectional approach, we examine literature that explores the relationship between sex and/or gender and rehabilitation access, use, adherence, outcomes, and caregiving. Following a comprehensive search, 65 documents met the inclusion criteria for this scoping review of published literature. Articles were coded for rehabilitation-related themes and categorized by type of rehabilitation, setting, and age of participants, to explore how existing literature aligned with documented global rehabilitation needs. Responding to a common conflation of sex and gender in the existing literature and a frequent misrepresentation of sex and gender as binary, the researchers also developed a schema to determine whether existing literature accurately represented sex and gender. RESULTS: The literature generally described worse rehabilitation access, use, adherence, and outcomes and a higher caregiving burden for conditions with rehabilitation needs among women than men. It also highlighted the interacting effects of social and structural factors like socioeconomic status, racial or ethnic identity, lack of referral, and inadequate insurance on rehabilitation participation and outcomes. However, existing literature on gender and rehabilitation has focused disproportionately on a few types of rehabilitation among adults in high-income country contexts and does not correspond with global geographic or condition-based rehabilitation needs. Furthermore, no articles were determined to have provided an apt depiction of sex and gender. CONCLUSION: This review highlights a gap in global knowledge about the relationship between sex and/or gender and rehabilitation participation and outcomes within health systems. Future research should rely on social science and intersectional approaches to elucidate how gender and other social norms, roles, and structures influence a gender disparity in rehabilitation participation and outcomes. Health systems should prioritize person-centered, gender-responsive care, which involves delivering services that are responsive to the complex social norms, roles, and structures that intersect to shape gender inequitable rehabilitation participation and outcomes in diverse contexts.

The relationship between inequitable gender norms and provider attitudes and quality of care in maternal health services in Rwanda: a mixed methods study.

BACKGROUND: Rwanda has made great progress in improving reproductive, maternal, and newborn health (RMNH) care; however, barriers to ensuring timely and full RMNH service utilization persist, including women's limited decision-making power and poor-quality care. This study sought to better understand whether and how gender and power dynamics between providers and clients affect their perceptions and experiences of quality care during antenatal care, labor and childbirth. METHODS: This mixed methods study included a self-administered survey with 151 RMNH providers with questions on attitudes about gender roles, RMNH care, provider-client relations, labor and childbirth, which took place between January to February 2018. Two separate factor analyses were conducted on provider responses to create a Gender Attitudes Scale and an RMNH Quality of Care Scale. Three focus group discussions (FGDs) conducted in February 2019 with RMNH providers, female and male clients, explored attitudes about gender norms, provision and quality of RMNH care, provider-client interactions and power dynamics, and men's involvement. Data were analyzed thematically. RESULTS: Inequitable gender norms and attitudes - among both RMNH care providers and clients - impact the quality of RMNH care. The qualitative results illustrate how gender norms and attitudes influence the provision of care and provider-client interactions, in addition to the impact of men's involvement on the quality of care. Complementing this finding, the survey found a relationship between health providers' gender attitudes and their attitudes towards quality RMNH care: gender equitable attitudes were associated with greater support for respectful, quality RMNH care. CONCLUSIONS: Our findings suggest that gender attitudes and power dynamics between providers and their clients, and between female clients and their partners, can negatively impact the utilization and provision of quality RMNH care. There is a need for capacity building efforts to challenge health providers' inequitable gender attitudes and practices and equip them to be aware of gender and power dynamics between themselves and their clients. These efforts can be made alongside community interventions to transform harmful gender norms, including those that increase women's agency and autonomy over their bodies and their health care, promote uptake of health services, and improve couple power dynamics.

The role of gender power relations on women's health outcomes: evidence from a maternal health coverage survey in Simiyu region, Tanzania.

BACKGROUND: Gender is a crucial consideration of human rights that impacts many priority maternal health outcomes. However, gender is often only reported in relation to sex-disaggregated data in health coverage surveys. Few coverage surveys to date have integrated a more expansive set of gender-related questions and indicators, especially in low- to middle-income countries that have high levels of reported gender inequality. Using various gender-sensitive indicators, we investigated the role of gender power relations within households on women's health outcomes in Simiyu region, Tanzania. METHODS: We assessed 34 questions around gender dynamics reported by men and women against 18 women's health outcomes. We created directed acyclic graphs (DAGs) to theorize the relationship between indicators, outcomes, and sociodemographic covariates. We grouped gender variables into four categories using an established gender framework: (1) women's decision-making, (2) household labor-sharing, (3) women's resource access, and (4) norms/beliefs. Gender indicators that were most proximate to the health outcomes in the DAG were tested using multivariate logistic regression, adjusting for sociodemographic factors. RESULTS: The overall percent agreement of gender-related indicators within couples was 68.6%. The lowest couple concordance was a woman's autonomy to decide to see family/friends without permission from her husband/partner (40.1%). A number of relationships between gender-related indicators and health outcomes emerged: questions from the decision-making domain were found to play a large role in women's health outcomes, and condoms and contraceptive outcomes had the most robust relationship with gender indicators. Women who reported being able to make their own health decisions were 1.57 times (95% CI: 1.12, 2.20) more likely to use condoms. Women who reported that they decide how many children they had also reported high contraception use (OR: 1.79, 95% CI: 1.34, 2.39). Seeking care at the health facility was also associated with women's autonomy for making major household purchases (OR: 1.35, 95% CI: 1.13, 1.62). CONCLUSIONS: The association between decision-making and other gender domains with women's health outcomes highlights the need for heightened attention to gender dimensions of intervention coverage in maternal health. Future studies should integrate and analyze gender-sensitive questions within coverage surveys.

Disrupting gender norms in health systems: making the case for change.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Maternal health challenges experienced by adolescents; could community score cards address them? A case study of Kibuku District- Uganda.

INTRODUCTION: Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges. METHODS: This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach. FINDINGS: This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges. CONCLUSION: The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

COVID-19 and the Gendered Use of Emojis on Twitter: Infodemiology Study.

BACKGROUND: The online discussion around the COVID-19 pandemic is multifaceted, and it is important to examine the different ways by which online users express themselves. Since emojis are used as effective vehicles to convey ideas and sentiments, they can offer important insight into the public's gendered discourses about the pandemic. OBJECTIVE: This study aims at exploring how people of different genders (eg, men, women, and sex and gender minorities) are discussed in relation to COVID-19 through the study of Twitter emojis. METHODS: We collected over 50 million tweets referencing the hashtags #Covid-19 and #Covid19 for a period of more than 2 months in early 2020. Using a mixed method, we extracted three data sets containing tweets that reference men, women, and sexual and gender minorities, and we then analyzed emoji use along each gender category. We identified five major themes in our analysis including morbidity fears, health concerns, employment and financial issues, praise for frontline workers, and unique gendered emoji use. The top 600 emojis were manually classified based on their sentiment, indicating how positive, negative, or neutral each emoji is and studying their use frequencies. RESULTS: The findings indicate that the majority of emojis are overwhelmingly positive in nature along the different genders, but sexual and gender minorities, and to a lesser extent women, are discussed more negatively than men. There were also many differences alongside discourses of men, women, and gender minorities when certain topics were discussed, such as death, financial and employment matters, gratitude, and health care, and several unique gendered emojis were used to express specific issues like community support. CONCLUSIONS: Emoji research can shed light on the gendered impacts of COVID-19, offering researchers an important source of information on health crises as they happen in real time.

Mainstreaming gender into global health programming to improve women's health.

In this paper, a case is made for mainstreaming gender into global women's health programming and policies. The potential implications of conflating "gender" with "women'" in the design and evaluation of women's health programming are first considered. HIV/AIDS case studies are then used to depict examples of (a) where gender has been well integrated and (b) where policies fall short of gender mainstreaming. Finally, practical approaches to mainstream gender in a meaningful way into the design and evaluation of women's health programming and policies are provided for practitioners and researchers.

Maternal and newborn health needs for women with walking disabilities; "the twists and turns": a case study in Kibuku District Uganda.

BACKGROUND: In Uganda 13% of persons have at least one form of disability. The United Nations' Convention on the Rights of Persons with Disabilities guarantees persons with disabilities the same level of right to access quality and affordable healthcare as persons without disability. Understanding the needs of women with walking disabilities is key in formulating flexible, acceptable and responsive health systems to their needs and hence to improve their access to care. This study therefore explores the maternal and newborn health (MNH)-related needs of women with walking disabilities in Kibuku District Uganda. METHODS: We carried out a qualitative study in September 2017 in three sub-counties of Kibuku district. Four In-depth Interviews (IDIs) among purposively selected women who had walking disabilities and who had given birth within two years from the study date were conducted. Trained research assistants used a pretested IDI guide translated into the local language to collect data. All IDIs were audio recorded and transcribed verbatim before analysis. The thematic areas explored during analysis included psychosocial, mobility, health facility and personal needs of women with walking disabilities. Data was analyzed manually using framework analysis. RESULTS: We found that women with walking disabilities had psychosocial, mobility, special services and personal needs. Psychosocial needs included; partners', communities', families' and health workers' acceptance. Mobility needs were associated with transport unsuitability, difficulty in finding transport and high cost of transport. Health facility needs included; infrastructure, and responsive health services needs while personal MNH needs were; personal protective wear, basic needs and birth preparedness items. CONCLUSIONS: Women with walking disabilities have needs addressable by their communities and the health system. Communities, and health workers need to be sensitized on these needs and policies to meet and implement health system-related needs of women with disability.

Intersectionality and global health leadership: parity is not enough.

There has been a welcome emphasis on gender issues in global health in recent years in the discourse around human resources for health. Although it is estimated that up to 75% of health workers are female (World Health Organization, Global strategy on human resources for health: Workforce 2030, 2016), this gender ratio is not reflected in the top levels of leadership in international or national health systems and global health organizations (Global Health 50/50, The Global Health 50/50 report: how gender responsive are the world's leading global health organizations, 2018; Clark, Lancet, 391:918-20, 2018). This imbalance has led to a deeper exploration of the role of women in leadership and the barriers they face through initiatives such as the WHO Global Strategy on Human Resources for Health: Workforce 2030, the UN High Level Commission on Health Employment and Economic Growth, the Global Health 50/50 Reports, Women in Global Health, and #LancetWomen. These movements focus on advocating for increasing women's participation in leadership. While efforts to reduce gender imbalance in global health leadership are critical and gaining momentum, it is imperative that we look beyond parity and recognize that women are a heterogeneous group and that the privileges and disadvantages that hinder and enable women's career progression cannot be reduced to a shared universal experience, explained only by gender. Hence, we must take into account the ways in which gender intersects with other social identities and stratifiers to create unique experiences of marginalization and disadvantage.

Why are fewer women rising to the top? A life history gender analysis of Cambodia's health workforce.

BACKGROUND: An adequate and qualified health workforce is critical for achieving Universal Health Coverage (UHC) and responding to the Sustainable Development Goals (SDGs). Frontline health workers who are mainly women, play important roles in responses to crisis. Despite women making up the vast majority of the health workforce, men occupy the majority of leadership positions. This study aims to understand the career progression of female health workers by exploring how gender norms influence women's upward career trajectories. METHODS: A qualitative methodology deployed a life history approach was used to explore the perspectives and experiences of health workers in Battambang province, Cambodia. Twenty male and female health managers were purposively selected based five criteria: age 40 and above, starting their career during 1980s or 1990s, clinical skills, management roles and evidence of career progression. Themes and sub-themes were developed based on available data and informed by Tlaiss's (2013) social theory framework in order to understand how gender norms, roles and relations shape the career of women in the health industry. RESULTS: The findings from life histories show that gender norms shape men's and women's career progression at different levels of society. At the macro level, social, cultural, political, and gender norms are favorably changing by allowing more women to enter medical education; however, leadership is bias towards men. At the meso organziational level, empowerment of women in the health sector has increased with the support of gender working groups and women's associations. At the micro individual level, female facility managers identified capacity and qualifications as important factors in helping women to obtain leadership positions. CONCLUSION: While Cambodia has made progress, it still has far to go to achieve equality in leadership. Promoting gender equity in leadership within the health workforce requires a long vision and commitment along with collaboration among different stakeholders and across social structures. If more women are not able to obtain leadership roles, the goals of having an equitable health system, promoting UHC, and responding to the SDGs milestones by leaving no one behind will remain unattainable objectives.

How do gender and disability influence the ability of the poor to benefit from pro-poor health financing policies in Kenya? An intersectional analysis.

BACKGROUND: Health inequity has mainly been linked to differences in economic status, with the poor facing greater challenges accessing healthcare than the less poor. To extend financial coverage to the poor and vulnerable, Kenya has therefore implemented several pro-poor health policy reforms. However, other social determinants of health such as gender and disability also influence health status and access to care. This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them. METHODS: We applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. We collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. We analyzed data using a thematic approach drawing from the study's conceptual framework. RESULTS: Women with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services. CONCLUSIONS: Intersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.

Gendered health systems: evidence from low- and middle-income countries.

BACKGROUND: Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. METHODS: The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. RESULTS: Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. CONCLUSION: The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.