What are your paper’s main findings?

HIV prevalence among pregnant women in Malawi is estimated at 8.7% and several programmes to introduce lifelong antiretroviral therapy (ARV) exist to prevent new HIV infection. Such programmes are described as “test and treat” and are now the recommended policy of the World Health Organization (WHO). One successful programme is Option B+, which managed to more than double the number of HIV-positive pregnant and lactating women on ART within a year. However, this success has unintended consequences as demand increases in what are already overburdened health facilities. 

This research examined the challenges from the perspective of health-care workers (HCW) across 14 districts in central and southern regions of Malawi. HCWs described an overburdened system in which they struggle to consistently provide quality care and where waiting times can range between 2 and 9 hours. This finding itself is not surprising; however, a reflexive thematic gender analysis of the data revealed a number of additional insights that were masked in previous studies. These included complex and detrimental relations of power and practice that risked endangering women and alienating accompanying men as fathers and husbands. The engagement of men in these roles is considered critical for partner-testing and prevention of new transmission, privacy and disclosure, women’s long-term adherence to ARV, and combatting stigma in the wider communities. But, as one HCW reported during interview, “the infrastructure is just not male-friendly”. Our gender-attentive research questions led us to probe further on what this might mean and reflect on the gendered barriers to accepting and adhering to ART. 

How can these findings better inform health policy discussion and improve Option B+ programmes?

Engaging men and boys has become something of a mantra in the global arena of gender equality activity; but rather significantly, this research provides a data-driven example where the failure to include men as partners and fathers can impact on the health of mother, father and children alike. Participants in the study proposed several practical steps that might encourage couples to attend clinics together, including bicycle stands and locks, accompanying-men waiting areas, and the inclusion of men in the singing and dancing that can take place at the clinics. Whilst context-specific, they point towards simple interventions that could have a direct impact on health status. 

Health interventions are often described as gender blind, by which it is said that they assume no gender dimension of a programme’s implementation. The WHO, and most other health actors, consider this to be problematic since it eschews the underlying structural gender relations of any given context and ignores norms, roles and relations. Whilst health interventions are unlikely to be able to upend patriarchal structure of power, the WHO Gender Responsive Assessment Scale describes how programmes and policies can be gender transformative by addressing gender-based health inequities. The findings from this study go some way towards thinking about very context-specific ways that Option B+ and other similar programmes can become more gender transformative and thereby enhance health for all. 

What does the method of “reflexive thematic analysis” consist of and what were its advantages for your analysis?

Data generated in large studies such as these comes in many forms – quantitative and qualitative. Most health researchers now think that mixed-method approaches provide the most robust evidence upon which decision-making on health system and programme planning can reliably depend. There are many qualitative methods – such as field diary notes and direct ethnographic observations – that enable us to gain a reflexive perspective on social contexts. These form an important part of the analysis and can usually enhance our understanding of other data streams that might be more quantitative and also biomedical. When we conduct a thematic analysis, we actively draw out themes from across our sources typically driven by leading research questions in the first instance. We aim also to be highly reflexive and iterative, by which we not only carve out space for new and emergent themes that we may not have previously noticed, but also seek to tease out new patterns among these themes. Importantly, in studies such as these, the analysis is a team effort. This is practically a necessity given the scale of the data, but also serves an important methodological benchmark by providing inter-rater reliability. This simply means that several researchers lend their thinking and analytical minds to the same data and then discuss, debate, even dispute interpretations until they reach a point of inter-rater saturation that distills one or more key findings. In our case, we are a multidisciplinary team, which additionally provides us with interdisciplinary reliability enhancing the method overall. 

What areas of further research could benefit from this paper?

Gendered dimensions of health are long-since neglected in international, public and global health interventions and programmes. Health researchers necessarily deal with the material body, its pathologies, structures and cellular composition. Too often, the inclusion of gender has simply meant a default to including and analysing women as well as men; a sex-based analysis of disaggregated data. When we understand gender as one determinant of health among many others, and its intersection with other social stratifiers, we begin to unpack how gender analyses can reveal aspects of health and disease that might not otherwise seem so apparent in our data, and that these insights can actually enhance health for everyone. My view is all health research, interventions and programmes would be more successful and certainly more scientifically rigorous, if they included an analysis of the gendered dimensions. 

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Full citation of the article:
Phiri Nozgechi, Kali Tal, Claire Somerville, Malango T. Msukwa, and Olivia Keiser. “‘I Do All I Can but I Still Fail Them’: Health System Barriers to Providing Option B+ to Pregnant and Lactating Women in Malawi”. PLoS ONE 14, no. 9 (2019): e0222138. doi:10.1371/journal.pone.0222138. 

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Interview by Guilherme Mateus Suedekum, PhD Candidate in International Economics.
Banner image: Shutterstock/com.