Background
A majority of Pakistani women is illiterate and dependent on their male guardians (e.g. father, husband, brother, son) for seeking health care or accessing the resources and information needed to maintain their health [
1]. With the exception of a tiny privileged minority, women’s social role is largely restricted to household chores. Therefore, they have limited exposure to or contact with the outside world [
2,
3]. Furthermore, these women cannot take independent and autonomous decisions on issues related to their reproductive and general health [
4]. Additionally, due to the under-developed health care system and insufficient transport and communication facilities, rural women cannot get appropriate antenatal, delivery, or postnatal care services. As a result, there are high rates of maternal mortality and morbidity, especially among women of low socio-economic status [
5]. The results of the Global Burden of Disease study 2010 indicate the relevance of maternal and neonatal disorders in terms of disability-adjusted life years (DALYs) in Pakistan. The DALY is a summary measure of population health, which describes the overall disease burden, expressed as the number of years of life lost due to premature mortality (YLL) and the years of life lived with disability (YLD). In Pakistan, maternal and neonatal disorders accounted for 11.9% of the total age-standardized DALYs. In comparison, DALYs attributable to maternal and neonatal disorders in countries of the developed world accounted for only 2.5% of the total age-standardized DALYs in 2010 [
6]. Being relatively socially powerless, most of these women are vulnerable to various types of abuse and human rights violations, including sexual exploitation, spousal violence, and denial of reproductive freedom [
7].
Given the serious deficit in their literacy and numeracy skills, the possession and independent use of information and communication technology (ICT) equipment (especially mobile phones, computers) are still considered to be a “man’s job” and women are incapable or reluctant to operate such equipment [
8]. A combination of these factors can severely restrict women’s ability to access and use innovative information for the improvement of their health and well-being.
Women, ICTs and empowerment
Recent advancements and popularization of ICTs, especially mobile phones, text messages and emails, have opened up new opportunities to upgrade the level and quality of information for marginalized women [
9]. These technologies are inexpensive, user-friendly, and are also available in remote regions [
10]. Because of technological innovations, ICTs can reach out to poor and socially excluded rural women by crossing the barriers of infrastructural underdevelopment, illiteracy, and the many restrictions and inhibitions imposed by the rigid patriarchal regime [
11].
Nonetheless, the mere provision of ICTs may not be helpful in creating information equality or empowering marginalized women. Research has reported that some developing countries have successfully harnessed ICTs to expedite the process of women’s capacity building [
10,
12‐
14] and their involvement in income-generating activities. Although technology opens up new opportunities, it has limitations: ICTs cannot automatically create information equality or cater to the information needs of socially disadvantaged women. Technology, not being gender neutral, cannot itself guarantee empowerment [
15]; rather, it could further widen the digital divide [
10,
16,
17].
Women’s access to health information
Studies have reported that, under conservative patriarchal regimes, any initiative meant to empower women is received with suspicion and skepticism [
18]. In rural areas of Pakistan, women are usually denied access to information [
10] and the information they do get is scrutinized and controlled by their male guardians. If they get any information at all, it might not be relevant or applicable to their real life because of their multiple dependencies on men. Furthermore, women lack economic resources and social support to try innovative initiatives.
In developing countries, one of the most crucial areas of women’s lives is the availability of relevant and timely information about their health and disease prevention [
19]. In Pakistan, both traditional and modern medical systems coexist [
20] and women receive health-related information from both traditional and modern sources [
21‐
24]. The sources of traditional medical information include family elders, traditional birth attendants (TBAs), spiritual healers, and
hakeems[
21]. The sources of “modern” medical information include officials of the government’s health department, doctors, paramedics, community-based lady health workers (LHWs), TV, radio, advertisements for pharmaceutical products, etc. Since traditional and modern sources of health-related information represent different world-views and bodies of knowledge, sometimes the information provided appears to be contradictory. This adds to confusion among the end-users (women) [
21‐
23]. There seems no effective and viable institutional mechanism to clear the confusion and cater to the women’s health-related information needs [
22].
Rational and aims of research
There are challenges and complications in providing health-related information to Pakistani women. Despite the overflow of information, especially through cable TV channels, Pakistani women are particularly disadvantaged in terms of accessing information that is relevant and applicable to their health-related issues. The problem is further complicated because of women-specific cultural restrictions. For example, women are discouraged from talking openly about their reproductive health issues as these are considered to be “women’s problems”.
Additionally, some women’s health conditions are stigmatized, such as sexually transmitted infections and abortion. Therefore, they are reluctant to talk about these topics. In such a conservative environment, it is not easy to upgrade the level and quality of health-related information for rural women [
25]. Nonetheless, recent advancements in modern information technology have opened up new avenues to reach out to these women by cutting across cultural, structural, patriarchal, and geographical boundaries [
10,
12‐
14]. Particularly, cell phones have increased women’s accessibility and connectivity because of affordability and usability. Providing information using ICTs is mainly used to mobilize the community to solve their own health problems [
22]. However, there is paucity of literature that describes how this approach could be beneficial for rural women within their cultural, structural and economic contexts.
This paper intends to document the experiences gained from the establishment of an Information and Communication Center (ICC) in improving the level of health-related information of rural women in Sialkot, Pakistan. This paper also evaluates the capacity of ICC in improving the level of health-related information by conducting a cross-sectional survey with women who directly or indirectly sought information from the ICC.
Discussion
As in other developing countries, in Pakistan access to information is not evenly distributed, and neither is the capacity to understand and utilize the available information. For instance, some sections of society have disproportionally high access to knowledge and information and also use that information to their socioeconomic advantage [
34,
35]. Conversely, illiterates and the poor, including women, old, and marginalized people have lesser access to information, and as a result they become further isolated and excluded [
10,
19]. Recent research has shown that the digitally driven flow of information, instead of bridging the information gap, is further widening it [
10,
36].
In Pakistan, the importance of information for human development and poverty alleviation is not yet fully recognized. Despite the fact that information is essential for the maintenance of health and well-being, the official Department of Health has made no systematic arrangements to improve the level of health information. Women, irrespective of location, need information on family health, food and nutrition, family planning, and child education as well as opportunities to become involved in socio-economic growth [
23], but a majority of rural Pakistani women are deprived of access to knowledge and information [
10,
23,
37].
The information deficit tends to cause countless and lifelong deprivations such as poor health, the inability to earn independently or protect their basic health rights, and a lack of reproductive autonomy. In essence, women who are deprived of knowledge and information cannot help themselves and remain trapped in a vicious cycle of poverty [
38]. This could be one reason why Pakistan is ranked 134th out of 135 countries in terms of the gender gap. This means that Pakistani women are considerably below the global average on four sub-indexes: economic participation, educational attainment, health and survival, and political empowerment [
39].
For the provision of this information, there is a need for the democratization of knowledge and an inclusive approach to enhance access to information. But information systems do not operate in a vacuum; the provision of information entails some sort of social change and may upset the existing political order and gender relations. With our experience of the ICC, we noted that provision of information to women was a sensitive and challenging endeavor, particularly in rural areas. The local culture was very cautious and skeptical about any possible change in the role and status of women. In a strict patriarchal regime such as Pakistan, women are only allowed to access “culturally correct and dramatically useful” information.
The experience of the ICC showed that health-related information was abundant and easily available. But the real problem was the absence of a cultural mechanism that made sense of this information for common people, especially for rural women. For this, a culturally relevant information processing system needs to be developed. A system that connects people to each other despite barriers of time, distance, and literacy is in high demand among poor rural communities [
38]. Such a system can only be developed with the active participation and engagement of the end-users, the village women.
Despite various limitations, the greatest success of the ICC was to provide an opportunity for ordinary poor women to become engaged in the process of discourse and dialogue about health-related information on their doorstep. The encouraging aspect is that most of the local women, illiterates included, were fully aware of the importance of information and became proactively involved in the activities of the ICC.
The results of the evaluation of the functioning of the ICC showed that the women who had direct or indirect contact with it had better levels of information than the no contact group. This indicates some success in improving the quality and quantity of health-related information for women. Nonetheless, it does not necessarily mean that the no contact group lacked information just because of their lack of connection with the ICC. There is a possibility that these women might belong to families that place harsh restrictions on their mobility or establishing outside contact with other women.
Strengths of the ICC
The functioning of the ICC brought many unexpected outcomes. Firstly, it exposed the redundancy and irrelevance of information available on the “official websites of government departments”. The participants of the ICC termed standard “one-size-fits-all” information useless for them. The ICC provided the government functionaries a platform where they interacted with “common women” in an informal environment and they knew the worth of their “information products”. In this way, ICC helped the government functionaries to improve their information provision services.
Secondly, the ICC tried to bridge the conceptual and cognitive gap between modern medical system and indigenous medical system. It may be noted that the government health department provides health-related scientific information in the areas of reproductive health, sanitation, and prevention of epidemics. But in villages, where the literacy level is quite low, women usually believe in the indigenous medical system, which is different from the modern bio-medical system. Since both systems are grounded on different language, terminology and world-view, the transfer of knowledge/information from one system to another needs a trusted and credible local institution. The ICC successfully performed this function.
Thirdly, the health-related information was just printed or presented and nobody was there to address the questions, concerns, and fears of women about its applicability and relevance to their health needs. It was just one-way flow of information. For instance, in the local culture, there was a tradition to give a bath to an infant immediately after birth. But doctors viewed this as a dangerous practice because the infant is exposed to a sudden change of temperature. Now, just giving the information that “one should not give a bath to infants immediate after delivery” is not enough, unless women are thoroughly educated about the harmful effects of this practice in a culturally understandable way. So, it is not just a question of giving information, there needs to be a comprehensive strategy to change the health-related behavior of women. At ICC, the participants comprehensively and frankly discussed information. Such live and locally understandable debates at the ICC thoroughly addressed the women’s concerns and removed their deep-seated fears about what might happen if they opted to abandon their traditional health beliefs and practices.
Limitations of the functioning of ICC
Despite various strengths of the ICC, there were some structural and procedural limitations of the functioning of ICC. Firstly, there was a serious shortage of health-related information which could be relevant and applicable for the local population. In some situations, women were disappointed when the ICC management was unable to provide them appropriate information. It may be noted that ICC had no mandate to generate health-related technical information which otherwise was not available in lucid local language (e.g., information related to prevention and treatment of reproductive tract infections). Given the paucity of relevant and updated information, sometimes, the ICC management had to refer these women to distant government institutions and the women were reluctant to contact these organizations because of various cultural and infrastructural inhibitions. It was one of the major limitations of the ICC.
Secondly, sometimes, cultural norms of gender segregation undermined the functioning of ICC. For example, many local experts and functionaries of government departments were male. When they visited the ICC to disseminate information, some conservative local leaders raised objections to these “co-gatherings” and considered them contrary to the cultural norms and religious tradition.
Thirdly, frequent breakdown of electricity, disruption in internet connectivity, high temperature in summer season and general feeling of insecurity undermined the smooth functioning of the ICC. For instance, in the absence of electricity (in summer, daily breakdown of electricity was 8–12 hours) it was simply not possible to continue information providing sessions at ICC because of hot and humid weather and stoppage of ICT tools and devices.
Strengths and limitations of the study
The major strength of this study is that the ICC operations were embedded in the real life of the women within their institutional and community contexts. The women’s perspectives on functioning of the ICC were drawn by direct, constant, and engaging interactions in the natural setting. Hence, this pilot study has good prospects of replication in similar settings to improve health information of rural women.
Nonetheless, short duration of the project was its limitation. Additional positive impacts can be assumed by enriching the community health information system for a longer duration. Similarly, the evaluation phase of this study has some limitations. Women in the direct and no contact group greatly differ in respect to their socio-demographic characteristics, so it was difficult to discern accurate results regarding their knowledge about reproductive and general health issues. Additionally, the survey was cross-sectional in nature: hence, we were unable to check that whether the health information imparted through the ICC was followed.
Conclusions
In short, the experience of the ICC deepened our understanding of the health-related information needs of rural women in Pakistan. Based on the experiences gained from the ICC, we suggest that the provision of standard one-way information is not enough. In order to make women capable of utilizing health-related information, Pakistani policy makers, academia, and development experts need to make concerted efforts to create information according to local needs and demands. It is not safe to assume that the technology will automatically empower women and improve their access to health-related information. Technology does help, but society needs to develop a social mechanism whereby women become engaged and involved in information discourse and dialogue at grass-roots level.
There is a paucity of research in Pakistan on the development of health-related information systems which could be useful for local population. For this, the first step is to establish community-based and community-owned information dissemination institutions. The ICC was a step in this direction. It is also important that Pakistani policy makers understand the complexity and multidimensionality of the information needs of various sections of the society and increasing plurality of information provision sources. It is suggested to compare the effectiveness of information received through different sources of information (e.g., ICTs, print media, radio and TV) and to determine the relative impact of different sources of information on behavior-change of people. Future research ought to focus on the main health concerns of rural women, their health information needs, and the barriers to getting health-related information within their cultural and structural limitations.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MZZ conceptualized the study. RZ and MZZ carried out the study and participated in the field research. They also performed the qualitative and statistical analysis. SQ and FF contributed to the interpretation of data. RZ, MZZ, SQ and FF drafted the manuscript and contributed in revising the manuscript. All authors read and approved the final manuscript.