Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda

The study, conducted in 2015 and 2016, was qualitative and used photovoice as a community-based participatory research method. The study employed ten CHWs (five males and five females) who took photographs concerning gender and ethics issues related to their work for a period of 5 months. This paper specifically presents the findings regarding gender from the research. During the period of photography, five monthly meetings were held among the participants and researchers to discuss the photos, and take note of emerging issues.

The study was conducted in Bulwanyi parish, Ssisa sub-county, Wakiso district, located in the central region of Uganda. Bulwanyi parish was purposively selected for involvement in this study due to the earlier work done by the researchers in the area [19]. Ssisa sub-county is predominantly rural with a population of 94 238 (45 272 males and 47 966 females), 23 992 households, and an average household size of 3.8 [20]. The main economic activities carried out in the area are agriculture and small-scale trade. A section of the population is also involved in brick making and stone quarrying. As is the case in most parts of the country, CHWs exist in this area and are the first contact of the community with the health system.

The ten CHWs who participated in the research were selected by local leaders in the area who included village chairpersons and mobilizers. These local leaders did the selection because they were familiar with the CHWs that existed in the community. The criteria used in the selection of CHWs were provided by the researchers which included having an equal gender representation (five males and five females) and diversity in terms of socio-economic status and village of origin. The CHWs were selected from various villages so as to expand the range of experiences during photography and subsequent discussions. The selected CHWs were aged 25 to 55 years, and among them, nine had attended secondary education while eight were married with an average of six children (Table 1). All the CHWs had been involved in this role of supporting their communities for over 3 years.

After selecting the participants, a training workshop was conducted to establish the CHWs’ understanding of gender and ethics in their own perspective and to orient them on the research on gender and ethics using photovoice. The workshop, which was conducted at a field office of Makerere University School of Public Health in Ssisa sub-county, was facilitated by the researchers and lasted 1 day. The topics covered during the training were photovoice methodology, research principles such as voluntary participation and informed consent, CHWs’ perspectives on gender including differential roles of male and female CHWs, use and care for cameras, and ethical issues in photovoice research. During the training, every CHW was provided with a digital camera for use during the research. In addition, CHWs were provided with a notebook to take note of any issues related to the research that may not be captured on camera for example when consent to take photos is not provided by a community member.

At the end of the training workshop, CHWs were assigned to take photographs related to gender and ethics during the course of their work for a period of 5 months. The CHWs were not restricted on the number of photos they could take as long as they related to the study themes of gender and ethics. A follow-up meeting of CHWs by the research team 2 weeks after commencement of photography was conducted so as to address the challenges faced during taking photographs such as those related to charging the cameras. During the entire period of photography, CHWs were supervised by the researchers to ensure the assignment was carried out as planned, and to address any emerging challenges. The supervision involved regular visits to the CHWs as well as providing support needed as part of the research.

All photos taken by CHWs for purposes of the study were presented and discussed in five monthly meetings. In addition to CHWs, the meetings which lasted between 2 and 3 h were facilitated by two researchers. One researcher facilitated the meetings while the other provided support including note taking and logistical assistance such as transferring photos to a laptop. The meetings for the first 3 months were conducted separately for males and females while those for the last 2 months were held jointly. The separation of males and females was done to allow free discussion of gender-related issues. The last two meetings were combined so as to explore emerging issues that required the presence of CHWs of both genders. During these meetings, each CHW talked about the photographs they took and how they related to the study topics. The photographs, which were transferred to the laptop before commencement of the meeting, were projected to a screen to facilitate the discussion. After each photo had been presented, other CHWs had the opportunity to talk about it either asking a question or discussing it in another way they felt related to the study themes. After exhausting all photos a CHW had taken in the previous month, they were given the opportunity to present any issues that they had captured in their notebook. Any issues that emerged from the previous monthly meeting were presented after all photographs had been discussed.

All proceedings of the meetings were audio recorded in the local language (Luganda) and later transcribed verbatim by one of the researchers. After verification of the transcripts, they were translated to English for analysis. The translated transcripts were read by another member of the research team to ensure that the activity had been done adequately. The transcripts were imported into Atlas ti version 6.0.15 and read several times to identify initial codes based on repeated and emerging issues. Data were analysed using conventional content analysis [21] where codes and categories arising from the data were used. During the analysis, researchers immersed themselves in the data without any preconceived categories allowing new insights to emerge. Related codes identified from the data were grouped together to form categories and later merged into themes. All themes are described in the results and illustrated with selected quotes and photographs from CHWs.

The study got approval from Makerere University School of Public Health Higher Degrees, Research, and Ethics Committee, and was registered at the Uganda National Council for Science and Technology. All CHWs provided voluntary written informed consent before participation in the study after clearly explaining to them the nature of the research including potential risks and benefits. It was emphasized to the CHWs during the training that they needed to obtain verbal consent from community members before they took their photographs. No personal information about the CHWs was collected during course of the study, and all research data were handled confidentially. No photograph taken as part of the study was to be used for any form of dissemination (including this publication) without the written consent of both the photographer and any individual(s) appearing in it.

From the photos and resulting discussions, it was noted that male CHWs were consulted more by men for their own health concerns. These concerns included personal illness, condom use, circumcision, and other reproductive health issues. They also consulted them about other issues that were not directly related to reproductive health such as alcoholism. Men’s preference for male CHWs is captured in the quotation below.

Men easily explain their private sexuality issues to us [male CHWs] for example when they contract sexually transmitted infections, they can come and describe to us the symptoms they are experiencing and we advise them accordingly. In addition, they also find it easier to request for condoms from male CHWs which is sometimes harder for them to do among female CHWs. (Photographer 1, male, age 55)

When men in the community fall sick, they were quick to contact male CHWs. This was established to be partly because they would not want to reveal personal information to female CHWs including knowing about their health condition. Indeed, in scenarios where men had conditions which required physical body examination, male CHWs were more utilized (Fig. 1).

This man was sick and in his bedroom. He invited me to his home to attend to him. Being male, it was easier for me to go to his bedroom and examine him from there which may not have been the case with a female CHW. He easily removed his shirt and explained to me his illness, and I later referred him to the health facility. (Photographer 5, male, age 40)

In some cases, women in the community who had family problems contacted male CHWs to counsel their husbands. These family issues included failure to provide adequate support to their families, refusal to escort their wives to the hospital, and denial of using contraception which highlights the potentially transformatory role male CHWs can play in changing gender inequalities as illustrated below.

This lady was pregnant and she requested me to speak to the man responsible for her pregnancy to tell him the importance of seeking antenatal care as she had wanted to start going to the health facility but had not received support from him. She told me that she had tried to speak to him herself but the man refused to listen, and that since I am a male CHW, the man would easily heed my advice. I then met the man and told him to go to the health facility with his wife which he accepted. I later met the lady and she was so happy. She told me that she had gone with him to the health centre and they were attended to very fast therefore she was very thankful for the role I played. (Photographer 5, male, age 40)

CHW discussions spurred by the photographs also highlighted that when women had reproductive health issues such as concerning family planning, female CHWs were preferred and easily accepted. Female CHWs were also often called upon to counsel teenagers and married couples in the community, at times resorting to gender-conforming coping strategies, as shown below.

There is a woman who had quarreled with the husband who later beat her so much yet she was 6 months pregnant. She then came and told me about it, and asked for advice because she wanted to leave the man. As a female CHW, who is married, and a parent, it was easy for her to approach me, and I told her to calm down and talk to the husband, because she wanted to leave the children yet it would be bad to leave them there without a mother. (Photographer 2, female, age 30)

From the study discussions, female CHWs were more knowledgeable on maternal issues including pregnancy danger signs and antenatal care. They had a lot of experience in dealing with most of the maternal health problems which they often shared with women. CHWs revealed that women in the community confide a lot in female CHWs especially when they are faced with pregnancy-related problems. Female CHWs also usually paid visits to expectant women and advised them accordingly.

It was noted that although both male and female CHWs treat childhood illnesses, females were more involved in this activity, and other related roles such as immunization. It emerged from the discussions and photos that female CHWs spent more time treating children and exhibited a lot of passion while handling them (Fig. 2). Experiences of female CHWs looking after their own children contributed to their comfort in supporting children and the confidence community members had in them. Indeed, community members were many times keen to seek services from female CHWs whenever their children were sick or in need of a public health intervention as illustrated below.

In that photo, that woman had refused to take the child for immunisation. I approached her and told her to take the child to be immunised as it was being carried out by qualified health professionals. I explained to her well and she agreed to take the child for immunisation. She easily accepted what I had told her since I am a mother with children just like her. (Photographer 2, female, age 30)

It was revealed from the photos and discussions that male CHWs were faster in responding to health emergencies in terms of taking the sick, especially children and pregnant women, to health facilities than their female counterparts. Ease of male CHWs responding to emergencies was because they had more access to means of transport such as bicycles and motorcycles (Fig. 3). This was not only in terms of possession but also the social norms that constrain women’s ability to ride bicycles or motorcycles.

Men find it easier than women to rush sick children to the hospital in case they are referred. In that photo, the child was sick and I had referred him to a health facility. As a male CHW who owns a motorcycle, I managed to quickly take the child to the health facility. (Photographer 9, male, age 25)

As a male CHW, I can use any means of transport available like a bicycle or motorcycle or car to transport a patient to a health facility in case of any problem in the community. For a female CHW, it might be hard to use certain means of transport like bicycles to transport a patient to the hospital. (Photographer 10, male, age 31)

Regarding mobilising communities for public health campaigns such as immunization or monitoring field activities across villages, CHWs agreed that male CHWs covered larger areas compared to females. Male CHWs’ advantages to use transport also enabled them to take up supervisory roles within CHWs’ work which include data collection and compilation among fellow CHWs.

“When we are doing our roles in the community like visiting homes, men travel longer distances since we are more energetic than women. A man can move to a larger area and visit many homes if the day is for conducting home visits compared to a woman. (Photographer 10, male, age 31)

The photos and discussions indicate that male CHWs were more involved in manual activities such as renovation of latrines, cleaning and desilting wells (Fig. 4), and constructing barriers to prevent animals from accessing water sources. This was because of the gendered division of labour in communities in addition to social norms that restrict women from engaging in physical interventions such as cleaning wells. Instead, women were engaged in other activities like mobilising the community, digging the path to the sources, and preparing food for the men who were working.

I was trying to help a certain woman since her latrine wall was cracked and the bricks had fallen off on one side so I was putting them back. This was necessary as she was being seen by passersby whenever she was using the latrine. However, if I was a female CHW, I may not have managed to put back those bricks as it involved a lot of energy. (Photographer 9, male, age 25)

From the study discussions, it was established that female CHWs spent more time in the communities due to the gendered division of paid labour. Women spend most of their time at home doing unremunerated domestic and care work such as cooking, house cleaning, washing clothes, and looking after children. The few female CHWs who carried out income-generating activities were either involved in agriculture in their home gardens or small-scale retail business within their homes. Therefore, anytime there was a problem or a health visitor in the community (Fig. 5), female CHWs were usually locally available to attend to them, in contrast to male CHWs who often went for income-generating work away from their homes and communities.

I was treating a patient very early in the morning. It is sometimes hard to find a male community health worker at home at such a time. Many times, they would have already gone for work but me, I was still around. (Photographer 8, female, age 28)

Since female CHWs were based in their communities, they were also able to identify and discuss with other community members issues related to water, sanitation, and hygiene. These include poorly drained wells (Fig. 6), people washing near water sources, unscreened latrines, and latrines without superstructure.

I found these children washing clothes near the water source as I had gone to collect water. I asked them why they were doing so and they said that it is very hard for them to fetch water to take home for washing clothes. I asked who had sent them and they told me that it was their parents. I took the responsibility and went to speak to the parents, and explained to them the implications this can have, and we agreed that this would not happen again. It is usually females who go to wells hence it is easier for them to find such concerns in the community. (Photographer 3, female, age 49)