Spring 2015

Please take some time to read Spring 2015 WGS 1272 students’ final paper abstracts. Enjoy!

A Multilevel Community-based Maternal Health Intervention in Rural Eritrea by Hanna Amanuel

The lifetime risk of a woman dying from reproductive complications in Eritrea is 1 in 52. In the US, it is in 1,800. In Eritrea, universal healthcare legislation includes free obstetric care in hospitals. Despite this policy, the majority of women (73%) birth with traditional birth attendants (TBAs) at home, where they cannot access emergency care in case of obstetric complications. After a 30-year-war for independence ending in 1993, Eritrea—categorized as a “least developed” country by the UN—has struggled to develop an equitable and quality maternal healthcare system. I employ three theoretical frameworks in framing the problem and designing an intervention: social-ecological, human rights, and intersectional approaches. From my review of the available literature and personal experiences around Enghela, a rural village in the southern part of the country, I have focused on four critical factors that impact women’s maternal health. These factors are: (1) the disproportionately high burden of abortion complications, due in part to policy restrictions; (2) an over-burdened workforce and disrespectful maternal healthcare; (3) the non-availability of transport to healthcare facilities due to low socioeconomic conditions; and, finally, (4) the lack of communication between traditional birth attendants and healthcare providers. My proposed community-based intervention addresses these factors at the public policy, institutional, community, and interpersonal levels by advocating to decriminalize medical abortions, train healthcare professionals on respectful, community-specific care and keep them accountable to patients, facilitate transportation to health centers, integrate TBAs in healthcare system, and finally upscale the existing maternity waiting homes intervention.

Contraceptive Use Among Adolescent Females in Kenya by Corinne Bain

The lack of contraceptive use in Kenya leads to harmful consequences and this is especially prevalent among the adolescent female population. It is necessary to address these harmful consequences by exploring the existing problems among the adolescent female population in Kenya and create potential motivations for increasing contraceptive use. A multi-level intervention is created in this paper by investigating the social determinants of the low percentage of contraceptive use within this population in Kenya. Intervention activities are presented at each level (intrapersonal, interpersonal, institutional and societal) and make up the multi-level intervention. The intervention activity for the intrapersonal level is a participatory communication system with a focus on research methodology uncovering the customs and common dialogue of the targeted population. In order to increase benefits of interpersonal relationships, providing communication skills to teachers, parents and other authority figures could lead to a better understanding of contraceptive use. Institutional systems provide an accessible area to distribute this information as well; therefore national sex education curriculum has the potential to distribute accurate information in a comfortable setting. On a societal level, an intervention activity that aims to solve the problems surrounding comfortable discussions and stigmatizations of contraceptives is the use of media and community-based campaigns used to normalize contraceptive use in conversation. A combination of these proposed intervention activities make up a multi-level intervention attempting to increase the use of contraceptives and ultimately decrease harmful and dangerous consequences of unprotected sex.

Using Education, Ad Campaigns, the Law, and Teaching Work/Life Skills to Prevent the Spread of HIV in Young Women Ages 15-25

In Botswana, HIV has reached epidemic proportions: currently a quarter of the population has either HIV or full-blown AIDS. Of the hundreds of thousands of new transmissions each year, a disproportionately large number, up to 35%, are young women under the age of twenty-five. This paper aims at uncovering social factors that lead to such a high prevalence rate in young women, and what can be done to reduce the number of new infections, and the overall prevalence rate in young women. A few of the social factors identified through research were the fact that there is no formal sexual education for most children in Botswana, that most women are economically dependent on men, that cultural norms give men all the power in relationships, and that there is no penalty for willfully passing on HIV to unwitting partners. Based on the social factors identified, there are four main recommendations for interventions that should help to lower the HIV prevalence in young women under he age of twenty-five the Botswana. The first is to put a formal sexual education in place in every school in the country. The second intervention is to create an ad campaign targeting young women, and the older men they enter relationships with, warning them about the dangers of HIV/AIDS. The third is to set up community supported businesses and farms that the young women can work on, thereby increasing their financial independence and decrease the risk of them entering high-risk relationships. The final recommendation is to criminalize the willful transmission of HIV by a HIV+ person to an unwitting partner. These recommendations should help to fix the prevalence and transmission rates in Botswana.

A Multilevel Community-Based Intervention Addressing Social Factors That Contribute To Low Rates of Family Planning Use Among Married Women in India by Helen Clark

This paper examines the social factors that have led to low rates of contraceptive among married women in India and proposes a multilevel community based intervention that addresses those social factors. This paper uses an ecological public health model as a framework for examining these social factors and the levels at which they operate – individual, interpersonal, community, institutional, and policy. The 2006 India National Family Health Survey reported that only 48.5% of married women are currently using a modern form of family planning, with the vast majority of that number accounted for by female sterilization. Low rates of contraceptive use lead to early age of first childbirth and unhealthy spacing of childbirth for married women in India. This paper identifies several key social factors that contribute to low rates of contraceptive use: high rates of domestic violence, misperceptions about side effects caused by contraceptive methods, low rates of one-on-one contraceptive counseling from healthcare providers, and the normalization of sterilization as a major family planning method. The multilevel community-based intervention detailed in this paper focuses on a few programs that address these factors at multiple levels: a community-based education workshop program, restructuring healthcare provider training to emphasize the importance of family planning for maternal and infant health, and policy revision to reduce the number of coerced female sterilizations in India.

Multi-Level Intervention to Combat Maternal Mortality among Rural Hausa Women in Northern Nigeria

More than one tenth of the global maternal deaths occurring each year take place within Nigeria. Within the nation, the Hausa tribe of northern Nigeria makes up the largest percentage of maternal deaths. These figures clearly show the imperative need for interventions targeting maternal mortality within this population. Using a social determinants of health framework, three major social factors were found to significantly contribute to the high prevalence of maternal mortality among women living within rural Hausa communities. At the structural level, socio-economic constraints within this population are barriers to access to antenatal and emergency health care. At the interpersonal level, spousal and familial pressures experienced by adolescents to marry early often result in high-risk adolescent pregnancies. Finally, at the societal level, the Islamic practice of purdah, (female seclusion) often results in social and economic isolation that limits Hausa women’s access to antenatal and perinatal care in the case of obstetrical emergencies. After determining these social factors, the social-ecological model was used as a theoretical framework to propose multiple interventions operating at different levels in order to combat this health issue and create solutions that address rural Hausa women’s short term needs and lay the foundation for long term improvements in the target population’s social circumstances.

HIV/AIDS in Tanzania: Social Factors Influencing the Effects of the HIV/AIDS Epidemic on Adolescent Girls and a Proposition for a Multi-Level Community Intervention by Stephanie Hadley

Adolescent girls living in Tanzania have twice the likelihood of contracting HIV than their adolescent male counterparts. Navigating through one of the most difficult transitional periods of their lives, adolescent girls are faced with new social pressures and decisions about their health that have the potential to largely impact their futures. Viewing this scenario in relation to the social ecological and life-course theoretical frameworks, this paper will analyze the effects of three different social factors on the prevalence of HIV/AIDS within the adolescent girl population. At the interpersonal level, it will examine how transactional sex relationships heighten a woman’s risk for contracting HIV. It will then look at the institutional level to determine the reasons why HIV testing rates are so low amongst adolescent girls, followed by explaining where community-based HIV/AIDS stigma comes from and how it is detrimental to all individuals, whether HIV positive and negative. The paper will conclude by explaining how the establishment of safe houses for women involved in transactional sex, opt-out strategies coinciding with nationwide testing days, and a multi-media campaign to address stigma have the potential to change the course of the HIV/AIDS epidemic forever.

Addressing Inequities in Access to Abortion Services for Rural Women in Mexico

In 2007, the Mexico City Legislative Assembly approved a landmark legislation decriminalizing elective first-trimester abortions. This groundbreaking amendment, one of the most progressive in the Latin American and South American regions, however, triggered a conservative backlash among other states in the country. Because abortion laws are under federal mandate, women living outside of the federal district continue to experience limited access to abortion services due to continued, restrictive legislation. This unequal access to abortion disproportionately affects rural, poor and indigenous women in particular. Motivated by a human rights and public health theoretical approach, this report recognizes the health risks and the violation of women’s reproductive rights and self-determination that restrictive abortion laws procure. An ecological framework motivates analysis of the social factors that make it harder for women to access safe abortion services and more likely to increase risk of unsafe abortion. The author proposed three community-based interventions that target different levels: strengthening of sex education programs to address disparities in individual’s access to knowledge; implementation of training procedures to destigmatize abortion services and practitioners who perform these procedures in medical institutions; and coordination of grassroots organizations that work in poor, rural and indigenous communities to spread awareness about sexual and reproductive health. All three interventions work to erode current abortion stigma by increasing knowledge about reproductive health. Furthermore, all work to increase women’s access to family planning services, including abortion services.

Contraceptive use among adolescent girls in rural Nicaragua: a multilevel analysis by Megan 

Rates of adolescent pregnancy in Nicaragua are the highest in Latin America, with nearly 50% of the female population reporting pregnancy before the age of 20. Of these reports, almost half are unintended (Decat et. al., 2015). One significant problem contributing to the high rates of unintended adolescent pregnancy in Nicaragua is that adolescents, especially below the age of 19, do not consistently use available contraceptive methods (Lion et. al., 2009). While contraceptives are widely available, there are social barriers to access that prevent young women from accessing the resources, especially in rural communities. Access to contraceptives is a human right and those who cannot access contraceptives are at increased risk for future social and biological obstacles to success. This paper proposes interventions that target contraceptive use amongst rural adolescents in Nicaragua in a multi-level, social ecological framework. Gender double standards will be addressed at the society level, sex education will be addressed on the individual level, and capacity for effective adolescent reproductive healthcare will be addressed on the institutional level. On the society level, I propose an advertisement campaign; on the individual level I propose a peer-driven sex education program to be taught in schools; and on the institutional level I propose a voucher system involving training community health workers to provide safe, confidential, and easily accessible reproductive health care and counseling for adolescents. By addressing social norms, knowledge about the acceptability of contraceptive use, and institutional capacity for adolescent care, individuals will be empowered to access contraceptives and rates of unintended teen pregnancy will decrease in rural areas of Nicaragua.

Is There A Choice: How Social Factors Influence the Choice to Become a Surrogate for Poor Women in Urban India by Bianca

As of 2011, the Indian Council of Medical Research and National Commission for Women in India approximated that there are 3,000 surrogacy clinics in India, constituting a $445 million business (Bailey, 2011). The women who choose to become surrogates are often poor and are employed in low-paying jobs; as a result, they view surrogacy as a lucrative alternative to labor that pays less (2011). The following analysis will use a social ecological model, which conceptualizes behaviors as the product of influences from multiple social factors that operate on multiple levels, as well as a reproductive rights framework, which frames the right of men and women to make their own reproductive decisions as a human right, to elucidate the various social factors that restrict the choice of poor women in urban India to become surrogates (McLeroy et al., 1988; Cook & Fathalla, 1996). In order to provide poor women in urban India with greater agency in making the decision to become a surrogate, I propose an intervention that includes three activities, one to target a social factor at a specific level. One activity will operate at the public policy level to create policy that counters gender norms that limit employment opportunities for women. The second activity will target poor women’s lack of knowledge concerning surrogacy at the intrapersonal level through community surrogacy information centers. The final activity will be a poster and multimedia campaign to target stigma against surrogates at the community level. These activities will incorporate the government, various organizations and community members to create a comprehensive intervention that can have a sustained positive impact on the degree of control poor women experience when they make the decision to become surrogates.

Community Based Interventions Targeting HIV Risk Among Young Women in Rural Nigeria by Sydney Reed

Even with recent advances in antiretroviral therapies and prevention campaigns, HIV/AIDS continues to be a major contributor to the global burden of disease. Nigeria is one of the countries most affected, accounting for the second highest number of new cases annually and 30% of mother-to-child transmission. Using the social ecological model and life course theory as frameworks for analysis, this paper evaluates three social determinants of HIV risk among women aged 15-24 in rural Nigeria and recommends community based interventions at multiple levels to address these issues.  Interdisciplinary research pointed to HIV-related societal stigma, low rates of condom use, and lack of understanding of HIV prevention, transmission, and treatment as key elements contributing to increased HIV-risk among young women in rural Nigeria. I suggest building community centers to provide health education programs and support groups to reduce HIV-related stigma and improve interpersonal relations between community members and HIV positive individuals, broadcasting widespread media campaigns to promote increased condom use, and implementing peer education programs in secondary schools to increase HIV knowledge among adolescents such that they are equipped. Together these interventions aim to increase adoption of HIV preventative behaviors among young women in rural Nigeria and their partners and increased utilization of HIV treatment options.

Reforming Sex Education + Removing Barriers to Sexual Health Knowledge for Adolescents in India: A Three Level Intervention Plan by Rachel 

Comprehensive sexual education for adolescents is essential to producing a healthy and knowledgeable population. Although India implemented an Adolescent Education Programme in 2005 to promote sexual education as standard in all schools, implementation did not reach all regions and the program faced considerable criticism and pushback from conservative policy makers in recent years who believe that comprehensive sexual education is too explicit and inappropriate for young people (Das 212). In order to improve sexual education across India, policy makers should use evidence from recent meta-analyses and surveys that demonstrate the costeffectiveness and improvements to health that comprehensive sexual education produces and make sexuality education standard for all schools, engage community structures to build a peer network that disseminates information to adolescents, and employ and train counselors to improve individuals’ ability to access information. Using this multi-level intervention, the program will directly expand and improve sexual education and indirectly reduce social norms that prevent individuals from accessing sexual and reproductive health knowledge.

Disparities in maternal mortality: Addressing adolescent women in rural Bangladesh by Kimberly Schaefer

The prevalence of maternal mortality in low-income countries is a reproductive health issue indicative of both global and local health inequities and social disparities. In Bangladesh, a country marked by high population density and pervasive poverty, remarkable progress has been made in reducing the maternal mortality ratio over the past several decades, but these changes have taken place in the absence of improvements in other maternal health indicators. Improvements have not affected all populations to the same extent; large-scale statistics do little to capture the pervasiveness and urgency of the problem for women in poor rural populations. Additionally, adolescent pregnancy is more widespread in these rural regions, and this entails greater risk of complications during delivery and future social and economic disadvantages for these mothers. This paper focuses on how countrywide changes related to maternal health have affected experiences of adolescent women in rural Bangladesh, given these existing disparities. Building off of the social-ecological and the social determinants of health frameworks, the intervention discussed in this paper aims to reduce maternal mortality through increasing utilization of skilled birth attendants during delivery. This intervention acts on the individual level to influence health-seeking behaviors through participatory women’s groups, on the institutional level to increase the accessibility of and interaction with skilled birth attendants using the voucher program, and on the policy level to introduce policies that are closely aligned with health equity goals.

HIV Risk and Barriers to Accessing HIV-Related Care for Women in Rural Uganda

Sub-Saharan Africa has been the most heavily impacted area by HIV/AIDS in the world, and Uganda has been one of the most successful countries in the region in combating the epidemic. Despite their success, women are persistently more vulnerable to HIV/AIDS, and rural populations have seen a rise in HIV incidence, against the national trend. Analysis of the social factors influencing HIV risk and barriers to access of HIV-related care using social ecological and life-course frameworks yield education level (individual), stigmatization of HIV (societal), and rural place of residence (structural) as the social factors that are highly relevant to this population. Within the last decade, a negative correlation between education and HIV incidence has been observed, likely due to the increased responsiveness to HIV-related educational campaigns among individuals with higher educational attainment. A mentoring program between women enrolled in secondary education and young girls was the designed intervention to encourage young girls to remain in school and pursue secondary education. Increased stigmatization of HIV increased barriers of access to HIV testing and care, and HIV/AIDS is more heavily stigmatized in rural areas compared to urban areas. An advertisement campaign dispelling common myths about HIV/AIDS was the intervention for this social factor, with the goal of destigmatizing HIV/AIDS. Increased barriers to access HIV testing and care were observed among women living in rural areas due to transportation cost and time. Introducing a network of mobile clinics throughout rural Uganda was the designed intervention for this social factor.

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