Our son is ‘our asset, future, and bank’: exploring gender-related factors influencing adherence to advice and treatment-seeking guidance following hospital discharge among infants and young children in Bangladesh
Authors: Uddin Md. Fakhar , Molyneux Sassy , Muraya Kui , Hossain Md. Alamgir , Islam Md. Aminul , Shahid Abu Sadat Mohammad Sayeem Bin , Zakayo Scholastica M , Njeru Rita Wanjuki , Berkley James A , Walson Judd L. , Ahmed Tahmeed , Sarma Haribondhu , Chisti Mohammod Jobayer 
Published: August 2020

Abstract
Background
Post-hospital discharge mortality risk is high among vulnerable subgroups of children in many low and middle-income countries (LMICs). The available literature suggests that gender plays an important role in post-discharge adherence to medical advice, treatment-seeking and recovery for ill children in LMICs, including those with undernutrition. We are not aware of any studies that have specifically explored gender-related factors influencing adherence to advice and treatment-seeking guidance following hospital discharge in young children in LMICs.
Methods
A qualitative study was embedded within a larger multi-country multi-disciplinary observational cohort study known as the Childhood Acute Illness & Nutrition (CHAIN) Network. Primary data through formal interviews were collected from household members of 22 purposively selected cohort children, who were visited repeatedly in their homes over 6 months following hospital discharge (total n = 78 visits to homes). Household interviews were complemented by individual interviews with 6 community representatives, 11 community health workers and 12 facility-based health workers, as well as group interviews with 24 community representatives. Data were analysed using NVivo11 software, using both narrative and thematic approaches.
Results
We identified a range of health service/system level gender-related factors that impacted families’ post-hospital discharge adherence to medical advice, treatment-seeking and recovery. These included: fewer female medical practitioners being available in healthcare facilities, which influenced mothers’ interest and ability to consult them promptly for their child’s illnesses; gender-related challenges for female (and male) community health workers in supporting mothers with counselling and advice; and male caregivers’ being largely absent from the paediatric wards where information sessions to support post-discharge care are offered. Gendered influences at household/community level post-discharge, which interplayed with those at health service/system level, included: women’s role as primary caretakers for children and available levels of support; male family members having a dominant role in decision-making related to food and treatment-seeking behaviour; and greater reluctance among parents to invest money and time in the treatment of daughters over sons.
Conclusions
A complex web of gender related factors operate at both the health systems/services level and at the household/community level, with potentially important implications for post-hospital discharge adherence to advice and treatment-seeking for young children. Immediate interventions that may help support positive change include introducing training and support processes that build awareness among all stakeholders – including male family members - of how gender impacts on child health and recovery, and about how adverse consequences of gender-based discrimination can be alleviated. Specific initiatives include those focused on communication in facilities and homes, and changes in routine practices such as who is present in facility interactions. To maximise and sustain the impact of any such immediate actions and interventions, the structural determinants of women’s position in society and drivers of gender inequity must also be tackled. This requires interventions to ensure equal equitable opportunities for men and women in all aspects of life, including access to education and income generation activities. Given patriarchal norms locally and globally, men will likely need special targeting and support in achieving this.