Status of Gender Mainstreaming Implementation in the Health Profession in Selected Health Facilities of Lusaka Urban District in Zambia

Status of Gender Mainstreaming Implementation in the Health Profession in Selected Health Facilities of Lusaka Urban District in Zambia

Charles Muchimba Hakoma, Francis Simui & Gistered Muleya

Institute of Distance Education, University of Zambia

DOI: https://doi.org/10.51244/IJRSI.2024.1103049

Received: 06 March 2024; Accepted: 18 March 2024; Published: 20 April 2024

ABSTRACT

Zambia grapples with the pervasive issue of gender inequality, despite its commitment to global and regional gender agreements and the implementation of legal, policy, and institutional frameworks, including the adoption of gender mainstreaming concepts. This qualitative study employs a case study design to investigate gender inequalities within the nursing profession. Findings reveal persistent gender disparities, echoing similar conclusions drawn by Keddie (2022) that mere representation and key metrics are insufficient for achieving gender equality. Recommendations are made for the Ministry of Health Department of Nursing Services, the Nursing and Midwifery Council of Zambia (NMCZ), and the Zambia Union of Nurses Organization (ZUNO) to go beyond token inclusion of males in nursing training, emphasize career counseling in secondary schools to promote a positive perception of nursing, counter negative public perceptions, and address various professional development barriers hindering minority participation, such as males.

Key words: Gender, Mainstreaming, Gender Mainstreaming, Health Profession & Zambia

BACKGROUND

Gender Mainstreaming is a worldwide issue or an international approach to promoting equality between females and males. It is based on recognition that gender inequality operates at all levels and in all sectors of society and thus needs to be addressed in the mainstream (National Agency for the Control of HIV/AIDS, 2015).  According to Peterson et al., (2021), gender mainstreaming has been on the political agenda since the 1990s, when it was globally adopted during the 1995 United Nations world conference on women which was held in Beijing China as an international strategy to achieve gender equality at all levels. In other words, at global level, the term gender mainstreaming was re-emphasized as a global strategy during the 1995 United Nations world conference for women which was held in Beijing China in order to promote gender equality or attain the absence of any form of discrimination as a result of one’s sex or gender identity (United Nations Development Programme, 2014 – 2017).

The gender mainstreaming concept was also subsequently adopted by the European Union (EU) in 1996 as a means to promote gender equality in all EU policies (Peterson et al., 2021.) Additionally, when one talks about gender equality, it means providing full participation of people of all genders. It is about equal rights and opportunities regardless of sex (Legg et. al. 2023). According to the European policy making Council, gender is about socially constructed roles, responsibilities and expectations that pertain to both males and females (Council of Europe,1998).

Ryan, (2022) did a study and found that in the past fifty years (50) globally, a lot of gender mainstreaming work has been achieved. However, gender inequality has remained persistent at all levels including workplaces. The report by Leal Filho et al., (2022), has also found that gender inequality was still pervasive across the world and women were still experiencing a series of disadvantages, in comparison to men. Yet, Sustainable Development (SD) requires that all people should enjoy equal rights and be able to appreciate lives, free from violence and discrimination. Through SDG 5, gender equality is rightfully at the heart of the 2030 Agenda for sustainable development.

To address gender inequalities, the Zambian Government has strengthened the policy and legal frameworks (Mushing et al., 2023). However, inequality has been identified as one of the bottlenecks to development (Ministry of Agriculture and Livestock, 2014). MoH recognized the importance of gender equality in health programming way back in 1990s at the time of implementing the Health Reforms. The Ministry decided to adopt the gender mainstreaming concept in the reforms. Through its statutory bodies such NMCZ mandated to train all nurses in Zambia, went ahead to adopt the concept by incorporating it in the 2014 revised training curriculum for Registered Nurses (General Nursing Council, 2014). Although MoH has put in place a few guidelines on how to implement the gender mainstreaming concept, by different players, no clear guidelines have been developed for proper guidance. As a result, implementation has been very difficult, because even the concept itself was viewed and reported being new and a confusing term (Cabinet Office, 2000).

In a health professions like nursing, gender mainstreaming means transforming unequal social and institutional structures among male and female nurses (Ross 2017). However, data obtained in Zambia from MoH for the period of 2015 – 2019, showed a drastic reduction in the number of recruited male nurses from 48.7% in 2015 to 31.3% in 2019 (MoH, 2020). This data obtained in Zambia from MoH, seems to suggest that ender mainstreaming implementation in nursing has not been fully realized. Against this background this study had to seek exploring gender mainstreaming implementation in the health profession of nursing focusing on selected 1st level public and private health facilities in Lusaka Urban District in Zambia including overall in-charges of nurses in selected 1^st level hospitals (i.e. public and private) and the overall in – charge of nursing at MoH Headquarters, NMCZ, ZUNO, Provincial Health Office (PHO) for Lusaka Province and the overall in – charge of nurses at the Lusaka District Health Office (LDHO).

Statement of the Problem

While health profession bodies such as NMCZ has adopted gender mainstreaming as a central approach to promoting gender equality in nursing, there seems to be different results on the ground. For instance, data obtained from the MoH for the period of 2015 – 2019, showed a drastic reduction in the number of recruited male nurses from 48.7% in 2015 to 31.3% in 2019 (MoH, 2020). This data seems to suggest that gender mainstreaming strategy is not achieving the intended target. In other words, policy, legal, institutional frameworks; and programmes can be established by any organization such as the NMCZ to play a vital role in promoting gender equality, but the number of males who join such a profession which has been a female dominated for many years, can still remain a minority. It was due to such observed gap that led to conducting a study like this one to explore gender mainstreaming implementation in the health profession especially nursing in Zambia.

Purpose of the Study

The purpose of this study was to explore the current status of gender mainstreaming implementation in the health profession in selected 1^st level health facilities in Lusaka Urban District in Zambia.

Specific Research Objective

The study sought to establish the current status of gender mainstreaming implementation in the health profession in selected health facilities of Lusaka urban district in Zambia.

Significance of the Study

The significance of this study was that policy makers may be able to formulate practical policy, guidelines, and procedures regarding the current status of gender mainstreaming implementation in the health profession. In addition, to make health professional of nursing acquire knowledge and skills regarding current status of gender mainstreaming implementation in the health profession.

Theoretical Frameworks

This study was anchored on two (2) theories (i.e., gender performativity theory by Judith and structural functionalism theory for Durkheim). Emil is the proponent of the theory of structural functionalism while Butler is for gender performativity theory. Butler a gender scholar who changed the study of gender identity by bringing revolutionary ideas.To Butler, gender performativity theory meant that, anyone qualified to be called a male or a female. In her Gender Trouble book, Butler defines gender as repeated stylization of the body or repeated “acts” within a high regulatory framework that congeal over time to produce the appearance of a substance of natural sort of being. It is also known that there are feminists that regard gender as merely male, female or binary. For instance, at the time of the birth of a child, a child is assigned a sex either a boy or a girl. Butler’s gender performative theory entails that gender goes beyond biological classification such as a male or a female. However, she also believes that gender is socially constructed including sex which is pronounced at birth of any child. She illustrates further about gender as what a male or female does in a stylized manner repeatedly such as the way a male or a female talk, dress which are institutionalized as norms on how men and women should think and behave. Butler further recommends that feminists should seek to understand how the category of “women” is produced and restrained by the means through which social change is sought. She further, challenges the common-sense understandings of gender as a mere representation and argues that far from feminist representations of just women in the linguistic sense being a simple reflection of what women are. She asks a series of far reaching and deeper radical probing questions and argues that gender should not be taken as a simple derivation from sex. As a result, Butler’s work has changed the way of thinking about gender. In other words, gender performativity theory has demonstrated that gender is about going beyond mere representation or participation or inclusion of females and males. To Butler, gender ontology/reality is performative because it could be learnt, practiced and shaped as a sequence of acts or repetitions (Butler et al., 2011).

LITERATURE REVIEW

Global Perspective of Gender Mainstreaming Implementation

At global level, Hedlin et al., (2023) in Sweden did a study entitled “The Glass Funnel: A Tool to Analyze the Gender Regime of Healthcare Education and Work” which revealed that regardless of a number of efforts to eliminate gender segregation within Sweden, working life is still marked by traditional gender patterns. For instance, in Sweden, gender in nursing men tended to gain advantages, but as is the case for vocational training, in healthcare, men not only experience benefits but they also risk being questioned and met with prejudice. Further, it was revealed that, there was a notion of male nurses not being ‘real men. However, the study by Hedlin et al., (2023)’s was not focused on gender mainstreaming implementation in the nursing profession and it was not anchored on any theoretical framework.

Livari et al (2023), also did a qualitative study on, “Participatory design meets gender equality in European Higher Education Institutions (HEIs).” This study was not anchored on a theoretical framework and the study population targeted on European Higher Education Institutions and not nursing. Jess Mark et al. (2022) in the Philippines did also a study and found that disparities, discrimination and biases persisted despite social, political, and economic changes. Jess Mark et al. (2022)’s finding was in agreement with that of Michelle (2022) in Australia which also revealed that despite much progress in the past 50 years, workplace gender inequality remains a persistent problem. However, Michelle (2022)’s study was not anchored on any theoretical framework and the study population was not the nurses.

In France, Breda et al., (2022) did a study which also found that gender stereotypes do exist. In Australia, Keddie (2022) conducted a study on gender equality reform and police organizations which revealed that understanding representation and understanding key metrics of gender equality are necessary parts of achieving gender equality but they are not sufficient. Keddie (2022) further explained that such numbers are a great starting point as they identify problem areas to be rectified, but they do not tell the whole story. However, Keddie (2022)’s study, was not anchored on any theory and the study population was not the nurses. In Greece, Cardon – Molto et al (2022) did a study on, “students’ perceptions of gender mainstreaming implementation in the University Teaching in Greece”. The purpose of the study was to explore the status of gender mainstreaming implementation among the University students and it was found that formal preparation for gender mainstreaming implementation was practically non-existent.

Gülay (2013) did a study which revealed that at international level, there were various … agreed upon regional and world/international frameworks, resolutions, undertaken in the twentieth century towards pervasive gender inequalities. However, Gülay (2013) found that a visible gap remains between policy and practice and between rhetoric and reality. At operational level, health professionals such as nurses, have been reported to be associated with social stereotypes which could hindered the profession’s development and future prospects as a scientific discipline (Perez, et al., 2022).

In Sweden, another study was done by Freidenvall et al. (2019), on, “implementing gender mainstreaming in Swedish Model Municipalities” and it was found that the key obstacles to the implementation of gender mainstreaming is complacency. Complacency is, the perception that work on gender mainstreaming was satisfactory and that there was no need of an extra attention to it.

Gupta et al. (2023) also did a study on, “beyond gender mainstreaming humanitarian action organizations and culture” and reported that mainstreaming was attributed due to lack of effectiveness as a result of lack of expertise, funding, accountability, compliance commitment, lack of planning and Monitoring and Evaluation (M&E) strengthening and lack of tracking resources. Additionally, Gupta et al. (2023) also revealed that there was conceptual confusion, insufficient allocation of financial resources. The study was not anchored on any theory and the study population was not nurses.

Sundari Ravindran et al. (2021) in Malaysia did also a study on, which revealed that while the United Nations has for a long time implemented strategies to tackle deep-rooted gender-based inequalities and discrimination in its programmes and policies, there was still limited evidence on successful.

Shannon et al (2019) in Britain did also which revealed that gender equality is a human rightand is essential to the achievement of peaceful societies with full human potential and sustainable development and recognized as one of the most important determinants of health and economic development. However, it was recognized that gender, remains a complex issue in health and development. The study also revealed that even if the term gender was a “widely used, it was often perceived as being misunderstood whereby sometimes mistakenly conflated with sex or used to refer only to women”. Further, Shannon et al (2019)’s study recommended that there was a need to go beyond quantitative gender equality and strive for cultural transformation that allows for inclusion of values of transparency, honesty, fairness and justice. As stated in Ryan (2022)’s study, numbers in gender equality aren’t enough but to go beyond numbers is what matters most and to strive to adopt cultural transformation that allows for inclusion of values of transparency, honesty, fairness and justice

Another study was conducted by Bustreo et al. (2022) which revealed that gender inequality is one of the biggest obstacles to realizing the Sustainable Development Agenda by 2030 and that it also that gender mainstreaming offers a way to address gender discrimination and contributes to achieving the 5^th Sustainable Development Goal (sdg).

Raghavan et al. (2023) also conducted a study which revealed that despite global promotion of gender mainstreaming as a tool for meeting gender equality objectives, no country is set to achieve gender equality by 2030. This study mainly reflected on what worked and what more was needed to be done to deliver on its promise. In Bustreo et al. (2022)’s study, it was found that there were three (3) barriers to effective gender mainstreaming implementation. These include conceptual challenges, the need for leadership commitment, and overcoming practical constraints. In addition, Bustreo et al. (2022) found that there was also conceptual confusion in two-folds. First, to make gender issues ‘main’, or more precisely, normal and then make it widely accepted in contrast to ‘gender side-streaming’. It was revealed by Bustreo et al. (2022) that in many cases ‘mainstreaming’ was at best operationalized as the need to add ‘women’s interests’ to existing policies and programmes, rather than an approach to addressing unequal gendered power relations. Secondly, it was revealed that there was also confusion about the term ‘gender’ itself on its meaning, and why it was necessary to understand the critical dimensions of it. Bustreo et al. (2022) further explained that there was still a gender mainstreaming conceptual gap which was contributing to it being reduced to a technical exercise with a reliance on toolkits and guidance. Bustreo et al. (2022) revealed that moving beyond a tick-box exercise required high-level commitment and resources to gender mainstreaming and gender equality more broadly.

Rai et al, (2022) in Nepal also did on, “Rethinking gender mainstreaming in agricultural innovation policy in Nepal: a critical gender analysis” which revealed that gender mainstreaming has been prioritized in national areas like in sector policies. Yet, at the national level, the policy does not always work to effect change when implemented at the local scale. It was also further revealed that in less-developed nations, it is rare to find a critical analysis of the mainstreaming process and its successes or failures.

Sub-Saharan Perspective of Gender Mainstreaming Implementation

A study by Muyomi (2014) in Kenya found that there were challenges in implementing gender mainstreaming strategy in line ministries. This finding was similar to Cheludo (2022)’s study in Botswana which also revealed that gender mainstreaming was limited by structural barriers of transforming unequal gender relations.

In Malawi, Chinkhata and Langley (2018) did a study on gender mainstreaming in Nursing Education and found that there were challenges in including Malawian student male nurses during undergraduate nursing training.  The study by Chinkhata and Langley (2018) looked at professional socialization processes of Malawian student male nurses during their undergraduate training. The study also revealed that males still remained a minority in the nursing profession.

Another study by Winter (2017) on gender mainstreaming revealed that nursing was still a female dominated occupation. In other words, despite the South African Government making efforts to achieve gender equality, the numbers of female nurses superseded the numbers of male nurses by far.

Akumuntu et al, (2020) in Rwanda also did a study on, “promoting gender equality in Rwanda” and it revealed that there were still challenges of gender inequalities despite Rwanda putting tremendous efforts such as putting in place legal, policy and institutional frameworks. For example, men still lagged behind in terms of percentage while the number of female nurses was higher than the male nurses.

Nepemba (2021) in Namibia, did a study on gender mainstreaming implementation on the progress made in the application of gender mainstreaming and to identify the challenges associated with the application of gender mainstreaming in the Namibian Correctional Service Facility. The revealed that, while the policy framework for gender mainstreaming can be in place, but implementation is still lacking. Further, the study revealed that gender inequality cannot be adequately addressed by viewing it based on improvements in women’s work and representation.

Another study by Shash and Forden (2016) in Egypt revealed that although gender mainstreaming can play a role in reducing gender inequality”, there is a need to rethink its implementation and recommended.

In 2020, Okongwu in Nigeria, also did a study and found that though some progresses have been made to reduce inequality in Nigeria, discrimination remains a problem to women and is exacerbated by factors such as culture, religion, social practices, discrimination including the patriarchy system. In addition, the study indicated that there is structural gender inequality in families and society where men are trained for leadership activities while women are constrained to domestic activities which affect them self – worth and confidence later in their actual life and career. The study also revealed that the patriarchy system normalizes the fact that men are leaders in homes and society and therefore there is a tendency that anywhere a man is seen in a position of power and leadership and it is viewed as normal while the opposite as an anomaly. For instance, predominant religions hold that God created men as leaders in families including the entire society and as a result, women are expected to be subordinates and submit to their leadership. In communities, individuals are indoctrinated with these religious views through socialization and education to accept them as natural and a divine order from God. Boys are therefore raised with a belief that God has ordained them already to be heads in their homes while girls are raised and trained to be good and virtuous wives and to learn to be submissive to their husbands.

Njoroge et al. (2021) in South Sudan also did a study and recommended that, there was a need for the government of South Sudan to establish more strict measures to ensure that there was gender equity in employment in both private and public service. Additionally, there was also a need to have stakeholders for South Sudan government to create awareness to the public on the importance of the implementation of the existing National Gender Policy. Further, it was also recommended to the government of South Sudan to increase resource the allocation for gender mainstreaming activities. In addition, the study by Akumuntu et al, (2020) in Rwanda also revealed that despite putting tremendous efforts legal, policy and institutional frameworks, men still lagged behind in terms of percentage whereby the number of female nurses was higher than the male nurses. Further, Njoroge, et al., (2021) also revealed that despite the existence of National Gender Policy put in place by the government of South Sudan, the gender mainstreaming implementation was found still not clear.

Another study was done by William (2019) which revealed that although the government of Tanzania had taken measures to mainstream gender in government institutions, there is little investigated in the workplaces of NGOs.

Zambian Perspective of Gender Mainstreaming Implementation.

Kafukanya et al, (2019) did a study which revealed that, Zambia still ranks 139th out of 188 countries with regards to gender equality indicators. Further, it was revealed that almost all African countries Zambia inclusive have ratified the Convention on the Elimination of Discrimination against Women, except for Sudan and Somalia (Kafukanya et al., 2019). However, Zambia has failed to match up with the achievements of its Southern African Development Community (SADC) counterparts despite having put in place a number of legal, policy frameworks and various international treaties signed (Kafukanya et al, 2019). The slow achievement of Zambia to attain gender equity and equality revealed by Kafukanya et al, (2018) is in agreement with the finding by Sialubanje et al (2018) who also found that despite the Zambian government making progress on prioritizing gender mainstreaming, progress was still low. This finding is in agreement with what has been reported by Ministry of Gender (2019) that there was slow progress made regarding gender mainstreaming across all sectors in the Zambian economy. Ministry of Gender (2019) revealed that this deficiency is primarily attributed to limited understanding of gender itself and gender mainstreaming. It was also revealed that there was also a general lack of appreciation for the importance of gender issues by people working in the public and private sectors which translated into a reluctance to properly implement gender mainstreaming strategies in developmental programmes.

Shula (2023) also did a study which revealed that despite all positive strides Zambia has made in recent years, regarding gender mainstreaming implementation, gender disparities have persisted. Shula (2023) further revealed that cultural, social, and economic landscape shapes these gender dynamics, emphasizing the need to examine the concept of gender equality within the Zambian context. Further, the study revealed that there was an influence of societal norms and deep-rooted structures on gender roles. Therefore, analyzing, emphasizing their impact on conscious and unconscious biases is critical.

As earlier alluded to, in 2014, Zambia revised its National Gender Policy (Ministry of Gender and Child Development, 2014), put in place the National Health Strategic Plan 2017 – 2021and came up with the Vision 2030 which also facilitated the development of the Anti – Gender Based Violence National Policy. In addition, Zambia has put in place institutional frameworks and provision of the national gender mainstreaming coordination for all sectors health inclusive through creation of the Gender Desk in the Office of the Vice President headed by a specific Permanent Secretary (PS). Additionally, Zambia has signed a number of agreements, treaties, protocols, declarations especially those that contain strong languages against gender inequalities. Besides that, a number of gender summit meetings, conventions have been attended to where resolutions at global and regional levels in the twentieth century have also been made.

In all, the reviewed literature at global, regional and local levels, showed that there were limited specific studies that were conducted to establish the current status of gender mainstreaming implementation in the nursing profession. However, the scanty studies that were done, were not specific to gender mainstreaming implementation in the nursing profession. Therefore, this study became justifiable to be conducted targeting the nursing profession because it is the main pillar of the health care delivery system in Zambia constituting 75% of the total workforce of MoH. This observation agrees with the National Health Strategic Plan 2017 – 2021 for Zambia which states that, “Nurses and Midwives are the largest workforce in the health sector providing almost 80% of care to individuals.”

METHODOLOGY

Research Design

This study adopted a qualitative methodology with a case design because there was a great need to obtain an in-depth understanding of how gender mainstreaming implementation done in the nursing profession. In addition, a case study explores in – depth, interprets opinions, feelings, experiences, and inner thoughts of the studied. In this study Focus Group Discussions (FGDs) and in – depth face – to – face interviews and document reviews were employed to capture the actual practical experiences, perceptions, opinions, attitudes, feelings, and thoughts of nurses on the ground surrounding gender mainstreaming implementation in a natural setting. In other words, the central tenet of the researcher to adopt a case study approach in a “naturalistic environment” designed to carry out an in-depth exploration to determine gender mainstreaming implementation in the nursing profession.

Study Site

The study site was Lusaka Urban District in six (6) selected 1st level hospitals (i.e., 3 public and 3 private) and inclusion of the MoH HQ, NMCZ, ZUNO, LPHO and LDHO, were purposively selected.

Study Population

In this study population were the nurses drawn from six (6) selected 1st level hospitals (i.e., 3 public and 3 private), inclusion of overall in – charges of nurses for six (6) selected 1^st level hospitals, overall, in-charge of nurses at MoH HQ, NMCZ, ZUNO, LPHO and LDHO, were purposively selected.

Target Population

The target population were general nurses drawn from six (6) selected 1st level hospitals (i.e., 3 public and 3 private), inclusion of overall in – charges of nurses for six (6) selected 1^st level hospitals, overall, in-charges of nurses at MoH HQ, NMCZ, ZUNO, LPHO and LDHO who were purposively selected.

Sampling Strategy

This is a case study and a minimum sample size of fifty (50) nurses were purposively selected from participating three (3) public and three (3) private 1st level hospitals; and MoH HQ, NMCZ, ZUNO, LPHO and LDHO.

Sampling Procedure

Since the study used qualitative approach, the non-random probability sampling procedure was used to select purposively the general nurses that were drawn from six (6) selected 1st level hospitals (i.e., 3 public and 3 private) to participate during the Focus Group Discussions (FGDs), the overall in – charges of nurses for six (6) selected 1^st level hospitals and the overall in-charges of nurses at MoH HQ, NMCZ, ZUNO, LPHO and LDHO for in – depth interviews as Key Informants (KIs) and for participating during document reviews using a checklist.

In short, this study used a non- probability sampling approach using a purposive sampling technique to select 50 study participants. Purposive is a technique whereby a researcher does a deliberate selection of participants that conform to pre – determined criteria. In this study. The non-random probability sampling approach was used because it was found to be relevant for selecting study participants to conduct 11 in – depth face – to face interviews, 6 Focus Group Discussions (FGDs) and 11 documents reviews because it provided room to deliberately select individuals subjectively that were perceived by the researcher to possess relevant knowledge, skills and competence for the study phenomenon. In other words, study participants were selected because, they satisfactorily met the sampling objective. Further, purposive sampling, offers an opportunity to select a pool of capable individuals for the study. Welman et al. (2005) justifies purposive sampling as the most important type of non – probability sampling because a researcher relies on his/her experience and characterized by a desire by the researcher to meet a goal other than representativeness. Cooper et al. (2011) explains that, judgment sampling, entails that a researcher picks the sample he/she thinks will deliver the best information in order to satisfy the study objectives in question.

The eligibility criteria for inclusion was that only nurses found working in six (6) selected 1st level hospitals (i.e., 3 public and 3 private) at the time of data collection were allowed to participate in the study. It also included overall in – charges of nurses in six (6) selected 1^st level hospitals (i.e., 3 public and 3 private) and overall and in – charges of nurses at MoH HQ, NMCZ, ZUNO, LPHO and at LDHO, and at. Additionally, the selection criteria included willingness voluntarily of those participants to participate in the study which was shown by signing the informed consent.

Data Generation

Before conducting this study, permission in written was obtained from UNZA Ethics Committee, the National Health Research Authority, MoH Permanent Secretary in – charge of Technical Services, the Provincial Health Director for Lusaka Province, the District Director for Lusaka District and the in – charges of the six (6) selected 1st level hospitals (i.e., 3 public and 3 private). For data collection, unstructured interview schedule with open – ended questions was used for all 11 in – depth interviews of overall in -charges of nurses as Key Informants and 6 FGDs of general nurses in 6 selected 1st level hospitals (i.e., 3 public and 3 private). For document review, a checklist was used for data collection.

According to Bowling (2014), “unstructured interview schedule” simply means a face-to-face interview with topics listed but with few specific questions and no fixed questions. These unstructured in -depth interviews were chosen because they delved beneath when interviewing Key Informants (KIs) and during FGDs to obtain the true meanings of gender mainstreaming implementation in the nursing profession. The in -depth interviews enabled the researcher to assess existing attitudes, behaviours and experiences of nurses regarding gender mainstreaming implementation in the nursing profession. In other words, in – depth interviews allowed nurses to tell their own stories in their own words, the processes and actions or practices regarding gender mainstreaming implementation in the nursing profession. In other words, this was a testimony study (Bowling, 2014). All precautions stated above were taken into consideration because of the sensitivity nature of the study as it focused on concerns and needs of female and male nurses regarding gender mainstreaming implementation in the nursing profession. Additionally, using the unstructured interview schedule, FGDs were conducted and using a checklist, document reviews were conducted. FGD is an efficient data collection technique used in Social Science Research to obtain qualitative data from multiple participants and it is less intimidating for participants and it also allows the researcher to encourage groups to explain their experiences, opinions, perceptions, beliefs and attitudes in – depth while document review, simply means analyzing documents, interpret and identify their limitations in relation to the study phenomenon (Payne, 2004). Each FGD lasted not more than 60 minutes while in – depth Interviews for Key Informants (KIs) not more than 45 minutes and document review took 40 minutes. FGDs went on until data saturation occurred after reaching six (6) interviews. Data saturation simply means FGD participants not bringing out any new information or a situation whereby same information from participants keeps on coming or repeatedly regardless of researcher probing further. All the FGDs and in– Depth Interviews were audio – recorded for transcribed verbatim and then authenticated for accuracy and completeness by the most experienced qualitative researcher. All interviews began with assurance of the participants and signing of the consent, followed by questioning based on the study objectives.

Data Analysis

In this study, the researcher explored the current status of gender mainstreaming implementation in the nursing profession as a broad policy approach on a macro and micro levels, translated into more tangible articulations in specific 11 unique strategic study sites (i.e., MoH HQ, ZUNO, NMCZ, LPHO, LDHO, 3 public 1^st level hospitals, and 3 private 1^st level hospitals). Data collected in this study draws on conducted qualitative interviews involving 50 participants as sample size selected purposively as the starting point for gender mainstreaming implementation in the nursing profession. The researcher investigated on 50 nurses to find out how gender mainstreaming implementation in the nursing profession as a broad policy strategy which was incorporated in the revised 2014 curriculum for training of registered nurses in Zambia was translated, organized into more specific conceptual process at all levels in practical terms to fit their local contexts. The results below highlight how the nursing profession in 11 strategic study sites translated gender mainstreaming implementation in the nursing profession through 50 participants that were involved in this study. Data collected was analyzed, using Content Analysis (CA because it was found to be an appropriate approach for tape recorded data collected through FGDs and in-depth Interviews of Key Informants (KIs). Content Analysis, requires identifying relevant data gathered, coding, categorizing and generating themes based on underlying meaning of the data. However, CA has both strengths and weaknesses. For instance, one of the strengths is that it is flexible as it can be used on a wider range of data types such as written records, interviews recordings and speech transcriptions. Despite its strengths, Content Analysis has also weaknesses such as not being reliable to come up or draw conclusions from data gathered and analyzed. For example, drawing conclusions from CA Approach which focuses much on making final conclusions on the frequency of words and phrases or their relationships to each other, can be a subjective process and decreases reliability. In addition, study results cannot be usually generalized.

Ethical Consideration

Before embarking on this study, the researcher had to seek for permission in writing from the University of Zambia (UNZA) Ethics Committee, MoH Permanent Secretary in – charge of Technical Services, the Provincial Health Director for Lusaka Province, the District Director of Health for Lusaka and in – charges of nurses at the District Health Office and from the participating selected 1st level public and private health facilities in Lusaka Urban district. Further, participants were also requested to participate voluntarily by first obtaining consent for seeking their willingness to take part in this study. The purpose of the study was explained to the study participants and explained to them that the information that was to be provided by them was to be kept as confidential without revealing their identities. In other words, the researcher had to seek approval of moral good practical ethics in order to avoid any harm that could have emanated during the study. Additionally, the researcher had also to seek ethics that were mostly considered in a qualitative case study such as obtaining informed consent, the importance of explaining to participants that they were free to withdraw at any time from the study, the importance of the maintenance of confidentiality (Ngozwana, 2018). It was made clear to the studied about their rights in research from the beginning. The participants were informed that the information they were to give, was purely for academic purposes and no one was to be requested to disclose his/her identities without their consent. In addition, participants were also informed that if they did not want to respond to any question, they were allowed to proceed or go to the next question. Further, the participants were also informed about the duration of both the Focus Group Discussion (FGD) which each was to take not more than 60 minutes while in – depth Interviews for Key Informants (KIs) not more than 45 minutes and document review using a checklist for about 40 minutes.

Trustworthiness of the Data

The four (4) proposed criteria by Lincoln and Guba in 1985 include; credibility transferability, dependability, and confirmability criteria for validity and reliability in qualitative research. Credibility is crucial criteria in qualitative research that has been proposed in several quality frameworks. The techniques used by the researcher to establish credibility for this study included prolonged engagement of study participants, triangulation, peer debriefing and member checks. Using prolonged engagement of participants technique, the researcher spent not less than thirty (30) to forty (40) days in the actual sites of the researched in order to develop an in – depth understanding of gender mainstreaming implementation in the nursing profession. With the use of triangulation technique which means, the usage of different or several data sources of information from the field by examining evidence from the sources and using it to build a coherent justification for themes. To achieve this, the researcher repeatedly establish identifiable patterns while conducting 11 face – to face interviews of Key Informants (KIs), six (6) Focus Group Discussions (FGDs) on general nurses and did document reviews. During each FGD, the participants were asked to provide honest responses. In addition, the researcher used the peer debriefing technique as well. Additionally, to ensure credibility of the study findings, the researcher used member checking to determine the accuracy of the qualitative findings by making follow – up interviews with study participants and providing them an opportunity for them to comment on the findings.

FINDINGS AND DISCUSSION

Current Status of Gender Mainstreaming Implementation

The objective and the research question of this study was to establish the current status of gender mainstreaming implementation in the health profession of selected health facilities of Lusaka urban district in Zambia. Twenty (20) out of forty (40) female nurses who participated in this study representing 50% revealed that the status of gender mainstreaming in the nursing profession was just statical or mere representation of males to train as nurses while females still continued dominating the nursing profession. The study found that representation or inclusion of male in the nursing profession was the one considered as gender mainstreaming implementation when it was not.

<CNO0001>‘’… the number of male nurses and midwives we have, is still smaller compared to the number of female nurses and midwives that we have”.

<CNO0001>” You know, at all levels of service provision, the number of females employed by the Ministry of Health was huge than that of the males. However, when you look at holding strategic positions such as Principal Tutor positions, the number of males was higher than that of females despite being smaller at training, recruitment and deployment levels.

“…I think I would real conclude that it is being implemented, considering that males who were not part of the profession at the beginning are now being accepted in the profession and being given the responsibilities to manage the health facilities as well as training institutions.”

The participation of the male nurses aamu… has increased in their aah, education and their specialization.

The what the participants revealed regarding this study representation of males in the nursing profession came out as the emergent them with increased number of males in nursing and nursing remained female dominated profession and sub-themes.

This study focused on the emergent theme “representation of males in the nursing profession. Participants shared that, gender mainstreaming implementation was starting from 1980s and 1990s when males were allowed by the Zambian Government to start training in nursing. Participants revealed that, for more than three (3) decades now from the time males were allowed to be as nurses, there has been an increase in number of males going into the nursing especially during student enrolments in nursing schools and recruitment. However, participants revealed that the record of an increase of male training as nurses, remained very low while that of the female folk, continued increasing rendering nursing still female dominated working against one United Nations SDG 5 which aims to achieve gender equality by ending all forms of discrimination, violence and harmful practices and it is a human right, a precondition one for realizing all other prescribed UN Global Goals in the 2030 sustainable development agenda (UN, 2023).

This study which explored the current status of gender mainstreaming implementation in the nursing profession, found that representation or inclusion of males in nursing was regarded as gender mainstreaming implementation in the nursing profession. This finding is similar with that of Keddie (2022) which found that understanding representation and understanding key metrics of gender equality are necessary parts of achieving gender equality but they are not enough. Keddie (2022) further stated that numbers are a great starting point as they identify problem areas to be rectified, but they do not tell the whole story. Even Ministry of Gender in 2019’s report it was revealed that there was low gender mainstreaming in Zambia. The Ministry further revealed that there was also slow progress made in as far as gender mainstreaming implementation was concerned across all sectors in Zambia. This deficiency in the enabling framework is primarily attributed to limited understanding of gender and gender mainstreaming. The Ministry of Gender in 2019 reported that there was a general lack of appreciation for the importance of gender issues by people working in the public and private sectors.

In Molto et al (2022)’s study, it was found that the formal preparation for gender mainstreaming implementation in university teaching was practically non-existent. Further, Molto et al (2022)’s study, showed some similarity to those of this study which revealed that the status of gender mainstreaming implementation in University Teaching Institutions was practically non – existent. In other words, Molto et al (2022)’s findings suggest that gender mainstreaming implementation was poorly considered at Institutional curricular, and rational level.

Other study by Keddie (2022) found that understanding representation and understanding key metrics of gender equality are necessary parts of achieving gender equality but they are not enough. In addition, Keddie (2022) also explained that such numbers are a great starting point as they identify problem areas to be rectified, but they do not tell the whole story. Keddie (2022) also recognized that gender inequality could not be addressed without transforming the hierarchical and masculinized cultures of policing organizations. In other words, Keddie (2022) suggested that gender inequality can only be addressed by overcoming injustice, meaning, dismantling institutionalized obstacles that prevent some people from participating on a par with others, as full partners in social interaction. In short, to address a complex issue such as gender inequalities, numbers just aren’t enough.

Keddie (2022) revealed that gender mainstreaming implementation requires going beyond mere representation just as Judith Pamela Butler and Ross (2017) stated. Ross (2017)’s article revealed that gender mainstreaming means transforming unequal social and institutional structures into equality.

With Butler the proponent of the performativity theory changed the way of studying gender by going beyond mere representation or just statistical basis ignoring social type of gender.

In as far as Butler is concerned, there is biological gender and societal gender. Biological gender, means the status of as female, male, or intersex depending on their chromosomes, reproductive organs, and other characteristics. Social gender refers to the characteristics of women, men, girls and boys and socially constructed. This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other. As a social construct, gender varies from society to society and can change over time. Nevertheless, Butler’s gender performativity theory is not perfect. It has been heavily criticized globally especially when a person may identify as male or female. In other words, genderqueer is another term for someone who opens about their sexual orientation. They may or may not identify themselves as heterosexual or same-gender-loving. Butler also observed that such populations can be abandoned to unliveable, precarious lives and unnoticed deaths without any serious public accountability.

The global criticism of Butler’s gender performativity theory especially when other individuals may identify themselves as male or female, or as between genders, or as a mix of the two which is known as genderqueer, is not legally supported by the Zambian constitution. Sambo and Kaaba (2022) revealed that, Zambia being a Christian nation does not allow same sex relationships as they are perceived to violate “public morality.” Further, Butler elaborated that in contemporary globalized, neoliberal world, more and more people are living in such situations, without adequate social support, sustainable environments or access to the public sphere. In another way, Butler reminds society that vulnerability is not all bad; it is what makes life possible. All bodies must be in some way open to the world and to others. They must be able to take in and give out: to eat, breathe, speak, be intimate. Butler says a body that is unable to do this could not be alive. Ultimately, she reminds, poetically, that to be fully ourselves, we need each other.

To address some skepticisms about relying so much on Butler’s genderqueer component which has been heavily criticized, it is the reason why this study was anchored on another theoretical framework of Structural functionalism developed by Emil Durkheim who has contributed a lot to societal transformational perspective on the study of gender for balancing life by considering societal values, norms, rules, beliefs for orderliness. According to Durkheim, values, are critical societal agreed upon norms which are meant for law and order and they can differ from place to place. These are rules, norms of the game to guide individuals living in communities on how to conduct themselves to continue being accepted. In other words, values are societal culturally prescribed norms, rules which have to be followed by everyone in order to be accepted and live together in harmony in any community. Durkheim’s Structural Functionalism Theory strongly believes that in order for everyone in society to perform his/her own tasks in an orderly manner, there are values, norms or rules put in place by communities to be observed. These values, norms, rules differ from place to place since they are socially constructed. In all, what was found as key in this study regarding the current status of gender mainstreaming implementation, is that gender mainstreaming implementation in the nursing profession was just regarded as representation or inclusion of males in the nursing profession minus going beyond.

CONCLUSION AND RECOMMENDATIONS

The objective and the research question for this study were both answered. The major finding of this study is that the current status of gender mainstreaming implementation, it was just regarded as a mere representation or inclusion of males training as nurses minus going into much detail or beyond. In other words, the study revealed that gender mainstreaming implementation in the nursing profession was perceived happening because males were now being incorporated or included into nursing training. However, it was found that females were still dominating the nursing profession despite the NMCZ adopting the gender mainstreaming concept in the 2014 revised curriculum for training registered nurses. This finding did not concur with Butler’s performativity and Emil Durkheim’s structural functionalism theories because both theories challenge the common-sense understandings of gender as a mere representation. She argues that far from feminist representations of just women in the linguistic sense being a simple reflection of what women are. For Butler she asks a series of far reaching and deeper radical probing questions.

Recommendations

1. Department of the nursing services at MoH to start promoting gender mainstreaming implementation that goes beyond mere representation or inclusion males to train as nurses;
2. Nursing and Midwifery as a careerfor both males and females should be strongly incorporated    by MoH in career counselling in secondary schools;
3. NMCZ should take measures to stop the public’s negative portrayal of nursing as just feminine or career of individuals who merely followers’ doctors’ orders only; and
4. NMCZ should focus on multiple aspects of professional development that affect the participation of under-represented minorities such as the health profession like nursing.

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