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Archive for February, 2013

Enabling women: interventions for disabled women in the developing world

February 28th, 2013

I wanted to focus this piece on highlighting intervention efforts that have been made in developing countries for people with disabilities. My last post focused on the concept of disability as a “social construct”—if you are not at a disadvantage to a peer in society, are you disabled? Throughout my case study-like posts, what I have really come to realize is the importance of health services in preventing “disability” entirely.  Disability is a state I think comes from your environment. If your environment provides you with the services you need to live well, you shouldn’t feel disabled. It is our job to provide the services a disabled person needs to be a fully-abled member of society. Ability is something we can provide women and children with the proper devices and services.

One such intervention that comes to mind is very basic—providing wheelchairs to   women with disabilities. An NGO called “The Free Wheelchair Mission” was started by Don Schoendorfer after he saw a disabled woman crawling across a dirt road during a visit to rural Morocco—obviously a traumatic vision that haunted him forever. Schoendorfer uses a very unique and cheap approach to providing wheelchairs. Schoendorfer’s approach was to create as many cheap and secure wheelchairs as possible for distribution. The solution he came up with was unique; these wheelchairs are literally plastic patio chairs secured onto steel frames with added bicycle wheels and mountain bike tires. The Mission’s average cost to manufacture, ship and distribute a wheelchair to countries like China, Morocco, Ghana, India, Peru, Uganda and Zambia is around $41.00. From 1999 to 2003, the Mission sent over 23,000 free wheelchairs to 33 developing countries without widespread disability services.

Interventions by NGOs like these are crucial because of the long standing miseducation and stigma that exists against disabled people in many developing countries (this was something I touched on in my last post). Even in countries like Bangladesh, where policymakers have, on paper, demonstrated an interest in providing devices and services to women and children with disabilities, in practice, these impoverished countries do not have the funding to actually give disabled people the services and devices they need. For example, the National Constitution of Bangladesh actually has numerous provisions that obligates the government “to protect the rights and dignity of all citizens of the country equally and without bias whatsoever.” And, additionally, the government developed a National Action Plan in 2006 involving forty-six ministries and divisions of government to undertake specific activities for persons with disabilities, from implementing widespread rehabilitation services to providing specialized education to children with disability.

However, the Bangladeshi government still needs help from abroad to cover the costs of caring for its disabled population. Why? Because it keeps growing and the funding these ministries can provide for services is not enough. Gains in health care by the government are made alongside an increase in surviving children with disabilities, an increased number of people incurring disabilities due to old age, and continual widespread malnutrition. The prevalence of people with disabilities is likely to continue to rise in Bangladesh over time, and the international community will need to help Bangladesh provide sustainable support for disabled women and children

USAID supports one such sustainable intitiative called “Reach Out & Care, Inc” (ROC). ROC currently supports rehabilitation services for disabled children in Iraq and Morroco, but aims to increase its support to countries like Bangladesh. What is key about ROC is its sustainability—it provides training based on WHO guidelines to regional centers provding mobility devices, services and education to women and children with physical and/or mental disabilities. This helps governments like Bangladesh because while certain legislation can cover the costs of basic devices, like wheelchairs, it cannot also cover the costs of proper training for workers in rehabilitation and education centers, which is a crucial component in empowering and enabling women and children with disabilities. ROC also brings in Western developments to these care facilities in Iraq and Morocco, collaborating with the public and private sectors and medical device designers to improve existing device designs and develop more inexpensive mobility devices for people in developing countries. ROC trains not only rehabilitation and education providers, but manufacturers. When ROC leaves a regional facility, that facility will have people with the capability to manufacture and assemble up to 100 secure and modernized wheelchairs per month.  ROC aims to spread the use of high quality devices, physical and medical therapy, ongoing care, and prescription of mobility devices to the developing world-an all encompassing and sustainable approach to intervention in developing countries. These are the types of interventions that are needed all around the world, and these interventions are so rewarding because what they do is enable women and children, quite literally. What an empowering thought—we can use intervention to empower and literally enable a woman in the world.  I hope that USAID and other NGOs continue to invest in these types of powerful interventions.

 

Witchcraft and HIV: Nakato's Story

February 28th, 2013

“Many of us celebrate our ‘Africanism’ and heritage by praising our sense of community, our extended family relationships, and our togetherness. We hail our openness and love of sharing stories, but how many of us can feel free and comfortable talking about HIV/AIDS, let alone give testimonies of our personal experiences? I call upon you to… learn and build a community of support where a culture of sharing and discussion remains one way of looking HIV/AIDS in the face and vowing to live and fight on. It would be a pity if we as women do not learn from others’ experiences and realize how important it is to know our HIV status.”

-Angelina Wapakhabulo, Positive Women Leaders of Uganda

 

Wapakhabulo’s statement not only addresses the culture of silence around HIV/AIDS but also expresses the value in learning from others’ encounters with the disease. This quote is the inspiration of this week’s blog, as I introduce a woman named Nakato and detail her experience with HIV/AIDS in Uganda. My blogs have focused on how cultural practices, sexual behavior norms, and male sexual privilege promote the transmission and spread of HIV/AIDS in Africa, namely Zambia. This week, I wanted to share a narrative of a woman living with HIV to provide a more organic sense of the struggle, rather than the overarching complications or roadblocks that typically come to mind. I came across I Dare to Say: African Women Share Their Stories of Hope and Survival in Green Library and was struck by the powerful, detailed true stories of African women. Femrite, the Uganda Women Writers Association encouraged many women to tell their life stories, offering an in-depth glimpse into how injustice has followed them every step of the way throughout childhood and into adulthood.

Nakato’s story demonstrates how cultural beliefs in witchcraft, lack of education about HIV/AIDS, and stigma surrounding the disease impact women’s rights to love, health, and support networks. In 1976 in the Mityana district of Uganda, Nakato was born a breach twin. Because she was born two hours later than her twin and caused difficulty during labor for her mother, she was condemned to an ill-fate by her family. Cultural belief was that Nakato should be starved as punishment for the difficult birth, and she thus did not receive any breast milk while her twin sister was breast-fed. Family members referred to her not by name, but by musota (demon), mbuzi (snake), musiru (goat), or murderer (omutemu) because her difficult birth had almost resulted in her mother’s death. She was years behind her twin in schooling and was forced to do manual labor and take care of her mother’s children from her second husband. Cultural stigma about breach babies thus created many social and health implications for Nakato.

It is important to understand the role of cultural beliefs in social determinants of health. In Nakato’s case, her desire to be loved and respected caused her to be submissive and gullible in her relationships with men, abstaining from asking them personal questions or about where they went on the weekends. When her flesh tore during her first labor, causing a large wound, her boyfriend continued to have sexual intercourse with her despite the health hazard and excruciating pain. He told her it would help heal the wound and she believed him. When her baby was gravely ill and her boyfriend told her not to bring him to the hospital, she consented and the baby died two weeks later. When her boyfriend was on his deathbed with tuberculosis, she found out that he had a wife and children. It was not until much later that she found out that he had AIDS.

Nakato ventured from man to man, longing for connection and the provision of a home. Lacking economic stability left her at the mercy of men who treated her wrongly. After being told repeatedly throughout her childhood that she was unintelligent, she began to not trust her instincts and believe her inner thoughts were irrational. Lack of empowerment precluded her from a strong sense of self or autonomy.

What I found to be most startling was that Nakato believed HIV was transmitted by witchcraft, and people could be rid of the disease if their body was not a “favorable” habitat. Because she did not know how the disease was transmitted, she never inquired about or used condoms and unknowingly spread the disease to upwards of ten men. Despite this lack of access to important information about HIV, people in the community still shunned and stigmatized those with the disease. Nakato was a target or ridicule because of her actions and HIV status, of which she was totally unequipped to protect herself against. At the end of her account, after learning more about the disease, she expressed sadness and guilt about transmitting it to other men. Ultimately, Nakato went to work for TASO, an AIDS support organization, helping other women, while educating herself and finding a network of support.

For me, Nakato’s story puts the spread of HIV into perspective. The factors that contribute to the rapid transmission of the disease include lack of education and an environment where women feel that asserting themselves or talking about HIV with their partners will cause their partners to leave them. Female empowerment starts at the family level, during childhood. Thus, not only do efforts need to be taken to educate women about HIV but steps must be taken to empower women so that they can rely on their own brains and hands to make decisions and make a living. In this way, self-worth is a preventative measure against HIV.

 

I Dare to Say: African Women Share Their Stories of Hope and Survival. Hilda Twongyeirwe. Lawrence Hill Books. Chicago. 2006.

Recommendations for Mental Health Interventions in Latin America

February 28th, 2013

Issues in mental health are more pervasive among women than men (1). In Latin America, poverty and violence exacerbate many of the triggers to mental health illness thus many women end up experiencing it(4). Depression and Schizophrenia are particularly common mental disorders among Latin American women (2).

A meta-analysis of mental disorder perceptions in Latin America, Community perception of mental disorders: A systematic review of Latin American and Caribbean studies (3), sought to identify mental illness stigma notions in Latin America. They found that the majority of the studies were in Mexico and concentrated in the 1980’s. The majority of the studies were in urban areas, signaling the need for studies about mental illness perceptions in rural areas, largely populated by indigenous and/or destitute communities. They found that educated and/or wealthy people were more likely to have a positive perception of those with mental illnesses (still considered them functional in society). They also found that schizophrenia was more likely to be recognized as an illness than depression and that depression wasn’t considered very serious.

According to the findings in the meta-analysis, there is need for outreach efforts to inform communities about the severity and types of mental disorders. Most of these efforts are needed in poor, uneducated communities where perceptions of mental illness are still negative. It is also important to note that perceptions of mental illness can be drastically different by country or region, thus interventions should be tailored to them.

As mentioned in one of my previous blog posts, there must be a negotiation between cultural medicine and Western medicine among Latin American patients and the Western medical system. A psychiatry elective, Jordan Sloshower, reflected in the Journal of Global Health about cross-cultural issues in Peruvian mental health. Jordan Sloshower observed the practices of  Comisión de Salud Mental de Ayacucho (COSMA) in Ayacucho, Peru and Instituto Nacional de Salud Mental Honorio Delgado—Hideyo Noguchi (commonly called “Noguchi”). In Noguchi he spoke to a schizophrenic female patient: “ she enthusiastically described to me how she had ended up in the hospital and recounted recent supernatural experiences. She told me about energies she felt from television screens and fears she had, as well as some messages she had intuitively received from a variety of sources”. He goes on to reflect, “ Perhaps, if we had been in Ayacucho or a cultural context where speaking of spirits and witchcraft was more commonplace, such remarks would not have evoked suspicion of psychosis”. As illustrated by this experience, healthcare providers must also be sensitive about local cultural beliefs and ensure their diagnoses aren’t ethnocentric. Also, this patient did not feel comfortable taking medication for her mental disorder, thus treatment should be within the patients’ comfort zone.

While Jordan Sloshower observed the practices of  Comisión de Salud Mental de Ayacucho (COSMA) in Ayacucho, Peru he was impressed at the outreach efforts by psychiatrists.  These psychiatrists would do home visits for rural patients and were free of cost. From a clinical standpoint, home visits were more beneficial for the patient-doctor relationship and for the doctor’s judgement of the patient’s health. By visiting patients at their home, the doctors had insight of their home-life, poverty, accessibility, etc and thus had a holistic view of the patient. The home visits also initiated constructive dialogue about mental illness in families and the larger community, breaking down stigma and promoting support. This support is essential for Latin-American women with mental disorders because familial relations are extremely important in their culture. Although this intervention is wonderful, it would be difficult to replicate out of pure altruism in other Latin-American countries.

 

 

  1. http://www.nimh.nih.gov/health/publications/women-and-depression-discovering-hope/complete-index.shtml
  2. http://www.ghjournal.org/jgh-print/fall-2012-issue/on-the-path-to-mental-health-in-the-andes-reflections-from-a-psychiatry-elective-in-urban-and-rural-peru/
  3. http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=1c9d6333-24e9-46e3-ba38-cd65f8122968%40sessionmgr13&vid=2&hid=11
  4. http://www.ghjournal.org/jgh-print/fall-2012-issue/on-the-path-to-mental-health-in-the-andes-reflections-from-a-psychiatry-elective-in-urban-and-rural-peru/

Indigenous Gender Relations

February 28th, 2013

62 percent of Bolivia’s population is indigenous and in rural areas, indigenous languages are spoken by 72 percent of the population. Illiteracy affects one of every four women over the age of 35, and only 30 percent of indigenous women give birth in hospitals, as compared to 55 percent of non-indigenous women (1). The differences between indigenous and non-indigenous populations lead to vast disparities in access to healthcare, education and decent jobs. In previous posts, I’ve focused on discussing how already established gender relations affect women’s health. For this post, I will focus on indigenous women, and how gender differences have unfortunately become more pronounced to illustrate the changes that occur in populations that to the development of inequality between men and women.

In the Andes, the rural, indigenous, Aymara community established the concept of thakhi, otherwise known as the “path of duties”. The  idea of the “path of duties” is a manifestation of the structure that provides cultural context of gender relations in the Aymara society. By focusing on the changes to the path, the transformation processes accompanying the dynamics of gender concepts can be noted. Previously, the pareja (Spanish word for couple, or husband and wife) was the most important unity as it guaranteed the reproduction of society. Individuals could only accumulate prestige if a man and woman married and live jointly in a partnership. This partnership expressed gender relationships based on the duality of gender complementarity (2).

However, recent migration of men has resulted in changes in the design of the partnership, and has created a gendered division of labor. Increasingly hierarchy of gender differences takes away the original idea of equality of the thakhi. For example, society has undergone a reorganization in the division of labor, causing differences in cash income, social prestige and fluency in Spanish, which helps and individual become more prepared for the workforce (2).

Eventually, the function of dualism falls apart as the wife substitutes for her husband’s public duties in the village community. Advancement of couple begins to conflict with advancement of an individual, usually the husband’s. As men advance into the urban labor market, the women take the roles of a substitute in the village, and no longer function as a couple. In order for husband to be successful, he relies on the wife to accept smaller duties. The general social responsibility of the thakhi is gone, replaced by aspect of individual qualification.

While Bolivian women have been increasingly marginalized, a radio project has developed to reach indigenous women in their own languages. In 2003, Radio Atipiri was founded by Tania Ayma Calle with help from the Center for Education and Communication for Indigenous Communities and Peoples (CECOPI). The radio provides critical analysis of women daily events. The station also empowers women to be reporters and make their voices heard. Women write soap operas or act out dialogues that share their experiences in sexual reproductive health, gender relations, and violence (3). As Tania said, “It doesn’t matter if only the life of one woman is touched by the program, for sure this woman will change the life of her sisters and daughters. That is how we will achieve our goal”.

 

  1. (2004) Bolivia – Highlights. World Bank. Retrieved from http://go.worldbank.org/ZX284CZC80.
  2. Blumtritt, Andrea. (2013) Transloclity and Gender Dynamics: The Pareja and the Thakhi System in Bolivia. Bulletin of Latin American Research, 32(1): 3-16.
  3. Preston (2010). Indigenous Women in Bolivia Have a Voice. World Pulse. Retrieved from http://worldpulse.com/node/19742.

 

In Exodus: The Media's Take on Syria

February 28th, 2013

Day by day we are bombarded with global news, informing us of conflicts, decision making, and other worldly happenings. No doubt, this age of inter-connectedness (did I just make up a word?) via web has allowed for the spread and transmission of information to and from various pockets of the world. Using this knowledge, I want to use this post to share headlines about the civil conflict in Syria and it’s resulting transition of its people. I will list several quotes and photographs, and I challenge you as readers to discuss how the media has been playing a role in spreading awareness? Are they implying a call to action? Are these words and images enough? Would you be compelled to help? Which headline or photo (or both) speak the most to you, and why?

“U.S. President Barack Obama has approved $155 million in humanitarian aid for people in Syria and refugees fleeing the violence.”

“Fighting in Syria’s civil war has killed more than 60,000 people, most of them civilians, according to the United Nations. Tens of thousands have become refugees within the country, and up to 1 million Syrian refugees have fled the violence by seeking safety in Jordan, Lebanon, Iraq, and Turkey.”

“As the exodus of Syrians continues, Jordan isn’t just overrun; it’s overflowing.”

Jordan Overflowing with Syrians: http://www.cnn.com/video/?iid=article_sidebar#/video/world/2013/02/06/pkg-jamjoom-jordan-refugee-aid.cnn

Reflections of 14-year old Syrian Girl: http://www.cnn.com/video/#/video/international/2013/01/28/damon-syrian-refugee-cayanne.cnn

Syrian Refugees Find Stability in Iraq:  http://www.cnn.com/video/data/2.0/video/world/2013/02/18/damon-kurdish-refugee-camp.cnn.html

“Syrian war is everybody’s problem.”

Cultural Barriers to Accessing Health Care

February 28th, 2013

Women in Middle Eastern countries face an unusual cultural barrier to accessing healthcare. Often times the infrastructure and services can be available but women don’t use them. What is holding them back? This is a phenomenon studied in Muslim countries and in Muslim immigrant population in the US. Muslim women are often uncomfortable with US doctors and practices because they are not sensitive to their highly conservative and gender sensitive culture. Dr. Naureen Zafar, the director of the Medina Clinic at Harlem Hospital Center, said, “research has shown many devout Muslim women delay accessing health care and may have very advanced disease by the time they seek medical help”(1). Since the recognition of these cultural barriers, US doctors have started to accommodate to their patient needs to increase patient comfort levels.

A lot of comfort and trust in doctor patient relationships comes from having a doctor of the same sex. In a study of patients’ satisfaction in government hospitals in Jordan, 56 percent of women said they preferred female doctors (2). Dr Padela is a researcher on Islamic medical ethics and explains, “Though Muslims differ in their adherence to tradition, maintaining modesty is the ‘overarching Islamic ethic’ pertaining to interaction between the sexes”(1). Women often refuse to be in a room alone or examined by a male doctor. In the US this can sometimes be accommodated for by switching to a female doctor but is not always a possibility. Increasing the number of female doctors available in the Middle East could alleviate some of the anxiety about going to see a male doctor.

Another obstacle is the lack of independence. In countries such as Libya women are not allowed to travel without a male relative. For low-income families it may be too expensive to send two people to travel to a hospital and this can prevent adequate treatment for women (3). There are many cultural barriers and sensitivities that we need to be aware of when discussing access to health care, it is not solely a problem of economic ability and spread of technology. Reference 4 is an interesting article written for American clinicians working in the Middle East and talks about many of the cultural sensitivities that need to be addressed.

(1) http://www.nytimes.com/2010/11/01/health/01patients.html (2)http://www.prb.org/Articles/2006/GenderandEquityinAccesstoHealthCareServicesintheMiddleEastandNorthAfrica.aspx

(3) http://www.yalemedlaw.com/2011/04/gender-in-middle-eastern-health-care/

(4) http://repository.upenn.edu/cgi/viewcontent.cgi?article=1000&context=nrs&sei-redir=1&referer=http%3A%2F%2Fwww.google.com%2Furl%3Fsa%3Dt%26rct%3Dj%26q%3Dwomens%2520healh%2520care%2520in%2520middle%2520east%26source%3Dweb%26cd%3D6%26ved%3D0CGUQFjAF%26url%3Dhttp%253A%252F%252Frepository.upenn.edu%252Fcgi%252Fviewcontent.cgi%253Farticle%253D1000%2526context%253Dnrs%26ei%3DPEQwUc6lFLGujAKljoH4BQ%26usg%3DAFQjCNFZw2lDWTt_8RdVaVH59G4XjguVfg%26bvm%3Dbv.43148975%2Cd.cGE#search=%22womens%20healh%20care%20middle%20east%22

Nationwide Interventions for Cervical Cancer in the Philippines

February 28th, 2013

My past few blog posts have focused on community interventions to improve women’s reproductive and maternal health in the Philippines. This week, I want to discuss examples of an intervention that combines the efforts of both the public and private sphere – the Department of Health (DOH) and Merke Sharp & Dohme Philippines (MDS) – to improve women’s reproductive health nationwide. These sectors formed a partnership program, the National Cervical Cancer Prevention and Control Program, which offers free nationwide cervical cancer-screening for women aged 25 to 49 years old.[i]

Background on Cervical Cancer in the Philippines

            As the second most prevalent type of cancer in women (after breast cancer) in the Philippines, cervical cancer screening is vital to improving women’s reproductive health.[ii] In 2010, the prevalence rate for cervical cancer was 11.7% for every 100,000 women, or about 12 Filipino women died from cervical cancer per day.iii Cervical cancer rates have not changed since 1980, and the survival rate is 51.7%.ii

There are several problems with cervical cancer screening in the Philippines. One is the timing of cervical cancer diagnosis; about 66% of cervical cancer cases are diagnosed at an advanced stage, and mortality due to cervical cancer is high because of inadequate radiotherapy facilities.ii When screening does occur, it is often inadequate and inefficient in reaching the majority of the population. As I have mentioned before, the geography 7,100 islands that comprise the nation make it difficult to screen for cervical cancer in underserved, isolated communities. Thus, it is vital that the government and private sector cooperate to hold national cervical cancer screening programs, particularly with a focus on underserved communities.

Government and Private Sector Working Together

            The nationwide screening program facilitated by the DOH and MDS has occurred every May for five years. This national screening initiative was launched in order to reach out to more Filipino women in May, in honor of Cervical Cancer Awareness Month.i The screenings are typically offered to the public for free in 58 DOH hospitals around the country.

The National Cervical Cancer Prevention and Control Program consists of a three-pronged prevention approachi:

1. Primary prevention – Promotion of a healthy lifestyle and avoidance of risky sexual behavior

2. Secondary prevention – immediate screening for pre-cancerous lesions and other abnormalities and diagnosis

3. Tertiary prevention – Immediate treatment, when possible, to prevent the development of invasive cancer from precancerous lesions

For this partnership prevention program, the Philippines recently received the Gold Standard Award for Public-Private Partnership (PPP) from the Public Affairs Asia Network.[iii] The award recognized this partnership for its program achievements, including establishing a national symposium on cervical cancer prevention and control. Since the establishment of the partnership, more than 30,000 women have been screened for cervical cancer.iii Another positive aspect of this program is increased public awareness, which has pushed the agenda and support from both the public and private sectors to create a national policy focused on cervical cancer prevention, early diagnosis, and treatment.iii This program seems like a positive example of how government and private companies can work together to influence national policy and the reproductive health of women throughout the country.

Filling in the Gaps – Cervical Cancer Screening and Treatment in Underserved Filipino Communities

            One potential issue with the National Cervical Cancer Prevention and Control Program is the lack of services in isolated, rural communities, as most of the screenings have taken place in hospitals affiliated with the Department of Health. In order to address the lack of services and resources in rural communities, Family Planning Organization of the Philippines (FPOP), a member of the International Planned Parenthood Federation, aims to provide cervical cancer screenings to 120,000 poor and underserved women in rural communities. [iv]

To address the lack of resources in these communities, FPOP uses the Single Visit Approach, which involves screening through Visual Inspection with vinegar, which involves applying 3-5% acetic acid to the cervix and inspecting for precancerous lesions.iv If this test is positive for abnormalities, treatment can be administered in the form of Cryotherapy, which involves freezing the cervix with compressed carbon dioxide or nitrous oxide gas in order to destroy precancerous lesions.iv

As part of the Single Visit Approach, women are offered counseling, screening, complete pelvic examination, and discussion of results.iv The Single Visit Approach provides a practical method of screening for cervical cancer in under resourced communities because screening and treatment can take place in one visit with a health care provider, so it is both more affordable for low-income women and more efficient for health care providers.

 

These two nation-wide approaches to cervical cancer screening and prevention seem like positive steps to decreasing cervical cancer rates in the Philippines. In order to improve the reproductive health of Filipina women nationwide, I think it is especially important for national and community programs to work together to not only target urban areas where cervical cancer rates are highest, but also to reach out to poor and under resourced communities.

 


[i] Tiu, Olivia. DOH promotes one-stop cervical cancer screening. Philippine Information Agency. http://www.pia.gov.ph/news/index.php?article=1141336012279

[ii] Germar MJV. Interventions targeted at women to encourage the uptake of cervical screening: RHL commentary (last revised: 7 October 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.

http://apps.who.int/rhl/archives/mjgcom/en/index.html

[iii]PPP on Cervical Cancer advocacy wins Public Affairs Asia Award. The Manila Times Online. http://www.manilatimes.net/index.php/127-healthnews/40129-ppp-on-cervical-cancer-advocacy-wins-public-affairs-asia-award

[iv]Cervical Cancer Screening and Treatment of Women in Far flung Communities. Family Planning Organization of the Philippines. http://www.fpop1969.org/howtohelp/ccscreening.html

Women as Educated Participants in the Economy

February 28th, 2013

In developing countries, it is misleading to talk of women’s “entry” into the workforce.  Formal employment notwithstanding, women are always working in the home looking after children, cleaning, and cooking.  Since this is unpaid labor, it is not counted in official statistics such as GNP.  The need for women’s unpaid labor has been known to increases with economic shocks associated with pandemics (i.e. AIDS), or restructuring of the economy (i.e. post conflict).  Poor women do more unpaid work, work longer hours and may accept degrading working conditions during times of crisis, just to ensure that their families survive.   The societal value of housework and other forms of care work is little, and thus when domestic labor is paid, it is with minimum wages.   Women’s voices as workers (paid or unpaid), citizens, and consumers are often missing from debates on development, in politics and finance.

Systematic exclusion of women from access to schooling and the labor force led to this conception of domestic work as low-skill, low-value, and unworthy of greater rights/wages.  The exclusion of women from schooling translates into a less educated workforce, inefficient allocation of labor (missing out on the employment of almost half the population), lost productivity, and consequently diminished progress of economic development.  This would suggest that countries with higher standards of gender equality would be more likely to have higher economic growth.  Of course, the benefits of women’s education go beyond higher productivity for 50 percent of the population.  The ability to participate in the formal economy, if desired, can be considered a basic right.  Additionally, as I have talked about in previous posts, more educated women also tend to be healthier, earn higher income, have reduced fertility, and provide better health care and education to the children they do have — all of which have the possibility of lifting entire households out of poverty.

 

 

CEPIA

February 28th, 2013

This week I would like to tell you about CEPIA (Culture, Education, and Psychology for Infants and Adolescents). CEPIA is a non-profit and non-governmental organization that aims to provide cultural and educational activities as well as psychological services for underserved children in communities of the Guanacaste province on the Pacific Ocean coast of Costa Rica. The organization’s mission is to improve the quality of life of children and adolescents. This organization does not focus on addressing commercial sexual exploitation of children (CSEC) directly. However, I believe their efforts truly help with this issue indirectly.

The province of Guanacaste is a very popular touristic destination. Although this is beneficial in many ways, the booming industry also makes the children in these communities more vulnerable to sexual tourism. Moreover these communities are marked by stark inequalities. If you walk along the coastline you can quickly transition from beachfront mansions, usually owned by foreigners, to beachfront slums, usually owned by locals. Sadly, a high prevalence of poverty and domestic violence, including sexual abuse pervades in many families in the area. As we have learned, both domestic violence and poverty can drive children into prostitution.

CEPIA provides psychological assistance to children and adolescents survivors of abuse and violence. The organization also offers an after school program which includes computer and English lessons and sports programs. CEPIA also offers professional trainings in cooking, crafts, beauty care, eco-jewelry and others. Additionally, CEPIA supports students living in poverty by providing them with school materials, transportation, and uniforms.  This is very important because although education is free, these economic barriers still keep many children and adolescents away from school. The organization also hosts the only public library in the area, every Saturday afternoon.

CEPIA is also wonderful for addressing community needs not only by working directly with children and adolescents but also with their families. The organization hosts family movie nights every month and conferences for parents twice a year. Additionally, single mothers living in extreme poverty, who can be mothers of clients or clients themselves, can receive economic support by volunteering with the organization. CEPIA’s psychological, educational and cultural services helps children and families heal and become more empowered, which is likely to help them attain better opportunities in life and break the poverty and violence cycle.

 

http://www.cepiacostarica.org/

Refugee Services: Children in Need

February 28th, 2013

In discussing women in areas of widespread violence, the physical dangers of their location often take precedence over other implications toward health.  In the midst of war, this makes sense.  Protection from actual fighting, guns, bombs, landmines, raids, and other physical threats if crucial.  After this, acquisition of adequate supplies such as food, water, heat, shelter and sanitation are essential.  But once women and their families survive these traumatic environments, what happens to them? If they become refugees, are they left to fend for themselves, or possibly given assistance in finding housing if they are in an extremely hospitable area?  Refugees, especially those fleeing to new countries with drastically different cultures than their home countries, have a unique set of stressors and needs for satisfactory health.

A growing trend in the United States is beginning to address the needs of this population by providing mental health services to refugee children from conflict zones.  While studies have not been conducted to assess the most effective or cost-efficient methods for treating children, the need to protect and counsel children at risk for mental health issues as a result of seeking refuge in a country outside of their own is irrefutable.  Service providers recognize the need for treatments, and thus treat a wide variety of children from all cultures, and often assist in other venues outside of health care, including legal services and social work.

As a population, child refugees experience a different set of challenges and traumas from adult refugees.  They are uprooted from their homes, experience violence, either ongoing or short in duration, and are forced to adjust to a new culture outside of their own.  While adult refugees experience this as well, children have even less control than adults in finding a new home and building a life in their new country of refuge.  Because these changes happen during crucial times of development for children, they are at a great risk for suffering mental consequences from the massive changes and trauma associated with being a refugee.  Many children may not yet have developed the cognitive processes for coping with change and stress, and thus are more likely to experience physical and mental distress as a result.  This can come in many forms, not necessarily as severe mental disorders, but as problems with concentration, emotional instability, excitability, depression, panic attacks, behavioral changes, dizziness, lethargy, and sleeping disturbances, among other issues.

 

The Interventions

The National Child Traumatic Stress Network Refugee Trauma Task Force surveyed a number of providers across the United States to find the treatments being provided for refugee children.  As mentioned previously, while there have been few studies conducted to determine a standard plan of treatment for refugee children, the Refugee Trauma Task Force found that the methods used fell in to three main categories: school-based cognitive behavioral therapy, psychoeducational and parenting interventions for mothers, and art and expressive therapy.

 

School-based CBT

These interventions usually follow a standard course of around 10 weeks of group sessions, possibly with multiple sessions per week.  The sessions address the trauma experienced by participants, and focuses on methods such as therapeutic exposure, stress management techniques, cognitive restructuring, and current life-issue problem solving.  These interventions have been shown in decrease depression symptoms in the participating children.

 

Psychoeducational and Parenting Interventions

Interventions targeting the mothers of refugee children, presumably refugees themselves, these parenting interventions aim to improve the mental health of both the mother and the child.  Similar to the school-based CBT, psychoeducational and parenting interventions focus on trauma education and discussion, but also have a component focused on facilitating interactions between parent and child.  These interventions have been shown to improve the happiness of mothers and improve the conditions of the children involved as well.

 

Art and Expressive Therapy

Part of the uniqueness of dealing with a child population is the creativity necessary for treatment.  Creative art therapies allow for children to express their emotions without fear of embarrassment or the need for extensive language mastery that they may not possess.  Art can allow children to assert their feelings, identity, and sense of self without the need for words or other seemingly emotionally invasive measures. These interventions have not been the subject of many studies, and thus the outcomes appear to be somewhat ambiguous.  Without structure, the process can be confusing or stressful to children not inclined to be expressive through art, thus exacerbating the issue.  However, art therapies have the potential to be highly effective methods for coping in refugee children, especially if their native culture was one with high regard for storytelling.

 

Each intervention mentioned provides a different facet through which to combat mental distress in refugee children.  While these services are not universal yet, the fact that more and more health care providers are offering mental health care for refugee children is promising for the future.  Primary interventions aimed at improving the mental health of children before disorders occur and providing children with coping techniques and mechanisms to improve mental health are essential to supporting the overall health of a growing refugee population.

 

 

 

Sources

http://www.msf.org/source/mentalhealth/guidelines/MSF_mentalhealthguidelines.pdf

http://www.nctsnet.org/nctsn_assets/pdfs/promising_practices/MH_Interventions_for_Refugee_Children.pdf