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Last Words: Memo to the Director-General of the WHO

March 15th, 2012

Increased Funding for Adolescent Reproductive Health Essential to Improve the Quality of Life of Women

Executive Summary

The World Health Organization should prioritize funding for programs that support adolescent health and improve the Quality Adjusted Life Years (QALYs) among women. Adolescent reproductive health is a key stage in a woman’s development that determines the quality of life, morbidity, life expectancy and mortality of women across the world. Adolescent health encompasses several issues that should be addressed by international organizations such as WHO in order to reduce the negative impacts on women. For example, adolescents face issues such as unplanned pregnancies, unmet need for contraception, sexually transmitted diseases, child marriages, female genital mutilations, rape and violence, and unsafe abortions, issues that are prevalent in many societies. Therefore, it is critical for the WHO to support programs in communities that promote prevention and treatment for adolescents in order to protect their health and rights as women (1). Not only would improved funding for adolescent health programs improve women’s health status and reduce later adult disease burden, but also it will support the Director-General’s efforts to have the work of the WHO “judged by the impact … on the health of two populations: women and the people of Africa” (2). Funding adolescent health programs will have a positive impact on the health of women, especially in developing countries.

Background

Through extensive research on adolescent reproductive health this quarter, issues have been found to support the need for increased funding to improve adolescent health. According to the United Nations, reproductive health is the “state of complete physical, mental and social wellbeing, and not merely the absence of reproductive disease” (1). Reproductive health is crucial because it is a determinant of future health, quality of life, Disability Adjusted Life Years (DALYs), and economic productivity among women (1). Reproductive health is central to a woman’s life, and interventions targeted to improve women’s health should begin during early teen years when girls begin to sexually mature. For example, one of the most prevalent issues that affect adolescents in the developing world is the increased rate of early pregnancies and childbirths.  According to the World Health Organization (WHO), “about 16 million girls aged 15-19 give birth every year, … the vast majority of which occurs in developing countries” (3). Most of these pregnancies are unplanned due to lack of access to contraceptives, health care, education, early marriages, and barriers to abortion. Therefore, in most countries, young women resort to unsafe methods of abortion in order to terminate unwanted pregnancies, which result in about 13% of all maternal deaths among women. Globally, between 100, 000 to 200, 000 women die from unsafe abortions every year (4). Yet the rates of unsafe abortions are increasing worldwide. Therefore, these staggering statistics reveal the increased need to support women’s groups in endemic developing countries.

Implementation and Strategy

The WHO should use its international renown to address issues facing adolescent reproductive health through funding interventions that work at community level. First of all, education about sex and healthy practices should be addressed. In most cultures, sex is not discussed with adolescent girls, which leads to high rates of experimentation, and pregnancies. However, the problem is embedded in cultural systems that create stigma and discrimination around sexual issues. Nonetheless, teenagers are sexually active even without knowledge about safe practices (5). According to research, teenagers are heavily influenced by parent’s attitudes and ideas about sex. Yet, “educating children about sex is not a task that parents and other family members find easy” (6). Therefore, to improve adolescent sexual education both in the home and in schools, Parent Education Programs have been introduced in order to communicate accurate and useful information about sexuality and reproductive health to parents (6). The WHO and UNICEF support these programs in Sierra Leone, Malawi, Tanzania and Mexico. The introduction of these programs has led to increased awareness about adolescent reproductive health among communities, and in countries such as Vietnam and Egypt, educating parents also reduced the stigma against early sex education in schools. Education is a strategy that is very important to women’s health, and improving education in communities would advance the reproductive health status of women. In addition, the WHO should support other women’s movements in countries with widespread reproductive health problems such as the Equidad de Género women’s group in Mexico.  The group provides contraceptives to women, creates educational campaigns and lobbied the government to introduce a bill to include the emergency contraception pill in the national health care bill (7). Such efforts should be applauded among women’s groups because they increase women’s urgency and the ability to fight for their rights.

Moving Forward

By funding groups and organizations that support the reproductive health of adolescents, the WHO would contribute to a far enriched health status among women. The WHO seeks to enhance partnerships with organizations of the ground in order to improve health security, strengthen health care systems, promote development, and improve performance (2). I believe that through partnering with different groups that deal with women’s issues, the WHO would be able to improve health implementation in areas were poverty and social inequities are barriers to good health. I encourage the WHO to conduct further research in other adolescent health issues such as HIV/AIDS among youths in Tanzania, child marriages in Yemen, and sex trafficking in South Africa. These are also prominent issues that need international attention in order to meet the needs of young women in difficult situations. With a specific focus on adolescent reproductive health, the WHO would prevent pertinent health issues caused by structural violence against women, and support health equity and better quality of life for women in the developing world.

Works Cited

 

1. Guidelines on Reproductive Health, UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN), UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA). Accessed at <http://www.un.org/popin/unfpa/taskforce/guide/iatfreph.gdl.html>

2. The WHO Agenda, World Health Organization.  Accessed at <http://www.who.int/about/agenda/en/index.html>

3. 10 Facts about Adolescent Health, World Health Organization. Accessed at <http://www.who.int/features/factfiles/adolescent_health/en/index.html>

4. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, (2011) 6th Edition. World Health Organization files. Accessed at

<http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241501118/en/>

5. National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitudes and Experiences, (2003) Kaiser Family Foundation. <http://www.kff.org/youthhivstds/upload/national-survey-of-adolescents-and-young-adults.pdf>

6. Pathfinder International. Involving Parents in Reproductive Health Education for Youth. Focus on Young Adults, In FOCUS. Accessed at <www.pathfind.org/focus.htm>

7. “Birth Control in Mexico.” The Harvard Political Review, Accessed at <http://hpronline.org/covers/women-in-the-world/birth-control-in-mexico/>.

 

Remarks on the Health Status of Roma Women

March 15th, 2012

To the Members of the UN Human Rights Council,

It is an honor to communicate with you and share the findings from my research. As a college student in a class on International Women’s Health, I have had the opportunity to learn about the Roma minority in Europe, with a particular focus on women’s health status. It has been both a difficult and enlightening experience for me and I am writing this letter in order to share what I have learned and my hopes for a brighter future for the Roma. Just ten weeks ago, I had never heard of the term Roma or knew what group it referred to. I would have only recognized the term “gypsy” and my recollection would have triggered the image of Esmeralda from from the Disney adaptation of The Hunchback of Notre Dame. I was not aware of their history, culture, or conditions. My limited knowledge is probably representative of the average American.

I decided to study the Roma to expand my knowledge of minority health in the United States. Similar to many European countries, the United States has an overall high life expectancy, but significant disparities become apparent when the life expectancies of racial groups. A 2005 World Bank report published that the life expectancy of Roma in Central and Eastern Europe is on average 10 years less than the majority population (1). I share your concern to learn more about the causes of this discrepancy and how to prevent them. I began with a study of Roma housing experiences and read about forced evictions and cramped living conditions. For example, when Roma families in Serbia were moved from their settlement in 2009 for bridge reconstruction, they were not given adequate time or support for their move. They were forced to leave in three hours and bussed to containers in other parts of the city. The Amnesty International researcher on Serbia, Sian Jones, states that “eviction under these circumstances violates the right to an adequate standard of living, including rights to adequate housing, food, and water as guaranteed under the International Covenant on Economic, Social, and Cultural Rights” (2).
This right is also violated in Roma-made settlements that cover the outskirts of several European cities. Excluded from mainstream communities, they live in one-room homes made of sheet metal, wood, and whatever other scrap materials they could find. In Bulgaria, about four out of 10 Roma have no access to water and few have electricity (3). Other notable observations were the the high incidence of disease and other health problems. The close and unclean housing conditions contribute to the high rates of infectious diseases, especially tuberculosis and hepatitis, in Roma communities (4). Over half of Roma women in a French settlement had a present health problem (5). Although politicians desire in rhetoric for Roma inclusion, few efforts have been made. In (year), the Spanish Institute for Re-housing and Social Integration attempted to move 5,000 Roma families into Madrid. About eighty percent of families experienced little or no conflict with neighbors (6). This transition was surprisingly smooth considering that most majority population members consider Roma people the least desirable neighbors (7). This study demonstrates that xenophobia can be overcome, but governments must actively assist the Roma financially so they can afford rent and fully integrate into majority residential communities.

I explored many issues that Roma women face: domestic violence, low rates of education, verbal and physical abuse from health care professionals, and poor access to health services. I believe that these issues are the result of two causes: the inferior role of women in Roma communities and exclusion of Roma from majority society through low birth registration and discrimination. Roma girls and women are generally confined to the household at an early age. Those who attend school tend to drop out around ages 11 or 12 due to family pressure to stay at home and prepare for marriage (8). Since Roma culture varies among communities, I investigated the range of female marriage ages further. In more conservative groups, Kaldarashi and Bourgudzhie, the average age was 16 and in the more liberal group Roudari it was near 21 (9). The conservative communities also have greater instances of teen pregnancy. Roma women must work from within to change their status through improving education and economic independence. Yet, they can be assisted through local programming that focuses on school retention and job opportunities.

Discrimination is evident in many aspects of Roma  have with the majority population: housing, health care, education, and law enforcement. For majority population attitudes towards the Roma to change, they must have greater interaction with Roma people. This should be the result of government-supported initiatives that safeguard against abuse and improve birth registration of Roma so they can enjoy equal rights. The health mediator program is one development that needs more financial support to be fully effective. Mostly Roma women have been employed to serve as liaisons between the Roma communities and health and social services. In Serbia, where the program started in 2008, more than 280,000 Romani births have been registered with the government. Mediation in Roma interactions with majority European populations can lead to greater acceptance and social cohesion.

Through the process of learning about the Roma and their struggles, I now care deeply for their well-being especially the women. I believe awareness is the beginning of empathy; by educating the majority European populations about Roma conditions and encouraging equality will lead to governments making bolder changes. This process begins with increased research on Roma conditions. More needs to be known particularly about their health status and how the conditions of Roma in each country are similar or different. This information can lead to more targeted intervention proposals for local contexts and European Union-wide change. Ivan Ivanov, a human rights lawyer and director of the European Roma Information Office, stated that political will is low because “no politician has gained anything by dealing with Roma integration” (10). If people grow to value the Roma’s equal enjoyment of European Union rights, then the leaders of national governments will as well.

(1) http://www.socialwatch.eu/wcm/Roma_a_long_history_of_discrimination.html
(2) http://www.amnesty.org/en/for-media/press-releases/serbia-roma-evictions-endanger-people%E2%80%99s-lives-20090408
(3) http://www.trusselltrust.org/roma-community
(4) http://equality.uk.com/Health.html
(5) http://fra.europa.eu/fraWebsite/attachments/ROMA-HC-EN.pdf
(6) http://urbact.eu/fileadmin/Projects/Roma_Net/outputs_media/Case_study_rehousing__ES_May2011.pdf
(7) http://www.tol.org/client/article/23037-roma-lithuania.html
(8) http://www.ergonetwork.org/media/userfiles/media/egro/The%20right%20to%20Health%20-%20Challenges%20for%20Roma%20women%20Gabriela%20Hrabanova.pdf
(9) http://bnr.bg/sites/en/Lifestyle/BGEU/Pages/1711Earlymarriagesamonggypsywomen.aspx
(10) http://www.economist.com/node/17103983

Policy Shaping the Health Services Available to Adolescents in India

March 9th, 2012

In my final blog post, I would like to focus on the specific health services that adolescents have access to in South Asia and how this list is tailored by priorities in government policy.

A large picture view of the policies helped me identify with the government’s goals/priorities were for adolescent well-being. In 1983, the National Health Policy had adolescent groups are covered as part of whole population; covers general health, reproductive and sexual health, adolescents friendly health services, immunization, substance abuse, HIV/AIDS awareness, and  STDs/RTIs. In 2000, the national policy was expanded to address gender equity and equality, early marriage, unwanted pregnancy and unsafe abortion. [1]

In HIV testing and AIDS control policies, adolescents have not been considered a vulnerable group. Nutrition policies, however, address adolescence quite thoroughly because this is the section of the population that undergoes the most physical growth; special emphasis is given to micronutrient deficiencies like calcium, iron and vitamin A. Lastly, there is a national youth policy in the works that includes issues like health and nutrition, but also addresses issues like employment and understanding adolescent well-being in the context of their social and mental environments. [1]

But how were these goals/policies actually implemented? A study on Indian polices on adolescent health measured necessity for intervention and the efficacy of an intervention with the following indicators: years of education (because there was a huge gender gap in years completed), the degree of unmet need for family planning (two thirds of women are married by age 18 and FP services are not available to minors), and trends in teenage pregnancies (abortions and miscarriages are not increasing, but overall births are). [2]

Many programs were evaluated in this study, but a few that I would like to highlight are the [2]:

District Primary Education Program: This Department of Education program provides a special thrust to achieve universal coverage of primary education through decentralized planning and management, decentralized target setting, community mobilization, and district- and population-specific planning.

RCH Services Program: The RCH Program provides holistic maternal and child care, including increased access to contraceptives, safe management of unwanted pregnancies, enhanced nutrition, prevention and management of sexually transmitted infections, availability of reproductive health services to adolescents and educational outreach.

Integrated Child Development Services (ICDS) Scheme: The ICDS scheme offers an integrated package of early childhood care services. These services include supplementary feeding, immunization, health checkups, referral services for children up to six years of age and for expectant and nursing mothers, and nutrition and health education for mothers.

Adolescent Girl Scheme: This is a special intervention for girls ages 11–18 created to meet their special nutrition, education, and skill development needs. The scheme also aims at imparting skills and encouraging the involvement of girls in useful economic activities later in life.

State Plans of Action for the Girl Child: The governments of Karnataka, Madhya Pradesh, Tamil Nadu, and Goa have formulated state plans of action to tailor their policies to the girls’ issues within their states.

These plans of action are great on paper, but of course, there are some major gaps between policies/legislation and practice. Unfortunately, the laws and policies in relation to adolescents and the services provided for them are not explicit, and health care providers are often not fully aware of these laws and policies. Laws should take into account adolescents’ emerging needs and maturity while responding to local social contexts and maintaining basic human rights.

The issue of privacy is huge in the effectiveness of these laws. Concerns by adolescents about privacy can prevent them from accessing health care, even if they are able to give their own consent for the services being provided. Such concerns also influence where adolescents go for health services, and how and whether they will communicate openly with health care providers. [3]

Clearly the drafting of policy has affected the specific services that adolescents get: nutrition and some reproductive health services. The latter, however, is a much more recent policy emphasis and has still not been fully implemented in clinics or schools throughout the country. On top of that, key issues like the privacy of the millions of minors in India who end up pregnant or with STDs have yet to be addressed.

 

[1] http://www.yrshr.org/theme.asp?id=1

[2] http://www.policyproject.com/pubs/countryreports/ARH_India.pdf

[3] http://www.searo.who.int/LinkFiles/Meetings_Synthesizing_experiences.pdf

 

 

Under the shade

March 9th, 2012

This week, I carried out my research in order to find a second intervention that I thought seemed promising and was doing work in Africa to combat violence against women. Although my research enabled me to learn about a number of organizations (UNFPA, Raising Voices in Uganda, Vital Voices Global Partnership [and the work that they have done in Africa through the Global Partnership to end Violence against women], CARE), which I feel  would be beneficial for anyone who is interested to read about in order to gain knowledge on interventions being done in Africa  through these organizations, in this blog I will talk about an organization in Tanzania – Kivulini’s Women’s Rights Organization. I chose to focus my blog on this Non-governmental organization (NGO) because I felt that the interventions this organization is using tackles a number of issues that I have been discussing in my blog concerning domestic violence against women in Africa. In addition, given last week’s blog I was a little discouraged because I felt that women in African do not know their rights/existing laws concerning domestic violence against women and I wanted an intervention that tackles this issue, which this organization does.

Kivulini’s Women’s Rights Organization:

“In Swahili, Kivulini, literary means ‘in the shade/shelter. The title of this organization implies a safe place where women, men and children feel supported[5].”

Kivulini’s Women’s Rights Organization (will refer to it as Kivulini in this blog post) was established in 1999 by six women who felt compelled to tackle the growing issue of domestic violence that was rapidly growing in Mwanza, one of Tanzania’s two cities (second largest after Dare es Salaam). Kivulini tackles the issue of domestic violence against women by working closely with community members and leaders to change attitudes and behaviors that perpetuate violence. It also works with community volunteers in Mwanza region – currently has about 200 [2], who challenge traditional norms and customs that encourage gender-based violence, while also supporting and counseling victims of violence either by referring them to human rights organizations, hospitals, courts, and ward tribunals.

As an organization Kivulini’s mission statement states that, “women have the right to live free of violence in families and communities where relationships are based on equality, respect and value for women’s contributions, rights, and participation[1]“, working on promoting international conventions such as CEDAW (which Tanzania has signed and ratified) and pro-women laws.

The following are the main interventions/approaches (with a brief summary) that Kivulini has used in order to tackle the issue of domestic violence against women in Mwanza:

1) Advocacy : Through this intervention, Kurasini works with local ward leaders, professionals, NGOs and community members. Since the local government leaders are the first to be respond to family violence in Tanzania,  approached following family violence, Kivulini holds sessions with community leaders/members, etc. to review laws that effect women and children in their streets.

2) Community Awareness: works with the community at grassroot levels to promote women’s rights and prevent violence. This is done through educational sessions with community members, screening of educational videos concerning violence against women, facilitating community dialogue, theatre performances in community neighborhoods, festivals where people can meet and discuss the issues of violence against women.

3) Capacity Building: This is a Kivulini program aimed at building the capacity of community members, partners and staff through workshops, seminars, etc. which aid in skill development on tackling gender based violence (GBV) through a variety of trainings and workshops.

4) Economic Empowerment: Kivulini works on increasing women’s independence within their families and the community. It has provident training workshops on basic business skills to more than 560 grassroots members since 2002. These members pursue funds to set up savings and credit scheme to further assist small income generating activities. Majority of those trained were female (70%), with statistics showing that 75% of those who had received training were running their own small businesses successfully after two months [2].

5) Social Counseling and Legal Aid: This is an aspect of Kvulini’s intervention that I found fascinating. A lot of the work on counseling in Tanzania has been focused on HIV/AIDS counseling and there has been limited support to those who suffer from the psychological consequences of HIV/AIDS [3]. Kivulini has established a Social Counseling Center that aids women by giving them psychological counseling. “A trained counselor is available on a daily basis at the centre for women experiencing domestic violence.  Referrals are made to health care centers, the police, or social welfare offices and the counselors often accompany clients to provide support and help them negotiate the system [2]”.  In addition, Kivulini has a Legal Clinic that provides free legal counseling to women (teaching them their rights) and men and aid clients in the case whereby they wish to pursue their cases in court. The stats surrounding this intervention was amazing. Within a couple of years of establishment of the organization, “as of 30th July 2002, a total of 940 regular and new visits were recorded at the Centre for the year.  68 visitors came for basic information, while 449 received social counseling (showing the need for psychological interventions).  The Legal Clinic had a total of 161 clients [2]. Matrimonial cases had the highest ranking where clients’ issues were concerned, followed by inheritance/denial of properties, physical harassment, abandonment, and other domestic violence cases that affect children as well (e.g., rape, sodomy, mistreatment of domestic workers, etc.) [2]

6) Media and Learning materials in communities: Kivulini also works with journalists and the media to tackle how women are portrayed in the media. Through this organization, a media checklist has been developed for various journalists in the Mwanza region on their depiction of women on this issue, with the objective being to enable those working in the media to analyze stories written about violence against women. In addition, Kivulini works with communities to draw large scale colourful murals that depict family harmony in order to stimulate dialogue about the issue of GBV in Mwanza  and tackle cultural beliefs on this issue.

7) Research Development, Monitoring and Evaluation: Lastly, another component of Kivulini’s intervention that makes it outstanding is that it carries out research, monitoring and evaluation of its various programs to assure that they are effective and relevant to the community’s needs. This aspect of the intervention made me think about TeachAIDS and the importance of assuring that interventions are truly relevant to those it is seeking to aid.

I really like this organization because it tackles domestic violence in a number of different ways. Whereas most interventions do seek to combat violence against women through community outreach, this intervention was unique to me because it took the psychological impacts of victims of domestic violence in consideration by establishing a social counseling center (something that I have not seen in many other interventions in Africa). In addition, following up on issues of the law and domestic violence in Tanzania that I wrote about in my last blog, I really felt that this organization combated the ignorance surrounding women’s knowledge of their rights and women’s usage of the laws that are in existence. Lastly, although not mentioned above Kivulini owns a stationary and restaurant which makes it a self-sustaining organization due to ability to support itself financially. Its staff are females which provides them with employment (hence, opportunities to empower themselves economically).

References:

[1] http://www.kivulini.org/

[2] http://www.raisingvoices.org/files/KivuliniCaseStudy.FINAL.pdf

[3] http://www.kivulini.org/sites/default/files/resources/file/kivulini%202011-2015.pdf

[4]http://vitalvoices.org/what-we-do/regions/africa

[5] http://www.raisingvoices.org/kivulini.php

Giving Voice to Silent Victims: Promising Interventions for Sexual Abuse of Undocumented Mexican Immigrant Women in the U.S.

March 9th, 2012

In the first iteration of my blog this week, I outlined the rights that undocumented Mexican migrant women in the United States, including protection from an abusive partner or employer.  I was determined to find a promising intervention for this problem, since, as I discussed in a previous blog, Mexican and other migrant women make up such an integral part of the U.S. workforce and therefore their presence (and unfortunately the amount of abuse they endure) is unlikely to change anytime soon.

When I began my research on this topic, I discovered that this particular intervention is very tricky, because, for the most part, women who are present in the United States illegally wish to remain unknown to any entity that could cause them to be deported back to their home country, and therefore do not contact the people which could provide help and care in crisis situations (i.e. doctors, police officers, etc.).  So, how can we contact these women to inform them of their rights and their options for avoiding further abuse?

The first resource that I found was Voces Unidas, a nonprofit ‘pilot program for Mexican National Women and Children Survivors of Domestic Abuse’ created by the Center for Human Rights & Constitutional Law (1).  Their website provides directories of resources for counseling and support, health, homeless, and legal services, law enforcement contacts, and U.S. citizenship and immigration services and information on U.S. customs enforcement.   I found this website very powerful, because it provides hundred of contacts, including addresses and direct phone numbers for services in states and cities all over the country.  It is heartening to know that there is such a widespread community of people willing and able to provide help to this group of victimized women and children.

Unfortunately, while this is type of organization is vital for creating a network of support for Mexican migrant women who are victims of abuse, the fundamental problem is making sure that these women are aware that these resources exist and then enabling them to make use of them.  Many of the contacts listed in Voces Unidas’ directories are those of members of non profit organizations or shelters for battered women, homeless shelters, family planning centers, advocacy organizations, lawyers, and law enforcement officials who do not necessarily specialize in issues related to female undocumented immigrants, but who have expressed that they are willing and able to help these women.  This is great, but what is the use in the resources existing if the migrant women who need them do not even know they exist?

I found the website of an organization called Centro Presente, a “member-driven, state-wide Latin American immigrant organization dedicated to the self-determination and self-sufficiency of the Latin American immigrant community of Massachusetts” (2).  What is unique about this organization is that it is run by members of the Latin American immigration community, and therefore provides a more familiar community to undocumented workers who may feel detached from American society.  It is important to realize that many of the reasons that undocumented women do not seek out help is due to feeling isolated and unseen.  Many do not speak any or very little english and have little or no understanding of the U.S. legal system.  By having an outreach group run by Latin American immigrants, it may create a more comfortable environment for women who may be uncomfortable reaching out to members of a society with different values and perspectives than they may be used to.  The organization offers both adult education and legal counseling services, however, they do not specialize in sexual or physical abuse issues.

So, my proposition for an effective intervention is a partnership between two entities like Voces Unidas and Centro Presente.  In one part, a community where women can feel involved, valued, and comfortable, and in the other part, a network that provides specialized resources for the types of abuse that are unique for women.  I believe that fostering community and creating a space where women who have been subject to sexual and physical violence feel safe to bring up these issues is key.  In the case of Mexican undocumented female workers, the fact that resources exist is not sufficient- there needs to be community outreach and fostering that allow these women to come forward with their stories.

References
(1)”Welcome to Voces Unidas.” Mexico Project. Web. 09 Mar. 2012. <http://www.vocesunidas.org/>.
(2) Centro Presente. Web. 09 Mar. 2012. <http://www.cpresente.org/>.

Theatre: A Different Approach to HIV/AIDS Awareness

March 9th, 2012

For my last blog post, I would like to focus on a particularly different and interesting intervention for reproductive health education: theatre.

The story begins in Mozambique, one of the poorest countries in the world. Years of civil strife have left the nation, not only with a weak economy, but also without an adequate healthcare system. The lack of organized healthcare and budget has made it incredibly difficult for Mozambique to deal with its ongoing struggle against HIV/AIDS. According to UNAID, Mozambique is one of the ten most HIV/AIDS infected countries in the world, and 74,000 die annually to AIDS (5). Cultural factors also exacerbate the HIV/AIDS crisis. These factors include polygamy, gender inequality and domestic abuse, traditional beliefs and healing, and widow cleansing (5). The negative effects of each factor on HIV/AIDS prevention and treatment are listed below:

-       Polygamy: Mozambique has both matrilineal and patrilineal societies (i.e. after marriage, the couple becomes a part of either the wife’s or husband’s side of the family). In both groups, it is culturally acceptable to have multiple partners for women in the matrimonial societies and multiple partners for men in patrimonial societies. Multiple partners significantly increase the risk of HIV/AIDS.

-       Gender inequality and domestic abuse: Despite the presence of matrimonial societies, sadly, the predominant trend among Mozambican communities is the lack of inequality within the relationship. Women are often accused as the ones who have brought HIV/AIDS into the household, which can result in abandonment. Also, fear of domestic abuse leads many women to not get tested or ask their husbands to also get tested.

-       Traditional beliefs and healing: It is a common belief that HIV is caused by witchcraft. As a result, many Mozambicans will refer to a traditional healer to receive treatment. Traditional healers can also help spread HIV as they often use unsterilized material or recommend having sex with virgins as cures.

-       Widow cleansing: This is a death ritual, which aims to “clean” a widow after her husband has died. To remove the bad spirits from the household, the former husband’s brother must have sexual intercourse with the widow. Condoms are forbidden for the ritual. This practice also adds to the growing infected population.

Alvim Cossa, a native Mozambican, decided to approach the crucial issue of HIV/AIDS awareness differently. He established a non-profit cultural association known as Grupo de Teatro do Oprimidos (“Theatre of the Oppressed”) or GTO in 2001. The theatre group is based on his experience studying theatre methodology in Rio de Janeiro on scholarship from the United Nations Organization for Education, Science and Culture (UNESCO) (1). GTO is based on the teachings of Augusto Boal, a revolutionary dramatist, who developed the idea of the “spect-actor.” According to Boal, the audience should not be “spectators,” but should proactively participate as a “spect-actor” by inviting audience members to come on stage and demonstrate their ideas (3). Boal believed that through participation, audience members became “empowered” to generate social change. Cossa returned home and incorporated Boal’s “spect-actor” ideology into community plays that address the issues surrounding HIV/AIDS.

These plays are presented in open and public places such as markets, commercial centers, or schools. The plays are typically presented in the local languages as opposed to Portuguese (as only half the population speaks it). Play topics cover everyday situations such as a husband refusing to get tested for HIV/AIDS, or parents finding a condom in their child’s backpack. GTO actors are usually from the local community. What they see in regular life is incorporated into the play. A special role within the GTO is the “Joker” (5). The Joker facilitates an interactive space between the audience and actors. It is the Joker’s job to ask the audience for their input without leading them onto a specific solution. Rather, the Joker remains completely neutral and only encourages the audience to think critically. Men and women in the audience are encouraged to put on the character’s skirt or headscarf and actively engage in the play. Cuanja Muanza, an activist with the youth HIV educational group, Geracao Biz, gives HIV information sessions in Maputo (Mozambique’s capital) hospitals. She has stated that her young age has often deterred older listeners from taking her advice about HIV/AIDS prevention. However, she finds that theatre has been more effective in teaching a broader audience about the disease. Since 2006, 101 community theatre groups under GTO has reached 65,000 people in 10 provinces (4).

I was really intrigued by this intervention approach because it originated directly within the country of need. It was not a foreign organization coming into Mozambique and giving instructions on what to do. Furthermore, it is very effective in reaching a large number of the community as TV and radio access is limited, a largely illiterate population (so brochures probably wouldn’t help), huge language barriers, and the overall operation is relatively inexpensive. I also liked the idea of the “spect-actor” because it really does engage the audience. To see a similar situation like questioning a partner’s fidelity on stage allows one to feel that a sense of community in that one’s experiences are also felt by others in the community. Providing a more proactive role for the audience is a great way to spread knowledge about HIV/AIDS.

References

  1. “Mozambique: Art imitates life.” Plus News. 12 February 2008. <http://www.plusnews.org/Report.aspx?ReportId=76704>
  2. “Artsworld – The sound of the Orient.” (Video) 7 October 2008. <http://www.aljazeera.com/programmes/general/2008/10/200810494020845444.html>
  3. Paterson, Doug. “A Brief Biography of Augusto Boal.” Pedagogy & Theatre of the Oppressed. <http://www.ptoweb.org/boal.html>
  4. “Daniela Poggi documents the work of community theatre.” UNICEF. 20 January 2006. <http://www.unicef.org/mozambique/hiv_aids_3100.html>
  5. Robben, Annelieke. “Forum theatre as an alternative strategy in the fight against HIV/AIDS.” Wageningen University. November 2011. <http://edepot.wur.nl/185295>

 

 

 

Adopt a babushka in Kyrgyzstan!

March 9th, 2012

What is a babushka?  Basically, babushki are grandmothers or older women, who are often seen wearing headscarves.  They demand respect, and really do merit it.  These women have lived through Stalin, World War II, forced relocations, rationings and shortages, among many other hardships of the Soviet Union.  However, many young people and adults consider them “old and crazy”, and feel as if they are past their productive days.  They also no longer have a secure pension system to support them in their later years.

The average life expectancy for males in Russia is 64.3 years, but women can expect to live to 76.1 (these official government statistics actually seem pretty high given other sources that I have come across).  Most babushki are widows who live alone and rely on support from family.  Since the fall of communism, the social safety net they expected to use in retirement has proved to be unreliable and inadequate.

During the Soviet era, women could count on a relatively generous pension system.  The age of retirement was set at 55 after at least 20 years of work.  Time spent on maternity leave was given credit and women with more than 5 children were allowed to retire at 50.  About 55-85% of previous wages were replaced.  Not all health care was of high quality, but it was still at least available for free as part of a government system.

Since the 1990s, pensions have been greatly reduced in all post-Soviet states as they have gone through economic crises during their transitions to capitalism.  Women already earned less then men, so their pensions are generally lower than that of the average male, even though they live much longer than their husbands.  In Kyrgyzstan women earn about 55% of what men make, and so according, their pension will be 55% less than the average male’s.

The Kyrgyz government initially tried to implement a plan more generous than the Soviet system’s, but they were not able to back it up with the necessary funding and so it went bankrupt by 1994.  Now, pensions in the capital Bishkek are as low as $12/month, and in other regions they reach $5/month.  In addition, many adults have migrated to Russia in search of jobs and are not around to help take care of the older generation.  80% of pensioners are receiving pensions that are below the subsistence level.

I came across an NGO in Kyrgyzstan that addresses this issue.  Adopt a Babushka is based in two cities (Bishkek and Isfana) and they provide financial and social support to elderly who receive pensions less than $45/month and who do not have family member to take care of them.  While the program is not exclusively for women, due to the demographics 95% of beneficiaries are babushki.  Adopt a Babushka also attempts to raise awareness of the hardships elderly citizens face in Kyrgyzstan with media campaigns.  So far, 963 babushki have been adopted, and 114 have been screened and are on the waitlist.  A more comprehensive, government-led solution will be needed in the future, especially as Kyrgyzstan’s young population ages, but in the short-term Adopt a Babushka and similar programs are attempting to fill in the gaps.

 

References:

 

http://www.perepis-2010.ru/news/detail.php?ID=7049

http://elibrary.worldbank.org/docserver/download/2546.pdf?expires=1331277940&id=id&accname=guest&checksum=FD97A62DFCA159C1016785D41E294933

http://europeandcis.undp.org/gender/beijing/show/2A034573-F203-1EE9-B5AC187A2F867B4F

http://www.babushkaadoption.org/

http://www.swiss-cooperation.admin.ch/centralasia/en/Home/Activities_in_Kyrgyzstan/COMPLETED_PROJECTS/Babushka_Adoption

http://www.ilo.org/public/english/region/eurpro/moscow/news/2010/1026_2.htm 

http://countrystudies.us/kyrgyzstan/17.htm

 

 

 

 

 

 

Are You Sexually Healthy?

March 8th, 2012

In my previous blogs I have discussed the barriers to safe sex practices among Latinas. As you may recall, I discussed the lack of communication and discussion about sex and sexuality in the Latino community due to the perception  of sex as a taboo subject (Erby et. al, 2011). Furthermore, many Latinas experience feelings of guilt and shame surrounding sexuality. The combination of messages Latinas receive from the media, society, and religion perpetuate a negative attitude towards sexuality which leads to riskier sexual behavior. Most students receive some form of sexual education from their schools, however, I have found that most of the curricula used are culturally insensitive and have a very narrow approach. I understand that this approach is likely due to limitations by parents and government, but I believe a more holistic and comprehensive approach should be taken to sexual health education. In my search for such an intervention, I found Robinson et al.’s sexual health model used to prevent the spread of HIV. Although the model is not specifically targeted towards Latinas,  I believe its ten spoke approach to sexuality allows for adaptation to any specific group, including women of color.

-        The model is based on the assumption that sexually healthy people will engage in safer sex practices. The model defines sexual health ( incorporating definitions from various sources including the World Health Organization (WHO, 1975)) as the ability to be intimate with partner, communicate needs and desires effectively, and act responsibly while setting clear sexual boundaries. It encourages a much more sex positive approach than traditional sexual education models and stresses the value of sexual pleasure while addressing the challenges to achieving sexual health. Thus sexually healthy people are people who are sexually comfortable, literate, and competent. The ten spokes of the model are as follows:

  1. Sexual communication
  2. Culture and sexual identity
  3. Sexual anatomy functioning
  4. Sexual healthcare
  5. Barriers
  6. Body image
  7. Masturbation and fantasy
  8. Positive sexuality
  9. Intimacy and relationships
  10. Spirituality

The idea of the spokes is that they can be adapted to the needs of the target population to improve sexual health and decrease the prevalence of STIs and HIV in these communities. I find the focus on Culture and sexual identity to be especially important as they allow for a more effective intervention which tackles the issues underlying risky sexual behaviors while providing the tools for behavior change. For example, the study discusses encouraging the exploration of one’s own genitals among a group composed of women of color as they found these women were unfamiliar and uncomfortable with their own sexual anatomy. Because acceptance and comfort with one’s own sexuality is positively correlated with greater condom use(Fisher, 1984), encouraging women to understand and feel comfortable with their genitals may lead them to engage in safer sex practices.  I find their focus on promoting sexual positivity especially relevant to Latinas, as it aims to reduce guilt and shame over sexual practices through open discussion and dialogue.

 I find the most important aspect of this study to be the fact that they recognized the importance of Involving community members in curriculum design and implementation. Although the study is still in its preliminary stages, I find the positive results to be encouraging and strongly believe the model could be used to combat the rise in the prevalence of HIV among Latinas as well as promote greater overall sexual health. While this model may not be appropriate for youth, I think it can be used to educate young Latinas as well as older generations, which may in turn increase the communication about sex and sexuality in Latino families. Furthermore, I believe with a few small changes the model can be adapted to be used in with school aged children.

References:

Robinson et al, “The Sexual Health Model: application of a sexological approach to HIV prevention”. Health Education Research 17 (1): 43-57. 2002.

 

Recent Report by MSF on the Avoidable Crisis of Maternal Death

March 8th, 2012

Yesterday and one day before International Women’s Day, Doctors With Borders released a report called Maternal Death: The Avoidable Crisis which declares that 1,000 women a day die in childbirth (1).  The emergency of maternal health provides MSF with an opportunity to create a sustainable and long term plan to treat women during and after childbirth.  I have focused on the work of the International Medical Corps to provide care and education to combat maternal morality.  Since this MSF report is so interesting and recent, I hope to find ways in which MSF is creating more sustainable and longer-term plans for women.  With MSF and any health humanitarian organization in an area of crisis, the key to providing a sustainable program for maternal health really involves training the local and existing community members and health workers.

Kara Blackburn, the women’s health advisor for MSF, draws attention to the dire need of greater help for pregnant women and powerfully states, “Women need access to quality emergency obstetric care whether they live in Sydney, Port-au-Prince, or Mogadishu. The reality is the same for women in a modern hospital in a major city, or for those living in a conflict zone, a refugee camp, or under plastic sheeting following a devastating earthquake” (1).  She continues and states, “We must always remind ourselves that a maternal death is an avoidable death.”

The MSF report labels Nigeria and Burundi as zones where maternal morality is an actual emergency.  In Nigeria, there is such a high rate of maternal morality that MSF states “simply being pregnant can be life-threatening for a Nigerian women.” (2).  Fortunately, since creating a maternal ward in a hospital in Jahun in 2008, MSF has reduced the maternal mortality rate at the hospital from 6% in 2008 to 1.5% today.   Their approach to the maternal morality emergencies is different than other emergency situations they focus on; MSF is able to implement a long-term plan to treat the maternal mortality rates and they reach out to train staff and the existing infrastructure (2).  I found this approach more sustainable than their other approaches to women’s health; here MSF is trying to look at the entire situation and think long-term.

MSF is an outside and private organization that enters a village with skilled doctors, nurses and personnel, but the key to creating a long-term success in combating maternal morality lies in training existing community and health workers.  For example, the MSF has assisted over 19,000 births in the Democratic Republic of the Congo, where Enrica Bentivenga, a MSF obstetrician and gynecologist, works. Enrica states, “The Training of health workers in this practice has been a key element in the reduction of the rate.”  I wonder what kinds of training that MSF can provide for health workers in places which such high maternal mortality rates.

The 2008 “Field Friendly Guide to Integrate Emergency Obstetric Care (EmOC) in Humanitarian Organizations” is a comprehensive manual that provides board principles and detailed information on how to design and implement EmOC plans in humanitarian crises (3).  While I am not sure if the MSF used this manual, it is a detailed and powerful manual that considers issues from economic constraints affecting the access to EmOC to malaria effects in pregnant women to cultural and language barriers that women face.  According to the manual, their principles and information are evidence based and creates a plan to strengthen the local health system.  This manual seems to be a valuable tool for the staff of MSF and other humanitarian groups to train health workers and community members; it lays a powerful foundation for providing EmOC in areas that desperately need it.

According to a review about obstetric care in developing countries by the Health Policy and Planning in 2000, “Training alone is seldom sufficient for improved health services.”  (4) This comprehensive report compares the effectiveness of several training methods and designs.  Even with effective training of health workers, there are many factors that go into the effectiveness of maternal health programs, such as cultural and economic barriers.  However, given that maternal deaths are such a prevalent issue and avoidable issue, I hope that yesterday’s report by the MSF will prompt greater action.

Sources

1. Maternal Death: The Avoidable Crisis. Web. 8 March 2012. http://www.doctorswithoutborders.org/press/release.cfm?id=5813&cat=press-release

2.  Maternal Death: The Avoidable Crisis.  Doctors Without Borders.  Web. 8 March 2012. http://www.doctorswithoutborders.org/publications/reports/2012/Materna-Death-The-Avoidable-Crisis-singlepg.pdf

3. Field Friendly Guide to Integrate Emergency Obstetric Care in Humanitarian Organizations. Women’s Commission for Refugee Women and Children. 2008. 8 March 2012. Web. http://www.rhrc.org/resources/emoc/EmOC_ffg.pdf

4. Penny, Shereen and Murray, Susan F. “Training initiatives for essential obstetric care in developing countries: a ‘state of the art’ review.” Health and Policy Planning. 15 (4): 386-393. 8 March 2012. Web. http://heapol.oxfordjournals.org/content/15/4/386.full.pdf

 

CBT Intervention in Rural Pakistan

March 8th, 2012

As I have been reading interventions for mental health, I think it’s important to develop interventions that center on therapies that have been proven to work. Besides medications and other such treatments, one treatment option is psychotherapy or “talk therapy.” While psychotherapy alone might not be effective for the most severe forms of depression, the benefits for psychotherapy include learning coping mechanisms for everyday stressors, learn better communication skills about your condition, and gain new perspective on problems. Oftentimes, psychotherapy can also be combined with medication in a very effective way. Psychotherapy often encourages patients to take their medications properly and makes it easier for patients to stick to their treatment. Some common psychotherapies used are cognitive behavioral therapy (CBT), interpersonal therapy (ITP), psychodynamic therapy, and individual counseling. [i]

This blog post will focus on cognitive behavioral therapy. As I mentioned before, cognitive behavioral therapy is a talking therapy. This means that it works to solve problems (either emotional, behavioral, or cognitive) using systematic approaches to work to a goal or final state.  CBT is used to treat mood, anxiety, personality, eating, substance abuse, and psychotic disorders. CBT can be individual or group therapy. CBT was created by the combination of behavior therapy with cognitive therapy. This means that some of CBT therapies are more cognitive centered, focusing on changing irrational or maladaptive thoughts using various strategies like logical disputation. Other CBT therapies might be more behaviorally based, such as in vivo exposure therapy. Other CBT therapies might combine both aspects in the intervention, for example imaginary exposure therapy.  Many CBT therapies have been monitored for efficacy, and in today’s world of evidence-based treatment, CBT has been favored over other psychotherapies, such as psychodynamic treatments.[ii]

Perinatal depression was targeted in this intervention due to its high prevalence and negative health effects on the newborn infants. Perinatal depression is thought to affect 10-15% of mothers in the Western world, and even higher rates in developing countries, estimated at 16-35%. Perinatal depression has been associated with infant undernutrition and poor cognitive development.[iii] Despite the frequency of the disorder and the numerous negative outcomes associated with it, there are frequently few mental health professionals or resources to help these women. [iv] While there have been numerous studies in the West to prove the success of CBT interventions for perinatal depression, it is difficult to extrapolate this data to judge the effectiveness of these interventions in a developing country. Some potential difficulties include failure to adopt policies by health workers, incomplete integration into health services, or lack of priority. This intervention looked to study both the actual implementation and effectiveness of such an intervention in a developing country or in this case, rural Pakistan.[v]

This particular intervention in rural Pakistan (Gujar Khan and Kallar Syedan) studied the effects on the health of perinatally depressed women and their newborn infants after receiving cognitive behavioral therapy from a community health worker. In their study, half the women received cognitive behavioral therapy and the other half simply received enhanced routine care (serving as a controls).[vi]

Prior to the intervention, they visited the women and interviewed them to get a glimpse at local beliefs about health and about depression. They found that most women did not feel that depression required intervention and that the psychological benefit derived from therapy was not a “tangible gain.” They realized that any intervention would need to focus on a family level and not just the woman, though this woman needed to actively participate to gain from changes in attitudes and behavior. They realized that most health workers were already overburdened, and that any intervention would need to be easy to comprehend even by illiterate workers. They realized that local traditions also bar a woman from leaving her home 40 days after delivery, and any intervention would need to work around this.[vii] From this information, they began to develop a CBT therapy that would function effectively within this context.

The intervention included visits from local female health visitors every week during the last week of pregnancy, three times in the month after birth, and then once a month for nine months. These health visitors were trained health workers that delivered the CBT based Think Healthy Program using a manual with stepwise instructions. The premise of this program was active listening, involvement with family, discovering health beliefs, and proposing new ways of thinking.[viii] The Think Healthy Program involved three steps: identification of unhealthy or unhelpful thinking, replacing unhealthy thinking with healthy thinking, and practicing healthy thinking and behavior. The specific areas that these three steps targeted were mother’s personal health, the mother-infant relationship, and the psychosocial support of significant others. Throughout this intervention, health workers specifically avoided the word depression, but instead called it “stressed” or “burdened” to lessen the stigma. [ix]

While the CBT therapy compared to the control showed no differences in weight or height for age in the infants, there was a significant effect in maternal depression. The CBT intervention reduced the prevalence of major depression 59% compared to 27% in controls, thus halving the rate.[x] The CBT patients had reduced levels of depression symptoms and disability, increased overall functioning, and increased perceived social support. The CBT therapy was also shown to increase infant immunization rates and increased uptake of contraception at 12 months.[xi] [xii]

The strengths of this program included the step-wise intervention that really worked to change both the behavior and thought patterns of these women, hence the CBT therapy aspect of the intervention. Also, the intervention was both highly specific and flexible. The intervention was specifically tailored to respect the culture and attitudes of local women. Health workers were also trained to be able to adapt their programs to meet the specific needs of the women they were serving. This intervention also used the elevated social position of health workers in society to promote this as an important, relevant topic. The effectiveness, however, really depended on the persistence of the health workers. In this way, some of the limitations could be in the feasibility and sustainability of scaling up the intervention to, perhaps, a national level. For already overburdended health workers, continually working with depressed women could lead to burnout and dropoff in the intervention. Other limitations exist in communities without health workers. Despite these limitations to sustainability and feasibility when trying to scale up the intervention or continue it long term, the positive results, flexibility, and sensitivity of this intervention suggests it is a promising option for the future.

Addressing maternal mental health is a very related to and a key step for accomplishing many Millenium Development Goals, such as infant malnutrition, child mortality, maternal health, and female gender disadvantage. This intervention need not be confined to maternal depression, but it could be extended to address health issues for all issues with maternal or infant health. Another benefit of this intervention is by tied maternal health to infant health; this gives importance to the topic of maternal mental health and serves as an avenue to address all issues surrounding mental health issues in women. This intervention effectively delivers to a rural community in a developing country a therapy that has already been proven to work in the West. CBT offers a new solution to treat maternal depression. It can be integrated into the primary care level, improving ease of implementation and access. Finally, CBT is an effective therapy for women suffering from depression. Overall, the results of this study show that using CBT interventions into developing countries could be a very effective way to treat mental health problems.


[i] http://www.webmd.com/depression/guide/treatment-resistant-depression-psychotherapy

[ii] Wikipedia.org

[iii] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424205/

[iv] http://www.womensmentalhealth.org/posts/cognitive-behavioral-therapy-used-to-treat-depression-in-pakistani-women/

[v] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424205/

[vi] http://ebmh.bmj.com/content/12/2/45.full

[vii] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424205/

[viii] http://ebmh.bmj.com/content/12/2/45.full

[ix] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424205/

[x] http://www.who.int/workforcealliance/knowledge/resources/chw_mother_pakistan/en/index.html

[xi] http://ebmh.bmj.com/content/12/2/45.full

[xii] http://www.womensmentalhealth.org/posts/cognitive-behavioral-therapy-used-to-treat-depression-in-pakistani-women/

 

 

Sources:

“Psychotherapy (Talk Therapy) for Depression Treatment.” WebMD. WebMD. Web. 09 Mar. 2012. <http://www.webmd.com/depression/guide/treatment-resistant-depression-psychotherapy>.

Wikipedia. Wikimedia Foundation. Web. 09 Mar. 2012. http://www.wikipedia.org/

“Mass General Hospital.” Cognitive Behavioral Therapy Used to Treat Depression in Pakistani Women. Web. 09 Mar. 2012. <http://www.womensmentalhealth.org/posts/cognitive-behavioral-therapy-used-to-treat-depression-in-pakistani-women/>.

“CBT Improves Maternal Perinatal Depression in Rural Pakistan.” – 12 (2): 45. Web. 09 Mar. 2012. <http://ebmh.bmj.com/content/12/2/45.full>.

“Cognitive Behaviour Therapy-based Intervention by Community Health Workers for Mothers with Depression and Their Infants in Rural Pakistan: A Cluster-randomised Controlled Trial.” WHO. Web. 09 Mar. 2012. <http://www.who.int/workforcealliance/knowledge/resources/chw_mother_pakistan/en/index.html>.

Rahman, Atif. “Challenges and Opportunities in Developing a Psychological Intervention for Perinatal Depression in Rural Pakistan – a Multi-method Study.” Http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424205/. Arch Womens Ment Health. Web. 8 Mar. 2012.