Background
Past studies have shown that gender and health are related in many different ways [
1‐
3]. This is also the case when comparing the health-seeking inclination of men and women. In fact, gender relations, gendered notions in terms of health, cultural notions regarding how male bodies function differently than female bodies and gendered differences in access to health care have all been shown to shape differences in the health-seeking behaviour of men and women in many complex ways [
4]. Moreover, studies from across the globe show that gender differences with regard to health-seeking behaviour are not only influenced by factors such as power relations [
5], structural positions and age hierarchies [
6], culturally-prescribed gender roles [
7] or economic factors apart from cultural context [
8], but also illustrate that the way in which gender and health-seeking are inter-linked is unique for each setting [
9], including slum areas [
10].
Despite the presence of abundant studies on gender differences in health-seeking behaviour, it would be appropriate to explore these relationships in the context of different cultural settings, given the significant relevance of the socio-cultural context underlying varying health-seeking behaviours. By consequence, the present study investigates how health-seeking behaviour is influenced by gender interactions in slum areas. Urban slums in India differ from other communities because of their complex socio-cultural structure, due to cultural heterogeneity and acculturation [
11]. Being migrants, the lifestyle of the people itself changes a lot once they step into the slums, requiring them to make adjustments at every stage and compromise with every situation, resulting into the emergence of an acculturation in perception, attitude and psychological behaviour different from their native place. The impact of religious and cultural plurality compels the people to improvise their values, morals and attitudes. They adopt an attitude that is a mixture of both modernity and traditionalism [
12]. Many of the folk practices characteristic of urban slums is functional in coping with the disoriented and disorganised social conditions of industrialisation and urbanisation. Previous studies have shown that the health of slum populations is much worse than in other urban areas [
13]. Also, the public health impacts of health problems in slum areas are immense. As health and illness are identified, defined and categorised by culture based on people’s socio-cultural contexts and prior experiences, therefore, in order to discern the true nature of health and illness of the slum dwellers there is a need to understand from their perspective the mechanisms through which culture govern the decisions about recognising and evaluations of treatment. The contextual nature of gendered health-seeking practices like approaching other healthcare resources available in a given area also stems out simultaneously [
14]. Understanding gender differences in respect of therapeutic choices in the slum context is crucial to developing appropriate policies to promote and provide suitable treatment sources for women’s and men’s requirements and thereby ensure a better utilisation of health care facilities.
Literature review
Several publications in the area of gender and health have established that gender differences exist with respect to decision-making regarding the appropriate type of treatment. Some studies have found, for example, that women in developing countries utilise formal health care to a lesser extent than men [
15] and instead are more inclined towards traditional healing options [
16]. According to Harrison and colleague [
17], the gender socialisation process, which is in itself shaped by the socio-cultural ethos, also tends to impact health-related notions and habits, including decisions regarding when and where to seek help.
Gender also leads to differences when it comes to symptoms of illness expressed, social support mobilised thereafter and the socio-cultural ethos that tends to impact access to appropriate treatment and care. Studies examining gender differences in the experience and expression of symptoms propose that women not only ask for increased social support compared to men, but also report significantly higher rates of distress [
18,
19]. This may be partly explained by the fact that in certain societies social interactions and the exhibition of communal behaviour are considered as part of the feminine role, while the masculine role involves independency and giving prime focus towards familial responsibilities rather than looking into community needs [
20]. In contrast, Macintyre et al. [
21] consider that men are more willing to report and seek help for common cold complaints than women. They claim that such health-seeking behaviour emerges because illness among men is not easily acknowledged by professionals and that a clinical score based on a highly objective set of criteria, like quantity of nasal secretion, nature of swollen glands and so forth, is required to make their illness eligible for treatment.
Gender relations not only influence decisions regarding the expression of symptoms or distress and treatment, but also tend to create other societal obstacles in accessing health care for women. Vlassof [
22] shows, for instance, that women’s inferior status in family and society restricts their access to health care, decision-making, education and economic resources. As a result, women remain uninformed about health issues, fail to acknowledge illness or depend on older family members or men for receiving health care. This is more visible in countries where such structural constraints do not permit women to pay attention to or to seek health care services for their illnesses [
23].
Finally, gender differences may influence actual access to health care, including treatment. Although accepting sickness and getting treatment are more socially acceptable among women, they cannot easily avail themselves of treatment for an illness that is equated with social consequences. A study [
24] involving Caucasian men and women shows that women seeking treatment for alcohol addiction face greater social resistance than men. Besides, they are more likely to meet with opposition and a social penalty from family and friends for seeking general health care compared to men, who rarely face such opposition.
The above literature review suggests that gender and health-seeking behaviour can be linked in both direct and indirect ways. The way in which gender shapes health-seeking and access to health can, depending on the social and cultural context, work out positively as well as negatively for either gender. Studies on gender differences in health-seeking suggest that the situation in India is no different. In the Indian context, gender interactions and their inter-linkages affecting therapeutic behaviours in different rural settings have been explored intensively. For instance, studies examining health-seeking patterns across gender in the rural Indian states of Uttar Pradesh, Pune and West Bengal find that due to traditional gender preferences, cheaper public care providers are sought by households for girls, while for boys private qualified providers are consulted, more money is spent and greater distances are travelled, if necessary [
25‐
27].
A few quantitative studies report gender differences in health-seeking behaviour in Indian urban slums [
26,
28]. However, qualitative accounts of the complex gender relations affecting therapeutic choices behaviour are still missing. An in-depth understanding of the reasons underpinning gender differences is required, considering the different ways in which gender and health-seeking have been shown to be directly and indirectly related, and considering the contextual and cultural nature of these relationships. This qualitative study in line with emic perspective will enable to understand in-depth the combined influence of socio-cultural context, respondents’ perceptions and self-constructed meanings [
29‐
32] behind their behavioural patterns in healthcare utilization. Moreover, the unique socio-cultural context of India’s slums characterised by heterogeneous and dynamic populations [
33], can be expected to considerably differ from other (Indian) settings.
While placing the social context at the forefront of the gender and health-care agenda, this study aims to provide fresh insights into gender differences in health-seeking behaviour in the Sahid Smriti Colony, an urban slum in Kolkata, India. The key questions addressed in this study are: (1) Do gender preferences exist in making choices among the different available therapies in India’s urban slum settings? (2) If yes, what kinds of therapies are used by men and women in slum areas? (3) How do complex gender interactions function in slum settings and influence the therapeutic behaviour of men and women?
Methods
Study site
An exploratory study was conducted on slum dwellers in Kolkata during August–September 2012. According to the Kolkata Municipal Corporation (KMC), out of a total of 141 municipal wards, slums are spread in 138 wards. Out of these slums, Sahid Smriti Colony, situated at Baghajatin, under Kolkata Municipal Corporation (KMC) jurisdiction was selected. There were two reasons for selecting the Sahid Smriti Colony slum. Firstly, it is a peri-urban slum located on the south-eastern outskirts of the city. Being in a process of acculturation, a glimpse of both traditional and modern ways of life can be witnessed in a peri-urban slum [
34]. Secondly, such a transition is also witnessed in health practices. In Sahid Smriti slum, both folk and alternative healing practices exist and are utilised alongside formal health care. This slum was selected to see how complex gender interactions function within this setting in establishing preferences among these two domains of therapy.
Participant recruitment
The participants consisted of 34 men and 32 women living in the study slum. The characteristics of the 66 study participants are shown in Table
1. Given the linguistic, religious and cultural heterogeneity, an extensive sample was selected based on the following criteria: (1) belong to any of the three major religious groups predominant in the study slum, namely Hindu, Muslim and Christian; (2) over 16 years of age and limited to adults; (3) are native speakers of the Bengali language; (4) can clearly recall their experiences with regard to the causes, nature of treatment and provider sought; (5) consent to re- interviews, if and when necessary, during the study period; and (6) have been resident within the study slum for at least five years (people residing less than five years were mostly refugees). The sample size was decided following Daniel Bertaux’s [
35] concept of ‘theoretical saturation', which states that data saturation in a qualitative study typically occurs by the time 12 interviews have been analysed. Additional new patterns emerge rarely after that, as 12 individual interviews are enough to include 88–92% of information [
36]. Based on this recommendation in relation to the saturation threshold, the present study was based on an initial selection of 12 men and 12 women each from three religious groups in the study area, with a total of 72 participants. However, men and women could not be selected on an equal basis because of absenteeism or unwillingness to participate or refer to anyone. A total of 66 participants, i.e. 34 men and 32 women, agreed to participate. Mostly, after the eighth interview (of each man and each woman in the three religious groups) no new shared themes were generated from the interviews. Therefore, it was deemed that the data collection had reached a saturation point based on the data saturation model [
37,
38]. Four more interviews for data collection with Hindu and Muslim religious groups and two more interviews with Christian male participants
1 were carried out to ensure and confirm that no new themes emerged, but only instances of the same themes [
39‐
41]. The snowballing technique was used to select participants, as everyone in the study area was not comfortable in discussing health-seeking behaviour freely [
42]. Initially, an ex-municipal medical officer (personally known to the first author) was approached because of his good contacts with some health workers residing in the study slum. Sampling was therefore facilitated through one of these female health workers, using her knowledge about the slum dwellers. She introduced the first researcher to two women and three men. These initial five participants were asked to recruit participants of their own gender who not only met the inclusion criteria, but also were willing to discuss freely issues associated with treatment choices.
Table 1
Socio-demographic profile of participants in the study slum
Age groups |
16–30 | 10 | 17 |
31–45 | 19 | 11 |
46 and above | 5 | 4 |
Marital status |
Married | 25 | 26 |
Unmarried | 8 | 3 |
Widow | 0 | 2 |
Widower | 1 | 0 |
Separated | 0 | 1 |
Educational status |
Illiterate | 9 | 12 |
Literate | 25 | 20 |
Origin of the population |
Rural Kolkata | 24 | 27 |
Within Kolkata | 5 | 2 |
Bangladesh | 5 | 3 |
Social groups |
General | 10 | 7 |
Scheduled Castes (SCs) | 21 | 19 |
Scheduled Tribes (STs) | 3 | 6 |
Religion |
Hindu | 12 | 12 |
Muslim | 12 | 12 |
Christian | 10 | 8 |
Employment status |
Full employed | 16 | 1 |
Contractual | 11 | 0 |
Unemployed | 7 | 31 |
Data collection
In-depth face-to-face interviews were conducted with the participants by using a semi-structured interview guide with probing questions to keep the participants on track and also allow them to structure the interview by themselves, so as to bring forth the issues that were important to them. The questions were open-ended, so that the interviewer could probe more on particular concepts of interest to the study. The interviews focused on exploring different health choices influenced by gender in terms of the range of therapies utilised, factors influencing health-seeking decisions and the process of evaluating the efficacy of treatment from a gender viewpoint. Each face-to-face interview was conducted in a private room either in the participant’s house or in the workplace. At the moment of data saturation (that is, when no new data emerged and the existing literature did not add any new information), the data collection was ended. Interviews were later transcribed and translated into English. The interview guide was first created and piloted in English. After revisions and further piloting, the research team then translated the interview into Bengali. The translation was contextual rather than literal, meaning that questions were translated to relay the best meaning in colloquial spoken Bengali. Following a round of piloting with the Bengali interview guide, the questions were then back-translated into English to maintain consistency of meaning between the two versions. After conducting five pilot interviews in Bengali, the questions were further refined and finalised to best convey the essence of the questions. Each interview lasted around 45 to 60 min. All interviews were audio recorded, transcribed and translated into English. Since the field data was collected by the main researcher, a woman, this favoured openness of female respondents, who are traditionally more reserved. However, it may have introduced a bias in gathering the male perspectives and therefore adds a limitation to the study.
Data analysis
The in-depth interviews that were first audiotaped were later on written down word for word. Prior to that, the recordings were listened to several times to ensure the accuracy of the transcription. The transcribed data was then read and re-read several times. The transcripts were translated from Bengali into English. Professional help was sought out to examine the translations of the original text. Some corrections were made and inconsistency was avoided. Our analysis used descriptive codes to generate thematic concepts [
43]. The interviews with female participants were coded separately from the interviews with male participants. This approach was chosen to inductively grasp the difference between male and female experiences, in line with the aim of the study to investigate the ‘gendered experience’ of health-seeking behaviour.
The first author conducted the initial thematic analysis under the supervision of a sociologist (local facilitator) with extensive qualitative methods expertise. Briefly, the thematic analysis includes several phases: familiarise yourself with your data (team), generate initial codes (first author), search for themes (team), review themes (team), define and name themes (first and second author) and produce the report (team). The initial codes were framed by constantly moving back and forward between the entire dataset. These codes identified features of the data that the first author considered pertinent to the research question. After identifying a list of codes, these were sorted into potential sub-themes by combining different codes. Sub-themes were constantly compared and refined further, bearing in mind the aim of the study. The final themes were defined by focusing the analysis on a broader level and refined again. The real meaning of what each theme dealt with was captured and a satisfactory final thematic chart was developed by making clear and identifiable distinctions between the themes. The final phase consisted of developing a set of fully worked-out themes and writing the report. The reliability of the final themes was confirmed by choosing examples from the transcript to verify whether they illustrated elements of the themes. Issues within the themes could be clearly identified when compared with these extracts and thereby presented a coherent account of the point being made.
Ethical considerations
Because of the non-clinical and non-invasive nature of the study, this research has thoroughly followed the ethical guidelines framed by the National Committee For Ethics In Social Science Research In Health (NCESSRH)
2,3 [
44‐
46]. In line with these guidelines, oral consent to participate was obtained from all the participants, after the purpose of the study had been explained, and anonymity and confidentiality were assured. It was specifically explained that comments would not be attributed to a named individual without permission. Written consent was not sought in order to favour an atmosphere of trust, intimacy, and informality, which was believed to create the necessary conditions for the respondents to feel at ease and respond openly and truthfully. The Institute for Social and Economic Change (ISEC) in Bangalore, India, endorsed the project and functioned as a partner institution on site. The ISEC’s Ethics Committee formally examined the study protocol and provided ethical approval.
Discussion
This study examined the health-seeking behaviour of men and women residing in an urban slum in Kolkata, India, by exploring the underlying perceptions affecting differences in their therapeutic choices. Previous findings had highlighted that gender differences manifested in men being more inclined towards formal health care, whereas women were more inclined towards alternative health care [
15,
22]. Instead, the present analysis shows that both men and women make simultaneous use of formal and informal care. Yet, the key findings of this study show that they do so in different ways and have different motivations for their choices.
Women’s behaviour of mixing both formal and informal care indicates that they want to take care of their illness, but at the same time, they are keen on retaining their socio-cultural ethos, as reported in another study [
49]. This health-seeking behaviour of women can be related to their lower (perceived) position in the community than men, as a result of which they have to face socio-cultural hurdles in terms of mobility, code of conduct, maintaining family prestige (by behaving well) and maintaining secrecy about their health problems.
Our study reveals that women benefit more from social support, as acknowledged in other studies [
50‐
52]. Such social support is initiated through social integration with informal practitioners, who are distant kin or residing within the same neighbourhood. As shown in prior literature [
53,
54] our study also confirms that such social association is developed through gender roles of maintaining social ties with close-knit kin (natal and consanguineous kin) [
55] and another type of social relationships (neighbours and friends) [
56].
Choices stem from financial stresses that women face both at familial (depending on their husbands for money) and institutional levels (high consultation charges and expensive medications) while seeking medical care. Our study reveals that men often avoid acknowledging health problems of women even when they are serious, as is found in other studies [
57,
58]. Men who are guided by gender stereotypes in their views, according to which health is not considered as a core issue in life, think women are too sensitive to pain [
59]. By consequence, they tend to dismiss and underestimate women’s need for professional intervention. Men’s judgement and control over women’s health is directly linked to their financial autonomy. Failure to persuade husbands often makes women turn towards informal health care. Women are forced to stick to informal care, even knowing it can be less effective. If absolutely necessary, they try to seek formal care that is inexpensive. This finding supports other studies that have shown poor and disadvantageous women are less likely to utilise formal health care services compared to affluent women [
11] because of convenience, affordability and socio-cultural compatibility [
60,
61].
The inability to participate meaningfully in formal health care use is also due to information asymmetry as regards how to adequately utilise health benefits. Women prefer door-to-door information on health benefits, as pointed out by another study [
62]. In India, a major share of expenditure on health care is being borne out-of-pocket by the poor. This has resulted in after-treatment disasters such as selling or mortgaging assets and spending from savings, thus further worsening the poor’s financial conditions. Other findings point out that ignorance among the poor about free treatment and the complex and cumbersome procedures to obtain exemptions constrain the access of the poor to formal health care services [
63].
Unlike women, men in the study area do not have to conform to societal gender stereotypes. Therefore, they have more freedom and flexibility in making their choices among therapies. However, their gender role is associated with higher adherence to formal health care. This might be explained by the fact that men identify themselves and are recognised as the earning members of the family. As a result, they cannot risk staying at home for long periods of time due to illness. These reasons drive men to choose formal care that primarily allows them to work (and helps in reducing the risk of circumstantial problems) by curing them fast and completely. As a consequence, the effectiveness of the cure constitutes the main lens through which men judge the value of the care received. Men’s choice for self-care is motivated only by cost-effectiveness. Illnesses are initially taken care of by using drugs from drug stores. Men’s judgement regarding choices of therapy is only based on time and treatment efficacy, needs that are both met by formal health care. During clinical encounters, men are more likely to communicate less and prefer quick diagnoses. This response might point towards masculine ideology, according to which men are neither meant to show nor expect emotions and sympathy [
64], unlike women. Illness-related questions asked by clinical professionals make men comfortable; hence making professional care more preferable. This way, they feel can escape discussions about other social aspects, which are a potential consequence of the sympathetic exchange of words.
Another aspect of men’s unease related to informal healing is its indigenous concept of treatment, which is not scientific, is not aligned with medical or scholarly discourse, and include the application of rudimentary technology in health and healing, thus putting a question mark against the efficiency and reliability of treatment. However, further research is needed to ascertain how physicians in these two healing domains validate their therapies and to examine the actual accuracy of diagnosis in these two therapy domains.
Finally, when it comes to male/female choices of physicians and therapies, we found that women are sometimes moving back and forth between informal and formal health care or utilising both. Instead, men are generally static as regards their treatment choices. The reason might be that women bear more cultural demands, social responsibilities and economic consequences, whereas men bear only economic stressors. In order to adjust to these multiple factors, women state an ample number of reasons for making therapeutic choices compared to men. This may have implications for examining the appropriateness and suitability of treatment provided to women as compared to men. Further research is needed to assess the reasons for this apparent inconsistency or possibly perceived complementarity in using formal and informal therapies.
To conclude, it can be said that the notion of shortage may be a broader concept, which men and women residing in the urban slum of Kolkata experience and negotiate in a different way when it comes to the health care usage. Their very existence in society as immigrants exposes them to multi-faceted shortages in every aspect of life, the negative effect of which is also seen in their health-seeking behaviour. This suggests that medical adherence is secondary to the prevailing health care problems. Rather, policy approaches should be directed more towards effective communication, material access and awareness of social class in order to enhance users’ adherence.
Conclusion
We find that both men’s and women’s choices of treatment are related to their daily interactions with society, which create either a favourable or unfavourable condition for seeking a treatment. Both men and women utilise informal and formal therapies, but often move back and forth between the two domains to adjust to their economic situation and socio-cultural norms. However, men believe in a complete cure so as to avoid endangering their gender role; women place more of an emphasis on avoiding social and economic penalties and therefore improvise by adhering to poor-quality therapies. These findings can by no means be generalised to other contexts, and even generalisation to other slums should be made with caution, as every slum settlement presents a unique religious, ethnic, linguistic, socio-cultural and socio-economic composition. Furthermore, the focus of this paper is on gendered health experiences. It is therefore possible that other traits influencing health care-seeking behaviour and interacting with gender have not been addressed in the present study.
Acknowledgements
The authors express deep gratitude to the study participants for their voluntary participation and time and for generously sharing their experiences relevant to the study. Thanks to the key informants Pratimadi and Mainadi. Also thanks to Dr. Apurba Kumar Sinha, who ensured access among the slum dwellers for data collection. The authors also extend their sincere thanks to Prof. Manohar Yadav, who provided his guidance throughout the study, and to the Institute for Social and Economic Change (ISEC), Bangalore, India, for providing local support and monitoring throughout the research.