The Reproductive Agency Scale (RAS-17): development and validation in a cross-sectional study of pregnant Qatari and non-Qatari Arab Women.

BACKGROUND: Sustainable Development Goal (SDG) 5 prioritizes women's empowerment and gender equality, alone and as drivers of other SDGs. Efforts to validate universal measures of women's empowerment have eclipsed efforts to develop refined measures in local contexts and lifecycle stages. Measures of women's empowerment across the reproductive lifecycle remain limited, including in the Arab Middle East. METHODS: In this sequential, mixed-methods study, we developed and validated the Reproductive Agency Scale 17 (RAS-17) in 684 women having a normal pregnancy and receiving prenatal care at Hamad Medical Corporation in Doha, Qatar. Participants varied in age (19-46 years), trimester, gravidity (M3.3[SD2.1], range 1-14), and parity (M2.1[SD1.5], range 0-7). Using qualitative research and questionnaire reviews, we developed 44 pregnancy-specific and non-pregnancy-specific agency items. We performed exploratory then confirmatory factor analyses (EFA/CFA) in random split-half samples and multiple-group CFA to assess measurement invariance of the scale across Qatari (n = 260) and non-Qatari Arab (n = 342) women. RESULTS: Non-Qatari women agreed more strongly than Qatari women that every woman should have university education, and working outside home benefitted women. Qatari women agreed more strongly than non-Qatari women that a woman should be free to sell her property. Qatari women reported more influence than non-Qatari women in decisions about spending their money (M4.6 versus M4.4), food they can eat (M4.4 versus M4.2), and rest during pregnancy (M4.5 versus M4.2). Qatari and non-Qatari women typically reported going most places with permission if accompanied. A 17-item, three-factor model measuring women's intrinsic agency or awareness of economic rights (5 items) and instrumental agency in decision-making (5 items) and freedom of movement (7 items) had good fit and was partially invariant across groups. CONCLUSIONS: The RAS-17 is a contextual, multidimensional measure of women's reproductive agency validated in pregnant Qatari and non-Qatari Arab women. This scale integrates pregnancy-specific and non-pregnancy-specific items in dimensions of intrinsic agency and instrumental agency relevant to Arab women of reproductive age. The RAS-17 may be useful to screen for low reproductive agency as a predictor of maternal and perinatal outcomes. The RAS-17 should be validated in other samples to assess its full applicability across the reproductive life cycle.

Cognitive interviewing to improve women's empowerment questions in surveys: Application to the health and nutrition and intrahousehold relationships modules for the project-level Women's Empowerment in Agriculture Index.

In 2015, the United Nations adopted the Sustainable Development Goals, which include fostering gender equality and women's empowerment and ending hunger and malnutrition. To monitor progress and evaluate programmes that aim to achieve these goals, survey instruments are needed that can accurately assess related indicators. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) is being developed to address the need for an instrument that is sensitive to changes in empowerment over the duration of an intervention. The pro-WEAI includes new modules with previously untested survey questions, including a health and nutrition module (focused on women's agency in this area) and an intrahousehold relationships module. This study uses cognitive interviewing to identify how new survey questions might be misinterpreted and to understand what experiences women are referencing when they respond to these questions. This was undertaken with the goal of informing revision to the modules. The study was conducted in Bangladesh with women from nuclear, extended, and migrant-sending households and from two regions of the country to identify difficulties with interpretation and response formulation across these groups. Findings revealed that questions were generally understood, but participants occasionally responded to the wrong part of the question, did not understand key phrases, or were uncomfortable with questions. The findings also suggested ways to revise the modules and strengthen the pro-WEAI. The revised pro-WEAI health and nutrition and intrahousehold relationships modules will advance the ability to measure changes in these domains and their relationship with the health and nutritional status of women and their children.

Human and economic resources for empowerment and pregnancy-related mental health in the Arab Middle East: a systematic review.

This systematic review synthesizes research on the influence of human and economic resources for women's empowerment on their pre- and postnatal mental health, understudied in the Arab world. We include articles using quantitative methods from PubMed and Web of Science. Two researchers reviewed databases and selected articles, double reviewing 5% of articles designated for inclusion. Twenty-four articles met inclusion criteria. All 24 articles measured depression as an outcome, and three included additional mental health outcomes. Nine of 17 studies found an inverse association between education and depression; two of 12 studies found contradictory associations between employment and depression, and four of six studies found a positive association between financial stress and depression. These results suggest that there is a negative association between education and depression and a positive association between financial stress and depression among women in the Arab world. Firm conclusions warrant caution due to limited studies meeting inclusion criteria and large heterogeneity in mental health scales used, assessment measures, and definitions of human and economic resources for women's empowerment. It is likely that education reduces depression among postpartum women and that financial stress increases their depression. These findings can be used to aid in the design of interventions to improve mother and child outcomes. However, more research in the Arab world is needed on the relationship between human and economic resources for women's empowerment and perinatal mental health, and more consistency is needed in how resources and mental health are measured.

Validation of three mental health scales among pregnant women in Qatar.

OBJECTIVES: The objective of this study is to validate three mental health scales in a targeted sample of pregnant Arab women living in Qatar: the Kuwait University Anxiety Scale, the Perceived Stress Scale, and the Edinburgh Postnatal Depression Scale. METHODS: Random split-half exploratory factor analysis and confirmatory factor analyses (n = 336; n = 331), conducted separately, were used to evaluate scale dimensionality, factor loadings, and factor structure of the KUAS, the PSS, and the EPDS. RESULTS: Fit statistics for the three scales suggested adequate fit to the data and estimated factor loadings were positive, similar in magnitude, and were significant. The final CFA model for the KUAS supported a 19-item, two factor structure. CFA models also confirmed 8- and 10-item, single-factor structures for the PSS and EPDS, respectively. CONCLUSIONS: The validation of scales for these aspects of mental health in Arab pregnant women is critical to ensure appropriate screening, identification, and treatment to reduce the risk of sequelae in women and their children. Findings offer a useful comparison to mental-health scale validations in other Arab contexts.

Conflicting contraceptive norms for men: equal responsibility versus women's bodily autonomy.

Most research investigating how men and women in heterosexual relationships negotiate contraceptive use focuses on the women's point of view. Using a sample of 44 interviews with men attending a western US university, this study examines norms governing men's participation in contraceptive use and pregnancy prevention and their responses to those norms. The paper demonstrates how competing norms around sexual health decision-making and women's bodily autonomy contribute to unintended outcomes that undermine young people's quest for egalitarian sexual relationships. While men largely agree that responsibility for sexual health decision-making should be shared with women, they also believe that women should have power over their own bodies and sexual health. However, the coexistence of these two competing norms - which call for both equal responsibility in decision-making and women's bodily autonomy - results in a disconnect between men saying that sexual health decision-making should be equal, but not always participating equally. Thus, men largely give contraceptive decision-making power over to women, putting the burden of pregnancy prevention onto women and letting men off the hook. It is concluded that men's negotiation of these competing norms reinforces unequal power and inequality in sexual relationships.

Multilevel Influences on Depressive Symptoms among Men in Bangladesh.

Depression is a worldwide problem, and is especially prevalent in lower-income countries with insufficient resources and widespread poverty, such as Bangladesh. Yet multilevel determinants of depressive symptoms in men have not been studied in this context. We leverage a novel dataset from men in Bangladesh to determine the community- and individual-level influences of masculine dominance strain and financial strain on the frequency of married men's depressive symptoms in Bangladesh. Data were collected between January and June, 2011, as part of the UN Multi-Country Study of Men and Violence, conducted by The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Masculine dominance strain at both levels was related to the frequency of depressive symptoms. Financial strain only at the individual level was related to the frequency of depressive symptoms. We conclude that community-level economic interventions may not directly influence individual-level depression; however, addressing customary conceptions of masculinity at the community and individual level and addressing individual-level financial strain are promising joint strategies to improve married men's mental health in Bangladesh and similar settings.

Men's Perpetration of Partner Violence in Bangladesh: Community Gender Norms and Violence in Childhood.

Men's perpetration of intimate partner violence (IPV) is common, but its multilevel determinants are understudied. We leveraged novel data from a probability sample of 570 junior men (married, 18-34 years) from 50 urban and 62 rural communities who took part in the Bangladesh survey of the 2011 UN Multi-Country Study of Men and Violence. We tested whether more equitable community gender norms among senior men (N=938; married, 35-49 years) was negatively associated, and a junior man's greater exposure to childhood violence was positively associated, with his lifetime count (or scope) of physical IPV acts perpetrated. We also tested whether more equitable community gender norms mitigated the association of more violence in childhood with the lifetime scope of physical IPV acts perpetrated. Among younger married men, 50% reportedly ever perpetrated physical IPV, the mean lifetime scope of physical IPV types perpetrated was 1.1 (SD 1.3) out of 5.0 listed. A majority (64%) reported childhood exposure to violence. In multilevel Poisson models, a man with more childhood exposure to violence had a higher log scope (Est. 0.31, SE 0.04, p<.001) and a man living amidst the most equitable gender norms had a lower log scope (Est. -0.52, SE 0.19, p<.01) of physical IPV acts perpetrated; however, no significant cross-level interaction was observed. Interventions that address the trauma of childhood violence and that promote more equitable community gender norms may be needed to mitigate IPV perpetration by younger men.

The Association of Attitudes about Contraceptives with Contraceptive Use in a Random Sample of Colorado Women.

CONTEXT: Research regarding unintended pregnancy often focuses on how women make decisions about whether or not to use contraceptives, and structural barriers to contraception. Less research examines how multidimensional attitudinal characteristics may be associated with effective contraceptive use. METHODS: In fall 2007, we conducted a random telephone survey of 801 sexually active women in Colorado to assess associations of the attitudinal dimensions of Planning, Partner Communication, and Stigma and Misinformation with contraceptive use. We also examine demographic differences on hypothesized predictors. RESULTS: Stigma and Misinformation is higher in Latina women, women on Medicaid or with no insurance, women with less than a college degree, and women living in small towns or rural areas. Partner Communication attitudes are most positive among those with a bachelor's degree, and those with less than a high school degree, while they are most negative among those living in small towns and rural areas. In multivariate analysis, planning to use contraceptives is associated with greater likelihood of more effective contraceptive use. Higher levels of planning and partner communication are associated with greater likelihood of any contraceptive use. DISCUSSION: In addition to addressing structural barriers to contraception, interventions to address the need to plan for contraception are vital to mitigate the high prevalence of unintended pregnancies in the United States.

Low-income women's navigation of childbearing norms throughout the reproductive life course.

Shifts in family structure have affected age norms about both teenage childbearing and reproductive sterilization, but we lack research examining how childbearing norms are connected across the reproductive life course. Drawing on interviews from 40 low-income women in Colorado, we explored linkages between early childbearing and the desire for early sterilization. Specifically, we examined two narratives women use to negotiate competing norms throughout the reproductive life course. The low-income women in our study characterized their teenage childbearing experiences negatively and justified them using a "young and dumb" narrative. Women also asserted that reversible contraceptives do not work for them, using a "hyper-fertility" narrative to explain both their early childbearing and their desire for early sterilization. Our results illustrate the influence of mainstream social norms about childbearing timing on low-income women's lives and provide evidence of how women use narratives to explain and justify their violation of childbearing norms.

Do depressive symptoms in male and female adolescents predict unintended births in emerging adulthood?

Unintended birth and mental health are major public health problems in the United States. To date, little research has examined the relationship between depressive symptoms and unintended births, and no research has examined this relationship among men. Data from the National Longitudinal Survey of Adolescent Health (N = 14,271) were used to examine the relationship between depressive symptoms among females and males in adolescence and unintended first birth in emerging adulthood. Respondents who reported higher levels of depressive symptoms in adolescence were more likely to report an unintended birth (OR 1.93, p < 0.001) compared with respondents who did not have children. They were also more likely to report an unintended birth compared with respondents who had an intended birth (OR 1.28, p < 0.05). The relationship between adolescent depressive symptoms and unintended birth remained significant, controlling for background variables, and it did not differ by gender. Adolescent depressive symptoms are associated with unintended birth in emerging adulthood. Thus, policies designed to treat depressive symptoms in adolescence may be effective in reducing unintended pregnancy among young adults.

"I Just Wasn't Thinking": Strategic Ambiguity and Women's Accounts of Unprotected Sex.

Heterosexual university students continue to endorse sexual scripts that preference men's desire and sustain gendered power imbalances in sexual relationships and encounters, leading women to risk pregnancy by engaging in unprotected sex. Because young women also endorse norms encouraging them to protect themselves and their partners from unintended pregnancy, women are caught in a bind between two often competing norms. We conducted semi-structured individual interviews with university women (n = 45) to examine how they navigate these competing norms. We found that women explained risky contraceptive decisions by saying they "just weren't thinking," thus employing strategic ambiguity, or vague language used to maintain social status, to navigate between competing norms. Our findings suggest that women were actually thinking about risks and making calculated decisions in the moment which often privileged men, putting themselves at risk and sometimes causing distress. To save face, women presented the idea that they "just weren't thinking" in different ways that conformed to traditional notions of romance and sexuality: being in the moment, love and trust for their partner, and deferring to the perceived or actual wishes of men. We conclude that there is a need to promote and achieve affirmative sexuality which includes women feeling empowered to express their own sexual needs - whether that be consent or refusal, contraception, pleasure, or all of these.

Just One Shot? The Contextual Effects of Matched and Unmatched Intoxication on Perceptions of Consent in Ambiguous Alcohol-fueled Sexual Encounters.

The current research examined how contextual factors-the quantity of alcohol consumed by each partner, and whether this quantity matched-influenced how alcohol-fueled sexual encounters were perceived with regard to consent, coercion, sexual assault, and perceived responsibility of the focal partner for the outcome of the encounter. Across four studies (Ntotal = 535), participants read vignettes in which one person described a sexual encounter they had following a night out drinking. These scenarios differed within studies as a function of quantified alcohol consumed (1 shot; 15 shots) and whether both people in the vignettes consumed the same amount of alcohol (matched; unmatched). They also differed between studies as a function of whether the couples described were mixed gender or same gender. Across all four studies, scenarios in which both people in the scenario consumed different quantities of alcohol (i.e., 15 vs. 1 shot) were seen as less consensual, more coercive, and more likely to be an assault compared to scenarios where consumption was matched, especially at lower levels of intoxication (i.e., 1 shot each vs. 15 shots each). However, focal partners were also seen as less responsible for the outcome of the interaction when levels of intoxication were unmatched compared to matched. This pattern replicated across scenarios depicting same-gender and mixed-gender couples. These findings suggest that people prioritize information regarding whether sexual partners are "matched" or "unmatched" in terms of their intoxication when evaluating whether ambiguous sexual encounters are consensual and perceived individual responsibility.

Norms, Trust, and Backup Plans: U.S. College Women's Use of Withdrawal with Casual and Committed Romantic Partners.

This study integrates research on contraceptive prevalence with research on contraceptive dynamics in hookup culture to examine college women's use of withdrawal with sexual partners. Drawing on in-depth interviews with 57 women at a midwestern U.S. university, we analyzed women's explanations for using withdrawal for pregnancy prevention and framed our study within the research on gender norms, sexual scripts, and power dynamics. Findings showed withdrawal was normalized within collegiate hookup culture, and that women frequently relied on withdrawal as a secondary or backup method or when switching between methods. Women often followed up with emergency contraceptives if using withdrawal alone. With casual partners, women advocated for their own preferences, including for partners to withdraw. In committed relationships, women prioritized their partner's desires for condomless sex, but also linked withdrawal with trust and love. Thus, women in relationships may be disadvantaged by hookup culture norms suggesting sex is freely available, putting pressure on them to acquiesce to withdrawal. Many women used withdrawal despite acknowledging it was not the most desirable or effective method, emphasizing the need for a sexual health approach that acknowledges these tensions and strives to help women and their partners safely meet their sexual and contraceptive preferences.

It Happened to a Friend of Mine: The Influence of Perspective-taking on the Acknowledgment of Sexual Assault Following Ambiguous Sexual Encounters.

Failure to acknowledge that one has been the victim of sexual violence is an important, yet understudied, barrier that prevents women from seeking appropriate support following sexual violence. Drawing from a literature of demonstrating the benefits of self-distancing when evaluating emotionally charged personal information, the effects of self-distancing on acknowledgment of sexual assault were tested. Four experimental studies (Ntotal = 1,609) manipulated perspective-taking, either by asking women to imagine a series of hypothetical sexual encounters as experiences that happened to themselves or to their friends, or by asking women to describe a sexual experience from a first- or third-person perspective. Findings from the studies suggest that taking another person's perspective can help women to label ambiguous sexual experiences as more inappropriate and coercive. Notably, this did not seem to stem from women downplaying or dismissing experiences when they imagined themselves, as they reported anticipating more negative and less positive emotions in the scenarios where they imagined themselves compared to a friend. Nonetheless, in spite of the stronger anticipated negative emotional response when imagining themselves, women were less open to information about resources associated with sexual assault and support when they imagined themselves compared to a friend. This pattern of findings replicated for own, past sexual experiences but only to the extent that women spontaneously engaged in distanced perspective-taking themselves. This research suggests in addition to using contextual information to disambiguate and determine whether a sexual experience was inappropriate, taking a distanced perspective might provide a route through which women can come to terms with the experience and open up to the use of community-based services and sexual assault resources.

Vietnamese Men's Definitions of Intimate Partner Violence and Perceptions of Women's Recourse-Seeking.

The Vietnamese government has made efforts to promote gender equality and to discourage intimate partner violence (IPV), yet IPV remains a common experience for married women in Vietnam. IPV leads to severe injury, poor mental health, chronic disease, and substance abuse among women, yet little is known about why men perpetrate IPV. We explored how men defined IPV and perceived women's recourse-seeking following IPV in Vietnam. Using data from 10 in-depth interviews and two focus group discussions with Vietnamese men, taken from a parent study on attitudes about IPV in Vietnam, we found that men often viewed IPV against women as normal and justified violence occurring when a husband was "hot-tempered," drunk, or when the wife was seen as at fault. Men interviewed were often reluctant to endorse recourse-seeking on the part of the woman unless the violence was both frequent and severe. While frequent and severe IPV was seen as warranting recourse-seeking, infrequent or less severe IPV was normalized and seen as a private family issue. For less severe IPV, men felt that women could potentially engage in recourse such as running or hiding from a husband to avoid instances of IPV. Only when IPV was happening multiple times per week and was severe enough to warrant medical treatment was recourse such as approaching family or neighbors for help, notifying authorities, and petitioning for divorce seen as appropriate. Interventions with men are needed to support recourse-seeking for women and to reduce IPV in Vietnam.

Norms of Masculinity and the Cultural Narrative of Intimate Partner Violence Among Men in Vietnam.

Semi-structured interviews with 31 men in Hung Yen Province in Northern Vietnam are used to elucidate a conceptual narrative to understand men's perceptions and perpetration of intimate partner violence (IPV) in Vietnam. This narrative suggests that cultural definitions of masculinity and changes in women's participation in the labor force have contributed to status conflicts that normalize IPV as part of masculine superiority. The narratives of both IPV perpetrators and non-perpetrators demonstrate how violence is incorporated into the cultural definition of masculinity and illustrates how men use this definition to minimize their own and other men's perpetration. We suggest that attempts to reduce IPV in Vietnam must address constructions of masculinity and the socio-historical context of IPV by providing gender-sensitivity training and opportunities for men to evaluate critically how constructions of masculinity in their families and communities contribute to IPV perpetration.

Gender Norms, Violence in Childhood, and Men's Coercive Control in Marriage: A Multilevel Analysis of Young Men in Bangladesh.

OBJECTIVE: Coercive control in marriage is common in patriarchal settings, but multilevel determinants are understudied. METHOD: Using a probability sample of 570 junior men (married, 18-34 years) from the Bangladesh survey of the 2011 UN Multi-Country Study of Men and Violence, we examined how exposure to violence in childhood and community-level gender norms were related to men's attitudes about gender equity and use of controlling behavior. We tested whether community-level gender norms moderated the relationship between men's exposure to violence in childhood and our outcomes. RESULTS: According to results from multilevel Poisson regression models, as community gender norms become more equitable by 1 standard deviation, a junior married man's expected rate of controlling behavior is lower by 0.11, and his rate of agreement with gender equitable attitudes is higher by 0.27. More gender-equitable community norms were negatively related to a junior married man's use of controlling behavior. Childhood exposure to violence was not associated with use of controlling behavior. There was a significant cross-level interaction such that exposure to violence had a stronger negative impact on men's gender equitable attitudes in communities with lower overall gender equity than those with higher overall gender equity. The corresponding cross-level interaction effect was not significant for the controlling behavior outcome. CONCLUSIONS: More equitable community gender norms may encourage more gender-equitable attitudes and discourage use of controlling behavior among junior men, suggesting that interventions to change community gender norms may reduce coercive control of women in marriage.

Women's agency and its relationship to current contraceptive use in lower- and middle-income countries: A systematic review of the literature.

Research shows a positive relationship between women's empowerment and reproductive health. Yet we know little about the quantitative relationship between women's agency and contraceptive use. We conducted a systematic review of peer-reviewed literature assessing the link between women's decision-making and freedom of movement with their contraceptive use in lower- and middle-income countries. Of 102 articles that met the initial screening criteria, 12 met all inclusion and exclusion criteria. Of the 12 included studies, consistently positive associations with contraceptive use were found in those that measured decision-making and freedom of movement as separate constructs. Composite measures had a less clear relationship with contraceptive use. In conclusion, women's agency is associated with women's contraceptive use in lower- and middle-income countries. However, the relationship is sensitive to how agency and its components are measured. Our review suggests the need for consistent validation of scales for women's agency as well as more rigorous research using standardised and validated scales, when possible. Longitudinal and intervention studies in lower- and middle-income countries will be useful for understanding the causal impact of women's agency on contraceptive use, and will help to inform policies and programmes to increase contraceptive use in these settings.

Social resources and Arab women's perinatal mental health: A systematic review.

BACKGROUND: Women's mental health in the perinatal period is understudied worldwide and in Arab countries especially. AIM: This systematic review explores evidence of the association between women's social resources for empowerment in the Arab World and their mental health in the prenatal and postnatal (≤1year postpartum) periods. METHODS: Guided by Kabeer's framework of empowerment, the authors applied a search string in PubMed and Web of Science databases to identify studies in countries of the Arab League (hereafter the Arab World) that address mental health and social resources for women's empowerment in the perinatal period. FINDINGS: Of 1865 electronically retrieved articles, 23 met the inclusion criteria. Overall, the majority of studies found a positive association between social resources for empowerment and perinatal mental health. Seven studies explored the relationship between familial or general social support and prenatal mental health in Arab women, and found a significant positive association. Sixteen of the 18 studies of women in the postnatal period found that enabling familial, extra-familial, and/or general social support was positively associated with mental health. CONCLUSION: This review demonstrates an association between social resources and perinatal mental health, but there is a dearth of research in this area. We call for additional research on Arab women in the perinatal period using context-specific but standardized tools to assess social resources and mental health. Evidence on positive mental health, resilience, and the influence of social resources can guide the improvement of prenatal and postpartum care services.

Growing Old Behind Bars: Health Profiles of the Older Male Inmate Population in the United States.

OBJECTIVE: This study examines patterns of multimorbidity among elderly male inmates across four domains of health (chronic medical conditions, drug- and alcohol-related diseases, impairments, and mental and behavioral health) to understand the complex health care needs of this growing population. METHOD: We use the 2004 Survey of Inmates in State Correctional Facilities and Latent Class Regression Analysis to examine 22 health problems among 1,026 men aged 50 and older. RESULTS: There are four groups of elderly male inmates: (a) relatively healthy (45.1%), (b) substance users with behavioral health issues (23.4%), (c) chronic unhealthy with impairments and violence/injury (23.6%), and (d) very unhealthy across all domains (7.9%). These groups have unique sociodemographic background and incarceration history characteristics. CONCLUSION: This study demonstrates the complexity of health for elderly inmates. Prison health should continue to be monitored to aid correctional and community health programs in understanding clinical risks, exposures, and health care needs for this population.