title: The role of social geography on Lady Health Workers' mobility and effectiveness in Pakistan.
abstract: The Pakistan Lady Health Worker (LHW) program provides door-step reproductive health services in a context where patriarchal norms of seclusion constrain women's access to health care facilities. The program has not achieved optimal functioning, particularly in relation to raising levels of contraceptive use. One reason may be that the LHWs face the same mobility constraints that necessitated their appointment. Past research has documented the influence of gendered norms and extended family (biradari) relationships on rural women's mobility patterns. This study explores whether and how these socio-cultural factors also impact LHWs' home-visit rates. A mixed-method study was conducted across 21 villages in one district of Punjab in 2009-2010. Social mapping exercises with 21 LHWs were used to identify and survey 803 women of reproductive age. The survey data and maps were linked to visually delineate the LHWs' visitation patterns. In-depth interviews were conducted with 21 LHWs and 27 community members. Members of a LHW's biradari had two times higher odds of reporting a visit by their LHW and were twice as likely to be satisfied with their supply of contraceptives. Qualitative data showed that LHWs mobility led to a loss of status of women performing this role. Movement into space occupied by unrelated males was particularly shameful. Caste-based village hierarchies further discouraged visits beyond biradari boundaries. In response to these normative proscriptions, LHWs adopted strategies to reduce the amount of home visiting undertaken and to avoid visits to non-biradari homes. The findings suggest that LHW performance is constrained by both gender and biradari/caste-based hierarchies. Further, since LHWs tended to be poor and low caste, and at the same time preferentially visited co-members of their extended family who are likely to share similar socioeconomic circumstances, the program may be differentially providing health care services to poorer households, albeit through an unintended route.
authors.affiliation: School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 11405 - 87, Ave, Edmonton, AB T6G 1C9, Canada. zubia.mumtaz@ualberta.ca
authors.forename: Zubia
authors.initials: Z
authors.lastname: Mumtaz
authors.forename: Sarah
authors.initials: S
authors.lastname: Salway
authors.forename: Candace
authors.initials: C
authors.lastname: Nykiforuk
authors.forename: Afshan
authors.initials: A
authors.lastname: Bhatti
authors.forename: Anushka
authors.initials: A
authors.lastname: Ataullahjan
authors.forename: Bharati
authors.initials: B
authors.lastname: Ayyalasomayajula
mesh_terms: D000293:Adolescent; D000328:Adult; D003150:Community Health Workers; D003270:Contraceptive Agents / Q000600:supply & distribution; D003466:Cultural Characteristics; D005190:Family; D005260:Female; D006302:Health Services Research; D006608:Hierarchy, Social; D006792:House Calls / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D010154:Pakistan; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D015397:Program Evaluation; D036301:Qualitative Research; D034121:Reproductive Health Services / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*; D012959:Socioeconomic Factors; D055815:Young Adult
chemical_list: D003270:Contraceptive Agents
keywords: Caste; Community; Door-step services delivery; Family planning; Gender; Lady Health Workers; Pakistan; Women's mobility