The study results highlighted a nexus of gender stereotypes and status beliefs related to men and women, perceptions of their natural roles, and related social expectations and sanctions that kept women in voluntary HIV/AIDS caregiving and kept men out of it. The findings support the notion that HIV/AIDS caregiving is a gender-segregated job in which unpaid "women's work" in family structures is reproduced as unpaid care for others in the community (e.g., "Ever since we grew up, we know that sick people have been cared for by women in the families, they are doing it with all their strength"). The findings also support the contention that
gender essentialism and
male primacy figured in men's striking underrepresentation in HIV/AIDS caregiving activities. Expressions of gender essentialism included "Men are people who are angry quickly and they get fed-up" and "Women in nature are nurturing." There was evidence of what has been referred to as the "discourse of deficient and non-caring men" [
37], illustrated by the women's focus group statement that "men are not trustworthy people." At the same time, there was evidence of male primacy, including men's objection to volunteer work ("The job without incentives is a mockery"), the emphasis on the superiority of men's first aid skills ("I think men are much better. Women know nothing about 'safety' so we are above them") and the general expectation that men cannot be expected to work for free (i.e., volunteer work), even when unemployed.
Can "women's work" be desegregated?
A question must be posed here: What is required to mitigate the gender essentialism and male primacy that sustain occupational segregation in caregiving labour and to develop robust formal and informal workforces capable of providing critical and chronic HIV/AIDS care? Opinion seems to range from pessimism regarding the extent to which women's jobs can be desegregated, to cautious optimism. These perspectives should be kept in mind in HIV/AIDS and health workforce policy, program design, planning and implementation, and research.
"Pessimists" contend that gender stereotypes, status assumptions, and cognitive biases play such a powerful role in the organization of social relations, and that gender is such a fundamental organizing principle of status distribution and inequality in society, that attempts to meaningfully desegregate female-identified health jobs will fail, since men lose respect, status, discretionary time and money for doing "women's work" [
38]. The devaluation of women, and by extension, the activities and characteristics associated with women, is deeply inscribed in the cultural norms within a gender hierarchy [
39]. There will be "greater resistance to change that involves men taking on traditionally female activities than to change that involves women taking on traditionally male activities" because taking on "women's jobs" typically represents significant losses whereas assuming male activities usually represents an improvement of status for women [
40]. A related argument is that both men and women have deep interests in maintaining a clear and reasonably stable framework of gender beliefs and stereotypes that define and differentiate
who men and women are. In this line of reasoning, gender is so deeply embedded in social relations and institutions that few people are likely to tolerate serious disruptions to the basic system of sex labeling that underpins any gender system [
41]. The notion that both men and women have an interest in maintaining a clear framework of gender beliefs and stereotypes appears to be supported by some of the present study results as, for example, in the way public ridicule of men functioned to maintain gender boundaries in caregiving.
However, there is another body of opinion regarding the tractability of gender essentialism, one that might be called cautiously optimistic, which points to the need for strategies to delegitimize the stereotypes that underpin occupational segregation in very specific ways. This body of opinion is represented by what has been referred to earlier as "early stage work" (See the "Background" section). The Lesotho study findings lent themselves to cautious optimism both in female respondents' desire for more solidarity and in the male study respondents' self-reports that they were already assuming female-identified tasks, and that they believed themselves capable of performing or learning CHBC tasks, given training, public legitimacy, supervision and monetary incentives. The study demonstrated that gender segregation was linked to social consciousness (i.e., beliefs), which is amenable to change. Men's psychological flexibility was evidenced by the focus group observation that "In our tradition, there are things which are the responsibility of women, and caring for sick people is one such thing. It is obvious, though, that because of changing times and new diseases, both men and women should unite against HIV/AIDS." The study recommendations therefore included the interventions to act on this flexibility, address resistance to desegregation and delegitimize gender essentialist and male primacy stereotypes. For example:
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Change perceptions of the value (currently low-status) of caring labor and home-based care through a "public relations" campaign that communicates the benefits of HIV/AIDS (and all) caregiving to society or offer public honours and appreciation awards to long-time CHBC providers, with acknowledgment coming from high levels, to create a recognition opportunity that others would strive for.
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Recruit men for caregiving through traditional leaders' courts and means' associations;
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Make HIV/AIDS and domestic caregiving more attractive to men and boys starting with early childhood education and public campaigns that communicate the value of HIV/AIDS (and all) caregiving to society;
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Design training programs that are gender-integrated and that include men's and women's critical thinking about gender roles, stereotypes, and the equal sharing of responsibilities; Introduce male role models already engaged in CHBC. Include mentoring and peer support interventions;
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Review CHBC and primary and secondary school curricula to eliminate gender stereotyping; and
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Offer men and women the same financial and non financial incentives.
Training would presumably render men more socially acceptable as caregivers and bring about changes in men's and women's beliefs and practices. Offering men and financial incentives would presumably render HIV/AIDS caregiving as "breadwinning" for men, while at the same time place value on the "women's work" already done by female caregivers.
Strategies to increase gender equity in HIV/AIDS programs
There are four roughly discernable strategies that go to the heart of gender inequality and that are useful to consider for increasing gender equity in HIV/AIDS service delivery programs. They all assume the tractability of gender essentialism but differ in the comprehensiveness of approach, focus of interventions and likely effectiveness. Interventions may be included in more than one category. These strategies are summarized in Table
3.
Table 3
Strategies to increase gender equity in HIV/AIDS service delivery programs
Establish a new social consensus that directly addresses the ideology of difference inherent in gender essentialism, and the acceptance of the gender hierarchies inherent in male primacy Target gender power relations and the way in which culture and stereotypes influence unequal sharing of responsibilities On-going public dialogue about and in the sources of gender differences Public policy that stresses gender equality and the sharing of domestic and caregiving responsibility Zero tolerance for the use of stereotypical images of men and women | Promote early, deliberate, and sustained public education and social support regarding the value of caregiving and gender equality Train men and boys to provide care and support Use male role models and recognize men's positive contributions in HIV/AIDS caregiving Focus on engaging men and boys in existing AIDS plans and policies, especially national AIDS plans Improve health systems' capacity to reach men with HIV prevention and treatment services so as to reduce the burden of care Take work with men to scale by integrating a focus on men and gender equality into national programmes and policies that can reach large numbers of men and boys. | Mobilize women's groups and other activists Empower women to effect personal, political and social change Develop critical consciousness to take action against the oppressive elements in one's life, claiming rights, Challenge essentialist notions that unequal gender division of rights and duties is either natural (biological), or God- given or too difficult to change Target gender discrimination patriarchal control of decision-making positions, and patriarchal belief systems Increase access to and control of productive resources Offer comprehensive social protections for women | Involve men in non-personal care tasks or in currently male-identified tasks such as heavy lifting Men and women make small changes in how they as individuals participate in social systems to affect cultural systems in the longer term Recruit men as HIV caregivers |
The first strategy is the most comprehensive. It would require establishing a new social consensus that directly challenged the ideology of difference inherent in gender essentialism, and the gender hierarchies inherent in male primacy. This strategy would involve society-wide agreement that socially-constructed gender differences are counterproductive and that it is especially desirable to eliminate essentialist beliefs [
42]. This strategy would also require a "far-reaching set of reforms and innovative measures...to address the inequalities that pervade the distribution of responsibilities" [
43]. The strategy calls for immediate, concerted and direct efforts to change the social systems that produce these inequalities, since "the problem isn't how we train children to fit into the world; the problem is the world into which we fit them into" [
44]. An example might include bringing to scale a mass mobilization technique such as Stepping Stones, which has been widely used in sub-Saharan Africa to transform social norms and relationships around HIV/AIDS, reproductive health, gender-based violence and alcohol abuse. Through gender and age group dialogues, the Stepping Stones approach enables "the possibility of reconciliation between those in society wanting change and those resisting change, so that women and men are engaged together in the process of transformation of gender roles and relations" [
45]. While a strategy that aims for changing social consensus might be the most effective in achieving long-term gender equity in the region, arriving at such a consensus would require considerable resources, political and social will and great acumen to counter likely strong resistance.
Less daunting is a second, men's participation strategy, which involves early, deliberate, and sustained public education and social support regarding the value of caregiving and gender equality, use of male role models and the recognition of men's contributions as a way of shifting social norms and prompting other men to do the same, men-inclusive policies and political and civil society activism to change current attitudes and practice in favor of men's and women's equal sharing of the burden of HIV/AIDS care. This strategy draws on recent, early stage work promoting male involvement in parenting, reproductive health and family planning. It is reasonable to suppose that this early stage work may have some impact on men's participation in HIV/AIDS caregiving, but less reasonable to suppose that gender equity will increase in meaningful, sustainable ways if programmes do not directly address the gender essentialist and male primacy ideologies that underpin the gender segregation in HIV/AIDS caregiving. This strategy also seems limited in terms of its power to change gender power relations and the social construction of women's gender identity, an aspect that needs to be considered given the positive social value the Basotho women and men placed on women's caregiving.
The authors call attention to the need to explore women's internalization of gender essentialist and male primacy notions, and their experiences of caregiving inequalities and attempts to share the burden, points often lost in the discussion of men's participation in caregiving. This suggests a third, women's empowerment strategy that is both promising and problematic, given that "the quadruple burden placed by AIDS care on women - weaker health, social exclusion, lack of education and reduced economic power - makes it more difficult for women to advocate for change and engage in efforts to transform their lives and communities. Women's engagement in advocacy and activism is crucial to achieving gender equality, yet those who are fully occupied caring for relatives who are sick with AIDS are less able to participate in such activism" [
46]. Women's empowerment, however, is central to social equality, peace and development [
47]. Zambian gender activist Sara Longwe has stressed that the "quiet but determined patriarchal opposition to policies of gender equality" (which she sees as political opposition) requires mobilization for women's empowerment to "overcome the many forms of gender discrimination that stand in the way of development" [
48]. Interventions in a women's empowerment strategy should address claims that the "unequal gender division of rights and duties is either natural (biological), or God- given or too difficult to change (claimed to be hopelessly and irretrievably embedded in culture)" [
49]. In a women's empowerment strategy, change efforts would explicitly target the underlying causes of the unequal sharing of responsibilities (for example, gender status beliefs) and the development of women's critical consciousness, the outcome of which would be women's and girls' greater ability to claim their social and labour rights. For example, increasing women's self assertiveness to "challenge the dominance of male interests" that puts women at risk has become an important priority for HIV/AIDS work in the Zambian organization Thandizani, which has successful expanded its home-based care program, increased its referrals to health facilities, and brought about a greater reported sharing of household tasks and family responsibilities between husbands and wives [
50]. Such an empowerment strategy holds promise for long-term change and greater equity, as evidenced by the civil and political rights movements in India, the United States and South Africa.
Recent work in the sociology of gender is suggests an incremental approach which posits that while patriarchal privilege permits men to avoid domestic and caregiving work, it is nevertheless possible for men and women to make small changes in how they as individuals participate in social systems to affect cultural systems in the longer term [
51]. Examples of this incremental strategy might be to involve men in nonpersonal care tasks (such as cooking, obtaining water, or gathering firewood) or in currently male-identified tasks (such as heavy lifting) as initial steps toward a more equal involvement of men and women in all caring tasks. However, this type of incremental action is unlikely to impact the gender segregation of HIV/AIDS caregiving, especially in isolation.
Whatever the strategy or strategies chosen, potential resistance to the desegregation of HIV/AIDS caregiving cannot be ignored. Strategies should target both men and women, at some point and should be as comprehensive as possible. They should challenge gender essentialism, gender status beliefs such as male primacy and the relative power and privilege attached to men and women, starting in childhood. Change strategies should be carefully crafted, implemented, and evaluated using behavioural indicators. Further, change efforts should include government policies and programs that distribute the caregiving burden among families/households, markets, not-for profit and non-profit community organisations and the government [
52].
Finally, central to any and all effort to increase gender equity, HIV/AIDS and human resources policymakers, activists and programmers must recognize the gendered nature of CHBC, the inequalities and inequities in caregiving labour, and the attendant psychological, physical, and economic impact on women. Policymakers and program managers must immediately address women's and girls' short- and long-term disadvantage by providing the current female caregiving workforce with access to social protections (such as income replacement, medical benefits, credit towards a pension); offering training and supplies for caregiving services; and committing political will and resources to redress the lost opportunities for education, career, and income entailed by HIV/AIDS caregiving (e.g., build education credits or career progression into volunteer jobs).