Gender inequality and the risk of HIV among married couples in North India.

This study investigated the distribution and determinants of HIV risks among married couples in North India. Gender inequality emerged as a potential driver of HIV risks in this region. Data collection took place in 2003 in a probability survey of 3385 couples living in India's most populous state - Uttar Pradesh - and Uttaranchal. Couples' analyses utilizing generalized estimating equations showed that compared with husbands, wives were less knowledgeable about HIV (OR = 0.31, 95% CI = 0.27-0.36), more likely to consider themselves at risk for infection (OR = 6.86, 95% CI = 4.65-10.13), and less likely to feel that a wife had the right to refuse sex with her husband (OR = 0.50, 95% CI = 0.44-0.58). The proportion of husbands reporting non-marital sex in the past year was 7.1% and transactional sex in the past year, 2.2%. Among their wives, 73.4% were unaware of their husbands' non-marital sexual behaviors and only 28.9% of husbands reported condom use during their last non-marital sexual encounter. Logistic regression analyses showed that husbands' alcohol use, husbands' mobility, and urban residence were positively associated with husbands' non-marital sexual behaviors adjusting for other covariates. The data demonstrate that HIV prevention programs among couples in North India should consider both sexual risks and gender inequalities which potentially fuel HIV spread in this region.

Does addressing gender inequalities and empowering women and girls improve health and development programme outcomes?

This article presents evidence supporting the hypothesis that promoting gender equality and women's and girls' empowerment (GEWE) leads to better health and development outcomes. We reviewed the literature across six sectors-family planning (FP); maternal, newborn and child health (MNCH); nutrition; agriculture; water, sanitation and hygiene; and financial services for the poor-and found 76 studies from low and middle-income countries that met our inclusion criteria. Across these studies, we identified common GEWE variables that emerged repeatedly as significant predictors of sector outcomes. We grouped these variables into 10 thematic categories, which we termed 'gender-related levers'. These levers were then classified by the strength of evidence into Wedges, Foundations and Facilitators. Wedges are gender-related levers that had strong associations with improved outcomes across multiple sectors. They include: 'control over income/assets/resources', 'decision-making power' and 'education'. Elements of these levers overlap, but combined, they encapsulate agency. Increasing female agency promotes equality and broadly improves health and development for women, their families and their communities. The second classification, Foundations, displayed strong, positive associations across FP, MNCH and nutrition. Foundations have a more proximal relationship with sector outcomes and include: 'equitable interpersonal relationships', 'mobility' and 'personal safety'. Finally, the third group of levers, Facilitators, was associated with improved outcomes in two to three sectors and include: 'access to information', 'community groups', 'paid labour' and 'rights'. These levers make it easier for women and girls to achieve their goals and are more traditional elements of development programmes. Overall, gender-related levers were associated with improvements in a variety of health and development outcomes. Furthermore, these associations were cross-sectoral, suggesting that to fully realize the benefits of promoting GEWE, the development community must collaborate in co-ordinated and integrated ways across multiple sectors. More research is needed to identify the mechanisms by which gendered interventions work and under what circumstances.

Gender-based power and couples' HIV risk in Uttar Pradesh and Uttarakhand, north India.

CONTEXT: Gender inequality is a long-recognized driver of the HIV epidemic. However, few studies have investigated the association between gender-based power and HIV risk in India, which has the world's third largest HIV epidemic. METHODS: Population-based data collected in 2003 from 3,385 couples residing in Uttar Pradesh and Uttarakhand, North India, were used to examine associations between gender-based power (wife's autonomy and husband's inequitable gender attitudes) and indicators of couples' HIV risk (whether the husband had had premarital sex with someone other than his eventual spouse, extramarital sex in the past year or STI symptoms in the past year). Structural equation modeling was used to create composite variables for the gender-based power measures and test their associations with HIV risk measures. RESULTS: Twenty-four percent of husbands had had premarital sex, 7% had had extramarital sex in the past year and 6% had had STI symptoms in the past year. Structural equation models indicated that wives who reported higher levels of autonomy were less likely than other wives to have husbands who had had extramarital sex in the past year (direct association) or STI symptoms in the past year (indirect association). Moreover, husbands who endorsed more inequitable gender attitudes were more likely than others to report having had premarital sex with someone other than their spouse, which in turn was associated with having had extramarital sex and STI symptoms in the past year. CONCLUSIONS: If the associations identified in this study reflect a causal relationship between gender-based power and HIV risk behavior, then HIV prevention programs that successfully address inequitable gender roles may reduce HIV risks in North India.

Use of biomedical obstetric care in rural Tanzania: the role of social and material inequalities.

Despite over 20 years of efforts to improve maternal health, complications of pregnancy and childbirth continue to threaten women's lives in many countries of sub-Saharan Africa. To reduce maternal mortality levels and achieve Millennium Development Goal Five, institutions working for safe motherhood are committed to making biomedical obstetric care more available to women during childbirth. However, implementation of this strategy is not reaching women at the lower end of the socioeconomic spectrum for reasons that are not well understood. Using data from fieldwork conducted between September 2007 and June 2008, this study examines women's use of biomedical obstetric care in two rural districts of south-central Tanzania where this care was being supplied. Specifically, it seeks to explain how social and material inequalities affect decisions and behaviors related to childbirth. In addressing this aim we employed a mixed-methods study design. Effects of sociodemographic characteristics on obstetric care use were examined with logistic regression analysis (n = 1150), while perspectives and experiences of childbearing women were explored with participant observation and in-depth interviews (n = 48). The results from quantitative and qualitative study components were interpreted in light of each other. Statistically significant social and material factors related to use of care included ethnicity, education, parity, and household assets. Qualitative themes involved physical, economic, and social access to health facilities as well as issues of risk perception and self-identity. The overall findings suggest that use of obstetric care is influenced by a complex interplay of factors closely tied to relative status in family and community. As individual agents differentially positioned by multiple markers of power, women pragmatically negotiate amidst a wide array of deterrents and motivators to secure the best care they can. In order to improve use of biomedical obstetric care, interventions aimed at increasing availability of these services should focus on improving access for women who are disadvantaged.

Female autonomy as a contributing factor to women's HIV-related knowledge and behaviour in three culturally contrasting States in India.

Factors contributing to India's vulnerability to the AIDS epidemic include pervasive poverty, low levels of education and high gender stratification. This study uses data collected in the 1998-99 National Family Health Survey-2 (NFHS-2) to investigate the relationship between aspects of women's autonomy and four measures of HIV-related knowledge and behaviour--awareness and knowledge of HIV/AIDS, condom awareness and condom use--in three culturally contrasting states in India: Kerala (n=2884), Karnataka (n=4357) and Uttar Pradesh (n=8981). The NFHS-2 is a nationally representative survey of India, with a sampling scheme that was designed such that each state sample can be generalized back to represent ever-married women aged 15-49 living in the state. Kerala scores highest in the four health outcome measures, followed by Karnataka and then Uttar Pradesh, but condom use is lowest in Karnataka. Kerala also leads in the four dimensions of autonomy examined and in socio-demographic status, followed again by Karnataka and Uttar Pradesh. Despite these observed differences, in all three states, women with greater autonomy as measured by this study were more likely to be knowledgeable about AIDS and condoms and to use condoms, after controlling for socio-demographic factors. These results concur with other studies focusing on women's autonomy and health outcomes around the world, and point to the importance of incorporating a gender-based approach to AIDS prevention programmes in India.