Strategies needed to involve men, other family members.

PIP: Women typically do not make decisions about contraceptive use and family planning on their own, and many women often have little, if any, decision-making power in the home. Strategies are therefore needed to empower women, educate family members, and involve men in reproductive health programs. Policymakers should expand the range of male services and encourage the greater use of male contraceptive methods. Furthermore, health programs should include counseling to help men and women improve their communications skills and conduct education campaigns to inform men about the roles they can play in family planning. Men should also learn about the side effects of both male and female methods, since concern over method side effects can frustrate their support of family planning. Appropriate strategies can be tailored to meet individual group needs. Programs in Madagascar, Bangladesh, Honduras, and Nepal are described as examples of how the support of family members can positively affect family planning use and reproductive health.^ieng

HIV-related concerns and behaviors among Hispanic women.

Hispanic women whose sexual partners have other sexual partners may be at risk for HIV. A structured interview was administered to 106 Dominican and Puerto Rican women who reported that they knew or suspected that their partner had other partners. A subsample participated in qualitative interviews. The study assessed concern about HIV and predictors of condom use. The majority of women reported that they worried about getting HIV and almost half had been HIV-tested. Most of the women discussed HIV/AIDS concerns with their partners, and one-third reported some condom use. Predictors of condom use were: born in the Dominican Republic/Puerto Rico, having talked with their partner about being tested, and belief that he used condoms with others. Although the women were concerned about HIV, condom use was infrequent. Results suggested methods to address this discrepancy: introducing condoms early in the relationship, developing women-controlled methods, and directly influencing men's behavior.

PIP: Hispanic women in the US, especially injecting drug users and partners of infected men, have a disproportionate risk of acquiring the human immunodeficiency virus (HIV). This study focused on two groups of Hispanic women in New York City--45 Dominicans and 61 Puerto Ricans--who knew or suspected that their regular sexual partner was involved with other partners. Respondents were recruited from health clinics and social service agencies in 1992. Respondents had a relationship with their husband/boyfriend of at least one year's duration and no history of intravenous drug use. About half the women were living with their partner. 62% reported worrying "a lot" about HIV, and about half had been tested. 36% of Dominican and 33% of Puerto Rican women's partners used condoms with them; 27% of Dominican respondents and 41% of Puerto Rican women believed their partner used condoms with other partners. Logistic regression revealed that condom use was significantly more frequent among women born in the Dominican Republic or Puerto Rico as opposed to the US, women who talked to their partners about being tested for HIV, and those who believed their partner was using condoms with other women. In focus group discussions, women reported they felt more confident negotiating condom use for contraceptive purposes than for disease prevention. They further indicated it was easier to introduce condom use at the start of a sexual relationship.

Female condom study explores role of peer support in sustaining use. Women's forum.

PIP: The AIDS Control and Prevention (AIDSCAP) Project's Women's Initiative, together with the US Agency for International Development, supported a study of the use of female condoms. 96 women in 10 focus groups in Nairobi and Sao Paulo participated in a discussion group about their experiences with the female condom designed to determine how the female condom affects women's ability to negotiate safer sex and to identify reasons for continued use and nonuse of the device. The study design allowed participants to help each other devise strategies for negotiating the use of the female condom with their partners and to sustain that use through peer support. Most of the women reported that use of the condom gave them the courage to discuss sex with their husbands and boyfriends. They remained, however, wary about occasionally denying their partners sexual intercourse. The study's design, women's networks, and men's perspective on the female condom are discussed. 55 men in six focus groups reported preferring the female condom over the tight and uncomfortable male condom, and planned to use them if made available.^ieng

Voices of impoverished Brazilian women: health implications of roles and resources.

This qualitative study was based on individual interviews with 75 Brazilian women in an impoverished peri-urban squatter community (favela) in southeastern Brazil. The purposes of the study were to describe women's role involvement in domestic and employment contexts; identify stresses and satisfactions of maternal, spousal, and employment roles; and assess personal and environmental role constraints and resources from the perspective of women's health. The analytic approach to the interview data was qualitative content analysis, through which thematic categories of maternal, spousal, and employment role satisfactions and stresses were identified by the researchers. Women's unrelenting work in the face of harsh social and economic environments was a broad theme woven throughout the women's descriptions of their lives. The confluence of role constraints affecting the participants' lives included poverty, marginalization, abuse, and lack of support and recognition by partners and society. In order to overcome great adversity and meet heavy role demands, these women relied on self, faith in God, family, and health resources. Implications for women's health promotion are discussed.

PIP: This article describes a qualitative study of women's role in an impoverished peri-urban squatter community in Brazil. The convenience sample included 75 women, comprised of Roman Catholics (51%), Protestants (17%), Spiritists (17%), and unreligiously-affiliated (11%). 26 women were illiterate. 49 had some primary school education. 59% had income that was below the poverty line. 92% reported their income as inadequate. 17 households did not have piped water, and 5 households did not have electricity. None had telephones. Only 28 had refrigerators. Interviews were conducted at the local health post among a sample that was largely unexposed to the questionnaire survey process, which sometimes posed difficulties. Attempts were made to seek out divergent cases or experiences and alternative explanations. Findings indicate that all the women identified themselves as the member of the household responsible for domestic housekeeping, and all saw that role as their most time- and energy-consuming. Most had at least 1 child. 72% were married, and 16% lived with a male partner. 12% were single, widowed, or divorced. Most were dependent upon spouses for economic support. 29 women had some employment outside the home. Women reported the lack of child care as a major reason for not being employed. There were other barriers. The women valued their role as mothers, but work and worries were dominant themes. Women complained about their partner's alcohol and drug misuse, domestic violence, and a lack of appreciation or affection. Working women reported socioeconomic satisfaction and work overload. Women's living conditions were harsh. Women showed considerable inner strength and creativity in dealing with demands and stresses.

Factors associated with Hispanic women's HIV-related communication and condom use with male partners.

To determine factors influencing Hispanic women's HIV-related communication and condom use with their primary male partner, 189 Dominican, Puerto Rican, and Mexican women were interviewed regarding sexual behaviour and condom use, relationship characteristics, perceived risk for HIV, and HIV-related communication with the primary male partner. Level of HIV-related communication with the primary male partner was associated with the woman's perceived risk for HIV and her rating of the openness with which she could communicate with her primary partner. Mexican women were less likely than Puerto Rican or Dominican women and women with multiple partners were less likely than those with one partner to communicate about HIV-related issues with their primary partner. Women reporting more condom use with their primary partner were younger, had discussed HIV-related issues more with the primary partner, and were less likely to expect negative reactions to requests for condom use than those reporting less condom use. These results suggest that prevention programmes that increase both general and HIV-specific communication between members of a couple may facilitate safer sex practices by the couple. Prevention programmes that encourage women to insist on condom use should consider the woman's expectations about her partner's reaction as a potential barrier to the initiation of safer sex practices.

PIP: To determine factors influencing Hispanic women's HIV-related communication and condom use with their primary male partner, 189 Dominican (n = 44), Puerto Rican (n = 54), and Mexican women (n = 91) 18-40 years old were interviewed regarding sexual behavior and condom use, relationship characteristics, perceived risk of HIV, and HIV-related communication with the primary male partner. They were recruited from the waiting rooms of primary health care clinics in the Washington Heights (Dominican), and East Harlem (Puerto Rican) sections of New York City and in El Paso, Texas (Mexican). Level of HIV-related communication with the primary male partner was associated with the woman's perceived risk of HIV. Mexican women were less likely than Puerto Rican or Dominican women and women with multiple partners were less likely than those with one partner to communicate about HIV-related issues with their primary partner. Puerto Rican and Dominican women reported more HIV-related communication with their primary partner than did Mexican women (p 0.02). 71% of the participants had told their partner they were worried about getting the AIDS virus from him. 59% of the women had asked their partner to change his behavior to this effect, but Mexican women were less likely to request such change and they were also the least likely to report any condom use (p 0.05). Overall, 74% of the women reported never using condoms with their primary partner in the past 6 months, 13% reported sometimes using condoms, and 13% reported always using them. Women reporting more condom use with their primary partner were younger, had discussed HIV-related issues more with the primary partner, and were less likely to expect negative reactions to requests for condom use than those reporting less condom use. These results suggest that prevention programs that increase both general and HIV-specific communication between members of a couple may facilitate safer sex practices by the couple.

Values under seige in Mexico: strategies for sheltering traditional values from change.

PIP: The adverse economic conditions of inflation and falling oil prices over the late 1970s and 1980s in Mexico forced many middle-class married women out of the home and into the workplace in order to help the family maintain its socioeconomic standing. Although this phenomenon ran directly against the traditional Mexican cultural construction of gender and family, many Uruapan middle-class couples had no alternative and rationalized the change by concealing, reinterpreting, or not directly challenging traditional values. Sections discuss the dilemma of middle-class families, Mexican middle-class adaptation to wives' employment, strategies for existing change in values, and the open acceptance of changed values. The author's comments and conclusions are based largely upon interviews with 16 married women of the period. It is concluded that even though the middle class resists them, changes have taken place over the past 20 years in the acceptance of married women in the workplace, the sharing of domestic work, fertility control, and equality between spouses in family decision making. It remains to be seen, however, whether these women will stop working and return to their formerly exclusive roles of wives and mothers if and when economic conditions improve in Mexico.^ieng

Chile: educational game, "Learning about AIDS: the Responsibility of All".

PIP: For more than 10 years, People's Health Education (EPES) has developed educational materials which call upon target audiences to integrate their practical experiences into a collective learning process based upon games. The methodology and materials aim to meet the needs of the most underprivileged sections of the population. EPES produced "Learning about AIDS: the responsibility of all," a game which can be used as it is or adapted to meet the needs of differing groups. The objectives of the game are to provide basic information on AIDS; to facilitate the expression of ideas, beliefs, and myths about AIDS; to promote forums for discussion in order to exchange opinions and views on sexuality and AIDS; to create awareness on how AIDS affects the community; and to create awareness of the need to prevent the disease. Played in couples to strengthen the level of interpersonal communication on such issues, the game is played because AIDS is a fact of everyday life which is affecting the community, because learning about AIDS will help people to protect themselves and their communities from the disease and groundless associated fears, and because open discussion is needed to help prevent more people from becoming infected with HIV.^ieng

Encouraging discussion with partners and building negotiation skills: HIV prevention strategies for women in relationships in Brazil, Tanzania and Indonesia.

PIP: Results from an ongoing 4-phase research and intervention project on women in relationships in Brazil, Tanzania, and Indonesia are discussed. The project is being conducted with the goal of increasing the levels of discussion with women's partners about sex, health, and ways to protect themselves from AIDS. Like men, women are at risk of contracting HIV from both their own behavior and that of their partners. Regarding condom use, however, women are at a particular disadvantage in that they must ask for and subsequently receive the consent of male partners before condoms will be used. Talking, discussing, and negotiating are therefore important processes to understand and employ when helping women to reduce their exposure to HIV. Preliminary results suggest that many women recognize the benefits of communicating in protecting themselves against AIDS, in bringing them closer to their partners, and in helping men change their behavior. Participants also recognize the potential of communication and negotiation in making male partners angry and suspicious, ultimately driving them away. Women who talked with their partners differed significantly from those who did not in their perceptions of what significant others, such as closest friends, doctors, church members, thought they should do. Strategies are discussed for increasing dialogue, with special attention given to the challenges of applying consumer research tools in developing countries.^ieng

[Men want to speak out]. / Los hombres piden la palabra.

PIP: Long before the appearance of oral contraceptives, men took the lead in controlling family size, especially in the developed countries, through use of condoms and withdrawal. But women now have almost total priority in the field of family planning (FP). The risks of too many pregnancies, FP services offered through maternal child health care workers, and the networks, and the women's liberation movement have been the main factors in the predominance of women in FP. In recent years, however, organizations and expert in FP have recognized the need to incorporate men in FP programs. Men must not take part in the struggle for improved living conditions. A recent report by the International Planned Parenthood Federation states that men have not only been almost ignored in FP programs, but have been excluded in the belief that they constitute an obstacle to the efficacy of programs. Failure to involve men in FP and contraceptive decisions has led to an increase in the rate of unplanned pregnancies and ultimately to as lower quality of life for many families. Men have also been neglected in the area of contraceptive research and development. It has proven much less difficult to develop a range of contraceptive methods to control the single egg produced each month by a woman then to control the millions of sperm produced by a man. Rapid heterosexual transmission of AIDS has prompted significant efforts to motivate men to use condoms, which has had a certain demographic effect. Information campaigns have been prepared to create male awareness of condom use and to change attitudes toward FP. Research has shown that men in different countries desire access to different contraceptive methods, but that many are mistrustful of new drugs and devices that are rumored to harm users. Some men also fear that use of new male contraceptives will bring a change in the balance of social control between the sexes. Only through information campaigns, increased services for men, personal contact in community activities, and communication between partners will real incorporation of men into the process of FP be possible. Available methods requiring male participation are the condom, vasectomy, withdrawal, and rhythm. Condoms protect against sexually transmitted diseases and are safe and effective when correctly used. Vasectomy is 99% effective but is a permanent method appropriate only for couples whose families are complete. Withdrawal is an ancient method used by an estimated 35 million couples in 1986, but like the rhythm method sit has a high failure rate.^ieng

A body ... for whom?

PIP: An opinion pole was conducted by the Mexican Health Department in 1988 to determine the problems facing women in terms of sexuality and reproductive activity. 1481 women from the Northeast, Bajio, and Southeast regions were included. The data showed that women feel they have more right to make decisions concerning motherhood and less when it comes to deciding when the couple is having sex. 31% of the women felt that it is the man who should decide when to have sex, while only 14% felt it is the man who should decide when to have children. 81% of the women with secondary school or higher education felt that both members of a couple have to decide when to have sex, compared with 45% of uneducated women. There is a 73% difference between urban and rural women when it comes to the decision that sexual relationships should be made by the couple. There is a 66% difference between women who have experience with contraception and those who have not concerning this type of decision. Uneducated rural women with a large number of children who have never used contraception are least likely to decide on the number of children, while 91% of higher educated women felt that it was a decision for the couple. 78% of urban women compared with 54% of rural women felt the same way. Another difference between urban and rural women is the value of the sex act. For urban women it is seen as having an affectionate value while rural women are more likely to associate the sex act with pregnancy.^ieng

[Negotiating safer sex]. / Negociando el sexo mas seguro.

PIP: Women have generally assumed responsibility for contraception since the appearance of oral contraceptives and IUDs. But AIDS prevention programs are now asking women to assume responsibility for safer sex through use of condoms, a male method. Women are being asked to carry condoms, to negotiate their use each time they have sex, and to insist if the partner resists. The problem with this strategy is that frequently it is the male partner who makes sexual decisions, and women have less negotiating power. Women are considered feminine if they assume a passive role in sexual activity. This work suggests strategies to improve the negotiating power of women. Options and problems of speaking about safer sex vary in accordance with the nature of the relationship. A woman with a new partner can try to ascertain his sexual history, but may gain no information on his probable health even if he tells her the truth. It may be easier to convince him to use a condom at least in the beginning of the romance. Women working in the sex industry often have greater trouble convincing their friends and lovers to use a condom than their clients. Some family planning workers have begun to speak of safer sex with all their clients. Role playing and workshops or discussions with small groups of women having similar problems may help women overcome their reticence about discussing sexual topics. Some general suggestions to help women negotiate safer sex include choosing an opportune moment and planning in advance what to say; daring to speak directly without beating around the bush (the partner may also be gathering courage to speak); practicing placing condoms on objects and if necessary placing one on the partner without speaking; being honest with the partner about sex, love, and fidelity; and remembering that protection from condoms is mutual given that it is not possible to know who is infected. Until now, programs to help women practice safer sex have concentrated on sex industry workers or family planning clients. Adolescents are a particularly vulnerable group because of their usual lack of knowledge when the initiate their sex lives. Some sex education classes are beginning to include materials instructing young girls in how to negotiate with boys seeking sexual favors. Printed materials such as simple pamphlets made available by family planning programs to young people can help to raise the topics of HIV infection and safer sex. Greater societal awareness of the problem and improvements in the opportunities for women to exercise their basic rights will be needed to ensure all women the power to protect their own health.^ieng

[The rights of the Colombian family in the U.N. Convention]. / El derecho de familia Colombiano frente a la Convencion de la O.N.U.

PIP: One of the most important texts that exists to eliminate discriminatory practice against women is Article 16 of the Convention on the Elimination of All Forms of Discrimination Against Women whose focus is on establishing equality between men and women in marriage. The State needs to intervene in the private lives of families because institutional discrimination against women often begins with the role she plays within the family. Article 16 gives equal weight to men and women in marriage. However, the Civil Code of Colombia has established the legal age of marriage to be 18 for men and women alike, while in a article it states that boys under 14 and girls under 12 are incapable of marriage. Article 16 forces countries that have ratified the Convention to enforce a legal age of marriage, because it acknowledges that a woman depends on her biological maturity to procreate. The Convention also gives women the same rights in deciding on the number and spacing of children. The goals of the Convention establishes equal rights between men and women as spouses, in matters of property and in the administration of all good and responsibilities of the family.^ieng

Act reforming the Civil Code, 17 August 1989. [Selected provisions].

PIP: Ecuador's Act reforming the Civil Code, August 17, 1989, covers filiation, marriage, termination of marriage, the status of married women, marital property, marriage contracts, and parent-child relations. Filiation can now be established by being born to a couple living in a non-marital, stable, monogamous, and legally recognized relationship. Marriage is no longer defined as indissoluble and life-long. A marriage cannot be nullified after two years of its celebration or the time when the grounds for nullification were discovered except when the ground is incest or bigamy. There is a 300-day waiting period for remarriage after divorce when the woman does not prove she is not pregnant or her future husband does not certify that he will recognize as his any child to whom she gives birth. Grave injuries or a hostile attitude may individually provide grounds for divorce. Voluntary and unjustified abandonment for more than one year continuously is now grounds for divorce; abandonment lasting more than three years gives either party grounds for divorce. Language providing that a husband must protect his wife and the wife be obedient to her husband is replaced with language providing that marriage is based on the equality of rights and duties of both spouses. Language providing that the husband has a right to have the wife live with and follow him is replaced with language providing that the spouses shall establish their residence by common agreement. Either spouse, rather than just the husband, may now manage the community property; the marriage certificate is to specify which spouse will ordinarily manage the community property. Language providing that children owe more duty and respect to their father than their mother is now sex-neutral. Both parents, rather than just the father, now have the right and the duty to direct the children's education. Provisions of the Code relating to parental authority are amended to make them refer to both parents, rather than just the father.^ieng

Civil Code (Amendment) (No. 2) Act, 1989 (No. 13 of 1989), 28 December 1989.

PIP: This Act amends various provisions of the Saint Lucia Civil Code to equalize the status of men and women. Among other things it provides 1) that husband and wife owe mutual protection to each other, rather than the husband owes protection to his wife and the wife owes obedience to her husband; 2) that the spouses shall live wherever they both agree to reside, rather than the wife is obligated to live with and follow her husband; 3) that both spouses are bound to supply each other with the necessities of life according to his or her means, rather than the husband is bound to supply the wife with the necessities of life according to his means and condition; 4) that, if an action for separation is dismissed, the parties are not obliged to resume cohabitation, rather than the husband is obliged to take back his wife and the wife is obliged to return; 5) that a married woman can become a guardian in all circumstances, rather than only if appointed jointly with her husband; 6) that a wife who has been appointed a guardian will continue to be a guardian if she remarries, rather than lose that ability; 7) that spouses shall together administer community property, rather than the husband shall administer it; and 8) that a wife who renounces the community will be responsible for debts to which she bound herself jointly and severally with her husband, rather than being freed from them.^ieng

[Survey of men provides reliable data on contraception in the Dominican Republic]. / Encuesta de varones proporciona datos confiables sobre la anticoncepcion en la Republica Dominicana.

PIP: Comparison of the results of 2 contraceptive prevalence surveys in the Dominican Republic, 1 of a sample of 4741 women in 1983 and the other of a sample of 4203 men in 1984, indicated that men and women have similar levels of knowledge and reported similar levels of use of contraceptives. Differences were noted in such areas as the acceptability of methods and the number of children each spouse desired. Both surveys were conducted by the National Council of Population and the Family. The women were aged 15-49 years and the men were 15-59. 2037 of the men were in union at the time of the survey and 2166 were single. The majority of respondents in both groups were under age 30. 44% of the men and 29% of the women under 30 were single. Dominican men are 5-10 years older than women on average when they enter stable unions. A comparison of age specific fertility rates of men and women showed that men have their highest level of fertility between 25-30 years and continue to reproduce beyond age 50, while women's fertility is highest between the ages of 20-29 and declines considerably thereafter. The total fertility rate was 4.2 for men aged 15-49 and 4.6 for men aged 15-59. It was 4.1 for women aged 15-49. Over 1/2 of men and 1/2 of women in union who had 2 or more children stated they wanted no more children, but at each parity men were more disposed to want another child. Women at all parities overestimated the number of children their partners wanted. The pill was the only contraceptive method that the majority of men and women who had ever been in union named spontaneously. When other methods were named, 94% of men and 97% of women ever in union knew about pills and female sterilization, 71% of men and 89% of women knew about IUDs, 71% of men and 80% of women knew about injectables, and 61% of men and 75% of women knew about vaginal methods. 92% of men and 88% of women knew about condoms. 46% of the women in union had been using a family planning method, including 27% who were sterilized and 9% who used pills. The responses of men when asked about their wives' contraceptive use were about the same. However, men reported higher use of male methods. 9% of men but only 1% of women reported using rhythm, 7% of men but 3% of women withdrawal, and 5% of men and 2% of women condoms. Among men not using a method, 61% reported they might use rhythm, condoms, withdrawal, or vasectomy in the future. 94% of men approved of at least 1 female method, but approval of specific methods varied widely. Over 80% of men in union approved of female sterilization and rhythm, but only 37% approved of pills and 41% of IUDs. The researchers concluded that men cooperate sufficiently to justify similar surveys in other Latin American countries, and that men can be reliable sources of information for programming and evaluation of family planning programs.^ieng

[Toward a predictive model of family planning]. / Hacia un modelo predictivo de la planificacion familiar.

PIP: A study of 1200 women aged 15-45 in Mexico City was conducted with the object of discovering the factors that have the greatest predictive value for attitudes, beliefs, intentions, and behavior in reference to family planning. Information was solicited by questionnaire with respect to 6 groups of variables: 1) independent variables (age, education, occupation and education of spouse, and whether the woman worked before marriage); 2) perceived value of children and family planning; 3) peer group norms; 4) marital relationship; 5) modernization; and 6) motivation. Factor analysis was applied to each of the groups ofvariables to determine which factors had the greatest impact within the group; then multiple regression analysis was applied to determine which factors had the greatest predictive value. A predictive model of family planning according to the results is illustrated and the various aspects discussed. It was found that the intention to use contraceptives and a good marital relationship (one with open communication and shared decision making) were the best predictors of effective family planning behavior.^ieng

The myth of macho dominance in decision making within Mexican and Chicano families.

PIP: The myth concerning Hispanic family life which prevails in the social science literature can best be summarized by abbreviated quotations attributed to Alvirez and Bean. The Mexican or Chicano husband is a macho autocrat who rules as "absolute head of the family with full authority over the wife and children" where "all major decisions are his responsibility." Domination by husbands in marriage is logically consistent with their wives' submissivesness accompanied by passive acceptance of the future, strong religious beliefs, and a tendency to reside in the temporal present. The myth is also deeply imbedded in the social pathology model: differences between Hispanics and Anglos are assumed to reflect negatively on Hispanics. The myth, it should be noted, is seldom subjected to the scrutiny of empirical inquiry. The review of 4 studies on both Mexican and Chicano samples fails to support the notion of male dominance in marital desision making. Refutation of the hypothesis of masculine dominance in marital decision making calls other components of the myth into question. Research among Hispanics on alledged female submissiveness, fatalism, eligiosity, and temporal perspective are called for. More sophisicated designs involving experimental manipulations are needed. Experimental studies on the process of decision making, actual behaviors involved in economic or budgetary negotiations, and parental interaction around childrearing would also be of interest. While the data reviewed may suggest that Hispanic males may behave differently from nonHispanic males in their family and marital lives, the behavior is not in the inappropriate fashion suggested by the myth with its strong connotations of social deviance. Additional research is recommended among Hispanics on sex role behavior among both men and women, with special emphasis on how it influences family life and marriage.^ieng