Gender diversity and inclusion

Introduction to gender and disability mainstreaming

This module is designed to equip the learner with skills and knowledge on gender and disability
issues which will enable him/her to work effectively in the community.
Gender refers to a set of characteristics and behavior that are prescribed for a particular sex by
society, and are learned through a socialization process. Gender is assimilated and learned, can
change over time and can vary within a given culture. Culture of a particular community
influences gender roles between men and women. Division of labour between the two sexes is
largely determined by one’s culture. Gender cannot be used interchangeably with sex.
Disability a physical, sensory, mental, or other impairment including visual, hearing or physical
disability which has a substantial long term adverse effect on a person’s ability to carry out usual
day to day activities. Any restriction or lack (resulting from impairment) ability to perform an
activity in a manner or range considered normal for human beings
UNIT 1: CONCEPTS AND PRINCIPLES IN GENDER
Definition of terms
Gender: refers to social differences and relations between men and women that are learnt,
changeable over time and have wide variations both within and between societies and cultures.
They distinct roles and behaviours may give rise to gender inequalities i.e. differences between
men and women that systematically favour one group. Gender is distinct from sex since it does
not refer to the different physical attributes of men and women, but to socially formed roles and
relations of men and women and the variable sets of beliefs and practices.
Gender stereotyping: refers to discrimination based on one’s sex. It may involve unfair
treatment or infringement upon the rights of a certain sex requiring them to act in a certain
manner. It is greatly influenced by culture and upbringing.
Gender equality: gender equality entails the concept that all human beings both men and
women are free to develop their personal abilities and make choices without the limitations set
by stereotypes, rigid gender roles and prejudices. This is the absence of discrimination on the
basis of a person’s sex in providing opportunities in allocating resources and benefits or in access
to services.
Gender equity: fairness of treatment for women and men according to their respective needs.
This may include equal treatment or treatment that is different but which is considered in terms
of rights, benefits, obligations and opportunities.
Gender sensitivity is the process by which people are made aware of how gender plays a role in
life through their treatment of others. Gender relations are present in all institutions and gender
sensitivity especially manifests in recognizing privilege and discrimination around gender;
women are generally seen as disadvantaged in society.
Discrimination: any distinction, exclusion or preference based on race, colour, sex, religion,
political opinion, national extraction or social origins which nullifies or impairs equality of
opportunities or treatment in employment or occupation. It refers to the different treatment of
men and women in employment, education and access to resources and benefits on the basis of
their sex. It may be direct or indirect.
Gender roles: they are learnt behaviour in a given society, community or social group in which
people are conditioned to perceive activities, tasks and responsibilities as male or female. The
perceptions are affected by age, class, caste, race, ethnicity, culture, religion or other ideologies
and by the geographical, economic and political environments.
Gender responsiveness: This is the creating of an environment through site selection, staff
selection, program development, content, and material that reflects an understanding of the
realities of individual’s lives and addresses the issues of the participants. Gender responsiveness
means that an individual is able address gender issues and hence take action to solve a gender
problem
Affirmative action: means special temporary measures to redress the effects of past
discrimination in order to establish de facto equal opportunity and treatment between men and
women once the consequences of the past discrimination have been rectified.
Gender transformation: It describes a situation where women and men change their way of
thinking from patriarchal towards a gender equality perspective.
Gender awareness: It is the knowledge and understanding of the differences in roles and
relations between women and men, especially in the work place.

Gender mainstreaming
Gender mainstreaming: the process of accessing the implication for women and men for any
planned action including legislation, policy and programs in any areas and at all levels. Before
decisions are made and taken, gender analysis is undertaken to assess the effect of the action on
both men and women.
Gender mainstreaming is a strategy for the achievement of gender equality and equity.
• Gender Mainstreaming includes gender-specific activities and affirmative action,
whenever women or men are in a particularly disadvantageous position.
• Gender-specific interventions can target women exclusively, men and women together, or
only men, to enable them to participate in and benefit equally from development efforts.
• These are necessary temporary measures designed to combat the direct and indirect
consequences of past discrimination
Purpose of gender mainstreaming
• To Reduce gender inequities that may exist in a given project area;
• To Ensure women and men’s specific needs are satisfied, that they benefit from the
project and that the project impacts positively on their lives;
• To Create the conditions for the equitable access of men and women to project resources
and benefits;
• To Create the conditions for the equitable participation in project implementation and
decision making processes.
Levels of gender mainstreaming
• Gender mainstreaming can be done at the following levels:
1. Policy
2. Institutional /organizational
3. Programmes/project
 1. Programmatic gender mainstreaming
Based on human rights principles of equality, participation and non- discrimination,
programmatic approaches systematically apply gender analysis methods to health problems to
better understand how gender norms, roles and relations affect the health of women and men
across the life course.
Programmatic gender mainstreaming can do the following:
a) Address how health problems affect women and men of all ages and groups
differently.
b) Focus on women empowerment and women-specific conditions to address historic and
current wrongs women and girls face
c)Examine how gender norms, roles and relations male behaviour and health outcomes
and how these shape the role of men in promoting gender equality
d) Adopt a broad equity approach to look at issues of age, socioeconomic status, ethnic
diversity, autonomy, empowerment, sexuality, etc. that may lead to inequities
e) Provide an evidence base to enable appropriate, effective and efficient health planning,
policy-making and service delivery.
2. Institutional Gender Mainstreaming:
a) This aspect looks at how organisations function: policy development and governance,
agenda-setting, administrative functions and overall system related issues.
b) Institutional gender mainstreaming acknowledges that an institution must be equipped
with mechanisms to create an enabling environment for programmatic approaches to
succeed.
c) It also ensures that organizational procedures and mechanisms do not reinforce patterns
of gender inequality in staffing, functions or governance.
d) Institutional gender mainstreaming seeks structural changes, calling for a transformation
of the public health agenda so as to include the participation of women and men from all
population groups in defining and implementing public health priorities and activities.
Institutional gender mainstreaming addresses the alignment of human and financial resources
and organizational policies, which include:
 Recruitment and staff benefit policies, such as:
 Establishing work-life balance
 Sex parity and gender balance in staff
 Equal opportunities for upward mobility
Role of CHA in Gender mainstreaming
 1. Recommending appropriate action for gaps in relation to health
2. Sensitising community members on gender mainstreaming issues
3. Identifying and taking appropriate action for common issues in relation to gender
mainstreaming
4. Training CHCs and CHVs on the importance on gender issues in the community
5. Follow up and monitor actions emerging from gender mainstreaming and planning
implementation sessions

Gender and Health

The distinct roles and behaviours of men and women in a given culture, dictated by the culture’s
gender norms and values, give rise to gender differences. Not all such differences between men
and women imply inequity.
Gender norms and values however, also give rise to gender inequalities. The fact that throughout
the world, women on average have lower cash incomes than men is an example of gender
inequality.
Both gender differences and inequalities can give rise to inequities between men and women in
health status and access to health care e.g.
 A woman cannot receive needed health care because norms in her community prevent her
from travelling alone to a clinic.
 A teenage boy dies in an accident because of trying to live up to his peers expectations
that young men should be bold risk takers
 A married woman contracts HIV because societal standards encourage her husband’s
promiscuity while simultaneously preventing her from insisting on a condom
 A country’s lung cancer mortality rate for men far outstrips the corresponding rate for
women because smoking is considered an attractive marker of masculinity, while it is
frowned upon in women.

Conditions for effective gender mainstreaming

Effective gender mainstreaming can occur if the following are in place:
• A clear gender policy
• Practical coordination of all gender mainstreaming initiatives
• A clear guide on gender mainstreaming and best practices
 • Training and capacity building
• Awareness creation and advocacy on gender mainstreaming
• Partnerships and networking for persons and institutions
• Research and information dissemination on gender issues
• Sex disaggregated data
• Resources mobilization
• Monitoring, evaluation and reporting.
Ways of achieving gender mainstreaming
 Carrying out a gender analysis regularly
 Carrying out participatory training
 Consultative meetings and feedback forums
 Preparation and dissemination of Information, Education and Communication (IEC)
materials
 Creation of data banks and resource centre on gender mainstreaming and support
services
 Creation of membership associations of people and organizations involved in
gender advocacy
 Participation of member associations in trade shows and exhibitions
 Media and publicity programs.
Process of gender mainstreaming
• Defining the gender issue
• Formulating objectives
• Mapping the situation
• Refining the issue
• Formulating policy issues from gender
• Implementation of gender matters as per the policy
• Communication
• Monitoring and evaluation
Gender-based violence and Human rights
Gender based violence
Gender-based violence (GBV): is violence that is directed against a person on the basis of
gender. It constitutes a breach of the fundamental right to life, liberty, security, and dignity,
equality between women and men, non-discrimination and physical and mental integrity. All acts
of gender based violence that result in or are likely to result in physical, sexual, psychological or
economic harm of suffering to women or men including threats of such acts, coercion or
arbitrary, deprivation of liberty whether occurring in public or in private life.
Causes of Gender based violence in the community
 Unequal gender relations and discrimination
 Situations of displacement
 Refugee and IDP camp
 Wars and conflicts
 Disruption of social structures
 Men’s loss of traditional roles
 Rapid changes in cultural traditions
 Poverty
 Frustration due to lack of productive work, decent or well- paid labour
 Alcohol and drug abuse
 Lack of respect for human rights

Forms of gender based violence

Although it is difficult to distinguish between different types of violence since they are not
mutually exclusive, gender based violence can be classified as:
• domestic violence,
• physical, psychological, threats of violence
• harmful and emotional violence which manifests as sexual harassment, rape, sexual
violence during conflict,
• harmful customary or traditional practices such as female genital mutilation, forced
marriages and honour crimes,
• trafficking in women and forced prostitution,
 • violations of human rights in armed conflict in particular murder, systematic rape, sexual
slavery and forced pregnancy, forced sterilization, forced abortion, coercive
contraceptives, female infanticide and prenatal sex selection
• Forced exposure to pornography, incest and virginity tests.

Response to GBV
 Referral systems
 Safety/security measures
 Health interventions
 Psychosocial support
 Legal measures

Prevention and Management of GBV

 Assessment/monitoring
 Protection-sensitive shelter and site planning
 Distribution and services
 Safety and security
 Raising community awareness
 Protection systems
 Ethics

Referral and support system at the community

The figure below present the referral system at the community level.
Fig. 1 Referral and support system at the community

Human rights
Human Rights they are internationally agreed standards which apply to all human beings.
Everybody is equally entitled to their human rights e.g. right to education, adequate food,
housing and social security, regardless of nationality, place of residence, sex, nationality, ethnic
group, colour, religion, or other status.
Human rights awareness: Educational frameworks that consider non-discrimination, gender
equality, anti-racism, and more help build an understanding and respect for human rights.
Categories of Human rights
There are three categories:
1. Civil and political rights
2. Economic, social, and cultural rights
3. Solidarity rights.
It has been typically understood that individuals and certain groups are bearers of human rights,
while the state is the prime organ that can protect and/or violate human rights.

Convention on the rights of persons with disabilities

 December 2006 the UN General Assembly adopted the Convention on the Rights of Persons
with Disabilities (CRPD).
 It is built upon the UN Standard Rules on the Equalization of Opportunities for Persons with
disabilities and the World Programme of Action Concerning Disabled Persons
 Is to promote, protect and ensure the full and equal enjoyment of all human rights and
fundamental freedoms by all persons with disabilities

Principles of human rights

Human rights are universal and inalienable; indivisible; interdependent and interrelated. They are
universal because everyone is born with and possesses the same rights, regardless of where they
live, their gender or race, or their religious, cultural or ethnic background. Inalienable because
people’s rights can never be taken away. Indivisible and interdependent because all rights –
political, civil, social, cultural and economic – are equal in importance and none can be fully
enjoyed without the others. They apply to all equally, and all have the right to participate in
decisions that affect their lives. They are upheld by the rule of law and strengthened through
legitimate claims for duty-bearers to be accountable to international standards.

Universality and Inalienability

Human rights are universal and inalienable. All people everywhere in the world are entitled to
them. The universality of human rights is encompassed in the words of Article 1 of
the Universal Declaration of Human Rights: “All human beings are born free and equal in
dignity and rights.”

Indivisibility
Human rights are indivisible. Whether they relate to civil, cultural, economic, political or social
issues, human rights are inherent to the dignity of every human person. Consequently, all human
rights have equal status, and cannot be positioned in a hierarchical order. Denial of one right
invariably impedes enjoyment of other rights. Thus, the right of everyone to an adequate
standard of living cannot be compromised at the expense of other rights, such as the right to
health or the right to education.

Interdependence and Interrelatedness

Human rights are interdependent and interrelated. Each one contributes to the realization of a
person’s human dignity through the satisfaction of his or her developmental, physical,
psychological and spiritual needs. The fulfilment of one right often depends, wholly or in part,
upon the fulfilment of others. For instance, fulfilment of the right to health may depend, in
certain circumstances, on fulfilment of the right to development, to education or to information.

Equality and Non-discrimination

All individuals are equal as human beings and by virtue of the inherent dignity of each human
person. No one, therefore, should suffer discrimination on the basis of race, colour, ethnicity,
gender, age, language, sexual orientation, religion, political or other opinion, national, social or
geographical origin, disability, property, birth or other status as established by human rights
standards.
Participation and Inclusion
All people have the right to participate in and access information relating to the decision-making
processes that affect their lives and well-being. Rights-based approaches require a high degree of
participation by communities, civil society, minorities, women, young people, indigenous
peoples and other identified groups.

Accountability and Rule of Law

States and other duty-bearers are answerable for the observance of human rights. In this regard,
they have to comply with the legal norms and standards enshrined in international human rights
instruments. Where they fail to do so, aggrieved rights-holders are entitled to institute
proceedings for appropriate redress before a competent court or other adjudicator in accordance
with the rules and procedures provided by law. Individuals, the media, civil society and the
international community play important roles in holding governments accountable for their
obligation to uphold human rights.

Every person is entitled to the following rights and fundamental freedoms:

1. Right to life
2. The right to equality, equal protection and equal benefit in law
3. Human dignity
4. Freedom and security
5. Protection from slavery, servitude & forced labour
6. Freedom of conscience, religion, belief and opinion
7. Freedom of expression
8. Freedom of the media
9. Right of access to information
10. Freedom of association
11. Right of assembly, demonstration, picketing and petition
12. Political rights
13. Freedom of movement and residence
14. Protection of right to property
15. Fair labour practices
16. Right to a clean and healthy environment
17. Right to economic and social rights (health, housing, food, water, social security &
education)
 18. Right to use of language and culture of one’s preference
19. Consumer rights
20. Fair administrative action
21. Right of access to justice and
22. Right to a fair hearing.
Practical sessions to be conducted by the course tutor.

UNIT TWO: EQUITY IN DISTRIBUTION OF COMMUNITY HEALTH RESOURCES

Concepts of health equity

Health equity means assuring conditions for the highest possible level of health for all people.
Achieving health equity requires valuing all individuals and populations, recognizing and
rectifying historical and contemporary injustices, and providing resources according to need.
Health disparities will be eliminated when health equity is achieved.

Health disparities means the structural health differences that adversely affect groups of people
who systematically experience greater economic, social, or environmental obstacles to health
based on their racial or ethnic group, religion, socioeconomic-status, gender, age, or mental
health; cognitive, sensory, or physical disability, sexual orientation or gender identity;
geographic location; or other characteristics historically linked to discrimination or exclusion.
Health disparities are the metric used to measure progress toward achieving health equity.

Social determinants of equity means systems of power that govern the equitable distribution of
resources and populations through decision making structures, policies, practices, norms and
values. Differential distribution of resources and populations can result in group-based structured
inequity including, but not limited to: racism, sexism, heterosexism, cissexism, classism and
able-ism and the intersections among them.

Social determinants of health means the conditions into which individuals are born and in which
individuals grow, live, work and age, including but not limited to:

a) Housing
 b) Education
c) Criminal justice
d) Employment
e) Neighborhood environment
f) Food insecurity
g) Health care access
h) Discrimination and social exclusion
i) Transportation.

“Health equity means ensuring that everyone has the chance to be as healthy as possible.
However, factors outside of a person’s control, such as discrimination and lack of resources,
can prevent them from achieving their best health. Working toward health equity is a way to
correct or challenge these factors. Health equity is the absence of systematic disparities in
health (or its social determinants) between more and less advantaged social groups. Social
advantage means wealth, power, and/or prestige—the attributes defining how people are
grouped in social hierarchies.
Health inequities put disadvantaged groups at further disadvantage with respect to health,
diminishing opportunities to be healthy. Health equity, an ethical concept based on the principle
of distributive justice, is also linked to human rights.”

Health disparity, equality and equity

People use many different terms when it comes to accessing healthcare, including health
disparity, health equality, and health equity.

Disparity is the quantity that separates a group from a reference point on a particular measure of
health that is expressed in terms of a rate, proportion, mean, or some other quantitative measure.
(HP2010)
Health equity is the fair distribution of health determinants, outcomes, and resources within and
between segments of the population, regardless of social standing
Inequity is a difference in the distribution or allocation of a resource between groups (usually
expressed as group specific rates)
Resources relevant to health include:
 Health insurance
 Education
 Flu vaccine
  Fresh food
 Clean air

Health disparity
Health disparity is a difference that affects a person’s ability to achieve their best health.
Examples of health disparities include race, gender, education, income, disability, geographic
location, and sexual orientation.
Health disparities create health inequities: Due to their differences or situation, some people do
not always have access to the same opportunities to better their health that other people have. A
health disparity is often beyond an individual’s control.
Two concepts refer to how to correct these health disparities: health equality and health equity.

Health equality vs. health equity

Health equality means everyone has the same opportunities. Examples could include a
community center offering free or low-cost checkups to everyone.

Health equity means that people have opportunities based on their needs. An example could be
the same health center charging people based on their ability to pay. A person who cannot afford
care may receive it for free while another person may pay for the same care.

In short, health equality means everyone receives the same standard, while health equity means
everyone receives individualized care to bring them to the same level of health.

Health equality is not always preferable. For example, if a clinic offers free checkups every
morning, a person who must work during the morning cannot take advantage of this service.
While the clinic offers checkups to everyone on the same terms, some people still cannot take
advantage of the service.

Health equity would involve offering alternative checkup times in the afternoon or evening, so
everyone can access the service at a time that suits them.
Examples of services that promote health equity include:
  Providing health seminars and courses that are specific to the needs of certain ethnic
communities and racial groups.

 Providing low-cost services to those living in a low income household.

 Using mobile health screenings to help those who may not have access to transportation.

 Offering evening or late-night health appointments to those who work long hours and are
unable to access care.

 Providing better education, testing, and treatment access to communities particularly

impacted by certain conditions or diseases.

To promote health equity, government and community organizations must acknowledge and
attempt to remove barriers to care.

Major areas of health disparities

 Race and ethnicity.
 Gender.
 Sexual identity and orientation.
 Disability status or special health care needs.
 Geographic location (rural and urban)

Populations mostly affected by health disparity

1. Low income population
2. Elderly
3. LGBT (lesbians, Gay, bisexual and transgender)
4. Children
5. Underserved rural populations

Factors (determinants) contributing to health disparities

Many factors contribute to health disparities, including genetics, access to care, poor quality of
care, community features (e.g., inadequate access to healthy foods, poverty, limited personal
support systems and violence), environmental conditions (e.g., poor air quality), language
barriers and health behaviors.
Other
1. Poverty
2. Environmental threats
3. Inadequate access to health care
4. Individual and behavioral factors
 5. Educational inequalities
NB: Health disparities are preventable differences in the burden of disease, injury, violence,
or opportunities to achieve optimal health that are experienced by socially disadvantaged
populations.
Social determinants of health care disparities
They include factors like socioeconomic status, education, neighborhood and physical
environment, employment, and social support networks, as well as access to health care

Impact of health disparities

1. Unemployment
2. Poor accessibility to health care services
3. Illnesses
4. Inadequate education
5. Access to resources

Promoting equity in community health

Community- and faith-based organizations, employers, healthcare systems and providers, public
health agencies, policy makers, and others all play a key part in promoting fair access to health.
You—as an individual or member of an organization—can join the effort to ensure that all
communities have access to resources to maintain and manage good health.
Shared cultural, faith, and family values are common sources of social support. Finding ways to
maintain support and connection, even when physically apart, can empower and encourage
individuals and communities to protect themselves, care for those who become sick, keep kids
healthy, and better cope with stress.

Work with trusted local media (such as local or community newspapers, radio, TV) to share
information from CDC and other reputable public health organizations in formats and languages
suitable for diverse audiences.

Reach out to the local public health department to offer to be a community testing or vaccination
site, provide a platform for information-sharing, and share community insights.
Health promotion strategies to create awareness.

Summary
A basic principle of public health is that all people have a right to health. Differences in the
incidence and prevalence of health conditions and health status between groups are commonly
referred to as health disparities. Most health disparities affect groups marginalized because of
socioeconomic status, race/ethnicity, sexual orientation, gender, disability status, geographic
location, or some combination of these. People in such groups not only experience worse health
but also tend to have less access to the social determinants or conditions (e.g., healthy food, good
housing, good education, safe neighborhoods, freedom from racism and other forms of
discrimination) that support health. Health disparities are referred to as health inequities when
they are the result of the systematic and unjust distribution of these critical conditions. Health
equity, then, as understood in public health literature and practice, is when everyone has the
opportunity to “attain their full health potential” and no one is “disadvantaged from achieving
this potential because of their social position or other socially determined circumstance.”

UNIT THREE: DIVERSITY IN COMMUNITY HEALTH PROGRAMS

Definitions

Race

A categorization of humans based on shared physical or social qualities into groups generally
viewed as distinct within a given society.

Ethnicity

Ethnicity is a grouping of people who identify with each other on the basis of shared attributes
that distinguish them from other groups. Those attributes can include common sets of traditions,
ancestry, language, history, society, culture, nation, religion, or social treatment within their
residing area.

Sexual Orientation

Sexual orientation is an enduring pattern of romantic or sexual attraction (or a combination of

these) to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more
than one gender. These attractions are generally subsumed under heterosexuality, homosexuality,
and bisexuality.

National Origin

National origin is the nation where a person was born, or where that person's ancestors came
from. It also includes the diaspora of multi-ethnic states and societies that have a shared sense of
common identity identical to that of a nation while being made up of several component ethnic
groups.

Tribe

Category of human social group. It’s an aggregate of people united by ties of descent from a
common ancestor, a community of customs and traditions, adherence to the same leaders.

Caste

Caste is a form of social stratification characterized by hereditary transmission of a style of life

which often includes an occupation, ritual status in a hierarchy, and customary social interaction
and exclusion based on cultural notions of purity and pollution. In a system, a class structure that
is determined by birth. Loosely, it means that in some societies, the opportunities you have
access to depend on the family you happened to be born into.

Social Economic Status

Socioeconomic status is an economic and sociological combined total measure of a person's

work experience and of an individual's or family's economic access to resources and social
position in relation to other. It’s a measure of an individual's or family's social position relative to
others.

Thinking Style

Thinking style is an exploration of one’s experiences intentionally done for a purpose dealing
with comprehension, decision making, planning, problem solving, evaluation, action, and so on.
It is an approach as well as tips that are helpful for someone to solve and analyze problems he or
she is facing.

Learning Style

Learning style encompasses a process where an individual keeps information and new skills. It’s
an approach or a way applied in learning. In addition, every individual has their own way of
learning that he prefers the most compared to that of others.

Communication style
Communication style deals with one’s way to communicate with others using language,
behavior, gestures, etc. to make what the speaker is thinking and saying understood by his or her
listeners. One for example uses language with more body gestures while others with less body
gestures. The purpose is to make the speaker accepted by his or her listeners during interaction.

Many references report that communication style is viewed as accumulation of spoken and
illustrative communication elements. The one’s verbal messages is communicated to others in
words including (tone, stress, and intonation) as the main characteristic of communication style.

The communication style deals with:

(1) How one collects and processes information to make decision, and what type of information
one should reserve;

(2) How one tends to behave conditionally appropriate;

(3) How one faces a certain situation, organizes actions, makes relations, solves problems, and
adapts with different environments and situation.

 There are a lot of differences in communication style between males and females;
 The differences are due to communication contexts;
 There is connotation difference about who speaks more than the others;
 Males speak more than female informal groups or in meetings of males and females;
 Males always let females to speak more in informal meetings or when formal meetings
have changed to informal ones;
 Males and females who have similar expertise, will perform differently when speaking in
front of public(audience), that is males tend to speak more and longer than females,
 Males initiate more interaction and create more communication than females do.

Feedback Mechanisms in Health

Interactive communication and the ability to consider feedback are critical for linking
community Health workers and the community.

It’s of importance that creating a better work environment as well as a training system at the
organizational level that encourages community health workers to learn about health literacy and
to improve their communication skills. This could improve professional/community
relationships, increase the accessibility of health information for the public, and ultimately
improve community health (Yumiya et al., 2020).

Improving health literacy skills helps people to understand and use Feedback mechanisms and
accountability go hand in hand; feedback mechanisms hold organizations to account. Outside of
accountability, there are many benefits associated with feedback mechanisms which
organizations should consider when assessing whether or not to invest in feedback mechanisms.

Reasons for feedback mechanisms:

 Addressing problems early saves a lot of time and money

 Transparency increases organizational security
 Relationships with communities improve
 Beneficiary empowerment health information for health promotion.

Importance of Feedback to an Organization

 Helps to make sure your program is meeting people’s needs and rights. People have a
very good idea of what they need if we listen to them, it helps us to make sure that we are
helping to address these needs.
 Ensures the most vulnerable are included and benefit from projects. Accountability helps
to ensure that people are not being left out of projects or programs, especially the most
vulnerable. It can also reduce tensions if the community is involved in determining the
selection and entitlement criteria.
 Improves an organization’s relationship with communities. Trust and open
communication lead to efficiency and better outcomes.
 Increases sustainability through empowerment and ownership. The process of working
and achieving things together can strengthen communities. It builds confidence, skills,
capacity to co-operate, consciousness, and critical appraisal. This gives more power to
tackling their own challenges individually and collectively.
 Improves quality of programs. Addressing people’s concerns and feedback can lead to
adapting project activities and resulting in better impact.
 Generates learning and best practice. There is increasing donor interest and funding being
directed at accountability to communities, given the desire to bridge the gap between
 service providers and end users. Learning from community feedback can strengthen
future project design.
 Protect staff from claims of violence. Being transparent through good information
provision and having a good community feedback and response system helps us to be
open to community perspectives and this helps to reduce unfair acquisitions and build
trust.

Personality as a Variable in Diversity

It is easy to observe considerable variation among individuals in susceptibility to illness. Some

people will contract the flu, repeatedly suffer from headaches, or face life-threatening conditions
like cardiovascular disease, while their friends and associates remain healthy.

When illness occurs, some individuals recover quickly while others with similar symptoms
recover slowly or progress to chronic conditions. Perhaps most importantly, some people live
long lives while their peers succumb to death at a younger age. What are the sources of these
variations in individual health outcomes? Personality – a person’s biopsychosocial patterns of
reactions and behaviors – is a useful concept for addressing these issues because it is broad,
relatively stable, and multi-faceted. Personality is partly biologically based, develops in a family
and cultural environment, guides one onto certain life paths, and is evoked by social and
situational forces.

The most obvious causal link between personality and health involves risky behaviors such as
smoking, substance abuse, and unprotected sex; and protective behaviors such as proper
nutrition, weight control, physical activity, sleep, immunizations, safe driving, and regular
physical and dental examinations. The strongest associations are for smoking and tobacco use.
Health behaviors do mediate personality-health links to some extent, but significant variation
remains, indicating that other pathways are also relevant. personality influences the quality and
quantity of social relationships, socially dependent health behaviors, and associated health
outcomes. Conscientious individuals are more likely to have stable careers and marriages, which
in turn enhance their health and their levels of subsequent conscientiousness.

Personality influences the habits we form, the behaviors we engage in, the relationships we
develop, our appraisals and experiences of stressful challenges, the situations we commonly
choose, the reactions we evoke in others, and the lifelong pathways that we follow. Personality
itself is influenced by genetics, early experiences, life changes, maturation, illness, and social
and cultural relationships across time. These various pathways in turn link to health outcomes,
including physical fitness and long life, or decline and premature death.

Life trajectories begin early and are altered by a complex array of influences across the lifespan.
Personality plays an important role in understanding who gets sick and who stays healthy, but
links are neither straightforward nor simple. Multiple pathways are clearly relevant; the need
now is for more vigorous empirical investigation of these multiple causal pathways and
interactive effects. Only by being cognizant of the complex nature of personality’s relations to
health can we distill valid models, and then intervene appropriately.

UNIT FOUR: INCLUSION IN COMMUNITY HEALTH

Inclusion in Community health: Definition, social inclusion, factors contributing to social
exclusions among the most vulnerable, networking towards an inclusive society, disability
(Community based rehabilitation; disability act, strategies of promoting inclusion in community
health programmes).
Social Inclusion
Social inclusion is the process of improving the terms on which individuals and groups take part
in society improving the ability, opportunity and dignity of those disadvantaged on the basis of
their identity.
In every country, some groups confront barriers that prevent them from fully participating in
political, economic, and social life. These groups may be excluded not only through legal
systems, land, and labor markets, but also discriminatory or stigmatizing attitudes, beliefs, or
perceptions. Disadvantage is often based on gender, age, location, occupation, race, ethnicity,
religion, citizenship status, disability, and sexual orientation and gender identity (SOGI), among
other factors. This kind of social exclusion robs individuals of dignity, security, and the
opportunity to lead a better life. Unless the root causes of structural exclusion and discrimination
are addressed, it will be challenging to support sustainable inclusive growth and rapid poverty
reduction.
Social inclusion is the right thing to do, and it also makes good economic sense. Left
unaddressed, the exclusion of disadvantaged groups can be costly. At the individual level, the
most commonly measured impacts include the loss of wages, lifetime earnings, poor education,
and employment outcomes. Racism and discrimination also have physical and mental health
costs. At the national level, the economic cost of social exclusion can be captured by foregone
gross domestic product (GDP) and human capital wealth.
Exclusion, or the perception of exclusion, may cause certain groups to opt out of markets,
services, and spaces, with costs to both individuals and the economy. Globally, the loss in human
capital wealth due to gender inequality alone is estimated at $160.2 trillion. Afro-descendants
continue to experience significantly higher levels of poverty (2.5 times higher in Latin
America). 90 percent of children with disabilities in developing countries do not attend school. In
many countries, it is especially difficult to tackle LGBTI exclusion, discrimination, and violence.
To date, 70 countries continue to criminalize homosexuality.

Over time, exclusion can also contribute to social tensions and even risks of violence and
conflict, with significant long-term social and economic costs.

Forms of social exclusion

Table 1: Forms of social exclusion

Factors contributing to social exclusions among the most vulnerable

Social exclusion is what can happen when people or areas suffer from a combination of linked
problems such as unemployment, poor skills, low incomes, poor housing, high crime, poor health
and family breakdown.
Factors
Demographics –high rates of youth unemployment, increases in lone parenting, ageing and
migration are all demographic factors that can drive exclusion.
Labour market –increases in low pay and the dispersion of income between groups can drive
social exclusion.
Social policy –changes in benefits, expenditure on housing, health and social services can
increase financial divides, reduce and hinder equity of access.
Others
 Low incomes
 Unemployment,
 Lack of education,
 Limited access to transport,
 Poorer physical and mental health, and
 Discrimination are key drivers of exclusion for disabled people

The factors that drive people’s exclusion of others include:

o mental models, outlooks and values that may often be unexpressed and taken for granted,
o mental models of difference or otherness,
o understanding of the ideal, and
o Perceptions of valued or devalued roles.

Inclusive society
An inclusive society is a society that over-rides differences of race, gender, class, generation, and
geography, and ensures inclusion, equality of opportunity as well as capability of all members of
the society to determine an agreed set of social institutions that govern social interaction.
Elements of an inclusive society
The Social Summit defined that the aim of social integration is to create an inclusive society, in
which every individual, each with rights and responsibilities, has an active role to play. But what
makes some societies more inclusive than others? What are the critical elements for creating and
maintaining an inclusive society in practical terms? An inclusive society is based on the
fundamental human rights value, that is, “all human beings are born free and equal in dignity and
rights. They are endowed with reason and conscience and should act towards one another in a
spirit of brotherhood ” It is a society in which all members, regardless of their backgrounds, are
able and motivated to participate in civic, social, economic and political activities. For this to
happen, legal, regulatory and policy frameworks must be inclusive, and uphold and promote just
and inclusive processes in all areas of implementation, so that equal access to basic education,
public space, facilities and information are ensured, and diversity and cultural pluralism are
respected and accommodated. As a pre-requisite, respect for all human rights, freedoms, and the
rule of law, both at national and international levels, are fundamental. Every member of society,
no matter what his or her economic resources, political status, or social standing, must be treated
equally under the law. Legal instruments ensure the guiding principles that will guarantee equity.
Justice and equal opportunities for all citizens. Violators of human rights should be brought to
justice. The judiciary which serves to protect just societies must be impartial, accountable and
inclusive to giving weight to the opinions of those who defend the inclusiveness of the society at
the local, regional and national levels. Maintaining the security of all individuals and their living
environment is paramount in creating a feeling of inclusion and an atmosphere of participation in
society.
To create and sustain inclusive societies, it is critical that all members of society are able and
motivated to participate in civic, social, economic and political activities, both at the local and
national levels. A society where most members, if not all, feel that they are playing a part, have
access to their basic needs/livelihoods, and are provided with the opportunity to participate in
decision-making processes that affect their lives, is a society that will best foster principles of
inclusiveness.
The existence of a strong civil society is fundamental for active participation and making public
policies and institutions accountable. It fosters a respect for the rights, dignity and privileges of
all people, while assuming that they fulfill their responsibilities within their society. There must
be freedom for people to express diverse views and develop unconventional unique ideas.
Members of society must have the confidence to engage and interact with each other, and build
mutual trust while acknowledging their differences.
In order to encourage all-inclusive participation, there must be universal access to public
infrastructure and facilities (such as community centers, recreational facilities, public libraries,
resource centers with internet facilities, well maintained public schools, clinics, water supplies
and sanitations). These are the basic services which will create, when partly or fully put into
place, conditions for people to have a sense of belonging by not suffering the painful
consequence of being unable to afford them. As long as both the advantaged and disadvantaged
have equal access to or benefit from these public facilities and services, they will all feel less
burdened by their differences in socio-economic status, thus alleviating a possible sense of
exclusion or frustration.
It is important to note though, that access alone does not necessarily ensure use of public
facilities, as unequal relations within communities and households may inhibit the use of
facilities by vulnerable groups. Addressing the unequal power relations is therefore a necessary
step to increase participation. Similarly, equal access to public information plays an important
role in creating an inclusive society, as it will make popular participation possible with well-
informed members of society. Information that pertains to the society, such as what a community
owns, generates, or benefits from, should be made available to all. Collective participation,
through accepted representations of all classes and backgrounds, in the planning, implementation
and evaluation of community activities should be sought after. Publication/information sharing
and increasing the accessibility of the community’s activities will eliminate doubts and
suspicions which could otherwise create a sense of exclusion. The mass media can be used as an
effective tool to educate and enlighten members of society.
Equity in the distribution of wealth and resources is another critical element of inclusive
societies. How the resources are allocated and utilized will significantly affect the orientation of
a society, either towards a more integrated, inclusive society, or an exclusive, polarized, and
disintegrated one. Therefore, socio-economic policies should be geared towards managing
equitable distribution and equal opportunities. Inclusive policies, instructions and programs that
are sensitive to and cater to the less advantaged and vulnerable need to be put in place in all
areas/sectors, including public health, and effectively implemented. There is a need for a strong
monitoring and evaluation tools to demonstrate whether inclusiveness was actually achieved, as
well as highlight areas for improvement.
Another dimension of inclusive societies is tolerance for and appreciation of cultural diversity.
This includes societies that celebrate multiple and diverse expressions of identities. By
celebrating diversity, there is a recognition and affirmation of the differences between and
among members of society, which enables societies to move away from labeling, categorizing,
and classifying people, towards more inclusive policies. Also, enabling a diversity of opinions
provides the checks and balances crucial for the development of society, while allowing for the
greatest amount of diverse opinions to enter every discourse.
Education plays a critical role in this area, as it will provide opportunities to learn the history and
culture of one's own and other societies, which will cultivate the understanding and appreciation
of other societies, cultures and religions. Particularly for young people, education provides the
opportunity to instill values of respect and appreciation of diversity. At the same time, education
can empower those who are marginalized or excluded from participating in discussions and
decision-making. Learning about the historical processes and changes allows people to
understand the way in which they and others have been affected by socially inclusive or
exclusive policies, which ultimately influences the values, choices and judgments of individuals,
in particular, those who are in decision-making positions.
Effective leadership is crucial to the development of an inclusive society. Where leadership is
not representative of the society, a disconnection between the people and their leaders may
eventually result. The most common way of addressing this critical element at the local level is
by engaging in open consultations with members of society about municipal issues such as the
budget, and enhancing the free and timely flow of information to citizens and other stakeholders.
Popular participation in decision-making and policy formulation processes could be sought for at
all levels of governance. At the same time, there must be an effort made to achieve transparency
and accountability by all decision-makers and stakeholders.
Finally, there is a need to create positive narratives of an inclusive society of the future, and
enable each member of society to share, understand and contribute to those narratives. Potent
narratives on the future can act like a magnet drawing society towards its envisioned future. A
society with no vision for the future indicates a society in decline. Societies that maintain a unity
of purpose, or a shared vision embraced by the community, and encourage broad-based
stakeholder participation in the formulation of that goal, will be more inclusive as every member
will be working synergistically towards a unified objective.

Disability
Disability: a physical, sensory, mental, or other impairment including visual, hearing or
physical disability which has a substantial long term adverse effect on a person’s ability to carry
out usual day to day activities. Any restriction or lack (resulting from impairment) ability to
perform an activity in a manner or range considered normal for human beings.
Impairment: any loss or abnormality of a psychological or anatomical structure or function
Handicap: is a disadvantage for a given individual resulting from an impairment or a disability
that prevents the fulfilment of a role for the individual
Activity Limitation: An activity limitation is a difficulty encountered by an individual in
executing a task or action.
Disability discrimination is the act of treating someone with a disability less favorably than
someone without a disability.
Rehabilitation: is a process that assists people with disabilities to develop or strengthen their
physical, mental and social skills to meet their individual/collective specific skills. It involves
provision of therapy in various settings like institutions or in the community.
Historical background
Historically disability was largely understood in mythological or religious terms:-
 People with disabilities were considered to be possessed by devils or spirits
 It was often seen as a punishment for past wrongdoing.
Development of science and medicine in 19 th and 20th centuries has help to create an
understanding that disability has biological or medical basis
Most common causes of disability include: chronic diseases, injuries, mental health problems,
birth defects, malnutrition, HIV/AIDS and other communicable diseases

Conceptual models of disability

Traditional model – this model viewed people with physical, sensory or mental impairment as
people under spell of witchcraft, possessed by demons, or sinners being punished by God.
Medical model- have two perspectives
 Impairment perspective – considers disability as an intrinsic problem of the person,
directly caused by disease, trauma or other health condition which requires medical care.
  Functional limitations perspective- the difficulties people with disabilities experience in
getting around are considered as barriers that limit their chance in life.
 The functional limitation perspective expands the impairment perspective to include non
medical criteria but still focuses on the inability of people with disabilities to adapt to
society and measures people’s limitations against a standard of normality.
 Social model – is longer seen as an individual problem but also consider the society’s
failure to take into account people with disabilities.
 It focuses on the strengths of the person (and not on her limitations as in the medical
model) and values her potential.
Social model is based on two perspective
 Environmental perspective- sees disability as resulting from the physical and attitudinal
barriers that affect the person’s participation and create the disabling situation.
 The rights approach – considers that people with disabilities have the rights to enjoy
health and wellbeing and to participate fully in education, social, cultural, religious,
economic and political activities as any other citizen within the community.

Disability domains
They include mental, physical, emotional, behavioural disturbances, speech, sensory, seizure
disorder, congenital disorders and multiple disabilities.
Special interest disability groups: autism, epilepsy, Down’s syndrome, albinism, cerebral palsy,
impairment and congenital disabilities, deaf and dumbness, attention deficit disorder.
Principles of disability mainstreaming
 It is a proactive process
 It is a process that ensures joint responsibility among stakeholders based on interventions
and services
 It promotes disability prevention strategies , rehabilitation treatment concepts and safe
programs designed to control injury and disability
Roles of CHAs in disability mainstreaming
 Advocate for improved accessibility and inclusion of people with disabilities by making
contact with health facilities, schools and workplaces
 Providing information about services available within the community and linking people
with disabilities and their families with these services via referral and follow up
  Provide technical assistance, resources and training for CHVs and community resource
persons
 Supporting the development of referral networks between stakeholders
 Supporting community based rehabilitation programmes to build the capacity of
stakeholders and mainstreaming disability into existing programmes and services
 Supporting the evaluation, research and development of community based rehabilitation
representing the interests of people with disabilities
 Identifying people with disabilities, carrying out basic assessment of their function and
supporting them to form self-help groups
 Raising awareness in the community about disability to encourage the inclusion of
disabled people in the community

Community Based rehabilitation

Introduction
Community-based rehabilitation (CBR) was initiated by the World Health Organization (WHO),
following the Declaration of Alma-Ata in 1978.
It was promoted as a strategy to improve access to rehabilitation services for people with
disabilities in low-income and middle-income countries, by making optimum use of local
resources.
Community Based Rehabilitation is a strategy for rehabilitation, equalization of opportunities,
poverty reduction and social inclusion of people with disabilities.
Community based rehabilitation (CBR) services for persons with disability should support
people with disabilities in attaining their highest possible level of health, working across five key
areas: health promotion, prevention, medical care, rehabilitation and provision of assistive and
supportive devices. CBR facilitates inclusive health by working with the health sector to ensure
access for all people with disabilities and be responsive, community based and participatory.
While emphasis will be on prevention, early identification and referral of persons with
disabilities, the health and social interventions strategies are in place to complement this process.
Certain knowledge and skills for the prevention, early identification, referrals and basic training
for CHEWs and CHVs. Personnel skilled in rehabilitation technology will train and support
CHEWs and provide skilled intervention as necessary.
Mainstreaming the rights of persons with disabilities in the development agenda is a way to
achieve equality for people with disabilities. This enables them to contribute to creating
opportunities, sharing in the benefits, of development, and participating in decision making.

CBR Matrix
In light of the evolution of CBR into a broader multisectoral development strategy a matrix was
developed in 2004 to provide a common framework for CBR programmes.
The matrix consists of five key components – the health, education, livelihood, social and
empowerment.
Matrix has been designed to allow programmes to select options which best meet their local
needs, priorities and resources.
Principles of CBR
Inclusion – It is the act or practice which ensures including people with disabilities in
community life. It also means placing disability issues and people with disabilities in the
mainstream of activities, rather than as an afterthought.
Inclusion also means ‘convergence’ – that is, the involvement of people with disabilities in the
campaigns, struggles and activities of other oppressed groups which are not centered exclusively
on disability issues.
Participation – Means the involvement of disabled people as active contributors to the CBR
programmes from policy – making to implementation and evaluation for the simple reason that
they know best what they need.
Participation also means people with disability being a critical resource within CBR programme
– providing training, making decision.
Sustainability – The benefits of the programme must be lasting. This means an approach to
poverty alleviation where the socio-economic gains last beyond the short –term and benefit not
just the present but future generations.
The CBR activity must be sustainable beyond the immediate life of the programme itself – able
to continue beyond the initial intervention and thrive independently of the initiating agency.
Empowerment – Means that local people – and specifically people with disabilities and their
families make the programme decisions and control the resources. It means PWDs taking
leadership roles within programmes. It means ensuring that CBR workers, service providers and
facilitators are people with disabilities and all are adequately trained and supported.
It necessitates capacity building – that is the developing and using of the skills necessary to act
with authority and responsibility, independent of the initiating agencies and CBR programme.
Self –Advocacy – Means the central and consistent involvement of people with disabilities
defining for themselves the goals and processes for poverty alleviation.
Self- advocacy is collective notion not an individualistic one. It means self-determination. It
means mobilizing, organizing, representing, creating space for interaction and demands.

Strategies of promoting inclusion in community health

1. Welcoming spaces: Ensuring your programs and physical spaces are accessible and
welcoming to people with ID
2. Communication: Ensuring your communications including; written and spoken language,
materials, and interactions with the community are accessible to people without ID
3. Awareness and Training: Understanding your community and training your staff your
staff on barriers and challenges faced by people with ID, including on how to remove
them
4. Sustainable and intentional inclusion: building intentional and sustainable inclusion by
changing organizational culture to value and understand inclusion

Person–with-Disabilities Act
An Act of parliament to provide for the rights and rehabilitation of persons with disabilities; to
achieve equalization of opportunities for persons with disabilities; to establish the National
Council for persons with disabilities; and for connected purposes (Act No .14 of 2003.)
The tutor to take the learners through the disability act.
References/Further Readings
1. Chang W-C. The meaning and goals of equity in health. J Epidemiol Community Health
2002;56:488–91.
2. Baker E, Metzler M, Galea S. Addressing social determinants of health inequities:
learning from doing. American Journal of Public Health 2005;95(4):553–555.
3. Baker, I. (1994). The Strategic Silence: Gender and Economic Policy. London: Zed books
4. Government of Kenya (2010) Constitution of Kenya 2010. Nairobi: Government of
Kenya
5. Elson, D., (1993) Gender Aware Analysis and Development Economics. Journal of
International Development, Policy and planning, 5(2) 237-247
6. GoK (2011) Gender Mainstreaming Guidelines: Working Towards Gender Equality
through Gender Responsive National Planning
7. Moser, C. (1993) Gender Planning and Development: Theory Practice and Training.
Routledge, London