RESUMEN
This paper explores the relationship between changes in individual beliefs and behaviours, couple relationship dynamics and gender norms - and how interventions can influence these. It draws on longitudinal qualitative research with heterosexual couples who participated in the Indashyikirwa programme in Rwanda. The couples followed a curriculum designed to improve relationship skills and reduce the gender-inequitable beliefs, behaviours and norms that underpin intimate partner violence. Qualitative findings show that the programme resulted in moderate, but significant, positive 'shifts' in individual beliefs and behaviours, couple relationship dynamics and levels of inequality - increasing men's engagement in domestic duties, women's participation in household decision making, and women's access to economic resources. They also suggest which parts of the couples' curriculum were most effective in catalysing these changes. However, the data also show that these 'shifts' occurred without fully transforming deeply-entrenched beliefs and norms around gender roles and male authority over economic resources. The paper suggests that the persistence of these beliefs and norms constrained the extent of changes among couples - and could potentially constrain their longevity and act as an obstacle to longer-term, larger-scale changes in gender inequalities and violence.
Asunto(s)
Identidad de Género , Educación en Salud/tendencias , Relaciones Interpersonales , Parejas Sexuales/psicología , Adulto , Cultura , Toma de Decisiones Conjunta , Composición Familiar , Femenino , Humanos , Violencia de Pareja/prevención & control , Masculino , Hombres , Investigación Cualitativa , RwandaRESUMEN
BACKGROUND: Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. METHODS: We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. RESULTS: Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. CONCLUSION: In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers' access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.