Abstract
Background
Gender and equity are critical determinants of health and healthcare access. The perceptions of health workers can shape how gender and equity are integrated into primary care services, influencing both the quality and fairness of care delivery.
Objective
To assess health center staff perceptions of gender and equity in the Conakry health region, Guinea.
Methods
A descriptive cross-sectional survey was conducted in 19 health centers across the five communes of Conakry. The study included 412 health workers: physicians, nurses, midwives, technicians, and other patient-facing staff. Perceptions of gender and equity were measured using a structured questionnaire, and data were analyzed with descriptive statistics.
Results
Health workers predominantly held a biological view of gender, with most agreeing that biological characteristics mainly determine gender and that men’s and women’s roles are naturally different. A large proportion did not perceive gender as influencing daily work, career progression, or patient treatment. Despite generally positive views on organizational equity, the visibility of formal gender-related policies and structures was limited. More than half of the participants reported the absence of a gender-equity policy or focal point, while a strong majority supported training and sensitization on gender and equity.
Conclusions
Primary health care staff in Conakry report limited recognition of gender’s influence in their professional setting, alongside weak institutionalization of gender-responsive mechanisms, yet express a strong demand for targeted capacity-building. Strengthening policies, establishing clear focal points, and linking training to practical implementation tools are key opportunities for reinforcing gender and equity in Guinea’s primary health care system.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15497-9.
Keywords: Gender, Equity, Health workforce, Primary health care, Guinea, Conakry
Introduction
Gender and equity are essential concepts for understanding and reducing health inequalities. According to the World Health Organization (WHO), gender refers to socially constructed roles, behaviors, and norms associated with sex that shape health and access to care; equity implies the absence of unjust and avoidable differences between individuals, particularly in health. Integrating gender and equity into public health interventions supports fairer resource allocation and more responsive services [1].
In Guinea, policy frameworks support gender equality, including the National Gender Policy (Politique Nationale du Genre, PNG), which provides the national strategic framework for gender mainstreaming in public policies [2]. UNDP also supports gender integration through advocacy, capacity building, resource mobilization, and the promotion of women’s participation in decision-making [3]. In the same vein, Guinea has validated work aimed at integrating gender considerations into national adaptation planning processes, highlighting the importance of gender within national agendas [4].
Globally, the WHO reports that although women comprise a large share of the health workforce, they remain underrepresented in leadership positions, reflecting persistent inequalities [5]. Recent evidence similarly shows that cultural and organizational barriers can limit women’s access to decision-making roles in health leadership [6]. In African contexts, gender dynamics may also influence recruitment and retention patterns in community health workforces, as reported in Mozambique [7].
Despite these efforts, challenges persist in Guinea. Although progress has been reported, community and institutional norms and practices require further evolution to achieve meaningful equity [2]. Because these perceptions may shape professional practices and the organization of care, examining them addresses an important but under-studied dimension of health-system performance in Guinea. The objective of this study was therefore to assess perceptions of gender and equity among primary health care staff in the Conakry health region. Specifically, the study aimed to describe (i) how staff conceptualize gender, (ii) the perceived influence of gender on daily work, career opportunities, and patient care, (iii) perceived equity in the organization and functioning of their facilities, and (iv) the perceived availability of institutional mechanisms supporting gender equity.
Methods
Study design and setting
A descriptive, cross-sectional survey was conducted from January to March 2025 in 19 health centers across the five communes of Conakry (Kaloum, Dixinn, Matam, Matoto, Ratoma) (Fig. 1). The study targeted all categories of health workers (physicians, nurses, midwives, technicians, and other staff involved in patient care).
Fig. 1.
Map of the city of Conakry
Study population
The target population comprised all staff working in the selected health centers, including physicians, nurses, midwives, health technicians, and other patient-facing health workers.
Eligibility criteria
Inclusion criteria were: (i) being a health worker active in the facility for at least six months, (ii) providing free, informed, written consent, and (iii) being present on the day of data collection.
Exclusion criteria were: (i) being on extended leave or absent during data collection, or (ii) refusing to participate.
Sampling procedure and sample size
Health centers were selected to ensure representation of public primary health care facilities across the five communes of Conakry. Of the [TOTAL] public health centers operating in these communes, 19 were included [specify the basis for selection, e.g., stratification by commune and selection proportionate to the number of facilities per commune]. Within each participating facility, an exhaustive (census) approach was used rather than probability sampling of individuals: all eligible staff, across all professional categories, who were present and provided written consent on the day of data collection were invited to participate. The number of participants per facility therefore varied with facility size and staffing [optionally report median and range per facility]. The Schwartz formula was used a priori to define the minimum total number of participants required, which informed the number of facilities included.
The sample size was estimated using the Schwartz formula:
n = (Z² × p × (1 − p)) / d².
Where:
- n = required sample size.
- Z = Z-score corresponding to the desired confidence level (typically 1.96 for 95% confidence).
- p = estimated proportion of the attribute present in the population (if unknown, 0.5 is used for maximum variability).
- d = margin of error (precision, usually set at 0.05).
With a 95% confidence level, p = 0.5, and d = 0.05, the theoretical minimum sample size was approximately 385 participants.
Study variables
Variables included: sex (male/female), age, education level, years of experience, type of facility, perception of gender (understanding and appraisal of sex/gender-related differences in practice and patient interactions), and perception of equity (appraisal of equity in access, resource allocation, and quality of care).
Data collection
Data collection utilized a structured questionnaire comprising both closed and open-ended questions focused on perceptions of gender and equity. This questionnaire was designed specifically for the purposes of this study and has not been previously published; its development was informed by a review of the literature on gender and equity in health systems (see Additional file 1 for the English version of the questionnaire). The questionnaire was self-administered: paper copies were distributed to eligible staff in the participating facilities, completed by the respondents themselves, and collected on site. Completed questionnaires were then coded for subsequent analysis.
Data management and analysis
Data entry and cleaning were conducted using Microsoft Excel 2019. Statistical analyses were performed in R (version 4.5.2)—descriptive statistics, including frequencies, means, and standard deviations, summarized participant characteristics, and perceptions.
Ethical considerations
The protocol was submitted to the Scientific and Ethics Committee (Comité Scientifique et d’Éthique) of the Faculty of Social Sciences, Université Général Lansana Conté de Sonfonia-Conakry (UGLC-SC/FSS), which convened in ordinary session on 20 March 2025 and issued a favourable opinion (reference N°11.2/UGLC-SC/FSS/2025, dated 24 March 2025). The protocol was also submitted to the Department of Research of the National Institute of Public Health (INSP) of Kakoulimayah (reference N°001/DRS/INSP/2026). Written informed consent was obtained from all participants before participation. Confidentiality was maintained, results were used strictly for scientific purposes, and participants could withdraw at any time without consequence. All procedures were conducted in accordance with the Declaration of Helsinki (revised 2013) and applicable national ethical guidelines for research.
Results
Participant characteristics
A total of 412 health workers were included in the study. The mean age was 34 ± 9 years (range 19–86). The 18–34 age group was the most represented (241; 58%), followed by the 35–54 age group (154; 37%), while participants aged 55 years or older accounted for 17 (4.1%). The sample was predominantly female (260; 63%).
Regarding education, 187 (45%) participants had higher education, and 151 (37%) had professional/technical training. Other education levels were less frequent: lower secondary (24; 5.8%), upper secondary (38; 9.2%), primary (6; 1.5%), and other (6; 1.5%).
In terms of professional category, the most represented group was state-certified nurses (141; 34%), followed by midwives (83; 20%) and general practitioners (59; 14%). Laboratory technicians represented 48 (12%). The category “other professions” accounted for 42 (10%). Community health workers represented 13 (3.2%), pharmacists 9 (2.2%), administrative staff 9 (2.2%), and specialist physicians 8 (1.9%) (Table 1).
Table 1.
Sociodemographic characteristics of health center staff in Conakry, 2025 (N = 412)
| Characteristic | N = 412 | 95% CI |
|---|---|---|
| Age (years) | 34 ± 9 [19–86] | [33–35] |
| Age group | ||
| 18–34 | 241 (58%) | [54–63] |
| 35–54 | 154 (37%) | [33–42] |
| 55–86 | 17 (4.1%) | [2.5–6.7] |
| Sex | ||
| Female | 260 (63%) | [58–68] |
| Male | 152 (37%) | [32–42] |
| Education level | ||
| Higher education (Bachelor+ / “Bac+…”) | 187 (45%) | [41–50] |
| Professional/technical training | 151 (37%) | [32–42] |
| Primary | 6 (1.5%) | [0.59–3.3] |
| Lower secondary (middle school) | 24 (5.8%) | [3.8–8.7] |
| Upper secondary (high school) | 38 (9.2%) | [6.7–13] |
| Other (specify) | 6 (1.5%) | [0.59–3.3] |
| Profession | ||
| Community health worker | 13 (3.2%) | [1.8–5.5] |
| Other (specify) | 42 (10%) | [7.5–14] |
| State-certified nurse | 141 (34%) | [30–39] |
| General practitioner | 59 (14%) | [11–18] |
| Specialist physician | 8 (1.9%) | [0.91–3.9] |
| Administrative staff | 9 (2.2%) | [1.1–4.3] |
| Pharmacist | 9 (2.2%) | [1.1–4.3] |
| Midwife | 83 (20%) | [16–24] |
| Laboratory technician | 48 (12%) | [8.8–15] |
Perceptions of gender and equity in professional practices and responsibilities
Overall, most respondents did not perceive gender as a factor that directly influences health center functioning (Fig. 2). A large proportion expressed disagreement regarding the influence of gender on key professional dimensions: 72% disagreed that gender stereotypes affect daily work, 72% disagreed that gender influences career opportunities, and 72% disagreed that gender influences how patients are treated.
Fig. 2.
Health center staff perceptions of gender and equity in professional practices and responsibilities, Conakry, 2025 (N = 412). The figure displays the distribution of responses on a five-point Likert scale (strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree) to items addressing: (i) how gender is defined, (ii) socially assigned roles for women and men, (iii) perceived influence of gender on patient treatment, career opportunities, and daily work, and (iv) the perceived importance of considering gender to improve quality of care
Conversely, 72% of participants agreed that biological characteristics mainly determine gender, and 68% agreed that men’s and women’s roles are naturally different. More than half (53%) agreed that considering gender is important to improve the quality of healthcare (Fig. 2).
Perceived equity in the organization and functioning of health centers
Perceptions of equity in the organization and functioning of health centers were generally positive (Fig. 3). Agreement was particularly high for fair and equitable treatment of patients (93%) and for equity as a fundamental value in the facility’s functioning (90%).
Fig. 3.
Health center staff perceptions of equity in the organization and functioning of facilities, Conakry, 2025 (N = 412). The figure displays the distribution of responses on a five-point Likert scale regarding perceived equity within the facility: fair and equitable treatment of patients; equity as a fundamental value; equitable distribution of resources; management and decision-making procedures; opportunities for training and professional development; and salaries and benefits
High levels of agreement were also reported for equitable distribution of resources (85%), management and decision-making procedures (83%), and opportunities for training and professional development (82%). By contrast, perceived equity regarding salaries and social benefits was lower (70%) (Fig. 3).
Institutional mechanisms related to gender. Table 2 summarizes staff perceptions of the presence of institutional mechanisms for gender equity within their facilities. Nearly half of respondents (186; 45%) reported that their facility did not have a gender-equity policy or directive, whereas 117 (28%) reported that such a policy existed, and 109 (26%) did not know.
Table 2.
Health workers’ perceptions of the existence of gender-equity policies, mechanisms, and institutional arrangements (N = 412), Conakry health region, 2025
| Item | N = 412 | 95% CI |
|---|---|---|
| Does your facility have a gender-equity policy or directive? | ||
| I don’t know | 109 (26%) | [22–31] |
| No | 186 (45%) | [40–50] |
| Yes | 117 (28%) | [24–33] |
| Is there a gender focal point or gender unit in your facility? | ||
| I don’t know | 95 (23%) | [19–27] |
| No | 237 (58%) | [53–62] |
| Yes | 80 (19%) | [16–24] |
| Do you have access to recourse mechanisms in case of gender-based discrimination or harassment? | ||
| I don’t know | 107 (26%) | [22–31] |
| No | 133 (32%) | [28–37] |
| Yes | 172 (42%) | [37–47] |
| Would you support training/sensitization sessions on gender and equity? | ||
| No | 40 (9.7%) | [7.1–13] |
| Yes | 334 (81%) | [77–85] |
| Maybe | 38 (9.2%) | [6.7–13] |
Regarding the presence of a gender focal point/cell, 237 (58%) reported that none existed, 80 (19%) reported that it existed, and 95 (23%) did not know. For recourse mechanisms in case of discrimination or gender-based harassment, 172 (42%) reported having access, 133 (32%) reported no access, and 107 (26%) did not know.
Most respondents (334; 81%) were in favor of training/sensitization sessions on gender and equity, while 40 (9.7%) were not in favor and 38 (9.2%) were unsure (“maybe”) (Table 2).
Perceptions by sex
Perceptions were broadly similar between female (N = 260) and male (N = 152) respondents across all items (Table 3). In both groups, a majority strongly agreed that gender is mainly determined by biological characteristics (women 58%, men 50%) and that men’s and women’s roles are naturally different (women 50%, men 46%). Conversely, most respondents of both sexes strongly disagreed that gender influences how patients are treated (women 57%, men 54%), career opportunities (women 57%, men 56%), or daily work (women 60%, men 56%). Views were more divided on whether considering gender is important to improve the quality of care, with 35% of women and 29% of men strongly agreeing. No marked differences were observed between the sexes.
Table 3.
Distribution of perceptions of gender and equity by sex in the Conakry health region, 2025 (N = 412). Female: N = 260; Male: N = 152
| Statement / Response option | Female (N = 260) | Male (N = 152) |
|---|---|---|
| Gender is mainly determined by biological characteristics (sex). | ||
| Neither agree nor disagree | 16 (6.2%) | 6 (3.9%) |
| Strongly disagree | 33 (13%) | 26 (17%) |
| Somewhat agree | 41 (16%) | 28 (18%) |
| Somewhat disagree | 18 (6.9%) | 16 (11%) |
| Strongly agree | 152 (58%) | 76 (50%) |
| Men’s and women’s roles and responsibilities in society are naturally different. | ||
| Neither agree nor disagree | 9 (3.5%) | 6 (3.9%) |
| Strongly disagree | 46 (18%) | 25 (16%) |
| Somewhat agree | 48 (18%) | 32 (21%) |
| Somewhat disagree | 28 (11%) | 19 (13%) |
| Strongly agree | 129 (50%) | 70 (46%) |
| Gender influences how patients are treated in this health center. | ||
| Neither agree nor disagree | 13 (5.0%) | 9 (5.9%) |
| Strongly disagree | 148 (57%) | 82 (54%) |
| Somewhat agree | 22 (8.5%) | 18 (12%) |
| Somewhat disagree | 37 (14%) | 26 (17%) |
| Strongly agree | 40 (15%) | 17 (11%) |
| Gender influences career opportunities within this health center. | ||
| Neither agree nor disagree | 17 (6.5%) | 5 (3.3%) |
| Strongly disagree | 148 (57%) | 85 (56%) |
| Somewhat agree | 28 (11%) | 23 (15%) |
| Somewhat disagree | 38 (15%) | 23 (15%) |
| Strongly agree | 29 (11%) | 16 (11%) |
| Gender stereotypes affect staff’s daily work in this health center. | ||
| Neither agree nor disagree | 20 (7.7%) | 14 (9.2%) |
| Strongly disagree | 157 (60%) | 85 (56%) |
| Somewhat agree | 26 (10%) | 21 (14%) |
| Somewhat disagree | 34 (13%) | 19 (13%) |
| Strongly agree | 23 (8.8%) | 13 (8.6%) |
| Considering gender is important to improve the quality of healthcare. | ||
| Neither agree nor disagree | 21 (8.1%) | 9 (5.9%) |
| Strongly disagree | 77 (30%) | 39 (26%) |
| Somewhat agree | 43 (17%) | 40 (26%) |
| Somewhat disagree | 28 (11%) | 20 (13%) |
| Strongly agree | 91 (35%) | 44 (29%) |
Discussion
This study provides novel insight into health workers’ perceptions of gender and equity in Conakry, Guinea, at a time when national and international policies increasingly emphasize their importance in health systems. Compared to similar surveys in other African countries and international contexts, our findings highlight both common patterns and specificities of the Guinean context.
This cross-sectional survey of 412 health workers across 19 health centers in Conakry revealed three main findings. First, respondents predominantly held a biologically-oriented view of gender, with a majority agreeing that biological characteristics mainly determine gender and that men’s and women’s roles are naturally different. Second, most participants did not perceive gender as influencing professional practices, career advancement, or patient care, a pattern that contrasts with studies in other settings where the impact of gender is more widely acknowledged. Third, while perceptions of organizational equity were generally positive, there was limited awareness of, or access to, formal mechanisms such as gender-equity policies, focal points, or recourse systems. The strong demand for training and sensitization (81%) represents a concrete opportunity to support change.
The predominance of a biological framing of gender suggests that the distinction between sex (biological) and gender (socially constructed roles and norms) remains insufficiently recognized at the local level. This is consistent with findings from other low- and middle-income countries, but contrasts with higher levels of gender awareness reported among healthcare professionals in some international studies [8, 9]. In Guinea, gendered norms have been shown to shape providers’ clinical attitudes — for example, toward female genital mutilation and its medicalization — even where they are not explicitly framed as “gender” [10]. These results highlight the need for tailored capacity-building and educational interventions that address both conceptual and practical aspects of gender in healthcare.
The limited perception of gender influence on patient treatment and staff careers diverges from international evidence demonstrating that gender norms are often embedded within health systems, shaping both the delivery of care and career progression [6, 11, 12]. In the Guinean context, this finding may indicate that gender-related dynamics are not readily recognized by health workers, possibly due to limited training or the absence of institutional mechanisms to identify and address them. Future studies could employ direct observation or qualitative methods to understand these dynamics better; qualitative research on care experiences in Conakry has demonstrated the value of such approaches for surfacing dynamics that structured questionnaires may not capture [13].
Although equity was widely endorsed as a value among respondents, the absence of organizational structures to support systematic gender equity work—such as specific policies, focal points, and recourse mechanisms—reflects weak institutionalization. The literature underscores that meaningful change requires not only conceptual clarity but also robust implementation at both professional and organizational levels [7, 14, 15]. Strengthening these structures should therefore be a priority for policymakers and facility managers.
Internationally, persistent gender gaps in health workforce leadership and structural barriers for women are well-documented [16]. The paradox of a workforce largely delivered by women but led predominantly by men persists, underscoring the urgency of institutional reforms at all levels of the system [17]. This pattern is salient in Guinea, where the health workforce is predominantly female [18] yet continues to face well-documented challenges in development and retention [19].
The strong demand for training and sensitization is an actionable entry point. Structured educational strategies that integrate gender perspectives have been shown to improve recognition of differential needs, communication, and bias reduction among health professionals [15]. For maximum impact, such training should be directly linked to facility-level implementation mechanisms and accompanied by supportive policies and monitoring systems [14, 20].
Even when health workers do not perceive gender effects, evidence shows that clinician bias can still influence decision-making, and targeted interventions can reduce disparities [21, 22]. This may explain why gender is not seen as influential in practice when formal detection, monitoring, and accountability mechanisms are lacking.
At the national level, Guinea’s National Gender Policy (PNG) and the health sector’s strategic plan for gender and equity provide a strong policy framework [2, 4]. Broader national survey data likewise document persistent gender inequalities in Guinea [23], underscoring the gap between policy frameworks and everyday realities. However, limited awareness and implementation of these orientations at the facility level highlight the need for improved dissemination, operationalization, and monitoring. Facility-level actions—such as designating focal points, creating accessible recourse mechanisms, and linking training to practical tools—are essential for translating policy into practice.
Limitations
This study has several limitations. Its cross-sectional design prevents causal inference, and self-reported perceptions may be subject to social desirability bias. Because the questionnaire was self-administered, the responses may also have been influenced by acquiescence bias and by the absence of an interviewer to clarify items; moreover, the gender of survey personnel can itself modify responses in household surveys in sub-Saharan Africa [24]. In-depth interviews were not conducted; such qualitative approaches could have added value by capturing perceptions, motivations, and contextual nuances not covered by the structured instrument. In addition, focusing on perceptions rather than observed behaviours, and restricting the study to Conakry, limits the generalizability of the findings. Future research could combine direct observation with qualitative methods, and extend to other regions, to achieve a more comprehensive understanding [25].
Conclusions
This study reveals that health workers in Conakry predominantly hold a biological perspective of gender and perceive a limited influence of gender on their professional practices and career progression. While organizational equity is generally valued, the lack of visible gender-related policies and mechanisms within health centers constrains the effective promotion of gender and equity in care delivery. The strong demand for targeted training and sensitization presents a key opportunity: institutionalizing gender-responsive policies, establishing clear focal points, and linking training to practical tools could significantly strengthen the integration of gender and equity in primary health care. These findings highlight the urgent need for concrete actions by policymakers and facility managers to move beyond theoretical endorsement and achieve substantive progress toward equitable, gender-responsive health systems in Guinea.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors thank the managers of the participating health facilities for their collaboration, as well as all health professionals who agreed to participate in the study. They also thank the technical and administrative teams who facilitated data collection and study implementation.
Author contributions
H.B. designed the study, coordinated data collection, and oversaw the drafting of the manuscript. A.A.T. and J.S.B. contributed to the study design, data collection, and data analysis. A.F.T., A.W., and M.P.K. provided support for data management, statistical analysis, and interpretation of results. Z.T. provided methodological guidance and contributed to data interpretation and critical revision of the manuscript. P.M.C. contributed to the conceptual framework, interpretation of results, and substantive revisions of the manuscript. All authors have read and approved the final manuscript and agree to take responsibility for all aspects of the work.
Funding
Not reported.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Scientific and Ethics Committee (Comité Scientifique et d’Éthique) of the Faculty of Social Sciences, Université Général Lansana Conté de Sonfonia-Conakry (UGLC-SC/FSS), which convened in ordinary session on 20 March 2025 and issued a favourable opinion (reference N°11.2/UGLC-SC/FSS/2025, dated 24 March 2025). The protocol was also reviewed by the Department of Research of the National Institute of Public Health (INSP) of Kakoulimayah (reference N°001/DRS/INSP/2026). Written informed consent was obtained from all participants before participation. All procedures were conducted in accordance with the Declaration of Helsinki (revised 2013) and applicable national ethical guidelines for research.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.