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C-Channel Issue 14

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C-Channel header  November 2009

Dear Colleagues,

C-Channel No. 14, the monthly e-newsletter from C-Change, connects readers to current research findings in the peer-reviewed literature on social and behavior change communication (SBCC) in the health sector, particularly in the areas of family planning and reproductive health, HIV prevention and care, malaria prevention, antenatal care, maternal health, and gender norms. C-Change implements programs, conducts research, and carries out capacity strengthening in Africa, Asia, and Eastern Europe on SBCC in these areas.

C-Channel No. 14 highlights research on gender norms and the complex social issues that comprise the everyday reality for women, in particular, who must maneuver within the social and power dynamics of their culture and environment as they pursue schooling, work life, sexual relationships, marriage, and raising children. Articles cover research carried out in Bangladesh, Benin, Burkina Faso, Brazil, Ethiopia, Ghana, India, Japan, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mozambique, Namibia, Nigeria, Peru, Rwanda, Samoa, Serbia and Montenegro, South Africa, Swaziland, Tanzania, Thailand, Uganda, Zambia, and Zimbabwe.

C-Change has published "Gender norms and family planning decision-making in Tanzania: A qualitative study," a report on research carried out in Tanzania, examining the role of gender norms in decision making among young married women and men on issues of family planning and contraceptive use. The study found that gender factors, such as men's dominance in decision making and cultural norms that condone a man beating his wife if she uses contraceptives secretly, are barriers to use of modern contraceptives, but also determined that fear of side effects of modern contraceptives was a significant deterrent. C-Change also published "Incorporating Male Gender Norms into Family Planning and Reproductive Health Programs: Program Guidance Brief" to provide evidence-based recommendations to guide family planning programmers in the design, implementation, and evaluation of family planning programs that have a male gender norms component. Both documents are available on the C-Change website under Resources.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel


GENDER NORMS

1. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study

2. The role of partnership dynamics in determining the acceptability of condoms and microbicides

3. Young women's perceived ability to refuse sex in urban Cameroon

4. Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India

5. Men, HIV/AIDS, and human rights

6. "He will ask why the child gets sick so often": The gendered dynamics of intra-household bargaining over healthcare for children with fever in the Volta Region of Ghana

7. Exploring the role of economic empowerment in HIV prevention

8. Polygyny and women's health in sub-Saharan Africa

9. Factors associated with attitudes towards intimate partner violence against women: A comparative analysis of 17 sub-Saharan countries

10. The impact of gender and income on survival and retention in a South African antiretroviral therapy programme

11. When "no" means "yes": the gender implications of HIV programming in a Zimbabwean university

OTHER RESOURCES

"Strategic considerations for strengthening the linkages between family planning and HIV/AIDS policies, programs, and services" (Family Health International)

To access the FREE full report (34 pages), please click here


GENDER NORMS

1. Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study

Authors: Ellsberg M b; Jansen HA a; Heise L b; Watts CH c; Garcia-Moreno C a
Institutions: a WHO, Geneva, Switzerland; b PATH, Washington, DC; c London School of Hygiene and Tropical Medicine, London, UK
Source: Lancet 5 Apr 2008; 371(9619): 1165-72.

ABSTRACT

BACKGROUND: This article summarises findings from ten countries from the WHO multi-country study on women's health and domestic violence against women.

METHODS: Standardised population-based surveys were done between 2000 and 2003. Women aged 15-49 years were interviewed about their experiences of physically and sexually violent acts by a current or former intimate male partner, and about selected symptoms associated with physical and mental health. The women reporting physical violence by a partner were asked about injuries that resulted from this type of violence.

FINDINGS: 24,097 women completed interviews. Pooled analysis of all sites found significant associations between lifetime experiences of partner violence and self-reported poor health (odds ratio 1.6 [95% CI 1.5-1.8]), and with specific health problems in the previous 4 weeks: difficulty walking (1.6 [1.5-1.8]), difficulty with daily activities (1.6 [1.5-1.8]), pain (1.6 [1.5-1.7]), memory loss (1.8 [1.6-2.0]), dizziness (1.7 [1.6-1.8]), and vaginal discharge (1.8 [1.7-2.0]). For all settings combined, women who reported partner violence at least once in their life reported significantly more emotional distress, suicidal thoughts (2.9 [2.7-3.2]), and suicidal attempts (3.8 [3.3-4.5]), than non-abused women. These significant associations were maintained in almost all of the sites. Between 19% and 55% of women who had ever been physically abused by their partner were ever injured.

INTERPRETATION: In addition to being a breach of human rights, intimate partner violence is associated with serious public-health consequences that should be addressed in national and global health policies and programmes.

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2. The role of partnership dynamics in determining the acceptability of condoms and microbicides

Authors: Montgomery CM a; Lees S a,b; Stadler J c; Morar NS d; Ssali A e; Mwanza B f; Mntambo M c; Phillip J d; Watts C a; Pool R g
Institutions: a London School of Hygiene & Tropical Medicine, London, UK; b National Institute for Medical Research, Tanzania; c Reproductive Health and HIV Research Unit, University of the Witwatersrand, South Africa; d HIV Prevention Research Unit, Medical Research Council, South Africa; e Medical Research Council, UVRI Uganda research unit on AIDS, Masaka, Uganda; f Microbicides Development Programme, Zambia; g Barcelona Centre for International Health Research, University of Barcelona, Spain
Source: AIDS Care Jul 2008; 20(6): 733-40.

ABSTRACT

Microbicides are a class of substances under development that could reduce the sexual transmission of HIV and other sexually transmitted diseases when applied locally to genital mucosal surfaces. Microbicide acceptability research has largely focused on product characteristics, rather than processes of negotiation within relationships about use. Gender relations, decision-making power and communication within sexual relationships are recognised as important determinants of condom and contraceptive use, and are likely to determine microbicide use also. As part of social science research linked to the Microbicides Development Programme (MDP) we combine relationship-based theories with anthropological work conducted with women and men using a placebo gel. We explore communication and decision-making in gel and condom use, including constructions of risk and trust. During the MDP301 Phase III pilot study, in-depth interviews were conducted at sites in South Africa, Tanzania, Uganda and Zambia. Following four weeks of placebo gel use, women and their partners were asked about gel use and acceptability, partner involvement, sexual practices and condom use. Data from 45 couples at five sites were analysed using a grounded theory approach in NVivo. Participation in the study did not require women to inform their partners, yet our data shows women seeking permission from their partners, negotiating disclosure, exchanging information and persuading or motivating for gel use. Although gel was supposedly 'woman-controlled', men exercised considerable influence in determining whether and how it was used. Despite this, negotiations around use were largely successful, since the gel increased sexual pleasure and provided opportunities for intimate communication and the building of trust. Decisions about condom and microbicide use are made in a dyadic context and involve a complex negotiation of risk and trust. Whilst preferences relating to product characteristics are largely individual, use itself is dependent on partnership dynamics and the broader social context in which sexual risk management occurs.

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3. Young women's perceived ability to refuse sex in urban Cameroon

Authors: Hattori MK 1; DeRose L 2
Institutions: 1 University of Maryland, College Park, MD; 2 Brown University, Providence, RI
Source: Studies in Family Planning Dec 2008; 39(4): 309-20.

ABSTRACT

In many sub-Saharan African countries, young women face decreasing educational opportunities, age asymmetries between sexual partners, and high prevalence of HIV infection. This study draws upon data from the 2002 Cameroon Adolescent Reproductive Health Survey to analyze the determinants of young women's perceived ability to refuse sex in urban Cameroon. Our findings are consistent with predictions of social exchange theory: young women's status characteristics predict their vulnerability differently under different circumstances, and, overall, young women report having a lower ability to refuse sex in their relationships with men who offer to pay their school fees than in their relationships with men in positions of power over them. The costs and benefits of sexual exchanges made in order to continue one's education increase simultaneously in a context of declining enrollments and spreading HIV infection. When educational aspirations exceed opportunities, policy supporting access to education could reduce young women's need to employ their sexual resources in order to invest in their future.

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4. Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India

Authors: Krishnan S a,b,c; Rocca CH a,b; Hubbard AE d; Subbiah K e; Edmeades J f; Padian NS a,b
Institutions: a Women's Global Health Imperative, RTI International, San Francisco, CA; b Division of Epidemiology, School of Public Health, University of California, Berkeley, CA; c Centre for Public Policy, Indian Institute of Management, Bangalore, India; d Division of Biostatistics, School of Public Health, University of California, Berkeley, CA; e Samata Health Study, Bangalore, India; f International Center for Research on Women, Washington, DC
Source: Social Science & Medicine 12 Oct 2009; doi:10.1016/j.socscimed.2009.09.026 [Epub ahead of print]

ABSTRACT

The prevalence of physical domestic violence - violence against women perpetrated by husbands - is staggeringly high across the Indian subcontinent. Although gender-based power dynamics are thought to underlie women's vulnerability, relatively little is known about risk and protective factors. This prospective study in southern India examined the association between key economic aspects of gender-based power, namely spousal employment status, and physical domestic violence. In 2005-2006, 744 married women, aged 16-25, residing in low-income communities in Bangalore, India were enrolled in the study. Data were collected at enrollment, 12 and 24 months. Multivariable logistic regression models were used to examine the prospective association between women's employment status, their perceptions of their husband's employment stability, and domestic violence. Women who were unemployed at one visit and began employment by the next visit had an 80% higher odds of violence, as compared to women who maintained their unemployed status. Similarly, women whose husbands had stable employment at one visit and newly had difficulty with employment had 1.7 times the odds of violence, as compared to women whose husbands maintained their stable employment. To our knowledge, this study is the first from a developing country to confirm that changes in spousal employment status are associated with subsequent changes in violence risk. It points to the complex challenges of violence prevention, including the need for interventions among men and gender-transformative approaches to promote gender-equitable attitudes, practices and norms among men and women.

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5. Men, HIV/AIDS, and human rights

Authors: Peacock D 1,2,3; Stemple L 4; Sawires S 3,5; Coates TJ 3,5,6
Institutions: 1 Sonke Gender Justice, Cape Town, South Africa; 2 London School of Hygiene and Tropical Medicine's Gender, Violence and Health Centre, London, United Kingdom; 3 Program in Global Health, UCLA David Geffen School of Medicine, Los Angeles, CA; 4 UCLA School of Law, Los Angeles, CA; 5 Center for HIV Identification, Prevention and Treatment Services, UCLA David Geffen School of Medicine, Los Angeles, CA; 6 Department of Medicine, Infectious Diseases, UCLA David Geffen School of Medicine, Los Angeles, CA
Source: Journal of Acquired Immune Deficiency Syndromes 1 Jul 2009; 51 Suppl 3: S119-25.

ABSTRACT

Though still limited in scale, work with men to achieve gender equality is occurring on every continent and in many countries. A rapidly expanding evidence base demonstrates that rigorously implemented initiatives targeting men can change social practices that affect the health of both sexes, particularly in the context of HIV and AIDS. Too often however, messages only address the harm that regressive masculinity norms cause women, while neglecting the damage done to men by these norms. This article calls for a more inclusive approach which recognizes that men, far from being a monolithic group, have unequal access to health and rights depending on other intersecting forms of discrimination based on race, class, sexuality, disability, nationality, and the like. Messages that target men only as holders of privilege miss men who are disempowered or who themselves challenge rigid gender roles. The article makes recommendations which move beyond treating men simply as "the problem", and instead lays a foundation for engaging men both as agents of change and holders of rights to the ultimate benefit of women and men. Human rights and other policy interventions must avoid regressive stereotyping, and successful local initiatives should be taken to scale nationally and internationally.

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6. "He will ask why the child gets sick so often": The gendered dynamics of intra-household bargaining over healthcare for children with fever in the Volta Region of Ghana

Authors: Tolhurst R a; Amekudzi Y b; Nyonator FK c; Bertel Squire S a; Theobald S a
Institutions: a Liverpool School of Tropical Medicine, Liverpool, UK; b HACI, Ghana; c Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Ghana
Source: Social Science & Medicine Mar 2008; 66(5): 1106-17.

ABSTRACT

This paper explores the gendered dynamics of intra-household bargaining around treatment seeking for children with fever revealed through two qualitative research studies in the Volta Region of Ghana, and discusses the influence of different gender and health discourses on the likely policy implications drawn from such findings. Methods used included focus group discussions, in-depth and critical incidence interviews, and Participatory Learning and Action methods. We found that treatment seeking behaviour for children was influenced by norms of decision-making power and 'ownership' of children, access to and control over resources to pay for treatment, norms of responsibility for payment, marital status, household living arrangements, and the quality of relationships between mothers, fathers and elders. However, the implications of these findings may be interpreted from different perspectives. Most studies that have considered gender in relation to malaria have done so within a narrow biomedical approach to health that focuses only on the outcomes of gender relations in terms of the non-utilisation of allopathic healthcare. However, we argue that a 'gender transformatory' approach, which aims to promote women's empowerment, needs to include but go beyond this model, to consider broader potential outcomes of intra-household bargaining for women's and men's interests, including their livelihoods and 'bargaining positions'.

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7. Exploring the role of economic empowerment in HIV prevention

Authors: Kim J; Pronyk P; Barnett T; Watts C
Institution: School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Source: AIDS Dec 2008; 22 Suppl 4: S57-71.

ABSTRACT

It has been argued that women's economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the conditions, including sexual abstinence, condom use and multiple partnerships, which shape their risk of infection. In the face of escalating infection rates among women, and particularly young women, many have pointed to the potential importance of economic empowerment strategies for HIV prevention responses. Global evidence suggests that the relationship between poverty and HIV risk is complex, and that poverty on its own cannot be viewed simplistically as a driver of the HIV epidemic. Rather, its role appears to be multidimensional and to interact with a range of other factors, including mobility, social and economic inequalities and social capital, which converge in a particularly potent way for young women living in southern Africa. To date, there have been few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer that have been rigorously evaluated. This paper explores how programmes such as microfinance, livelihood training and efforts to safeguard women's food security and access to property have begun to incorporate an HIV prevention focus. Although such circumscribed interventions, by themselves, are unlikely to lead to significant impacts on a national or regional scale, they are useful for testing cross-sectoral partnership models, generating practical lessons and providing a metaphor for what might be possible in promoting women's economic empowerment more broadly. Despite numerous calls to 'mainstream AIDS' in economic development, cross-sectoral responses have not been widely taken up by government or other stakeholders. We suggest potential reasons for limited progress to date and conclude by presenting programme and policy recommendations for further exploring and harnessing linkages between economic empowerment and HIV prevention in Southern Africa.

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8. Polygyny and women's health in sub-Saharan Africa

Authors: Bove R a; Valeggia C b
Institutions: a Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; b Department of Anthropology, University of Pennsylvania, Philadelphia, PA
Source: Social Science & Medicine Jan 2009; 68(1): 21-9.

ABSTRACT

In this paper we review the literature on the association between polygyny and women's health in sub-Saharan Africa. We argue that polygyny is an example of "co-operative conflict" within households, with likely implications for the vulnerability of polygynous women to illness, and for their access to treatment. We begin with a review of polygyny and then examine vulnerability to sexually transmitted infections (STIs, including HIV) and differential reproductive outcomes. Polygyny is associated with an accelerated transmission of STIs, both because it permits a multiplication of sexual partners and because it correlates with low rates of condom use, poor communication between spouses, and age and power imbalances among other factors. Female fertility is affected by the interplay between marital rank, household status, and cultural norms in polygynous marriages. Finally, we present areas which have received only cursory attention: mental health and a premature, "social" menopause. Although data are scarce, polygyny seems to be associated with higher levels of anxiety and depression, particularly around stressful life events. It is our hope that the examples reviewed here will help build a framework for mixed method quality research, which in turn can inform decision makers on more appropriate, context-dependent health policies.

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9. Factors associated with attitudes towards intimate partner violence against women: A comparative analysis of 17 sub-Saharan countries

Authors: Uthman OA 1,2,3; Lawoko S 1; Moradi T 4
Institutions: 1 Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, Sweden; 2 Department of Public Health & Biostatistics, University of Birmingham, Birmingham, UK; 3 Center for Evidence-Based Global Health, Ilorin, Kwara State, Nigeria; 4 Department of Environmental Medicine, Division of Epidemiology, Karolinska Institutet, Stockholm, Sweden
Source: BMC International Health & Human Rights 20 Jul 2009; 9:14.

ABSTRACT

BACKGROUND: Violence against women, especially by intimate partners, is a serious public health problem that is associated with physical, reproductive and mental health consequences. Even though most societies proscribe violence against women, the reality is that violations against women's rights are often sanctioned under the garb of cultural practices and norms, or through misinterpretation of religious tenets.

METHODS: We utilised data from 17 Demographic and Health Surveys (DHS) conducted between 2003 and 2007 in sub-Saharan Africa to assess the net effects of socio-demographic factors on men's and women's attitudes toward intimate partner violence against women (IPVAW) using multiple logistic regression models estimated by likelihood ratio test.

RESULTS: IPVAW was widely accepted under certain circumstances by men and women in all the countries studied. Women were more likely to justify IPVAW than men. "Neglecting the children" was the most common reason agreed to by both women and men for justifying IPVAW followed by "going out without informing husband" and "arguing back with the husband". Increasing wealth status, education attainment, urbanization, access to media, and joint decision making were associated with decreased odds of justifying IPVAW in most countries.

CONCLUSION: In most Sub-Saharan African countries studied where IPVAW is widely accepted as a response to women's transgressing gender norms, men find less justification for the practice than do women. The present study suggests that proactive efforts are needed to change these norms, such as promotion of higher education and socio-demographic development. The magnitude and direction of factors associated with attitudes towards IPVAW varies widely across the countries, thus suggesting the significance of capitalizing on need-adapted interventions tailored to fit conditions in each country.

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10. The impact of gender and income on survival and retention in a South African antiretroviral therapy programme

Authors: Cornell M; Myer L; Kaplan R; Bekker LG; Wood R
Institution: The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
Source: Tropical Medicine & International Health Jul 2009; 14(7): 722-31.

ABSTRACT

OBJECTIVES: Despite the rapid expansion of antiretroviral therapy (ART) services in Africa, there are few data on whether outcomes differ for women and men and what factors may drive such variation. We investigated the association of gender and income with survival and retention in a South African ART programme.

METHODS: A total of 2196 treatment-naïve adults were followed for 1 year on ART. Proportional hazards regression was used to explore associations between baseline characteristics and survival and loss-to-follow-up (LTFU).

RESULTS: Patients were predominantly female (67%). Men presented at an older age and with more advanced HIV disease, and during early ART the crude death rate was higher among men than women (22.8 vs 12.5/100 person-years; P = 0.002). However in multivariate analysis, gender was not significantly associated with survival after adjusting for baseline clinical and immunovirological status (HR = 1.46, 95% CI = 0.96-2.22; P = 0.076). In late ART (4-12 months), there was no gender difference in mortality rates (3.5 vs 3.8/100 person-years; P = 0.817). In multivariate analysis, survival was strongly associated with age (HR = 1.05, 95% CI = 1.02-1.09; P < 0.001), CD4 count >150 vs <50 cells/microl (HR = 0.35, 95% CI = 0.14-0.87; P = 0.023) and any monthly income vs none (HR = 0.47, 95% CI = 0.25-0.88; P = 0.018). Having some monthly income was protective against LTFU at 1 year on ART (adjusted HR = 0.56, 95% CI = 0.39-0.82; P = 0.002).

CONCLUSION: Men's high early mortality on ART appears due largely to their presentation with more advanced HIV disease. Efforts are needed to enroll men into care earlier in HIV disease and to reduce socio-economic inequalities in ART programme outcomes.

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11. When "no" means "yes": the gender implications of HIV programming in a Zimbabwean university

Authors: Masvawure TB 1; Terry PE 2; Adlis S 3; Mhloyi M 4
Institutions: 1 Department of Anthropology and Archaeology and the Centre for the Study of AIDS, University of Pretoria, Pretoria, South Africa; 2 Staywell Health Management, Eagen, Minnesota; 3 Park Nicollet, Health Research Centre, St Louis Park, Minnesota; 4 Center for Population Studies, University of Zimbabwe, Zimbabwe
Source: Journal of the International Association of Physicians in AIDS Care Sep-Oct 2009; 8(5): 291-8.

ABSTRACT

OBJECTIVES: This study assessed the nature and extent of sexual risk-taking behavior by students in a Zimbabwean university and identified some of the sociocultural factors that facilitate sexual risk taking by female and male students. The main outcome measures of the study were condom use, number of sexual partners, and attitudes toward gender equity and equality.

METHODS: A cross-sectional design was used and a questionnaire was administered to 933 students. Information pertaining to students' sexual practices, condom use practices, attitudes toward HIV testing, and their beliefs pertaining to women's role in sexual decision making and a woman's right to refuse sexual intercourse were among some of the variables assessed.

RESULTS: The vast majority of the university students (83%) are sexually experienced; only a third used condoms at their last sexual encounter; the use or nonuse of condoms was significantly associated with age, sex, marital status, and attitudes toward gender issues. There were also significant differences in the sexual behavior and attitudes of female and male students.

CONCLUSION: Our study suggests that HIV prevention efforts targeted at university students need to incorporate a discussion of broader cultural beliefs, particularly those pertaining to gender role myths, if they are to be effective.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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