Methodological considerations
With this study, we have set the first attempt to use qualitative methods to explore women’s health seeking behavior in the oPt. In doing so, we have complemented existing literature on the epidemiological profile of the nation [
5,
33], on the functioning of the local health system [
4,
8,
34], and on the very limited evidence on determinants of access to care generated from quantitative studies [
12,
35]. The use of the Anderson model [
13] as the basis for the conceptual framework guiding data collection and analysis made our study potentially replicable in other settings and allowed for a more transparent comparison with findings emerging from other studies. The fact that the first author was herself a Palestinian woman, assisted on the field by another Palestinian (i.e. the second author), greatly facilitated data collection, ensuring that the interviews could be conducted in a culturally sensitive manner. The fact that someone internal to the society (i.e. the first author) and by someone external to the society (i.e. the third author) worked together on the analysis enhanced the triangulation process, often forcing the authors to question the material again in the light of discordant emerging interpretations [
30].
In spite of the relatively small number of women interviewed, we are confident that redundancy and saturation were reached because no new concepts emerged in the coding of the last six to eight interviews. The limited number of villages selected, however, does pose a challenge to the transferability of the results to the wider WB context. The selection of the villages in fact, was also shaped by pragmatic considerations on accessibility because of the political conflict and to the frequent road blockages. While we are confident that we could have not done any better given the circumstances under which the study was conducted, we are aware that women living in very remote areas of the WB might experience more extreme conditions than those shared by women in our study. Thus, our findings should be read as representing a “lower bound estimate” of what the socio-cultural, geographical, and health system factors that shape women’s health care seeking in the oPt.
Policy implications
With our study, we showed that women often resorted to self-treatment, delayed seeking professional care, and under-used educational and preventive health services. In line with Andersen’s model [
13], we revealed that women’s choices regarding health seeking were shaped by a combination of predisposing, enabling, and structural factors and perceived need. In particular, we identified socio-cultural influences as the central element shaping women’s health seeking behavior. Specifically, women’s gendered role within the family and in society as whole, Arab socio-cultural norms, and women’s health beliefs were found to be key in shaping women’s choices regarding their health. Elements related to the organizational structure of the health system, including quality of care, accessibility, and affordability, were also found to affect women’s health seeking. Women barely mentioned the prevailing political conflict as an element shaping their health seeking decisions, although they recognized its influence on impaired mobility and deteriorating living conditions.
This absence of focus on the political conflict in women’s discourse may at first sight appear surprising. The reader, however, must bear in mind that interviews were conducted in an open manner, with no explicit focus on the political conflict with Israel. Respondents could raise the point, if they wished to do so, but were not repeatedly probed to do so. The authors purposely selected this strategy, because they felt that all that is disseminated and therefore known on the oPt revolves around the conflict, with little attention being paid to other dimension of everyday life. Women did not insisted on the role of the conflict in mediating their health seeking decisions in an explicit manner, but rather allowed it to appear in between the lines when recognizing the limitations of their health care system. This is probably an indication that they are accustomed to the situation, potentially having lived their entire life with the conflict in the background, to the extent that they no longer recognize its explicit role in shaping their health seeking decisions. The most likely interpretation is that socio-political unrest molded and continues to mold the features of the health care system, as described in the introduction, but not necessarily people’s everyday decisions on health seeking, at least not on a conscious level.
Women’s evaluation of their health status and their perceived need for care represent the first indication of the socio-cultural influences acting on their health seeking. Women in fact, tended to rate their health status positively and to understate the need for care even in the presence of disease. This tendency, which has been observed before in Arab societies as well as among Arab women living in non-Arab societies [
16,
17], has been attributed to deeply internalized social and cultural norms, which induce women to conform to the expectation to be healthy and not to express publicly any complain on their health. Awareness of such behavior holds important consequences for health care provision. Health care providers should take into consideration women’s tendency to understate their health complaints and work to evaluate women’s objective health needs in relation to women’s subjective perceptions [
36]. Interventions should be designed to help women move beyond cultural expectations by recognizing and expressing health needs more openly.
Similarly to what previously reported by other authors in a variety of other settings [
37‐
40], this internalized expectation to be healthy inevitably limited women’s use of health services, in particular preventive ones, such as cancer screening. Women indicated that their use of health services was further limited by their gendered role within the family and a traditional social structure. Like in many other Arab countries, most rural women in the WB are bound to early marriage, repeated childbearing, and household responsibilities [
5,
41,
42]. Irrespective of socio-economic and educational status, these factors encumbered on women’s time and on their chance to care for their own health needs. Furthermore, in spite of being more aware of their health needs, even educated women could often not act upon them because of the socio-cultural constraints discussed so far.
Hence we postulated that, similarly to what observed in other settings [
39,
40], women’s education on its own is not enough to overcome socio-cultural influences on women’s health seeking behavior. Additional strategies, such as complex national political and economic interventions, ought to be developed to foster women’s empowerment, thus enabling women to overcome socio-cultural barriers in access to care [
43,
44]. The oPt could learn from the experience of other countries where working to enhance women’s economic autonomy and to foster women networks, for instance through the provision of micro-credit programs, resulted in overall empowerment and ultimately in a more informed use of health care services [
45‐
49].
Confirming findings from previous studies conducted among Arab women in other settings [
38,
39,
50], we suggested that women’s use of health services, especially with regard to prevention and care for chronic diseases, was further limited by the deeply rooted belief that health is in the hands of Allah. In line with previous theoretical as well as empirical research [
51,
52], this reinforced the principle that risk perceptions are embedded in cultural, ethical and religious traditions.
In the light of the increasing spread of chronic diseases [
6], such belief represents a major challenge for policy makers and health providers, especially in relation to the provision of preventive care services, including early cancer screening [
53]. Some authors have further postulated that fear to contradict such dominant religious beliefs might also induce Arab women not to utilize preventive care services out of fear of facing stigma in their community [
37,
54]. Involving religious and community leaders to discern health risks from religious beliefs represents an essential gateway to increase women’s awareness and encourage them to use preventive health services, in particular cancer screening [
55].
The influence of culturally rooted health beliefs on women’s health seeking behavior is also reflected in women’s extensive use of herbal remedies as an alternative to professional care. Other authors also reported similar findings in a previous study among female university students in the WB [
56], confirming a pattern which appears to be common both in many other low and middle income countries and among certain ethnic groups in high income countries [
57‐
59]. The co-existence of folk [home], traditional, and modern medicine is actually a well-documented phenomena across the world and does by no means appear surprising [
60]. This utilization pattern, however, raises important questions when considered in relation to the overall affordability of formal health services, including both direct monetary costs and time costs of consuming care. Similarly to what observed in other settings [
58,
61], women’s use of informal care in fact, was not motivated by mere preference, but more importantly by overall considerations on the accessibility of formal health care services. Furthermore, women’s use of informal care, including both over the counter and traditional drugs, raises important concerns on treatment efficacy, potential herb-drug and drug-drug interactions, and the development of resistance [
62‐
66]. Health policy makers should be aware of the complexity of women’s utilization patterns and address the issue with effective health education interventions, aimed at informing, if not reducing, the use of informal care.
Women also cited poor quality of care as the primary reason not to prefer governmental health services above private ones in spite of their lower price. Women’s willingness to pay for better quality at private facilities corroborates existing evidence on the poor quality of health care services at public facilities in the oPt, especially maternal care services [
2,
5,
67,
68] and reflects findings from other settings [
69‐
72]. However, while women in our study were primarily concerned with process indicators of health service delivery, such as waiting times and providers’ attitudes, previous research had focused on the assessment on system inputs, primarily the existence of an insufficient and poorly trained health workforce to meet the countries needs [
73].
Jointly assessing evidence from our study and from previous studies [
74,
75] suggests that investments in quality are likely to result in increased health service utilization and possibly in a shift from private to public providers. Similar to the experience of other middle income countries [
34,
76‐
79], public-private partnerships could also contribute to improve access to quality care. Such partnerships can probably be developed effectively only in a context of improved risk-pooling across the population [
4], expanding current health insurance coverage on all three dimensions [i.e. number of people covered, proportion of costs covered, and number of services covered] indicated in the recent World Health Report [
80]. Women’s use of services upon the payment of fees testifies the existence of a certain ability to pay which could be better capitalized if channeled toward fostering the expansion of insurance coverage.