Mellissa Withers

Rape Myth Attitudes in Rural Kenya Toward the Development of a Culturally Relevant Attitude Scale and “Blame Index”

Rape myth attitudes (RMAs) can excuse men for rape, placing blame on female victims. This study identified and classified RMAs in rural western Kenya through 31 focus group discussions with youths and adults. We found that about half of the participants were likely to blame victims unconditionally. Stereotypes about rape victims and perpetrators were rife. Five of seven standardly used RMA categories emerged spontaneously in focus groups, along with a new category: “she owed him.” Based on the data, we developed a “blame index” to assess the likelihood of community victim blaming in Kenya. To reduce victim blaming and bring about more prosecutions for rape, community education, teacher training, and reforms of rape laws are highly recommended.

Gendered power dynamics and women's negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya.

Abstract In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples’ negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women’s and couples’ negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or on the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male dominated reproductive decision making and women’s agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.

DESIRE FOR MORE CHILDREN, CONTRACEPTIVE USE AND UNMET NEED FOR FAMILY PLANNING IN A REMOTE AREA OF BALI, INDONESIA

Exploring fertility preferences in relation to contraceptive use can increase the understanding of future reproductive behaviour and unmet family planning needs. This knowledge can help assist women in meeting their reproductive goals. The influences on the desire for more children and current contraceptive use were examined among 1528 married women of reproductive age in an isolated community in Bali, Indonesia, using multivariate logistic regression analysis. Women who were younger, had fewer living children, had given birth in the past year and had regular access to health services were more likely to desire children. Being older, having fewer living children, not having regular access to health services, having given birth in the past year and having the desire for more children were associated with a lower likelihood of using contraception. Women with regular access to health care are more likely to desire more children, probably because they are confident in their ability to have successful birth outcomes. However, specialized clinics or family planning outreach workers may be required to reduce barriers to service utilization among some groups. The findings of this study identify key target populations for family planning, including older women and postpartum women--groups that may not perceive themselves to be at risk for unintended pregnancy. Meeting unmet need for family planning among these groups could help women meet their fertility goals, as well as reduce maternal morbidity and mortality.

‘Women now wear trousers’: men's perceptions of family planning in the context of changing gender relations in western Kenya

Gender inequity has been closely linked with unmet need for family planning among women in sub-Saharan Africa but the factors related to male family planning disapproval are not well-understood. This qualitative study explored mens perspectives of gender roles and cultural norms as they pertain to family planning. Twelve small group meetings were held with 106 married men in Nyanza Province, Kenya. Shifting gender relations made the definitions of manhood more tenuous than ever. Mens previous identities as sole breadwinners, which gave them significant control over decision-making, were being undermined by womens increasing labour force participation. While many men viewed family planning positively, fears that family planning would lead to more female sexual agency and promiscuity or that male roles would be further jeopardised were widespread and were major deterrents to male family planning approval. By addressing such fears, gender-sensitive programmes could help more men to accept family planning. Increased family planning education for men is needed to dispel misconceptions regarding family planning side-effects. Focusing on the advantages of family planning, namely financial benefits and reduced conflict among couples, could resonate with men. Community leaders, outreach workers and healthcare providers could help shift mens approval of joint decision-making around family size to other reproductive domains, such as family planning use.

Perspectives of Vulnerable US Hispanics With Rheumatoid Arthritis on Depression: Awareness, Barriers to Disclosure, and Treatment Options

Despite the high prevalence of depression among vulnerable Hispanics with rheumatoid arthritis (RA), many do not disclose it or seek treatment. This study explored patient perceptions of depression, its association with their primary disease, barriers to disclosure, reasons for low utilization of mental health care resources, and culturally acceptable intervention approaches.

Predictors of Workplace Sexual Health Policy at Sex Work Establishments in the Philippines

Abstract Based on the literature, we identified manager and establishment characteristics that we hypothesized are related to workplace policies that support HIV protective behavior.We developed a sexual health policy index consisting of 11 items as our outcome variable. We utilized both bivariate and multivariate analysis of variance. The significant variables in our bivariate analyses (establishment type, number of employees, manager age, and membership in manager association) were entered into a multivariate regression model. The model was significant (p<.01), and predicted 42) of the variability in the development and management of a workplace sexual health policy supportive of condom use. The significant predictors were number of employees and establishment type. In addition to individually-focused CSW interventions, HIV prevention programs should target managers and establishment policies. Future HIV prevention programs may need to focus on helping smaller establishments, in particular those with less employees, to build capacity and develop sexual health policy guidelines.

Gender, masculinity and migration: Mexican men and reproductive health in the Californian context

An appreciation of the social, cultural and economic dimensions of gender and sexuality is important in increasing reproductive health service utilisation. This analysis of recent Mexican male immigrants in Southern California focuses on changing views of gender roles, masculinity and relationship dynamics in the context of migration in order to explain low levels of reproductive healthcare utilisation. Semi-structured, in-depth interviews were conducted with 23 men who had migrated from Mexico. Some men saw their migratory experience as empowering, both individually and within the couple context. Migration reinforced positive male qualities, such as being a good provider. However, for others, the levelling of economic power between immigrant couples challenged traditional male gender roles and threatened mens identities. Maintaining control and decision-making power, especially in reproduction, remained tenacious, especially among older men. In response to immigration, however, mens views of ideal family size and contraceptive method preferences had evolved. The migration process caused some divisions in family networks and aspirations of fatherhood as an expression of masculinity contributed to varying levels of contraceptive use. Recommendations are made on factors that may empower male clients more actively to seek reproductive healthcare in the context of more equitable couple decision-making.

Do ambivalent women have an unmet need for family planning? A longitudinal study from Bali, Indonesia.

INTRODUCTION Fertility intentions often can predict contraceptive demand and fertility outcomes. Little is known about women reporting ambivalent fertility intentions, who are usually classified as having an unmet need for contraception. This studys objectives were to determine 1) which fertility intention group ambivalent women more closely resemble and 2) whether ambivalent women seem to have an unmet contraceptive need. METHODS We analyzed longitudinal data from 1,018 married Balinese women aged 15 to 45, of whom 33% desired more children, 52% wanted no more, and 14% were ambivalent. Ambivalent women were compared with those with definitive intentions using bivariate analyses. Regression analysis was used to determine the predictors of birth avoidance. RESULTS Although ambivalent women were significantly older, and had less education and more children than women who wanted more children, ambivalent women were more similar in their contraceptive use to those who wanted more children than those who wanted no more. However, in terms of birth outcomes, ambivalent women resembled more the women who intended to avoid childbearing: After 4 years, 33% of ambivalent women had another birth compared with 29% of women who wanted no more and 57% of women who desired more children. Contraceptive use at baseline did not predict ambivalent womens fertility outcomes, unlike the other groups. CONCLUSION Despite their relatively low rates of contraceptive use at baseline, ambivalent women generally avoided giving birth during the study period. This suggests that ambivalent women may not have a high unmet need for family planning.

Women’s empowerment and family planning: A review of the literature

This paper reviews the literature examining the relationship between womens empowerment and contraceptive use, unmet need for contraception and related family planning topics in developing countries. Searches were conducted using PubMed, Popline and Web of Science search engines in May 2013 to examine literature published between January 1990 and December 2012. Among the 46 articles included in the review, the majority were conducted in South Asia (n=24). Household decision-making (n=21) and mobility (n=17) were the most commonly examined domains of womens empowerment. Findings show that the relationship between empowerment and family planning is complex, with mixed positive and null associations. Consistently positive associations between empowerment and family planning outcomes were found for most family planning outcomes but those investigations represented fewer than two-fifths of the analyses. Current use of contraception was the most commonly studied family planning outcome, examined in more than half the analyses, but reviewed articles showed inconsistent findings. This review provides the first critical synthesis of the literature and assesses existing evidence between womens empowerment and family planning use.

Perceptions of misoprostol among providers and women seeking post-abortion care in Zimbabwe

Abstract In Zimbabwe, abortions are legally restricted and complications from unsafe abortions are a major public health concern. This study in 2012 explored women’s and providers’ perspectives in Zimbabwe on the acceptability of the use of misoprostol as a form of treatment for complications of abortion in post-abortion care. In-depth interviews were conducted with 115 participants at seven post-abortion care facilities. Participants included 73 women of reproductive age who received services for incomplete abortion and 42 providers, including physicians, nurses, midwives, general practitioners and casualty staff. Only 29 providers had previously used misoprostol with their own patients, and only 21 had received any formal training in its use. Nearly all women and providers preferred misoprostol to surgical abortion methods because it was perceived as less invasive, safer and more affordable. Women also generally preferred the non-surgical method, when given the option, as fears around surgery and risk were high. Most providers favoured removing legal restrictions on abortion, particularly medical abortion. Approving use of misoprostol for post-abortion care in Zimbabwe is important in order to reduce unsafe abortion and its related sequelae. Legal, policy and practice reforms must be accompanied by effective reproductive health curricula updates in medical, nursing and midwifery schools, as well as through updated training for current and potential providers of post-abortion care services nationwide. Our findings support the use of misoprostol in national post-abortion care programmes, as it is an acceptable and potentially life-saving treatment option. Résumé Au Zimbabwe, les avortements sont limités par la loi et les complications dues aux avortements à risque représentent un grave problème de santé publique. Cette étude de 2012 a analysé les perspectives des femmes et des prestataires au Zimbabwe sur l’acceptabilité de l’utilisation du misoprostol comme forme de traitement des complications de l’avortement dans les soins post-avortement. Des entretiens approfondis ont été menés avec 115 participants dans sept centres de soins post-avortement. Ont participé 73 femmes en âge de procréer qui avaient reçu des services pour avortement incomplet et 42 prestataires, notamment des médecins, des infirmières, des sages-femmes et des généralistes. Seuls 29 prestataires avaient déjà utilisé le misoprostol avec leurs propres patientes et à peine 21 avaient reçu une formation formelle sur son utilisation. Presque toutes les femmes et les prestataires préféraient le misoprostol aux méthodes d’avortement chirurgical car il était jugé moins invasif, plus sûr et plus abordable. En général, les femmes préféraient aussi la méthode non chirurgicale, lorsqu’elles avaient le choix, car l’acte chirurgical et les risques suscitaient de nombreuses craintes. La plupart des prestataires étaient favorables à la levée des limitations légales à l’avortement, en particulier l’avortement médicamenteux. L’approbation de l’utilisation du misoprostol pour les soins post-avortement au Zimbabwe est importante afin de réduire les avortements à risque et ses séquelles. Les réformes juridiques, politiques et pratiques doivent s’accompagner de mises à jour probantes du programme des études en santé génésique dans les écoles de formation des médecins, des infirmières et des sages-femmes, ainsi que d’une formation actualisée des prestataires actuels et potentiels de services de soins post-avortement dans l’ensemble du pays. Nos conclusions appuient l’utilisation du misoprostol dans les programmes nationaux de soins post-avortement, puisqu’il s’agit d’une option de traitement acceptable, qui a le potentiel de sauver des vies. Resumen En Zimbabue, el aborto es restringido por la ley y las complicaciones del aborto inseguro son un grave problema de salud pública. Este estudio en 2012 exploró las perspectivas de las mujeres y profesionales de la salud en Zimbabue respecto a la aceptabilidad del uso de misoprostol como una forma de tratamiento de las complicaciones del aborto en la atención postaborto. Se realizaron entrevistas a profundidad con 115 participantes en siete centros de atención postaborto. Los participantes fueron 73 mujeres en edad reproductiva, que recibieron servicios por aborto incompleto, y 42 prestadores de servicios, entre ellos médicos, enfermeras, parteras y médicos generales. Solo 29 prestadores de servicios habían usado misoprostol anteriormente en sus pacientes, y solo 21 habían recibido formación académica en su uso. Casi todas las mujeres y profesionales de la salud prefirieron el misoprostol a los métodos de aborto quirúrgico porque fue percibido como menos invasivo, más seguro y más asequible económicamente. Por lo general, las mujeres prefirieron el método no quirúrgico, cuando se les dio la opción, ya que tenían muchos temores en torno a la cirugía y el riesgo. La mayoría de los prestadores de servicios favorecieron eliminar las restricciones jurídicas referentes al aborto, particularmente el aborto con medicamentos. En Zimbabue, es importante aprobar el uso de misoprostol para la atención postaborto a fin de reducir el aborto inseguro y las secuelas relacionadas con éste. Las reformas de leyes, políticas y prácticas deben ir acompañadas de actualizaciones eficaces de currículos sobre salud reproductiva en facultades de medicina, enfermería y partería, así como de capacitación actualizada para actuales y futuros prestadores de servicios de atención postaborto a nivel nacional. Nuestros hallazgos respaldan el uso de misoprostol en programas nacionales de atención postaborto, ya que es una opción de tratamiento aceptable, que tiene el potencial de salvar vidas.