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Can Reproductive Health Education Empower Women? A Brazilian Qualitative Study

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Can Reproductive Health Education Empower Women? A Brazilian Qualitative Study

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CAN REPRODUCTIVE HEALTH EDUCATION
EMPOWER WOMEN? A BRAZILIAN QUALITATIVE STUDY
by
Isabela Cabral Felix de Sousa
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Education)
August 19 95
Copyright 19 95 Isabela Cabral Felix de Sousa
UMI Number: 9616959
Copyright 1995 by
Felix de Sousa, Isabela Cabral
All rights reserved.
UMI Microform 9616959
Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90007
This dissertation, written by
, 1 $ abe 1 a, .Cabra.l. . Fe 1 i x . de ..Sou s a...........
under the direction of h..e.r... Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillment of re
quirements for the degree of
D O C T O R OF PH ILOSO PH Y
c ..
D ean of G raduate Studies
Date
DISSERTATION COMMITTEE
Isabela Cabral Felix de Sousa Nelly P. Stromquist
CAN REPRODUCTIVE HEALTH EDUCATION
EMPOWER WOMEN? A BRAZILIAN QUALITATIVE STUDY
This study sought knowledge regarding women's empowerment and
women's perception of reproductive health empowerment in Brazil.
In a patriarchal society such as Brazil, where women have been
oppressed for a long time, women's empowerment is relevant for the
promotion of women, particularly poor women. The reproductive
health problems Brazilian women have seriously suffered from cannot
be dissociated from gender, race and class oppression. Brazilian
women lack adequate reproductive health care, reproductive health
education and social equality.
This study involved a qualitative analysis of a specific
Erazilian feminist-oriented health education program to note
attempts at empowerment of participant women in five dimensions,
the psychological, the cognitive, the economical, the political and
the physical. Protocols were created to interview 2 6 women
participating as client population and 5 women participating as
staff members. Observations were conducted in all settings
relevant to this health education program, such as the classes and
other facilities of the women's project. Data was analyzed through
a coding system and thematically presented.
A.11 women interviewed as client population appeared to become
empowered both in the psychological and the cognitive dimensions.
Most of these women also seemed to become empowered in the physical
dimension, reporting changes in their sexual lives. In regard to
the economic dimension, some women learned to reutilize the
resources they had but none became engaged in new income generating
activities. In respect to the political dimension, very few women
seemed to become empowered. Individual actions, not collective
actions were prevalent among most women. In addition to
perceptions of changes undergone by women themselves, many women
reported changes in their relationships with male partners and
physicians.
This study evinced that a nonformal program designed to teach
health education and sexuality can be an effective tool to bring
about women's empowerment in the psychological, cognitive and
physical dimensions. The study recommended that this program
should add efforts to empower women in the economic and the
political dimensions so that women's strategic gender needs can be
fully addressed.
ii
ACKNOWLEDGEMENTS
My gratitude is expressed to Dr. Nelly Stromquist,
chairperson of my dissertation, for her guidance and
criticism which always challenged me to look in new
directions. Dr. Nelly Stromquist has also helped me to
improve my understanding of gender relations. 1 also wish
to express r r t y appreciation to Dr. William Rideout and to
Dr. Edward Ransford, committee members for my dissertation,
for their encouragement and intellectual insights. I also
thank Dr. William Rideout's advisement throughout the
program. My appreciation is also expressed to Dr. Awdrey
Schwartz for her caring advisement and her teaching
enthusiasm.
I wish to express sincere thanks to all of the women
interviewed for sharing their experiences with me. My
appreciation is expressed to the coordinator of the program
studied who provided me with the necessary access to
conduct the fieldwork research. My admiration is also
expressed to this coordinator for her teaching skills that
seem to generate hope to all women participants.
For FundagSo Oswaldo Cruz I thank Evely Boruchovitch,
Simone Monteiro and Virginia Schall who provided me
encouragement to pursue graduate studies in the United
States.
I am indebted to the intellectual inspiration and
support received in the United States from Liane Abdenabi,
iii
Jos6 Paulo Devincenzo, AntSnio La Pastina, Ana Savitzki,
Rita Scheumann, Helizerme da Silva and Cassandra Thompson.
For my friends living in Brazil I thank Sandra Ban,
Marilia Brandao, Helena Gottschalk and Roberto Mahon who
have found creative ways to support me from a distance. I
also thank Carla Faria Leitao, Andrea Seixas Magalhaes and
Helena Torelly for their lasting intellectual influence.
At the School of Education at University of Southern
California, I am indebted to the collegial support received
from Pamella Dana, Hsiu-Hsia Huang and Karen Monkman.
I thank C.A.P.E.S. (Brazilian Ministry of Education)
and Rita Small Charitable Trust (University of Southern
California's School of Education) for the their financial
support.
Thanks also to the support received from my
grandmother Leonor, my aunt Sigrid, my brother Raul, my
brother Alfredo and my sister Mariana.
My deepest debt of gratitude is owed to my parents
Afonso and Astrid. As poets and writers my parents have
taught me patience for any writing endeavor, and as caring
parents have helped me to deal with the difficult
experiences of going through this Ph.D. program.
To all of these and many more besides, I owe a great
debt of gratitude.
To my parents for their
endless love and support.
V
TABLE OF CONTENTS
CHAPTERS
PAGES
I. THE PROBLEM AND ITS SETTING
Background Of The Problem........................... 1
Significance Of The Problem......................... 3
Purpose Of The Study.................................5
Definition Of Terms..................................6
Rationales For Conducting This Study................8
Methodology.........................................19
Methodological Assumptions........ 20
Delimitations.......................................20
Organization Of The Remainder Of The Study.........21
II. REVIEW OF RELATED LITERATURE
Primary Health Care Approaches, Health
Education And Popular Education....................22
Reproductive Health Definitions, The Birth
Of Family Planning In The Third World And
In Brazil, Brazilian Women's Reproductive
Health Problems 3 8
Women's Health Status, Women's Oppression
and Women's Health Decision-Making.................81
Empowerment As A Development Strategy
For Change..........................................95
III. METHODOLOGY
Conceptual Framework That Grounds The Research
Questions..........................................104
Research Questions.................................112
Localization And Population Of The Study...........113
Research Design....................................114
Data Collection And Analysis...................... 118
IV. FINDINGS
Organization Description.......................... 126
Women's Project Description....................... 127
The Health Education Program's Sites 12 9
The Health Education Program's Educational
Materials..........................................131
The Health Education Program's Classes....... .132
Objectives Of The Health Education Program.........133
Intended Contents Of The Health
Education Program................................. 135
Actual Contents Of The Health Education
Program............................................136
Intended Methodologies Of The Health
Education Program................................. 139
vi
Actual Methodologies Of The Health
Education Program................................... 141
The Features Of The Women Interviewed..............144
Empowerment In The Psychological Dimension:
An Unanimous Path Undertaken....................... 160
Empowerment In The Cognitive Dimension:
Another Unanimous Path Undertaken.................. 165
Empowerment In The Economic Dimension:
Productive Labor Changes Were Not Conquered.........169
Empowerment In The Political Dimension:
The Least Conquered Dimension...................... 174
Empowerment In The Physical Dimension:
Changes In Women's Sexuality........................179
Desire To Learn Takes Priority Over Health
Improvement......................................... 184
Community Participation:
Women's Unstructured Initiatives................... 186
Implementation Of The Health Education Program 188
Male Partner's Reactions To Women's Empowerment
As Diverse.......................................... 189
Religious Affiliation As Not Determinant Of
Opinions Related To Abortion and Sterilization 195
Health Education Program Changing Women's Points
Of View..............................................196
Conflicts Of A Liberation Notion Of Reproductive
Health With Brazilian Cultural Norms.............. 197
Personal Conflicts Emerged Through Program
Participation...................................... 200
Conflicts Of The Program Being Situated In The
Rooms of Churches.................................. 2 02
The Brazilian Health System Perceived As
Precarious..........................................2 04
Women's Health Decision-Making:
Another Path Being Undertaken......................205
Findings Interconnectedness........................208
V. CONCLUSION
Discussion..........................................211
Recommendations For Future Research............... 221
Methodological Recommendations
For Studies Of Empowerment.........................222
Conclusion..........................................225
BIBLIOGRAPHY........................................227
APPENDICES
A. Protocol For Oral Interviews
With The Client Population.........................251
B. Protocol For Oral Interviews
With The Staff Population..........................256
CAN REPRODUCTIVE HEALTH EDUCATION EMPOWER
WOMEN? A BRAZILIAN QUALITATIVE STUDY
CHAPTER I
Background Of The Problem
In the pertinent literature, it has been stressed that
reproductive health care for women is an area in great need
of improvement in Brazil. Brazilian women lack adequate
reproductive health care (Barroso & Bruschini, 1991;
Jacobson, 1993) and more than half of their deaths during
childbearing years have been related to reproductive
illnesses (Jacobson, 1993) .
There is a direct link between the promotion of
primary health care and the promotion of women's health
(Smyre, 1991). Among the eight essential elements of
primary health care, set forth by the Declaration of Alma-
Ata in 1978 to achieve the goal of health for all by the
year 2000, two of them are: health education, and maternal
and child health care, which includes family planning. Yet
these elements alone may not lead to innovative practices
in reproductive health care for women. For this goal to be
achieved, it is necessary that health education seek to
empower women, and that health care for women is not
designed and practiced solely as a vehicle for women their
role as a mother.
Primary health care programs take two approaches:
comprehensive and selective. Generally, it is within the
comprehensive approach that health educational programs aim
to empower the participants of health projects.
Empowerment of the participants does not only mean that
they are recipients of program activities, but also that
they actively participate in the definition of the health
problems of the community as well as in the design and
implementation of health programs.
There is a great need to give more attention to health
programs in development efforts. In comparing
international development programs, health programs have
been given less focus (Bolton, Kendall, Leontsini &
Whitaker, 1989). Castro and Bronfman (1993) analyzing the
growing emergence of feminist groups working with health
education, cited Cardaci (1989) who concluded that there
are few reports in the literature about these experiences.
This lack of reports is unfortunate since it has been
argued by Darcy de Oliveira and Harper (1985) that the real
education of women begun by the feminist movement comprised
of women, and for women, and which modifies women's
awareness, values and behaviors in regard to both their
individual and collective identities.
An empowering health education program's target
population is the most disadvantaged. Although poor men
represent a disadvantaged group vis a vis the rich, and may
very likely be in need of health education programs, poor
men have not been identified as the most disadvantaged
3
group of society. It is poor women who have this onerous
distinction. In fact, poor women have been identified as
being the population in most need of empowerment
{Stromquist, 1993).
Frequently, health cannot be understood only on the
individual level since the root of health problems may stem
from social, economic and political factors. In general,
poor health conditions for women have been, among other
factors, related to gender, class and race oppression.
Since health status can be adversely affected by a social
condition, and poor women constitute the most
underprivileged social group, it is necessary to envision
ways to advance women's social condition. Although health
education can concentrate on mechanisms to empower poor
women, for empowerment of poor oppressed women, other
strategies, in addition to education, such as women's
involvement in local organizations and networks should be
researched and implemented (Germain & Antrobus, 1989).
Significance Of The Problem
In a patriarchal society such as Brazil, where women
have been oppressed for a long time, women's empowerment is
particularly relevant to be fostered. The reproductive
health problems Brazilian women have seriously suffered
from cannot be dissociated from gender oppression.
Brazilian women lack adequate reproductive health care and
reproductive health education. Even the most advantaged
Brazilian women, albeit in much less serious ways than
their poor counterparts, are faced with problems related to
the limited fertility regulation methods available. Most
Brazilian women's options are restrained to the pill,
illegal abortions and tubal ligation (Dixon-Mueller &
Germain, 1993; Kabir & Araujo, 1991). This lack of options
has adverse health consequences for women. The illegality
of abortion in the country is an example of how limited
choices may promote reproductive illnesses. According to
Pinotti and Faundes (1989), many Brazilian women face
complications related to clandestine abortion, and there
are estimates that almost 50% of the Brazilian government
money designated to obstetric care has been spent on
complications related to abortion (Smyre, 1991) .
In addition to gender oppression, race and class
oppression in Brazil increase the likelihood of negative
consequences for women's reproductive health. The
Brazilian reproductive health care is class and race
stratified, favoring the rich and the White. This is
consonant with the fact that upper classes tend to have
more access to both public and private health care in most
countries (Akin, Birdsall & Ferranti, 1987). The
disparities between classes (and races since most Blacks
are poor in Brazil) in the Brazilian reproductive health
care do not emerge only in terms of distinct degrees of
5
access but also manifest in the divergent quality of health
services enjoyed by each social stratum.
Health programs which tackle the problem of the
reproductive health needs of poor women have been
implemented, but only a few have recognized--in addition to
the needs of modifying the Brazilian reproductive health
care system and the provision of health education--the need
for addressing the empowerment of poor women to change
their experiences of gender, class and race subordination.
The empowerment of women is important in order for women to
use health services effectively (Germain & Antrobus, 1989)
and to change the social order in ways that will benefit
them.
Purpose Of The Study
This study aimed to analyze ways in which some (if
any) mechanisms to empower women have already been
implemented in a specific Brazilian health education
program. Because the study was context specific, it sought
not only knowledge regarding women's empowerment but also
about women's perceptions of their own reproductive
empowerment, given Brazilian sexual cultural norms and its
ambiguous restrictive reproductive rights environment.
Even if empowerment attempts proved not to have been
implemented in this health education program, the study was
considered valid in showing paths that do and do not
promote empowerment. This study also could add to the few
reports on the literature of feminist groups working in
health education (Castro & Bronfman, 1993 cited Cardaci,
1989) .
Definition Of Terms
The definitions of the five dimensions of empowerment
employed in this study are as follow:
A) Empowerment in the psychological dimension means either
more beneficial perceptions women begin to have of
themselves, or modifications of participant women's skills
to relate to themselves and/or with others.
B) Empowerment in the cognitive dimension signifies the
participant women's exerting pressure on, conquering or
ameliorating of the obstacles to their abilities to learn.
C) Empowerment in the economical dimension implies the
participant women's exerting energy on, acquiring or
improving abilities to gain either money or economic power
by learning ways to make better use of resources.
D) Empowerment in the political dimension refers to the
participant women's exerting pressure for, gaining or
improving their abilities to organize with other people to
fight for a cause.
E) Empowerment in the physical dimension encompasses the
participant women's exerting more control, acquiring or
improving their abilities to control their own bodies.
The definitions used in this study of liberating
reproductive health, health practices and women's
empowerment in reproductive health are as follows.
The A) liberating reproductive health definition is
Germain's and Antrobus' (1989) :
... the ability to enjoy sexual relations without
fear of infection, unwanted pregnancy, or coercion; to
regulate fertility without risk of unpleasant or
dangerous side effects; to go safely through pregnancy
and childbirth, and to bear and raise healthy
children, (p. 18)
It is important to note that in this study the definition
of liberating reproductive health is not limited to women's
freedom in their reproductive years and encompasses men as
well.
The B) liberating health practices definition involves
a reproductive health education in which couples learn to
share the responsibilities (pleasure for both,
contraception and conception) and consequences (pregnancy,
undesired pregnancy and reproductive infections) of their
sexual practices and couples strive for their health well
being (mental, physical and social). In addition to this,
a liberating health practices definition encompasses "...
safe and appropriate contraception, and services for
sexually transmitted diseases, pregnancy, delivery, and
abortion" (Sai & Nassim, 1989, p. 103). Still, a
liberating health practices definition implies services for
the three types of reproductive infections, the sexually
transmitted diseases, the endogenic infections related to
non natural growth of organisms present in the genital
tract, and iatrogenic infections which are consequence of
medical malpractice. Finally, a liberating health
practices definition should involve the transformation of
gender power imbalances between physicians and patients.
The doctor-patient relationship can aggravate the power
inequality between men and women (The Boston Women's,
1992). Since in most medical encounters in which women are
patients they have male physicians a change is necessary
towards gender parity in these encounters.
The C) definition of women's empowerment in
reproductive health means the process under which women
control their own bodies. This implies that women report
changes in their perceptions and/or behaviors towards
living what was defined as liberating reproductive health
and/or liberating health services.
Rationales For Conducting This Study
A) The rationale for focusing on women's reproductive
health as a strategy that can lead to women's empowerment
There are many reasons for focusing on women's
reproductive health as a strategy that can lead to their
empowerment. First of all, reproductive health is relevant
to all women when defined as encompassing not only pregnant
women and mothers but also girls, nullipara, infertile
women, women who do not wish to become pregnant and women
who suffer from reproductive illnesses. Health problems
such as anemia, diabetes, osteoarthritis, rheumatoid
arthritis and worse vision affect more adult women than
adult men (Verbrugge & Wingard, 1987). But women's
reproductive health can be seen as a part of all women's
lives if they are aware of the necessary preventive
measures for cervical and breast cancers. This awareness
can unite women in the struggle for changing the present
health care system and for conquering abridgements of their
reproductive rights. It is recognized that in a country
like Brazil where social class differences divide women, a
common agenda can only be seen as a point of departure for
change. Although the feasibility of cross-class links
among women can be judged to be remote, Corcoran-Nantes
(1993) testified that Brazilian women can create them
through their participation in political parties and trade
unions with women from both feminist groups and women's
organizations.
Secondly, to discuss patriarchal health reproductive
values as they relate to health practices may lead to an
understanding that both of these values and practices need
to be changed in cooperation. It may empower women to
realize, for instance, that the fact that limiting women's
worth to the predication of motherhood has led to a limited
reproductive health care system focusing on pregnancy which
10
not only fails to meet other women's reproductive needs not
related to pregnancy, but ironically may even diminish
women's ability to become successfully pregnant and bear a
healthy child. A case in point: it has been testified by
Wasserheit and Holmes (1992) that some reproductive tract
infections, neglected as high priority by policy makers,
program planners and donor agencies may lead to women's
infertility, ectopic pregnancy, cervical cancer, poor
pregnancy, fetal wastage, low birth weight, congenital or
perinatal infection and transmission of HIV.
Thirdly, although women's health problems in general
can be related to oppression, women's reproductive health
problems in particular constitute the arena where more
oppression may be present, because reproductive health
problems often further relate to power imbalances present
in the sexual relationships women may have with men. The
quest for reproductive health leads to the questioning of
the power imbalances within sexual relationships. The
control of women's reproductivity implies the control of
women's sexuality (Agostino & Wahlberg, 1991). For women,
to begin to exercise control over their reproductive health
and sexuality can be an initial step for women's
empowerment. A good example of the need for questioning
power imbalances in sexual relationships between men and
women is suggested in a study by Holland, Ramazanoglu,
Scott, Sharpe and Thomson (1992), where they stated that
11
empowerment for the young women they researched would mean
transforming not only men's behavior and social pressures,
but these women's own ideas about sexuality, which would
criticize male power and place women's sexual pleasure as a
goal .
Fourthly, because sexual relationships occur in a
social context that is oppressive to women, to discuss
reproductive health encompasses further discussing gender
roles perpetuated by women. For instance, when social
values reinforce motherhood, a reason to become a mother
can be intertwined with other social conditions that are
oppressive to women. Faundes, Hardy and Pinotti (1989),
discussing women's desire to become pregnant stated that:
In countries with a strong Catholic tradition, where
the value system emphasizes women's fulfillment
through motherhood, women have many reasons for
wanting to become pregnant. Sometimes a pregnancy is
sought to force a marriage, or as a means of
strengthening a deteriorating relationship, or as an
expression of rebellion against societal values. In
the case of young girls, pregnancy may be a way to
escape a violent and deprived home. In sexually
repressive contexts such as Colombia, many women have
unwanted pregnancies because of ignorance and risk-
taking behavior, (p. 121)
In order for women to experience pregnancy not as an
option to overcome the above stated oppressive conditions,
it would be desirable to break the cycle of reinforcing
motherhood for all women so that new ways to struggle for
changing oppressive conditions can be envisioned and worked
towards.
12
Fifth, women's reproductive health is related to the
ways medical interventions have or have not been geared
towards women. It may be empowering to women to discuss
the current bias of medical practice in light of the
feminist critique of medicine, which emphasizes the fact
that while medical procedures concentrate on women's
reproduction over men's reproduction, medical procedures
have been minimal for women in regard to men in health
problems that both men and women share (Rodin & Ickovics,
1990; Zimmerman, 1987). This medical bias can be seen as
oppressive to women because it has implied placing the
responsibility of contraception mainly in the hands of
women; health problems have resulted from some
contraceptives used by women as well as from medical
interventions such as caesareans; and women may need more
medical intervention in other health areas--rather than
reproductive health--than they have been previously
provided.
Sixth, reproductive health is highly connected to
population and development policies. According to Moser
(1993), both anti-natalist and pro-natalist population
policies do not consider women's strategic gender need to
control their own fertility. To change this neglect is
germane to women's empowerment. Furthermore, comparing how
government laws, national governmental and nongovernmental
institutions, and international organizations have
influenced reproductive health can be critical to women's
empowerment. For instance, comparisons of the
discrepancies within and among countries in regard to
reproductive health problems experienced by women in light
of different regional and national policies can be
empowering for changing the situation. By knowing that
reproduction is the first cause of women's morbidity and
mortality in the Third World (Bolton, Kendall, Leontsini &
Whitaker, 1989), and that the World Health Organization
estimates that women from some developing countries
compared to those of the developed world have a 200 times
greater chance of dying when pregnant (Diczfalusy, 1989),
women may find it urgent to exert political pressure and to
take actions so that this dramatic situation can be
transformed into an advantage for women from the Third
World. For this to happen, it will be necessary that
models of health practice will be no longer transplanted
from the First World to the Third World, it must be
considered that, to solve problems in the latter, different
approaches may be needed because realities are not similar
(Pinotti & Faundes, 1983). Still, because some policies
that utilize women's abilities are not devised to benefit
them, it would be imperative for women's empowerment that
'all' women can participate in the process of policy
making. Hopefully, then, situations like the one argued by
Barroso (1989) in which in the 1970's both population and
14
development policies had an implicit understanding that
women were resourceful enough to solve other problems would
only be part of history.
Finally, to address women's reproductive health also
implies the questioning of social relations of production
and reproduction whereby differentiated social roles have
been established by sex. In the words of Barbieri (1993):
While the control that men exercise over the
reproduction and sexuality of women is central to
gender power, control over women's work is derived
from this. In order to keep close control over the
female body, the social division of labour gives women
certain essential tasks to ensure the reproduction of
the species and of society, but these are socially
devalued. In the same way, access to certain jobs and
political power is closed to certain jobs and
political power is closed to or very limited for
women, (p. 85)
A mechanism to ensure the gendered division of labor
has been the dissemination of wrong assumptions about
women's and men's health to keep women away from the labor
market. In Draper's (1991) study analyzing susceptibility
policies in some industries in the United States, she
concluded that: the common practice of excluding women
from the labor market due to the risk that women would have
reproductive problems if they worked has been grounded on
incomplete and on inconclusive scientific data, in some
cases the risk that men would have reproductive problems
due to work activities has indeed been greater than for
women, and not only gender has worked as a criterium for
exclusion but race and ethnicity as well. But whether
15
there is risk to reproduction or not from women's
activities, labor market decisions have not been favorable
to American pregnant women. Feitshans (1994) stated:
"Employment termination based on pregnancy is
discriminatory, but enforcement of a pregnant employee's
rights to continued employment and preservation of a
position with seniority are problematic" (p. 119).
The questioning of the relationship between production
and reproduction may also lead to the understanding that
the definitions of reproductive health have been to a large
extent culturally bounded, and that women, depending up on
their social class may have either helped to shape, accept
or reject these definitions. For instance, Reissman {1987)
demonstrated that in the United States women from upper and
middle class, together with physicians, have played major
roles transforming women's events such as childbirth,
abortion, contraception, menstruation, weight and
psychological problems into medical problems. Her study is
important because women of middle and upper classes are not
seen as passive in the medicalization of women process, and
because history and cross-cultural variations are used as
instruments to unravel the bias of the scientific claims of
medicine in the United States. Moreover, Martin (1992) in
studying 165 interviews conducted with American women {43%
from the working-class and 57% from the middle-class) found
that:
16
Middle-class women, much more likely to benefit from
investment in the productive system, have swallowed a
view of their reproductive system which sees
menstruation as failed production and as divorced from
women's own experience. Working-class women, perhaps
because they have less to gain from productive labor
in the society, have rejected the application of
models of production to their bodies, (p. 110)
Martin (1987) explained that the view of menstruation
as a wasteful failure portrayed by the medical model and
accepted by some women emerged due to the emphasis on birth
as an expected outcome for all women. This author argued
that the above focus led to the assignment of a negative
value to menstruation, which is indeed the only shared
experience of all women because it is independent of
factors such as being fertile or not, and sexual
preferences.
By discussing women's reproductive health, women may
find ways to contest the patriarchal relations of power
that have prevented them from owning their bodies, their
jobs and political power. Only then, may it be possible
for what Zimmerman (1987) stated as being an essential
principle in which the women's health movement is anchored:
"women have not had ultimate control over their own bodies
and their own health" (p. 442). By gaining control over
the very concrete and close dimension which is their
bodies, women may feel that the control and ownership of
other life dimensions such as economic power and political
power can also become real.
17
B) The rationale for selecting a program as a social space
where empowerment can emerge
Some of the features of the institution that support
this health educational program seem to lead to the
empowerment of its participants. This program is promoted
by a nongovernmental organization that is involved in
several research and social projects which aim to
ameliorate the lives of the most underprivileged groups in
Brazil, one of these being women. Moreover, this
institution does not aim to profit, meaning that no
ideology or health practice was sold at the expense of
women's health. Still, the fact that this institution is
supported by several international entities may provide for
discussions about, and coexistence of, conflicting
ideologies and hopefully not the imposition of any one of
them to the exclusion of others.
The health educational program itself has aspects that
may promote empowerment for women. First, the program is
part of a women's project designed by women and for them.
Thus, this women's project coincides with the above
description by Darcy de Oliveira and Harper (1985) of a
real education of women created by women and for women
which transforms women's awareness, values and behaviors in
regard to both their individual and collective identities.
Second, the particular focus of this program, which is to
enable women who participate in the program to become
18
community health workers, may generate empowerment of its
participants since the participants have to act as
community health leaders, which does not only imply
translating health knowledge, but rather reinterpreting
this knowledge according to different circumstances lived
by community members who are taking social actions to
promote change. Third, the health education program has a
good chance of leading to the empowerment of its
participants because it does not undertake a selective
approach to health, concentrating only on the physical
aspects of reproductive health and sexuality, but rather a
comprehensive one, teaching the relationship of
reproductive health and sexuality within the broader
context of social, economical, psychological, and spiritual
considerations. Fourth, the program targets women of low
income, which is the population most in need, and the
program's sites of instruction are located in the poor
municipalities of Rio de Janeiro. Fifth, the fact that the
program is not directed to a specific age group but
includes women of all ages, such as adolescents and older
women, can lead to empowerment since the needs of 'all'
women are addressed. Finally, the program is designed to
be a space where women with different religious
affiliations can be together. The sites of classes were
the rooms of a Methodist Church and of a Catholic Church.
Participant women's religious affiliation was pluralistic
19
in the rooms of both churches. This congregation among the
participants may promote empowerment. Division of the
oppressed is used as a tool to maintain the status quo
(Freire, 1993) and for the kind of Church that is truly
committed to the oppressed, the division among Protestants
and Catholics is not relevant {Freire, 1987).
Methodology
The design selected was naturalistic using
ethnographic techniques such as observations and
interviews. The analysis used was code analysis. Two
protocols were created to interview both client and staff
populations.
The health education program was located in two
counties close to the city of Rio de Janeiro. The program
reached both rural and urban populations.
The data were collected from oral interviews and
through fieldwork notes related to observations in the
classes, the health education program, the women's project
and the organization. Oral interviews were conducted with
31 women (26 from the client population and 5 belonging to
the staff population). The qualitative analysis of the
data identified several themes and examples that could
answer issues raised in the research questions.
20
Methodological Assumptions
1. The respondents responded honestly and their answers
depended on the quality of relationship established with
the interviewer.
2. The sample was sufficiently representative of the target
population to permit generalization of findings.
3. The reliability and validity of the protocols were
sufficient to permit accurate inferences regarding the
perceptions expressed by the population.
4. The data were accurately recorded and analyzed.
5. Results of data analysis were interpreted fairly and
accurately.
Delimitations
1. The time frame to conduct the field work was six months.
2. Because questions regarding sexuality and reproductive
care can cause embarrassment to the population, especially
for the client population whose personal experiences were
directly assessed, all respondents were--previous to the
interviews--assured anonymity, asked not to answer any
question they did not feel they should, asked to rephrase
at any time any statement given which they no longer felt
comfortable with, and asked to stop at any time if they
felt any discomfort to continue. Due to the need to assure
anonymity, fictitious names were given to the women
21
interviewed, to the women's project and to the
organization.
Organization Of The Remainder Of The Study
Chapter II is a review of related literature dealing
with the following themes: primary health care approaches,
health education and popular education; reproductive health
definition, the birth of family planning in the Third World
and in Brazil, and Brazilian women's reproductive health
problems; women's health status, women's oppression, and
women's health decision-making; and empowerment as a
development strategy for change.
Chapter III describes the conceptual framework that
grounds the research questions, the localization and
population of the study, the research design and the
procedures for data collection and analysis.
Chapter IV analyzes the data and presents the major
findings drawn from the data.
Chapter V encompasses a discussion of the findings and
recommendations for future research.
22
CHAPTER II
Review Of The Related Literature
A) Primary health care approaches, health education and
popular education
Comprehensive and selective health care approaches
In the pertinent literature, there are two approaches
which primary health care can adopt. While one is
technologically oriented and 'selective', the latter is
process oriented and 'comprehensive'. Rifkin and Walt
(1986) comparing the features of both said that the
selective primary health care defines health as an absence
of disease; overlooks equity issues; gives priorities to
medical technology and cost-effective analysis over
infrastructures, attitudes and perceptions; and values
community involvement only to the extent to which
individuals will readily accept the medical technologies
without accepting contributions from those outside the
health profession. Comprehensive primary health care is
described by these authors as conceptualizing health as a
physical, mental and social well-being; addressing equity
issues; advocating a multi-sectoral approach to health; and
stressing the importance of providing individuals with
abilities that lead them not only to decide what is best
for them, but also to participate in the planning,
implementation and evaluation of health programs.
23
Rifkin and Walt (1986) considered that the selective
and the comprehensive approaches were irreconcilable since
they have different frameworks. However, Warren (1989)
argued the feasibility of using both approaches in
conjunction since societies can use cheap and easy
technologies while waiting for development to occur, and
further claimed that selective primary health care had
recently begun to encompass education and agriculture. But
Rifkin and Walt (1986) criticized Warren in a previous
study for basing the conclusion that a selective approach
could be achieved at low cost on countries such as China,
Costa Rica, Sri Lanka, and the Kerala State in India, where
equity has been a political commitment and where there have
been policies and strategies aimed to insure that all
people have access to fundamental services.
The link between primary health care and health education
The role health education began to develop in primary
health care is well expressed by Li and Wong (1989) who
contended that:
The Declaration at Alma-Ata in 1978, which will remain
a landmark in the history of health care and health
education, recognizes health education as a means of
promoting individual and community self-reliance and
of developing people's ability to become full partners
in health promotion and care. (p. 4)
With the Declaration at Alma-Ata in 1978, the
following elements were considered as fundamental to
2 4
primary health care: education concerning prevailing
health problems and the methods of preventing and
controlling these health problems, promotion of food supply
and proper nutrition, an adequate supply of safe water and
basic sanitation, maternal and child health care that
includes family planning, immunization against the major
infectious diseases, prevention and control of locally
endemic diseases, appropriate treatment of common diseases
and injuries and provision of essential drugs (Cohen,
1990) .
Potential for empowerment in primary health care
approaches
Even though the comprehensive approach of primary
health care has as an agenda the generation of empowerment
for the community members, this approach will not always
promote empowerment. The task of empowerment may be
undermined if professionals continue to work within an
hierarchial model in which knowledge and power are not
shared with community members. Still, empowerment will be
difficult to achieve if no structural changes occur,
particularly in communities experiencing huge inequalities.
Moreover, empowerment through health will not happen if
community members will not ask for comprehensive health
knowledge and skills. Thus, the receptivity of community
members to such an approach is not always automatic or
25
guaranteed. Community members might perceive that
empowerment is not relevant to them in the terms project
planners have address it. Community members might even
have preference to other means to become empowered rather
than a comprehensive approach to health. They might
prefer, for instance, to acquire power through district
association meetings that work with social problems that do
not make health issues a priority.
Comparing the comprehensive approach with the
selective approach, the fact that the selective approach
has recently expanded its scope to involve education and
agriculture seems to make future differences between both
approaches more blurred. Nevertheless, the new selective
approach will remain problematic in leading to empowerment
if it continues to emphasize technology at the expense of
shifting attention away from the social structure,
especially in countries where community participation has
not traditionally occurred. A selective primary health
care approach can lead to empowerment djE by its short-term
focus community members are led to address equity issues.
In this case, the use of technology does not obscure social
issues, but rather it works in conciliation with them.
Nonformal education and popular education definitions
As the conceptualizations of primary health care
approaches have implications for the actualization of
26
empowerment so do the different definitions of education.
Fink (1992) delineated a distinction between nonformal and
popular education, concepts which have been confounded in
the American literature. On the one hand, the author
explained that nonformal education was first conceptualized
as an educational activity taking place outside the formal
education with the aim to offer specific knowledge to some
subgroups of a society. This author stated that nonformal
education appeared in Latin America in the late 1960's to
meet the educational needs not otherwise met by schooling
of the poor and marginal people such as young adult women.
Nonformal education programs can be run by the national
government, the international nongovernment organization
(NGOs) and the national Latin American NGOs and is aimed to
the individual's development of specific technical skills.
On the other hand, Fink described popular education as
being targeted to go beyond the individual and be a device
for social transformation. It is the latter kind of
education that has usually employed Paulo Freire's
conceptual framework and education activities where
awareness and action cannot be divorced from one another.
Popular education aims to empower not only in the
individual sphere as does nonformal education, but also
addresses the need to conquer power in the social sphere.
For Freire (1987), a liberating education is the one
grounded in a social practice, aiming for the liberation of
27
the oppressed classes. In Freire's (19 93) Pedagogy of the
Oppressed, the oppressed will become aware of the
oppressive reality and transform it through praxis. Freire
(1993) also envisioned a future without an oppressive
reality in which his pedagogy would involve through action
a process of endless liberation of mankind of myths
developed in the oppressive reality.
According to Freire (1994), the pedagogical dialogue
between an educator and the students relates to both the
content and the exposition made by the educator, and an
educator who is progressive must be democratic in both the
programming of the contents as well as in his/her teaching.
Freire (1994) claimed that for a progressive educator, the
use of small expository themes is not bad in itself as long
as the exposition is accompanied by an analysis of this
exposition, made by both students and teacher.
Comparing health education and education for literacy
Even though the concept of empowerment is new in the
field of health education, ideas similar to it have been
present since the field began (Li & Wong, 1989). But,
there are differences when education is targeted to the
acquisition of health skills instead of literacy skills,
which affects empowerment definitions. Wallerstein and
Bernstein (1988) compared health education for empowerment
and education for empowerment to the ideas on the subject
28
of the educator Paulo Freire. According to Wallerstein and
Bernstein, empowerment in health education shares with
Freire's ideas that it has to: begin by the problems of
the community; utilize active learning methods; and foster
community participation so that community members can
realize their own needs. These authors claimed that
empowerment in health education is more limited than
empowerment in education since, contrary to Freire' ideas
asserting that knowledge does not come from experts
imposing information and that the learning process involves
action and reflection, health education assumes that
individuals can make decisions regarding their health j l f .
they are provided with the information, skills and
reinforcement. Also that the learning process of some
health programs does not necessarily involve social action.
Potentials, problems and successes of empowerment in health
education and popular education
The definitions of health education have implications
for the possibility of empowerment. The etiology of health
education conceptualization was grounded in a narrow
bioreductionist medicine, which has had a profound impact
in the way health education programs have been carried out
and in turn have achieved limited success (Laura & Heaney,
1990). Nevertheless, Stabler (1984) argued that despite
the medical monopoly, health education in less developed
29
countries has been changing to focus more on social-
cultural decision-making than to endorse bio-medical
prescriptions. This shift was reported to have occurred
since the 1970's in Brazilian health educational projects
(Schall, Jurberg, Rozemberg, Vasconcellos, Boruchovitch, &
Felix-Sousa, 1987) .
The social-cultural decision-making framework is a
facilitative approach, rather than a prescriptive approach
as the bio-medical framework is (Stabler, 1984), and as
such it may promote empowerment since it is anchored in
health participation by the community. It is important to
stress that while the biomedical framework is in line with
the selective approach to health since both provide
priority to medical technology analysis over
infrastructures, attitudes and perceptions; the social-
cultural decision-making framework is in line with a
comprehensive approach to health insofar as both emphasize
social and psychological issues as germane to health and
the participation of community members in decision roles in
health programs.
The problems of health educational programs have been
related not only to the lack of a broad health approach,
but also to the way these programs have been conducted.
Hubley (1986) described the failures in the implementation
of health education in developing countries as stemming
from: the planning and communications processes, the
30
organization of health education, and the evaluation
process. Stromguist (1986), analyzing nonformal
educational projects supported by international development
agencies contended that those designed to promote the
acquisition of skills in agriculture, health, population
and sanitation have often paid small attention to their
educational activities. Still, Laura and Heaney (1990)
affirmed that the method of health education in past
programs had not fostered autonomy for the community and
individuals who are clients of the programs.
Thus, it is extremely important to learn what factors
lead to successful experiences in health education and
popular education. In a case study in China, Honglian et
al. (1991) advocated that health education worked in a
primary health care program due to the combined support it
has received from local commitment and modifications in:
health services, environment and legislation. If social
circumstances in which educational programs are attempted
play major roles for their success, it is crucial to
consider how to implement programs, particularly in adverse
social situations. For instance, La Belle (1986) suggested
that due to the social structures of Latin America and the
Caribbean countries, popular education cannot be targeted
only to transform social reality but needs as well to
endorse the status quo in order to exist. And La Belle
(1986) has indeed asserted that popular education has been
31
employed in health programs aiming in the long run to
provide empowerment to the community members in social,
economic and political spheres.
Stromquist (1994) analyzed two Latin American
educational experiences for and by women that appeared to
have been successful in promoting women's empowerment. A
summary of the author's description of these experiences is
provided below. One of these experiences was in Chile,
where the educational activities focused on women from
rural areas and emerged from the initiatives of a few
academic women. These educational activities' objectives
were to promote consciousness-raising and change the rural
women's disadvantaged status in society. While the
academic women considered that change was accomplished at
the personal level as women and as workers, they saw little
modification in terms of collective action. These academic
women concluded that comparatively while the consciousness-
raising effort was not very time consuming, the
transformation of this new awareness into collective action
was an effort that is not only time consuming but requires
high levels of support.
The other educational experience described by
Stromquist (1994) concerned an action-research project in
the city of Sao Paulo, Brazil. According to Stromquist
(1994), this project started by social scientists initially
had three objectives: to recreate the mother's club
32
history, to comprehend how women began participating in
these clubs, and to delineate the different functions these
clubs provided women.
Stromquist (1994) considered that women seem to have been
empowered from this experience as women and as political
actors and listed outcomes of this project: the organizing
of the first national feminist meeting on 'popular
education and the women's movement' which emphasized the
creation throughout the country of a research project
similar to the one conducted in Sao Paulo, the
participation of some women in the Brazilian Constitutional
Congress giving voice to decisions agreed upon in the above
meeting, and the participation in Brazilian 1990's
presidential elections and the formulation of a feminist
agenda by women who participated in the above meeting.
Among some of Stromquist's (1994) conclusions of these two
educational experiences were that the empowerment of women
may happen in different forms, gender consciousness-raising
was gained in these two experiences through concentration
on learning the experiences of women in their daily lives
and not making these experiences individualized, and the
discussion of the psychological dimension of empowerment
led to the discussion of the political dimension, but the
experience in Chile proved that increased political
awareness does not necessarily transform into political
action.
33
Because these two successful Latin American
experiences had in common an emphasis on the psychological
dimension of empowerment and on the collective sharing of
women's experiences, these two factors may be essential in
educational attempts to promote empowerment.
Community development as part of a comprehensive approach
to health care and health education
Li and Wong (1989) stated that the comprehensive
concept of primary health care has been associated with the
concept of community development. These authors explained
that the implementation of both these concepts have been
problematic, leading comprehensive primary health care to
move to selective primary health care and community
development to diminish its scope. However, even
conceptually, there has been criticism. For instance,
Stone (1992) stated that comprehensive primary health care
contains a serious contradiction when it aims the community
to set its own health needs and find ways to deal with
them. Since health planners have already determined what
the health needs are in the community as well as the
mechanism to be used in working with them, conflicts will
occur. Still, Khinduka (1969) criticized community
development conceptualization for having the potential to
postpone social structure changes, since its emphasis is on
attitudinal change and on a gradual change in the social
structure.
As primary health care has been associated with the
notion of community development, there has also been a
strong theoretical link between health education and
community involvement concepts dating back to 1953, and
thus preceding the Declaration of Alma-Ata in 1978 (Li &
Wong, 1989). That the goals of primary health care with
the Declaration of Alma-Ata give importance to the
utilization of the strategy of community participation
(Oakley, 1989) is expected, considering that health
education was sought as well as a strategy of primary
health care.
In addition to the concept of community development
the terms community participation and community
organization has been used in the literature on primary
health care. Goldsmith, Pillsbury and Nichols (1985)
distinguished between the last two notions defining
community participation as the actual involvement of
members in activities of decision making, implementation
research and evaluation and benefits of services; and
community organization as: "...processes and structures
through which members are or become organized for
participation in health promoting activities" (p. 7).
35
Potentials for community participation and organization
As with health education, community participation and
organization have experienced failures of implementation.
Goldsmith, Pillsbury and Nichols (1985) claimed that there
has been evidence to suggest that community participation
is boosted by community organization. Nevertheless, these
authors also pointed out that there are also data which
show that both community participation and community
organization are not easily accomplished, and that to
foster community organization is more difficult than to
generate community participation.
However, some studies have identified which features
may contribute to community participation or organization.
For instance, Garfield and Vermund (1986) testified that in
Nicaragua's malaria campaign, community organizing for
health occurred when it was associated with other interests
of the community. Still, Oakley (1989) cited a study in
the Americas where it was found that urban communities,
compared to the rural ones, were often more prone to take
part "in community involvement for health development. The
author explained that this was to be expected, given the
higher level of information and political awareness enjoyed
in the American urban communities over the rural ones.
Honglian et al. (1989) suggested the importance of
political commitment to foster community participation.
36
Considering the possibility of empowerment
actualization, both community participation and community
organization may take forms that may not lead to the
empowerment of their respective community members. Stone
(1992) affirmed that in Nepal it seemed to be a way to
disseminate Western cultural values of participation rather
than participation according to community cultural values.
As for community organization, it can be either externally
initiated (top-down approach) or internally initiated
(bottom-up approach), and it is only the latter approach
that has an agenda to empower community members. According
to Goldsmith, Pillsbury and Nichols (1985), while in the
top-down approach development and implementation are the
most important goals to be achieved, in the bottom-up
approach the priority is given to the development of the
capacity of the community to establish the project.
Social change has been difficult to be addressed in health
intervention
In agreement with Li and Wong (1989) who stated that,
conceptually, it is promising that the literature on health
intervention came to target both individual behavioral
change as well as social change, but that it still remains
to be understood how such concepts can be better translated
into practices that involve the social, economical and
political dimensions of health.
Part of the problem of unsuccessful implementations in
primary health care programs seems to be linked with the
priorities addressed by health planners in the
implementation of projects. For instance, it remains to be
understood how the successes and failures of implementation
of health programs vary depending upon the different
natures of the eight essential elements set forth by the
Alma-Ata Declaration.
Still, maternal child care programs are already
limited because they do not address all women's health
problems, but Heise (1993) alerted us to the fact that
maternal health programs have often neglected the mother's
needs and placed more emphasis on children's needs. Even
when women's needs are taken into account, family planning
programs emphasize contraception (Germain & Antrobus, 1989)
which is a limited approach because it does not involve the
discussion of women, sexuality, and conditions of quality
of life addressing factors such as housing, sanitation,
work, education, leisure and so on (Oliveira, Carvalho,
Frustock & Luz, 1992) . And structural conditions are so
important that Hernandez (1984), studying whether family
planning programs contributed to fertility reduction
between the mid 1960's to the mid 1970's--through studies
of individual Third World countries and a cross-national
research for 83 Third World's countries--came to the
conclusion that family planning programs' success was
38
limited depending on several socioeconomic conditions and
changes.
Health interventions, irrespective of whether they
encompass educational activities, depend on structural
circumstances. To not address these circumstances in
planning for health change undermines the achievement of
empowering objectives. Unfortunately, this lack of
emphasis on economical, political and social conditions
seems to be the major trend of primary health care
projects. According to Bolton, Kendall, Leontsini, and
Whitaker (1989), despite the Alma-Ata Declaration which
addresses the need to intersectoral approach to health,
community concerns and participation; since the 1980's
primary health programs have had primarily selective
approaches.
B) Reproductive Health Definitions, The Birth of Family
Planning In The Third World And In Brazil, And Brazilian
Women's Reproductive Health Problems
Reproductive health definitions
According to Dixon-Mueller (1993), the concept of
reproductive health became popular in the 1980's based on
the feminist idea that all women should have the right to
control their sexuality and reproduction. Dixon-Mueller
(1993) further emphasized that reproductive freedom and
rights cannot be divorced from other basic human rights,
39
for reproductive freedom is anchored in individual self-
determination. This author delineated differences among
reproductive rights such as: "the freedom to decide how
many children to have and when (or whether) to have them;
the right to have the information and means to regulate
one's fertility and the right to 'control one's own body'"
(p . 12 ) .
Germain's and Antrobus' (1989) notion of a liberating
reproductive health can be seen as meeting Dixon-Mueller's
three reproductive rights. Their definition is as follows:
. .. the ability to enjoy sexual relations without
fear of infection, unwanted pregnancy, or coercion; to
regulate fertility without risk of unpleasant or
dangerous side effects; to go safely through pregnancy
and childbirth, and to bear and raise healthy
children, (p. 18)
But a liberating reproductive health definition should
not be limited to women's freedom in their reproductive
years, and it should encompass men as well. Sai and Nassim
(1989), while discussing the distinctions between a
maternal health concept as opposed to reproductive health
concept, articulated as well the inclusion of men, girls
and adolescents in a liberating reproductive health
definition. These authors stated that the reproductive
health approach is broader than the maternal health
approach in that: (1) the health problems that women
experience regarding sexuality, pregnancy and delivery can
be understood as related not only to women's present health
status but to health problems in their childhood and
adolescence; (2) the maternal morbidity resulting or
aggravated by pregnancy needs to be further understood; {3)
the maternal mortality, which can no longer be defined as
the principal factor of women's health, must be seen
instead as an indication of the existence of greater
problems in regard to sexuality and pregnancy; (4) the
assessment of absolute and relative risks of pregnancy,
abortion and various methods of contraception can be
assessed towards all women of reproductive age and not just
pregnant women; (5) the health service provision can be
directed not only to pregnant women, but to male and female
adolescents, men, the unmarried, the infertile, those with
sexually transmitted diseases and those with unwanted
pregnancies.
For the empowerment of women to take place, health
services need not only be comprehensive in their approach,
but also have strategies that can meet all women's needs.
This is imperative because limited health approaches have
translated into health practices that cannot promote
emancipation for many women. Policy-makers and program
personnel have excluded men from family planning {Gallen,
Liskin & Kak, 1986). There is also evidence demonstrating
that many health programs targeting pregnant and married
women fail to meet the needs of:
41
...women who want to practice contraception, but are
excluded from services-the young, unmarried,
nullipara; or for whom available contraceptives are
unacceptable, contraindicated, or some combination of
these; women with unwanted pregnancies who want to
terminate the pregnancy; women with reproductive tract
infections, including STDs and AIDs, and/or subfertile
or infertile women; prepubescent girls aged 5-15
(unless they are married and/or pregnant) whose
reproductive systems are developing, and women with
other reproductive health problems (Germain, 1987, pp.
3-4) .
Due to the failure of health practices, Germain (1987)
emphasized that programs of reproductive health should have
two essential aims to provide choice in regard to
reproduction and to diminish illnesses and death related to
women's sexuality and reproduction. These two aims can be
interconnected since some of the circumstances that may
promote sexual transmitted diseases share many
commonalities with unplanned pregnancy, which is often one
of the results of inadequate fertility regulation. Cates
and Stone (1992) explained in regard to sexually
transmitted diseases that: "The conditions leading to
infection and unplanned pregnancy resemble each other in a
variety of ways" (pp. 75-76). These authors enumerated
four similarities among sexually transmitted diseases and
unplanned pregnancy: both result from sexual contact; both
are disadvantageous to women from a biological standpoint
because sexually transmitted diseases are more easily
caught by women than men and are harder to be diagnosed in
women than men, and because in an undesired pregnancy women
42
have to carry the burden, not men; both are related to the
power imbalance between the sexes in many cultures where
women have little control in their sexual encounters and
are expected to bear children to be valued; and both affect
more women who are under 2 5 and who are poor.
Thus, a liberating health practices definition
encompasses "... safe and appropriate contraception, and
services for sexually transmitted diseases, pregnancy,
delivery, and abortion" (Sai & Nassim, 1989, p. 103).
But, for liberating health practices, the aim to reduce
diseases related to women's sexuality and reproduction
should not be limited to sexually transmitted diseases
since, according to Wasserheit and Holmes (1992), there are
three kinds of reproductive tract infections. The first
kind is sexually transmitted disease and encompasses
chlamydial infection, gonorrhea, trichomoniasis, syphilis,
chancroid, genital herpes, genital warts, and human
immunodeficiency virus infection (HIV). The second kind is
endogenous infection caused by abnormal growth of organisms
that may be present in the genital tract. The third kind
is iatrogenic infection which is related to medical
intervention. Thus, liberating health practices should
address all three kinds of reproductive tract infections.
The liberating health practices' definition further
involves a reproductive health education in which couples
learn to share the responsibilities (pleasure for both,
43
contraception and conception) and consequences (pregnancy,
undesired pregnancy and reproductive infections) of their
sexual practices and couples strive for their health well
being (mental, physical and social).
Still, the doctor-patient relationship has been seen
as augmenting the power imbalance already in existence with
men and women (The Boston Women's, 1992). Because
reproductive health services generally occur in a context
with power imbalances in interactions among physicians and
patients, a change is necessary where: "... women need not
and cannot blindly accept the authority of what the
physician says and that the physician should accept the
validity of women's experiences" (Altekruse & Rosser, 1992,
p. 34). Thus, liberating health practices involve the
transformation of gender and social power imbalances
between physicians and patients.
The definition of women's empowerment in reproductive
health means the process under which women control their
own bodies. This implies that women report changes in
their perceptions and/or behaviors towards a liberating
reproductive health. This also signifies that women can
have access to liberating health services.
44
The birth of family planning in the Third World and in
Brazil
Finkle and McIntosh (1994) argued that the emergence
of family planning can be associated with a combination of
factors such as the political actors in the 1960's from
both the First World and Third World countries being
disappointed with the development of Third World countries,
scholars suggesting that the rapid population growth was
inversely associated with development, some poor countries
believing that population growth was the main feature
undermining their development, the appearance of the
intrauterine device which appeared to have many advantages
over the existing contraceptive methods, and the leadership
role the United States began to have on population
assistance in the year of 1965.
Watson (1977) provides a historical overview of the
birth of family planning policy and family planning program
adoption in the Third World. According to Watson, the
first country to adopt a family planning policy was India
in 1952. Thereafter, there was a rapid adoption of family
planning policies so that by over only two decades, in the
year of 1975, Watson claimed that 94% of 81 countries of
the Third World had family planning policies.
But family planning policies did not necessarily
precede family planning programs. While family planning
programs in Brazil appeared in the sixties, as in other
45
Latin America countries {Stycos, 1971), Giffin (1994)
stated that only in 1974 Brazil signed the Declaration of
Bucharest which supported: "the right of couples to control
fertility and the public duty to provide the means of
exercising this right" (p. 355).
The existence of a family planning policy did not
necessarily mean that all population of a country had
access to family planning programs. Watson showed evidence
that in 1975 Brazil, West Asia, North Africa and most of
Anglophone Sub-Saharan Africa did not have a national
family planning program broad enough to be offered to new
acceptors equivalent to 1% of the number of women in their
reproductive years.
The Civil Society for Family Welfare (BEMFAM)
appears to be the organization that has had the most marked
impact in the country. BEMFAM started to operate in Brazil
in the mid sixties, funded by the International Planned
Parenthood Federation (IPPF). BEMFAM endorses the view
that the causes of underdevelopment rest in high birth rate
and that this rate should be curtailed (Barroso &
Bruschini, 1991). Schultz (1993) stated that BEMFAM
distributes oral pills to any women, seldom mentioning
alternative methods. But BEMFAM's operation in Brazil has
not been homogenous, encompassing both clinical and
community-based delivery (CBD) systems, the latter
differing from one another and being mostly encountered in
46
the Northeast region of Brazil (Foreith, Rodrigues, Arruda
& Milare, 1983). Still, only the community-based delivery
system of BEMFAM's programs were described as involving
information and education through teachers and volunteers
community leaders (Rodrigues, 1977).
According to Schultz (1993), today there are in
Brazil, many private organizations working with family
planning programs which are similar to ones launched by
BEMFAM. Branford (1993) affirmed that there are in the
country some international organizations which support
sterilization programs. Schultz (1993) also affirmed that
in addition to BEMFAM in Brazil there are several women's
health centers and groups, that emerged based on the
women's health movement, encouraging women to discuss
health information given, as well as providing incentives
for them to exert political pressure to have both access to
health care and to individual choice. Garcia-Moreno and
Claro (1994) stated that: "In Brazil, the National Feminist
Network for Reproductive Health and Rights, founded in
August 1991 has 65 organizational members from all over the
country" (p. 49).
Although Brazil has adopted since the seventies a
family planning policy, Brazil did not adopt an explicit
population policy. Aramburu (1994) discussing between
government policies on contraception and government
policies on population and relying on United Nations's
47
information showed that Brazil had only the former kind of
policies. Because these two kinds of policies seem highly
interconnected, it can be argued that a Brazilian policy on
contraception allowing family planning programs
organizations in Brazil have partially endorsed a
population policy to control its population. Thus, the
Brazilian government's lack of a population policy can be
viewed as only partial lacking an explicit statement.
If the Brazilian government was seen as pro-natalist
from 1964 to 1978, reinforcing Brazilian demographic
expansion and the family institution (Alvarez, 1989), the
introduction of family planning programs in the mid sixties
in Brazil seems indeed the beginning of a change towards
limiting the control of the population. Alvarez (1989),
while studying family planning policies in depth in Brazil
identified three systemic factors that influenced
population policies from the late 1970's to the late
1980's. According to Alvarez, the first factor was the
shift of reproductive ideology within some parts of the
State. From 1978 to 1983, the reproductive ideology
endorsed by some segments of the State became gradually
anti-natalist as opposed to pro-natalist which was the
ideology supported until the late seventies. Yet the
segments of the State concerned with limiting population
control had divergence over ways to conquer this objective.
While some supported population control measures and thus
48
women's fertility regulation as a means to foster economic
development, others argued that population control could
best be attained through the development of Brazilian
educational and occupational systems. The second factor
identified by Alvarez was that after 1982 due to the
Brazilian debt crisis, Brazil did not have the same
political power and had to give in to old political
pressures of the international aid community's to adopt
population control. The third factor identified by Alvarez
was the social bases of endorsement the State procured
within the civil society, a strategy which then became
crucial because the political moment was one of
liberalization. According to Alvarez, with this strategy
the State adopted the Brazilian women's movement ideology
of reproductive rights to design its family planning
policy.
Despite the success accomplished in the design of
family planning policies at the State level that would
represent the ideology of a Brazilian women's movement, it
is recognized to date that the Brazilian feminist women's
movement has been powerful in defining a national women's
reproductive health policy, but has not had the necessary
influential capacity in translating this policy into
national practice due to political and structural
circumstances, since family planning services are often
private (Dixon-Mueller, 1993). Health programs for
49
Brazilian women, if not private, often have the influence
of private organizations. Ribeiro (1993) contended that in
a meeting in 1991 it was concluded that with the exception
of the municipality of Rio de Janeiro, in more than 35
Brazilian municipalities, programs to assist women's health
comprehensively named PAISM were not solely supported by
the government and received money from BEMFAM. In general,
PAISM's programs have not taken a comprehensive approach to
health care of women, concentrating on prenatal care
directed primarily towards adolescents (S.O.S Corpo, 1991).
Shortcomings of the Brazilian data related to Brazilian
women's reproductive health
The data related to Brazilian women's reproductive
health have several problems. There is lack of surveys
conducted in the country. This lack of surveys is so
critical that the 1986 Brazil Demographic and Health
Survey, conducted by the private organization BEMFAM, has
been cited as the first national survey of fertility and
family planning (Rutenberg & Ferraz, 1988). With the
existence of few surveys, there is subsequent need of
relying mostly on isolated studies.
Furthermore, even when surveys and research do exist,
gross figures about Brazilian women's contraceptive usage
are misleading due to aggregate figures. Being a diverse
country, different regions of Brazil do not always share
50
similar experiences. In regard to AIDS for instance,
although there is evidence that there are cases of the
disease in all Brazilian regions (Parker, 1993, analyzing
data from 1980 to 1992 produced by the Ministry of Health),
the disease has affected primarily the most developed
region of Brazil, the Southeast. Until 1989 most reports
of Brazilian AIDS's patients came from the State of Sao
Paulo (62.0%), followed by Rio de Janeiro (15.3%) (Peixinho
et al. , 1990) . Another example is sterilization, which is
practiced more by women in the Midwest (28.0% of them)
compared to 16.3% women in the North, 13.5% women in the
Northeast, 16.3% women in the Southeast and 13.1% women in
the South (Souto de Oliveira, 1993).
Gross figures about Brazilian women are further
misleading because huge differences exist among them in
relation to their social classes, races and ages and their
use of health services. For instance, the quality of
reproductive health care is worse for poor women than for
the rich. Poor women cannot afford the best medical
facilities where their richer counterparts undergo
clandestine abortions (Pinotti & Faundes, 1989). But not
only quality of health service differs among social
classes. Problems of access to reproductive health care
are also more prevalent among poor women. Darcy de
Oliveira, Ribeiro, Silva, Oliveira de Albuquerque and Padua
(1983) cited Jaime Landman, who argued that women from the
51
lower social class had less preventive prenatal and
customary health care.
Still, even though the federal Ministry of Health does
oblige reports on some specific diseases, those reports
related to reproductive health began only in 1986 and are
only related to AIDS and congenital syphilis (Faundes &
Tanaka, 1992) . The choice for having only two reproductive
problems is unfortunate given the fact that only two
sexually transmitted diseases are addressed and endogenous
and iatrogenic infections are ignored.
Another problem is that the Ministry of Health's
obligation to report cases has not always been followed.
AIDS's cases seem to be underestimated in Brazil. Chequer
et al. {1992) have argued that there is a great number of
unreported cases of AIDS in Brazil. And Daniel (1991)
cited a situation where statistics for AIDS patients in
Brazil have been both muddled and falsified. In regard to
congenital syphilis, national rates of this disease among
Brazilian newborns are not to be found in the literature, a
fact also experienced by Vaz, Guerra, Ferratto, Toledo and
Neto (1990) when studying the percentage of syphilis among
a group of pregnant women in Sao Paulo.
Prevalence of syphilis and AIDS
It is possible, however, to estimate that the
prevalence of syphilis can be significant in the poorer
regions of the country, because the disease incidence began
to increase in the 1960's mostly in the poorest countries
and have affected infants' mortality and children's
morbidity in its congenital form (Diniz, Ramos & Vaz,
1985). Case studies conducted with pregnant women in the
Southeast, which is the wealthiest region of Brazil,
evinced a 4.4% rate of syphilis among them in the City of
Ribeirao Preto (Barreto, Gongalves & Costa, 1985) and 5.2%
in the City of Sao Paulo (Vaz, Guerra, Ferratto, Toledo &
Neto, 1990) .
Despite the shortcoming of reporting AIDS's cases in
Brazil, the available information is worrisome. Analyzing
data from the Ministry of Health, from 1980 to mid-1992,
there have been 28,455 cases reported and 12,873 deaths
(Parker, 1993) . There are 1 million HIV infected persons
in Latin America and the projection for Latin America seems
to depend on the rate and expansion of HIV infection in
Brazil, a country which is estimated to have the
possibility of suffering a serious AIDS epidemic (World
Health Organization, 1991). Further examining statistics
collected by the World Health Organization (1990) of
reported cases from 1986 to 1990, Brazil was in second
position after the United States in the Americas, and was
in third position in the world, followed by the United
States and Uganda.
Parker (1993), analyzing statistics from the Ministry
of Health showed that there was a decrease in the male:
female ratio in regard to the spread of HIV infection
changing from 122/1 in 1984 to 5/1 in 1991. One year
later, in 1992, the male: female ratio was 4/1 and sexual
activity accounted for almost half of HIV transmission
among women (Paiva, 1993). Koifman et al. (1991)
demonstrated that AIDS' cases among Brazilian women 14
years and older, in the eighties, have been caused by
sexual transmission (34.2%), the use of intravenous drugs
(38.0%), blood transfusion (21.4%) and unknown factors
(6.5%). Cortes et al. (1989) alerted us to the fact that
HIV infection among heterosexuals in Brazil may experience
a rapid growth, specially among women, due to bisexual
activities; since these activities, more than the use of
intravenous drugs, have functioned as a bridge for the
transmission of HIV from homosexual groups to heterosexual
groups.
The spread of HIV is very serious among the poor
young. Luna (1991) cited evidence that HIV infection was
present in more than 1/3 of 700 abandoned Brazilian youths
that belonged to two youth institutions. This author
affirmed that representatives of street youth consider that
they engage into high-risk sexual activity not only for
money, but: as a rite of passage for men (homosexual or
bisexual experimentation and sexual intercourse), as a
birth control method for women (anal intercourse) and for
both sexes as a means to gain affection. Although there
are more street boys than street girls, the latter
population add to the gender oppression oppressive
conditions such as being socially excluded for living in
the streets, mostly Black and underage which combined
promote negative impacts on the street girls' health
statuses and also contributes to their death rates (Gomes,
1994) .
Misconstrued notions of reproductive health
Compared with other reproductive infections, the first
impression is that the richer availability of data on AIDS
as compared to other reproductive tract infections in
Brazil has been propelled not only by national concerns but
also those of the international health community. However,
Parker (1993) contended that the epidemic in Brazil has
received small attention compared to the one given to the
epidemic in the United States and Central Africa, because
Brazil is somewhat dissimilar in epidemiological features
and social and cultural forces and reactions. According to
Parker, international epidemiologists look in two
directions to map HIV transmission through male
homosexuality and drug injection, and through heterosexual
relations and transfusions with contaminated blood; and
these directions narrowly apply to Brazil because male
55
homosexuality and bisexuality practices occur differently
from those in the United States in that there is no
identified gay community in Brazil, and blood contamination
has been related more to social and political forces than
to the lack of economic resources. Daniel (1993),
discussing the problem of using an imported epidemiological
model for identifying HIV cases in Brazil, said in regard
to homosexuality among Brazilian men: "... men that have
sexual relations, occasionally or frequently, with other
men continue to consider themselves 'men' both
'heterosexual' and 'macho', playing an active role in
sexual relationships" (p. 37).
Even though more men than women in Brazil have been
viewed as being among risks groups that have acquired AIDS
such as homosexual men (41.9%) and bisexual men (19.5%)
(Peixinho et al., 1990), women are increasingly being
recognized as being at risk for HIV infection and
developing AIDS. Indeed, women have been argued to be at a
greater risk than men to acquire the disease due to the
social approval of male bisexualism given that the men
exhibit 'macho' behaviors, the neglect of women's sexuality
when they are not prostitutes, the delay of biomedicine to
accurately diagnose HIV/AIDS among women before terminal
stage of the disease, and the inferior status of women—
particularly those from poor classes (Guimaraes, 1994).
The fact that women are either represented as a
prostitutes or as 'family women' by the medical system
(Barbosa, 1993) did not lead to a correct mapping of the
AIDS's epidemic. While Brazilian female prostitutes have
been considered by the epidemiologists to have been at risk
since 1985, this recognition has not happened vis-a-vis
'family women' who were also at risk (Guimaraes, 1994).
Koifman, Quinhoes, Monteiro, Rodrigues and Koifman (19 91)
studying AIDS' cases during the eighties among adult women
from the municipality of Rio de Janeiro found an even
higher percentage of the disease among women who were
'family women' than women prostitutes. In Koifman's et al.
study the women which had the highest percentage of AIDS
were housewives (33.9%), domestic workers (14.4%) and
prostitutes (6.7%).
The smaller attention given to the Brazilian AIDS
epidemic highlights the fact that it is not only the
absence of systematic data on reproductive tract infections
that is serious in Brazil, but that this absence is only
one of the consequences of the misconstrued notions of the
severity of the problem. The neglect of problems related
to reproductive tract infections in Brazil in the last two
to three decades follows a global pattern (Faundes &
Tanaka, 1992). According to Wasserheit and Holmes (1992),
reproductive tract infections have been overlooked
worldwide because of the false assumptions that these
57
infections are not serious, not life-threatening, very-
complex, costly to be taken care of, and are present mainly
among the promiscuous adult population; the values and
attitudes associated with these infections are seen as
taboos; the donor agencies' policy of providing only
preventive care and not focusing on how curative care of
reproductive tract infections can prevent other infections
and diminish prevalence; the gender division of health care
services, whereas usually AIDS and sexual transmitted
diseases services target only men while family planning and
maternal-child health clinics target only women; society's
permissive tolerance of male promiscuity; and the low
status of women that may prevent them from controlling
their sexual encounters, all this means that priority is
not given to diseases that affect more women than men as is
the case for reproductive tract infections, and that places
the responsibility on women to avoid infection and
pregnancy.
Prevalence of reproductive related cancer for Brazilian
women
Cancer is another area of Brazilian women's
reproductive health that needs prevention and care. Cancer
constitutes the second cause of death among Brazilian women
15 years or older (Faerstein, Aquino & Ribeiro, 1985) . The
prevalence of cancer in Brazilian women is greater in those
58
parts of their bodies related to reproductive health such
as the uterus and the breast. According to the Ministry of
Health, the incidence of cancer among women were
distributed as follow: 15.2% uterus, 14.5% breast, 11.5
stomach, 6.0% trachea, bronchus and lung, 5.0% liver and
intrahepatic biliary routes, 4.4% colon, 3.3% ovary and
other uterus conjoined parts, 3.3% pancreas, 3.1% gall
bladder and extrahepatic biliary routes, 2.5 rectum and
30.8% all other parts (Ministerio da Saude, 1980).
Due to the higher prevalence of reproductive related
cancer for Brazilian women, preventive health care for
these areas should be emphasized by the health care system.
Inadequate fertility regulation care and the influence of
religion and government policies
In the context of the diversity of problems that may
arise in reproductive health, Brazilian women's
reproductive health problems that have been most stressed
in the literature have been the ones concerning the
inadequate fertility regulation care. Brazilian women have
not had proper information or enough access to safe
contraception and frequently have undergone clandestine
abortion (Barroso & Bruschini, 1991).
There are several influences surrounding the fertility
control in Brazil. National forces such as the Catholic
Church and the government make it problematic for women to
59
have their contraceptive needs taken care of. The Catholic
Church, which the majority of the Brazilian population is
affiliated with, only allows rhythm contraception (Morais,
1968). But with the exception of abortion and
sterilization, the Catholic Church's conservative position
on non-natural methods of contraception has been portrayed
in some occasions as not being so rigid (Finkle & McIntosh,
1994).
It is important to note that statistics for Catholic
affiliation in Brazil may vary. According to South America
Central (1993), almost 90% of the Brazilian population is
Catholic. Prandi and Pierucci (1994), studying religious
affiliation among the Brazilian voting population, which
excluded: illiterates not registered, young people between
16 years old and 18 years old not registered, and people
younger than 16 years old, found that 7 4.9% of the
population was Catholic, with Rio de Janeiro being the
Brazilian State with the least Catholics (59.3%).
Diversity of religious affiliation in Brazil can further
occur within regions of a State. For instance, Fernandes
(1992) concluded that the greatest percentage of Evangelic
affiliation (19.7%) and the least percentage of Catholic
affiliation (57.4%) lived in the Rio de Janeiro's
municipalities most distant from the metropolitan region of
the city.
60
Like the Catholic Church, government policies restrain
the use of contraceptives and prohibit abortion. Brazil is
considered to have very few method choices on contraception
(Aramburu, 1994). Jacobson (1993) cited Saxenian, who
stated that a recent study of the World Bank in Brazil
revealed that "...women's health reproductive needs are
'poorly met' in part because government policies limit
access to reversible contraceptives, such as condoms,
diaphragms and IUDs" (p. 23). Indeed, contraceptives are
not provided in the majority of public health services
(Dixon-Mueller & Germain, 1993) . Pills are acquired
through nongovernmental agencies, private doctors and
pharmacies where medical prescription is not required
(Germain & Ordway, 1989). Some Brazilian women seek
traditional medicine as an attempt to resolve their
contraceptive needs. Quintas (1986) reported among poor
women in Recife the use of teas as a way to avoid pregnancy
despite the acknowledged failure in leading to the intended
result.
The laws and the incidence of abortion
In the majority of cases abortion is illegal in
Brazil. The Brazilian law related to abortion was created
in 1940 and has only two exceptions for legal abortion
(Jornal Da Ciencia, 1994). Abortion is allowed if the
pregnancy is life threatening for the woman or if the
61
pregnancy is the result of a rape (Fragoso, 1987 & Hahner,
1990). Yet, even in these two cases, a pregnant woman may
still resort to clandestine abortion because she may not
acquire legal authorization to undergo it in a public
hospital (Pinotti & Faundes, 1989) where physicians are not
provided with learning on how to do abortions (Dixon-
Mueller & Germain, 1993) .
The Brazilian penalties concerning illegal abortion
vary according to the availability of a valid consent given
by a pregnant woman to undergo the procedure and the
physical consequences she may suffer due to the procedure.
According to Fragoso (1987), Article 124 of the law stated
that a pregnant woman who attempts to perform abortion or
agrees to undergo abortion with the help of another person,
is subject to a penalization of a period of one to three
years of imprisonment. Fragoso (1987) further contended
that Article 125 of the law implied that without an
agreement by the pregnant women to undergo abortion, the
physician who performs abortion is penalized with three to
ten years of imprisonment. Still, the author also stated
that Article 126 meant that for the physician who performs
abortion with the agreement of the pregnant women, the
penalty is one to four years of imprisonment. Fragoso
(1987) affirmed that in Article 12 6 there is a statement
that the agreement of a pregnant woman to undergo abortion
is not considered valid if she is not yet 14 years old, or
62
suffers from mental disability, or whether the agreement
was obtained either by means of forgery, threat or
violence. Finally, Fragoso {1987) explained that Article
127 informed that the penalty for the physician to perform
an illegal abortion can be increased by one third if as a
result of the abortion or of the means to perform it, the
pregnant woman begins to suffer severe physical problems or
dies.
Given the illegality of abortions in Brazil there are
nevertheless high estimates of abortions rates. Germain
and Ordway (1989) estimated that abortions in the country
annually ranged from one to four million. Yet, Pinotti and
Faundes (1989) contended that Brazilian abortion estimates
are imprecise and they ranged each year from 500 thousands
to four million. Brazilian women have undergone illegal
abortions by going to private doctors or to illegal
abortionists or even by provoking abortion themselves in a
variety of ways: drinking herbal teas or drugs, injecting
drugs, introducing caustic chemicals or harmful objects
into the cervix and uterus, applying abdominal pressure and
violent exercise (Arilha & Barbosa, 1993). Thus, many of
the illegal abortions in Brazil performed under unsafe
conditions, leaving every year 200,000 Brazilian women with
serious or even fatal complications (Schultz, 1993) . Hardy
and Alves (1992), studying Brazilian women who had abortion
complications and those women who did not, found that
63
induced abortion was risky only for women who did not have
the economic means to undergo it with the best personnel
and techniques. The dramatic reality of abortions in
Brazil has been related to the unregulated medical use of
oral contraception and the few contraceptive options
(Germain & Ordway, 1989). However, abortions only reveal
the main consequence of unwanted pregnancies (Pinotti &
Faundes, 19 89).
Conflicts of religiousness with fertility control practices
It cannot be emphasized enough that both the legal
status of abortion and formal religious affiliation in
Brazil are important, but do not account by themselves for
what happens in the country. In regard to abortion, Brazil
has been even cited as one of the 'lapsed law' countries
because abortion is easily performed in huge numbers
depending solely upon ability to pay (Dixon-Mueller, 1990).
In regard to religious affiliation, Guertechin (1987)
affirmed that Catholic affiliation seems to make no
difference in regard to fertility regulation. And the
Demographic Health Survey of 1986 conducted by BEMFAM found
that only 1.5% of the reasons given by the Brazilian
married women for not using contraceptives were related to
religious objection (Population Council. 1988).
Yet it is important to remember that the quantity of
abortions performed or the existence of contraceptive
64
practices does not mean that these incidents happen without
conflict for the women involved. For instance, Ribeiro
(1992), reflecting upon the experiences of nine
professional Catholic women in Rio de Janeiro between 30
and 55 years, contended that they encountered difficulties
and suffered when they began to use contraceptive devices
not allowed by the Catholic Church. This author argued for
the presence of a gap in the sphere of sexuality between
the Catholic Church doctrines and the practices of its
members.
Despite the fact that the Catholic Church has official
doctrines over human sexuality and reproduction, it cannot
be considered a monolithic institution or unchangeable
(Ribeiro, 1992). For instance, the Ecclesial Base
Communities in Brazil, concerned with the local needs of
its people and with space for discussion for its members
represents a point of departure from the traditional
Catholic Church. Nunes (1994), studying Catholic women
from Ecclesial Base Communities in Sao Paulo, found that
these women justify their contraceptive practices in light
of their need for individual autonomy. Likewise, Ribeiro
(1994), researching Catholic women from Ecclesial Base
Communities in Rio de Janeiro, affirmed that in regard to
contraception these women give priority to their individual
conscience when confronted with the gap between the
65
Catholic Church's official norm and the demands of concrete
reality.
Furthermore, it is important to stress that many
Brazilians belong to various religions at the same time.
Carvalho {1991) explained that not only do Brazilians tend
to have pluralistic religion affiliations but also that
different Brazilian religions have several degrees of
importance in the country, and compatibility with
Catholicism, which is hegemonic.
Sexuality as influenced by many ideological dimensions
It is more than relevant to emphasize that religious
affiliation does not constitute the only ideological
dimension in Brazil that may influence one's sexuality.
Brazilian cultural norms related to sexuality are diverse
and in many cases conflict with one another. Parker (1991)
identified the coexistence of several influences present in
the Brazilian sexual culture: the patriarchal ideology in
which sexual meanings are divided along the lines of gender
(male versus female, masculine versus feminine) and around
activity seen as a male attribute, versus passivity viewed
as a female feature; since the colonial times on, the
Catholic religion gave emphasis to the body, its acts and
the consequences of these acts to the soul and placed
positive value in gendered divisions; from the mid
nineteenth century on, the hygienic and the medical
66
discourses--the former anchored on the latter--established
differences between healthy sexual conducts as opposed to
unhealthy ones, while the medical discourse validated
sexual conduct aimed for reproduction, a goal that was seen
as the responsibility of each individual to society; and
the Brazilian erotic ideology that highly values sex for
pleasure.
Social changes and organizations that have modified
contraceptive care
In addition to Brazilian sexual ideologies and the
governmental prohibitions or restrictions, there have been
other factors that have influenced Brazilian women to
resolve some of their contraceptive needs. From the 1960's
onward there was a great decrease in the Brazilian total
fertility rate. Souto de Oliveira (1993), created a table
with data from the Brazilian Institute of Geography of
Statistics in which it can be seen that the Brazilian
fertility rate from the 1960's to the 1990's decreased from
5.8 to 2.7., while in the 3 0 years previous to this change
the fertility remained almost the same since: in the
decade of the 193 0's it was 6.2, in the decade of the
1940's it was 6.2 and from the decade of the 1950's it was
6.3 .
During the fertility rate transformation that began in
the 19 60's, economical, social and behavioral changes
67
occurred in the country. Both Brazilian urban and rural
populations have experienced this fertility decrease which
have been correlated with: the economical transformation
to hegemonic employment by wages (Oliveira, Carvalho,
Frustock & Luz, 19 92, p. 8} which were not conducive to
large families (Barroso & Bruschini, 1991), women's
increased participation in the labor market, the economic
crisis and instability and the growing use of
contraceptives by women (Souto de Oliveira, 1993). Subtle
mechanisms that reduced the incentive to large families in
Brazil were established by industrial and agrarian money,
where women with children were denied labor and some
companies began to ask for pregnancy tests and
sterilization receipts (S.O.S. Corpo--Grupo de Saude da
Mulher--Recife [S.O.S. Corpo], 1991).
Barroso (1987) argued that the reduction of Brazilian
large families can be associated with the questioning of
how several men utilized women's bodies. According to the
author, this questioning emerged due to multiple factors:
the urban migration and the growth of the cities which
contributed to the breaking off of traditional family and
neighborhood ties which, still coupled with the work
alienation, led couples to expect more of each other, and
the influence of mass media on women--particularly TV
romantic 'telenovelas' that were seen in three-fourths of
urban houses.
68
The impact of the Brazilian media on women's fertility
regulation has not been related to pro-family planning
messages, but rather to the general use of medias (McAnany
& Potter, 1992) . The medias involved: as in all of Latin
America, US messages regarding women's sexuality and
autonomy (Stromquist, 1989), the Brazilian 'telenovelas'
which in some instances have portrayed class and gender
oppression--more recently gender oppression has been shown
more than class oppression--and may provide models of
social change that concentrate on individual actions rather
than on collective ones (Vink, 1988), and advertising and
TV series which emphasize consumerism with its
compatibility with small families (Schultz, 1993).
It is important to note that fertility rates among
Brazilian women are far from being uniform. Analyzing one
of the tables from the results of the Demographic Health
Survey conducted by BEMFAM with fertility differentials
from 1983 to 1986 (Population Council, 1988), the fertility
rates for women in union were the following: 5.0 for rural
women, 3.0 for urban women, 6.5 for women with no
education, 5.1 for women with some primary education, 3.1
for women with complete primary education and 2.5 for women
with more than primary education. Still, Guertechin (1987)
addressed that although Brazilian fertility rates seem to
be inversely related to the level of income, this was not
always the case because fertility rates depend on a
69
combination of factors in addition to the level of income
such as level of education, employment, migration, patterns
of marriage and access to land.
Private or nongovernmental organizations also have had
an important role in the way women's fertility regulation
needs have been taken care of in the country. Yet the ways
private organizations have influenced the Brazilian
contraceptive needs have not been homogenous. Some
nongovernmental organizations have been mere distributors
of contraceptives without concern for the health and the
rights of the women who will use them. Other
nongovernmental organizations have been interested in women
not only having access to contraceptives more suitable to
them, but that women develop political awareness to fight
for both their rights related to and for reproductive
health care.
Two studies on Brazilian women's use of contraceptives
The use of contraceptives by Brazilian women was
investigated in 1986 in two different studies. While the
BEMFAM's survey included only married women aged 15 to 44
years old, the Brazilian Institute for Geography and
Statistics undertook the national research by household
sampling (IBGE-PNAD, 1986), which included both a greater
age range 15 to 54 years old women as well as unmarried
women. Still, while the BEMFAM's survey tables defined
70
sterilization practices as part of contraceptive methods,
this was not done by the IBGE-PNAD 1986's research.
Because of the differences in population studied it is
not possible to compare these studies. Nevertheless, it is
possible to include the sterilization information of the
IBGE-PNAD 1986's data as part of contraceptive practices as
was done by the BEMFAM's survey. With this inclusion, it
is possible to describe how the findings of both researches
produced similar results despite the differences in the
populations studied. To exemplify this similarity factors
such as percentage of women, level of education, age ranges
and number of children were contrasted in the description
below.
Results from the demographic health survey undertaken
by BEMFAM in the year of 1986 with Brazilian married women
aged 15 to 44, indicated that almost two thirds of this
population (65.8%) used contraceptives, being female
sterilization used by 26.9% women, the pill used by 25.2%
women and other methods used by 13.7% women and men
(Population Council, 1988). Analyzing data from the IBGE,
PNAD 1986's study (Anticoncepcao, 1991), it was found that
37.8% Brazilian women from 15 to 54 years old utilized
contraceptives: 15.8% women were sterilized, the pill was
used by 13.5% women and other methods were utilized by 8.5%
71
women, and that there was an incidence of only 0.4% male
sterilization.1
In both researches, education level was found to
influence contraceptive utilization. Investigating IBGE-
PNAD 1986's study (Anticoncepcao, 1991), it could be
demonstrated that among women with some education, there
was more contraceptive practice than with women who had no
education. Likewise, looking at BEMFAM's survey, it could
be shown that married women with more than primary
education had the highest level of contraceptive usage
(73.3%), followed by: married women with complete primary
education (69.9%), married women with some primary
education (58.6%) and married women with no education
(47.3%) (Population Council, 1988).
Age ranges affected contraceptive practices of
Brazilian women. The study by BEMFAM (Population Council,
1988) evinced that more than half of the married women in
the age range of 22 to 44 years old utilized
contraceptives. Studying IBGE-PNAD 1986's research
(Anticoncepcao, 1991) it could be concluded that more than
50% of Brazilian women in the age range of 20 to 44 years
old used contraceptives.
^osta (1991) and Souto de Oliveira (1993) studying the
same data from the Brazilian Institute of Geography and
Statistics found that 15.8% Brazilian women were sterilized,
but that 16.2% Brazilian women used the pill and that 5.8%
Brazilian women used other contraceptives methods rather than
the pill and sterilization.
72
The number of children Brazilian women had also
contributed to their contraceptive practices. Analyzing
the IBGE-PNAD 1986's survey (Anticoncepcao. 1991) and the
BEMFAM's survey (Population Council. 1988) it could be
seen, respectively, that all women and only married women
with two, three and four children used more contraceptives
than those who had one or more than four.
In any of the above studies the analysis of the
influence of more than one factor provides a clearer
understanding of contraceptive practices among Brazilian.
For instance, studying IBGE-PNAD 1986's research
(Anticoncepcao, 1991), it appeared that while race did not
have much influence in the choice for sterilization
procedure, it was a method prevalent among: 24% Black
women and women from mixed races, 2 6% White women and 2 6%
of Asian and aboriginal women or women with no statement of
their race; pills utilization demonstrated more differences
among races because they were used by: 20% of Black women
or women from mixed races, 27% of White women and 11% of
Asian or aboriginal women or women without statement of
their race. Adding to the age range factor, it could be
seen in the analysis of the same table that sterilization
was utilized by more than 30% of the White, Black women or
women from mixed races between the ages of 3 0 to 44, and
that the pill was used by more than 30% of the White, Black
women or women from mixed races between the ages of 15 to
73
29 years old. Thus, there was a link between the pill and
sterilization utilization among (White women, Black women
and women from mixed races) since the pill was in heavier
use before the thirties, exactly when sterilization began
to rise. Nevertheless, while the pill was used by almost
half of the White women between the ages of 15 to 24, the
pill was utilized by less Black women or women from mixed
races (27%) between the ages of 15 to 19 and by (36%)
between the ages of 20 to 24.2
Sterilization's laws and its practice
Sterilization is legally allowed only under
circumstances of health risk for women. But Costa (1991)
analyzing IBGE-PNAD 1986's study, contended that among the
15.8% sterilized Brazilian women, more than half of these
women or 8.0% of all women have been sterilized for family
planning reasons and not for health reasons as were the
remaining 7.8% women. Branford (1993) even cited the
senator Eva Blay who affirmed that the government has not
only permitted international organizations to fund
sterilizations in Brazil but also overlooked the fact that
politicians in two Brazilian states paid for sterilizations
in exchange for votes.
2Since no age range information was given in regard to
the Asian and aboriginal women or women from unreported
races, it was not possible to compare them with other races.
74
Costa (1991) also alerted us that because both the
DHS/BEMFAM and the IBGE, PNAD 1986 surveys included in
their statistics data of women who practiced sterilization
for health reasons and not for family planning reasons, the
percentage of married women in the DHS/BEMFAM survey
practicing contraception should have been 52.7% instead of
66.0%, excluding the 13.3% married women who undergone it
for health reasons; and that in the IBGE, PNAD 1986 survey,
the percentage of women using contraceptives should have
been 30.0% instead of 37.8%, taking out of the sample the
7.8% of women who had sterilizations for health reasons.
Since by law sterilizations cannot be provided on
demand to women, they must be concealed. Quintas (1986)
affirmed that sterilizations among poor women in Recife
have happened clandestinely or in public hospitals through
caesareans. Barros, Vaughan, Victora and Huttly (1991)
affirmed that doctors in hospitals are receiving unreported
money from their patients for this procedure. In general,
sterilizations have been provided mainly by private and
public hospitals and by few family planning clinics
(Rutenberg & Ferraz, 1988).
Brazilian caesarean epidemic as related to sterilization
The Brazilian caesareans' rates are not consistent in
the literature. On the one hand, Germain and Ordway (1989)
argued that they account for 40 to 60 percent of birth
deliveries in the country. One the other hand, Rutenberg
and Ferraz (1988) contended that Brazil has one of the
highest incidence of caesareans in the world, but that the
incidence was much smaller, constituting 26% of all births
There are many reasons why caesarean sections are
performed in Brazil. The demand by women for
sterilizations through caesareans in Brazil has been
documented. And women also are sterilized because they
have caesareans. Barros et al. (1991), studying the
problem of the Brazilian caesarean epidemic in depth
testified that medical institutions have been providing it
for economic reasons since the incidence of caesareans
increases with the income of the family, due to the belief
that after the first caesarean others have to follow, and
in order to lawfully perform sterilizations which are only
allowed in special conditions--such as a caesarean.
Health problems associated with caesarean
Caesarean sections in Brazil should be questioned not
only because they are not always performed for the safety
of the mother and the infant, but because they may lead to
iatrogenic infection. In Brazil, caesareans have been
related in some case studies with the development of
puerperal infection and have been estimated to be one of
the main reasons for maternal mortality, which rates very
high considering that the level of economic development of
76
the country (Faundes & Tanaka, 1992). Brazilian caesarean
sections are considered to be the fifth cause of death
among women from 15 to 49 years old, after hypertension,
hemorrhage, puerperal infection and abortion (Barbosa &
Arilha, 1993). In the United States, where there are data
about outcomes related to caesareans, maternal mortality is
four times higher in caesarean interventions than in
vaginal delivery and more than one third of women that
undergo caesareans develop infections (Rodin & Ickovics,
1990); but there is evidence suggesting that caesarean
procedures decrease infants' neonatal mortality (Amirikia,
Zarewych, & Evans, 1981). As sterilization through
caesareans may have negative health consequences for women,
so do other contraceptive methods and different ways to
interrupt pregnancy as well.
Risky contraceptives and drugs sold over the counter
Jacobson (1993) cited Saxenian who stated that some
of the contraceptives that can be bought in Brazil over the
counter are banned for being unsafe or used with
restrictions in other countries. However, risky
contraceptives are not the only questionable items being
sold in pharmacies. There are drugs sold over the counter
that have been used as abortifacients. In an interesting
study conducted in the pharmacies of two Brazilian cities
by Cabral de Barros (1991), the author showed the
77
recommendation--mostly by a sales clerk--of abortifacients
in huge numbers (71.6% of pharmacies studied in Recife and
67.0% of pharmacies studied in Fortaleza) in simulated
cases of delayed menstruation and pregnancy, instead of
referring the person to a doctor, a midwife and a
laboratory, or even denying the sale of the drug.
Cabral de Barros (1991) reported in the above study
that Cytotec was one of the abortifacients mostly
recommended in pharmacies to be used by Brazilian women to
induce abortion. Cytotec has been sold with the name of
Misoprostol in Brazil (Arilha & Barbosa, 1993) .
Nevertheless, Cytotec was reported to be unsafe if not
medically regulated, as well as being ineffective if taken
without its partner drug ("Misoprostol and Legal", 1991).
And comparing the information given in instructions about
the drug in the United States and in Brazil, the
instructions in Brazil are less specific, which lead
doctors to use the drug improperly (Mercucci & Bonfim,
1991). Cytotec is medically recommended to treat ulcers
(Arilha & Barbosa, 1993 ; Branford, 1993), or with
Dicroantil, medically suggested to help in the treatment of
cardiological problems (Arilha & Barbosa, 1993).
Arilha and Barbosa (1993), discussed the fact that the
drug was first sold in mid 1986, and in mid 1991 there was
a government restriction over the sale of Cytotec.
Nevertheless, according to these authors there has been an
78
expanding black market for this drug, imported mostly from
Argentina and the United States.
A few of the reasons for the use of Cytotec
The perceptions of patients and physicians regarding
the use of Cytotec in Brazil has been studied by Arilha and
Barbosa (1993). These authors' study of 14 in-depth
interviews among women aged 14 to 40 years old from diverse
social stratum found three main reasons given by them for
the drug usage: for women with less than 20 years--old
Cytotec facilitated the decision regarding abortion because
they did not have courage to go to clinics that would
perform abortion; for middle class women--Cytotec
simplified the abortion process because it allowed privacy,
was less invasive, and accelerated the abortion process by
diminishing the time between the decision to abort and the
abortion, and for poor women--Cytotec was considered a
safer method, which would not kill them, as opposed to
other methods such as the introduction in the uterus of
objects or caustic substance. Some of the perceptions of
the physicians working in the public health system of the
city of Sao Paulo was assessed by Arilha and Barbosa (1993)
through two focus groups discussions with 14 obstetrician/
gynecologists: one group had eight women and the other six
men. The issues talked in these groups were: the use of
Cytotec as a way that allowed people not to have to
79
confront abortion penalties; possible health problems
related to Cytotec; the difficulties in knowing the
medication's correct dosage; a comparison with other
abortifacient methods; how Cytotec seemed to diminish
maternal diseases and death and how Cytotec appeared to be
of easier utilization for both patients and doctors; and
how physicians that did not perform abortion began to keep
their patients by informing their patients about Cytotec
and treating them after using it, instead of letting them
seek an abortion on their own. This last point was
considered interesting by the authors because Cytotec has
changed the historical segregation in Brazil among doctors
who performed abortions illegally and those who did not
because the latter doctors began to recommend the use of
the drug and to treat the women after the effects of the
drug had been seen.
Further research is needed in Brazilian reproductive health
There are unanswered questions related to Brazilian
reproductive health. First of all, the extent to which
traditional medicine is used in order to replace scientific
medicine is unclear. The poor quality of health services
for poor women can be argued as one of the factors leading
women to seek other kinds of treatment that are not
scientific. In a study of the reproductive stories of
women undertaken by Scheper-Hughes's (1984) in the State of
80
Pernambuco, it was testified that the poor residents'
option for public health care was not adequate--sometimes
iatrogenic--and that the population tended to resort mostly
to pharmacies, and to self-treatment through herbs or Afro-
Brazilian possession cults. Secondly, it seems interesting
to further investigate whether multiple religious
affi1iations--and what kind{s) of religion(s) one chooses
to be affiliated with--reinforce, loosen or make no
difference, concerning adoption of restrictive norms of
fertility regulation. Thirdly, since Brazilian sexual
cultural ideologies may be conflictive, an understanding of
the role they play in shaping one's identity, values and
behavior related to sexuality and reproductive health is
needed. Fourthly, a clearer picture of contraceptive
practices is needed in Brazil. For instance, in the IBGE-
PNAD 1986's research, the method of asking race definition
by self-declaration cannot provide us with an accurate
understanding of the situation, because perceptions of race
belonging in the country seem not always to coincide.
Fifth, although it is estimated that there are
complications related to unsafe abortions and caesareans
{Faundes & . Tanaka, 1992), it is unclear what the specific
health problems are that have occurred and how they differ
due to the circumstances of these procedures. It would be
important to have knowledge of the relationships that
complications have with the presence or the absence of
81
medical care received before and after these situations,
and the different kinds of abortions and caesareans
performed. Finally, although there are networks through
which the nongovernmental organizations that attempt
innovative reproductive health care in Brazil can be
identified, there is lack of data on these experiences.
This study will address only one experience that a specific
nongovernmental organization has been involved with.
C) Women's Health. Status, Women's Oppression And Women's
Health Decision-making
Women's health status as related to gender roles
Differentiated gender roles create different
conditions related to the emergence of health problems.
Verbrugge and Wingard (1987) contended that: "Males and
females are exposed to different physical risks of disease
and injury because of differences in lifestyle, work and
leisure activities, and possible levels of stress and
reactions to it" (p. 126). The importance of gender roles
is such that recent changes in lifestyles undergone by
women have transformed epidemiological trends. Rodin and
Ickovics (1990) showed evidence to support that in the last
decades modifications in social structure and roles,
specifically women's increased substance abuse and work
force participation, resulted in psychological and
behavioral changes that affected women's health.
82
Gender roles clearly do not account for all the
evidence related to health problems. Sex specific or
biological factors do play an important role as well in
current differences between sexes in the etiology of
diseases explained by Verbrugge and Wingard (1987) as being
related to morbidity, mortality, age; severity of disease
and type of disease. Nevertheless, without neglecting the
importance of biological factors, this literature review
focuses on the evidence supporting the extent to which
gender roles that are oppressive to women have been
negatively impacting on their health.
Women have been the main agents of health, providing
major care for the sick, the disabled, and the elderly (The
World's Women. 1991). Women carry the accountability for
family's health care and in developing countries most
health care occurs within the home realm (Buvinic S c
Yudelman, 1989). While women's participation has been
crucial to family health, there is evidence to suggest that
women may gain, through education skills and knowledge,
that are essential to health development.
Education for women is associated with development.
Psacharopoulos and Woodhall (1985) argued that educated
females are likely to generate national development not
only for the change that education can make for women's
participation in the work force, but also for the benefits
in family welfare, family planning, health and child care.
83
A study conducted with 72 developing countries, which
included Brazil, demonstrated that expanding female
secondary schooling has a greater impact on diminishing
fertility and mortality than do family planning and health
programs, particularly in countries with low female
secondary school enrollment (Subbarao & Raney, 1992) .
Also, Cochrane (1982) explained how women's education in
the Third World was more associated with reduced fertility
than with men's education. Yet Buvinic (1976) cautioned
that although there is evidence to suggest that diminished
fertility is associated with both education and employment
opportunities for women, this association is higher in the
First World than in the Third World, and is not always
consistent, due to the presence of other factors. Buvinic
argued that the association between fertility and education
was influenced by factors such as rural/urban residence,
socio-economic status, age at first marriage, and the
husbands' education; and that the association between
fertility and employment was affected among other
additional factors by rural/urban residence, education and
modern and traditional sectors of the economy.
Despite the additional contributions education for
women can make to health development, this development has
been commonly argued in terms of the improved conditions of
women's families only. This development argument often
neglects the fact that women's health status has not been
84
promoted in equal terms, compared to those of men and
children. The fact that women lack social, economic and
political power, makes them less able to promote their
health conditions. Worldwide, women's oppression has
prevented them from exerting a complete role in changing
their social environment (Sundsvall Statement, 1989).
Women's oppression as leading to negative health status
Women's oppression does negatively affect their
health conditions. There is evidence to suggest that
empowerment is related to health promotion (Wallerstein &
Bernstein, 1988) and conversely that oppression is
associated with negative health conditions (Sherwin, 1991) .
To address the need for improving women's health
conditions, it is also necessary to address the need for
women's empowerment and to discuss women's present
oppression as it relates to adverse health conditions, and
women's health decision making in the health care system.
Oppression creates circumstances of increased health
risks for women. One of the most dramatic circumstances is
poverty. Jacobson (1993) has identified poverty as being
the most terrible disease, because its health effects are
many; and women, more than men, are more susceptible to it
since they do not have the same opportunities, which are
the ones that often accompany paid labor. Renzetti and
Curran (1992), comparing low-income and high-income
85
countries in terms of life expectancies, stated that in
Third World countries life expectancy seems to be
associated with: 1 1 . ..gender norms and also to the
feminization of poverty..." (p.308). Even among the poor
in the United States more children, women and people of
color have more diseases and die younger than their
educated and richer counterparts (The Boston Women's.
1992) .
Employment discrimination is also part of women's
oppression even if poverty is not in question, and the lack
of employment may or may not be related to adverse health
conditions. Sorensen and Verbrugge (1987) argued that the
theoretical view that health conditions worsened when women
had the double burden of working for paid labor, in
addition to housework responsibilities, did not take into
account all the evidence. According to these authors, it
is necessary to look at employment conditions that may be
either negative or positive to health, depending upon
whether the job is stressful or provides satisfaction for
women. Still, women's paid employment contributes
positively to the health of their families. Mothers more
than fathers are inclined to spend their earnings on their
children's health (Buvinic & Yudelman, 1989). Yet, as part
of women's oppression, Blumberg (1991) contended that the
value of women's economic earnings may equate to less
economic power in relation to men within the household; and
86
that the more economic power women have the more self-
confident they are, the more they can influence decisions
regarding fertility and the domestic sphere, and the more
they have the power to express their will in the
relationship. Acero (1991) even stated:
Gender roles in society will remain relatively
unchanged without a transformation of power relations
in the household. The theory that more equal
contributions to household income will lead to more
equitable distribution of power within them turns out
to be too simplistic. It is necessary to look at ways
in which authority is associated with the use and
distribution of income and other social resources and
services through which power is negotiated, (p. 123)
Women's oppression is related to the fact that food
and health care services may not be available in the same
proportion for women as they are for men. For instance,
Khan, Dastidar and Bairathi (1984) stated that in India,
women have been entitled to a lesser amount and less
nutritional food supply as compared to men. Likewise,
women face restrictions due to cultural customs to the
access of health care. Timyan, Brechin, Measham and
Ogunleye (1993) advocated that in Egypt and Cameroon the
fact that physicians are primarily males, coupled with the
cultural customs that women should not be seen by a male
without permission from their male guardians or husbands,
creates difficulties in women's utilization of health
services. Even when women have access to health care,
cultural norms may make it difficult for women to fight
against signs of oppression. In Brazil, Darcy de Oliveira
87
et al. (1983) contended that women fear to complain about
being sexually harassed by their doctors, thinking that
they might not receive future health care by the
institution where the doctors work, as well as that if
their husbands discover the harassment they will forbid
their wives to seek further health care.
Women's oppression is present in many of the sexual
relationships women may have with men and may promote
emotional and physical health problems for women. Gender
oppression in sexual relationship affects women's health to
such an extent that Cates and Stone (1992) suggested that
to diminish sexually transmitted diseases and unplanned
pregnancy, public health officials would have to address
the power imbalance between the sexes because:
In some cultures, women have little say about when,
with whom and under what conditions sexual relations
occur. This situation influences whether any measures
are used to prevent infection, unplanned pregnancy or
both. Moreover, in many societies where the woman's
status depends on her role as a wife and a mother, she
is expected to bear children and is ostracized if she
does not or cannot. Even if she suspects that her
husband had acquired an STD through an extramarital
sexual contact, she may not be able to protect herself
from infection. The result may be a cruel paradox, in
which her husband divorces her because tubal infection
has impaired her ability to reproduce, (p. 76)
As part of women's oppression in sexual relationships,
there can be violence which has undoubtedly negative
effects on women's health. Heise (1993) even contended
that gender violence could be one of the most important
factors leading to morbidity and mental illness among
women, and was associated with women's deaths in China and
India. This author also claimed that involuntary pregnancy
has not been considered an act of violence and that there
is no agenda from an international initiative to promote
physical safety of the pregnant women, despite the evidence
that they have been physically abused. Still, Heise
(1994), analyzing World Bank data on the burden of disease
on the world, argued that gender-based violence--rape and
domestic violence that can lead to health problems such as
STDs, depression and injuries--is similar in its high
percentage to other health problems experienced by women.
Women's oppression is further associated with higher
rates of illiteracy among women than men in most nations
(Fagerlind & Saha, 1989). Stromguist (1990) argued that
for women, minority ethnic groups and rural population
literacy is a mechanism to acquire rights. That women's
health rights are more promoted when females are literate
can be inferred through studies cited by Timyan et al.
(1993). In these studies, it was indicated that education
has been positively associated with women's improved access
to health care and to their demands for better quality in
health services.
Women's decision-making is needed to improve their health
Women's lack of power is reflected in research which
has worked to a great extent as a tool for the maintenance
89
and legitimization of the groups that oppress (Meis, 1983) .
The conclusions that researchers reach, as well as their
absence in some areas of studies, may support gender
discrimination. Smith (1990), studying the fact that the
statistics of mental illness in the United States has
claimed more women than men, argued that these figures are
anchored in the patriarchal relations of ruling. There has
also been less research on women's health than men's even
for health problems that affect both sexes (Rodin &
Ickovics, 1990) .
Health decisions have been shaped by the patriarchal
system in which the societies are grounded, and those
decisions have been oppressive to women. Worldwide, women
represent a minority in positions of authority and have not
been able to voice their health concerns in health policies
(Jacobson, 1993). In the United States women, among other
minority groups, have been in an inferior position to
receive health care treatment. Sherwin (1991) cited
McMurray, who reviewed several studies about gender-
decision making in the American health care system. It was
concluded that women have much less access than men to
medical diagnostic and intervention services. But in the
United States there have been differences of treatment
among different women. Renzetti and Curran (1992) pointed
out that historically, poor and minority American women
90
have been victims of medical institutions more than the
rich and non-minority women.
In the health care profession women are also a
minority in positions of authority. Sherwin (1991) stated
that in the United States: "Within existing health care
structures, women do most of the work associated with
health care, but they are, for the most part, excluded from
making the policy decisions that shape the system" (p.
228). Renzetti and Curran (1992) affirmed that American
women constituted almost 90% of workers in the health
system but less than 20% of physicians.
As a consequence of the gender stratification in the
professions of the health care system, when women take part
in medical encounters as patients they usually have male
doctors. And this doctor-patient relationship has been
described as exacerbating the power imbalance already
present in male and female relationships (The Boston
Women's, 1992). Renzetti and Curran (1992) contended that
when the feminist health care movement appeared in the
1960's in the United States, women described many of their
medical encounters as having two common characteristics:
exhibition of doctor's patronizing and reproachful
behaviors, and their own feelings of degradation. Aguilera
(1988) cited a study done by Rodo in Chile where women were
asked to associate words with physicians and some of the
responses were "prepotency" and "humiliation".
91
Gender and social stratification appear to affect
communications in the medical encounters. American women
and poorer classes have been described as having a larger
number of communication problems with physicians
(Cockerman, 1992). However, it is possible that at least
for women's patients these communication problems might not
be related to the amount of information given by the
doctor, since Waitzkin (1984), studying doctor
communication in-depth, found that American female patients
received more information than male patients.
A woman's ability to became active in the medical
decision-making process seems in part to be related to the
patient's similarity to the physician's social background
(Cockerman, 1993, cited Bouton et al.). Szasz and
Hollender (1987) explained that the model of mutual
participation of physician and patient presupposes
similarity between those involved in the relationship in
respect to intellectual abilities, education and
experiences. Weisman and Teitelbaum (1987) argued that
status congruence between physician and patient was a
factor that could contribute to improved rapport and to
patients' reported behavior.
The medical practice has been described as being
paternalistic and having the potential to aggravate women's
lack of power (Sherwin, 1991). There is need for
empowering women as both health workers and as patients.
92
For example, in professions such as nursing, which is
traditionally a female profession and holds less social
status than the position of a physician, Boughn (1991)
contended that there is a need for nursing students to feel
a connection between the care they provide and their
empowerment. Still, Schwartz, Wolf and Skipper (1987)
contended that American nursing schools are including in
their curriculum the relationship the profession has to a
woman's power. And as patients, Midmer (1992) discussed
the advantages of empowering women by a new model of women-
centered childbirth in which the mother would be the
principal, the birth would be viewed as a process of life,
the family may or may not be present, according to the
mother's choice, and the physician would be the birth
facilitator.
Despite the lack of power women have in their
encounters as patients, it is important to stress that in
some medical encounters women may be seen as being in the
position to make decisions. Lazarus (1983), studying the
physicians point of views in regard to the treatment of
breast cancer, identified some physicians stating that they
offer choices to the patient. Still, the discussion of
medical issues by women may empower them. Within medical
practice, health education is one of the areas where there
has been more feminist action primarily through the
emergence, in the last few years, of a growing number of
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women's groups that discuss disease and health issues
according to women's own interpretation and experiences
(Castro & Bronfman, 1993).
It remains to be investigated the decision-making of
women patients in medical encounters in other countries,
rather than the United States. For poor women especially,
it would appear imperative to find ways of empowering them
in medical encounters, since most doctors come from
advantaged backgrounds and will not share as much decision
making with them as they will with more affluent patients.
However, since in most countries the medical discourse
itself tends to overlook social issues (Waitzkin & Britt,
1989), empowerment in the decision-making process may not
lead to social structure change, but mostly to individual
change.
Nevertheless, studies not specifically related to the
medical encounter but to the health care system may also be
revealing and could be useful for comparisons. For
instance, in some cases women's decision-making may be not
an apparent phenomena for either the hospital staff or for
the patient. Frye (1991) cited a testimonial of a
Cambodian woman, who upset with the hospital's refusal to
allow her to make decisions, smiled to the nurses but
admitted later that she did not listen to them.
Still, some studies suggest that other factors outside
the medical encounter contribute to women's decision
94
making. Agostino and Wahlberg (1991), studying 65 women in
Rome stated that abortion decisions involved both partners
and that women seemed to come to medical encounters knowing
what they wanted and not seeking advice to make their
decisions. Likewise, Pariani, Heer and Ardsol Jr. (1992)
contended that clinical observations in East Java suggested
that women selected a contraceptive alternative before
becoming clients in family planning programs. Also Tucker
(1986), studying Indians in rural Peru found that women
that worked full time were more likely to utilize modern
contraceptive methods than to use natural methods or to not
use any contraceptive method at all.
Moreover, to understand women's decision-making
regarding reproductive health, it would be interesting to
not consider that this process is only a rational one.
Buvinic (1976) suggested that to comprehend fertility
decision-making processes, it would be necessary to take
into account that the individual is active and changeable
and that his/her behaviors are guided by both non-analytic
and analytic frameworks, and to use research procedures
that are sensitive to cultural and societal peculiarities.
Finally, there appears to be a connection between
women's decision-making in health and their empowerment.
The women's capacity to decide issues related to health in
their medical encounters reflects their empowerment not
only because it threatens the traditional authoritarian
95
doctor-patient relationship of these encounters, but
because this capacity may even change the treatment. In
regard to this last point, Fisher (1987) studying the
medical discourse related to treatment decisions for
choosing a hysterectomy in the United States, demonstrated
that decisions were socially produced by the interaction of
the male doctor and the female patient. Her finding showed
that the authoritarian power of the male doctor role as
well as the patient's ability to question the information
received and the treatment suggested carried great weight
in shaping the decision-making process.
D) Empowerment As A Development Strategy For Change
Empowerment definitions
Empowerment is not only a term employed in the health
care field, but it has carried different meanings which are
not always emancipatory (Stromquist, 1993). An example of
a strategy for empowering women that can be questioned as
not seeking to emancipate them was given by Antrobus (1989,
p. 189), who stated that international agencies, such as
the World Bank and UNICEF, have used women's empowerment as
a way to endorse the withdrawal of the accountability of
government expenditures on social services to place this
responsibility in women's hands.
The liberating connotation of empowerment:
96
...is one which brings up the question of personal
agency rather than reliance on intermediaries, one
that links action to needs, and one that results in
making significant collective change. It is also a
concept that does not merely concern personal identity
but brings out a broader analysis of human rights
(Stromquist, 1993, p. 1).
Empowerment in its emancipatory meaning should not be
the accomplishment of only gender needs that do not contest
the status quo. A distinction delineated by Maxine
Molyneux between gender interests that are practical and
strategic is of particular relevance. According to
Molyneux (1985), while the practical needs do not question
the present unbalanced distribution of power in which women
occupy a subordinated position, the strategic needs do aim
at gender parity. For instance, the World Development
Report (1993) suggested that it is necessary to empower
women by augmenting their education and eliminating many
social discriminations faced by them so that their health
and that of their families can ameliorate. Because women's
abilities to date represent a greater potential for their
families' health than men's abilities, empowerment of women
to be emancipatory should not only mean increasing women's
abilities which represent only practical needs, but it
should also address strategic needs such as changing the
conditions of gender inequality that makes men's abilities
to give health care to their families inferior to those of
women.
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Empowerment potentials and dimensions
There may be different, not necessarily exclusive,
emancipatory potentials for empowerment. Friedmann (19 92)
suggested that empowerment could generate an alternative
development which has as an objective the promotion of
power to the household and to its individual members.
Stromquist (19 93) advocated that empowerment could lead to
the transformation of the power balance in relationships
and institutions if it focused on adult women, since they
are the ones who have experienced domination and can change
the reproduction of patriarchy. Likewise, Germain and
Antrobus (1989), discussing mechanisms for women's
empowerment contended that in women's health, two kinds of
power relations exist: "relations between the individual
(or group) and others in the immediate environment (e.g.,
family members, neighbors, and others in the community, and
relations between the individual (or group) and the
institutions that control resources" (p. 20).
Empowerment can encompass many dimensions. Stromquist
(1993) defined four dimensions the cognitive, the
psychological, the economic, and the political. Friedmann
(1992) discussed the existence of three dimensions the
social, the political and the psychological. Both
authors's definitions have in common the fact that the
psychological dimension of empowerment may be influenced by
other dimensions. While Stromquist claimed that the
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economic dimension reinforces the psychological one,
Friedmann pointed out that the psychological dimension is
affected by the social and political dimensions and vice-
versa .
The notion of autonomy encompasses physical autonomy,
which is a kind of empowerment over one's own body
(Schrijvers, 1991). The right of women to control their
own body is a feminist principle which encompasses both
sexual and reproductive rights, implying that women should
exert control over their sexual and reproductive capacities
and have integrity as physical persons (Dixon-Mueller,
1993) .
And there have been other new, pressing issues being
discussed in regard to the control of one's own body.
Rothman (1987) explained that feminist issues related to
reproduction have become increasingly complex over the
period of only the last decade. While the first issues
feminist dealt with were related to supporting women's
'personal choice' in regard to motherhood and
contraception, nowadays due to the technological advances
offered to select an offspring's features--either by
choosing the sex or by eliminating possible disabilities--
and the social transformations that created, among other
things, a market of surrogate mothers and caesareans
imposed by law, the issues feminists are raising now
encompass 'the limits of individual autonomy'.
In whatever case, it is important to note that
physical autonomy or physical empowerment for women will be
highly correlated with the level of their empowerment in
other dimensions. Berer and Ray (1993) stated: "The
imbalance in power between men and women--economically,
socially and physically--is responsible for much of the
lack of safety in sexual relationships" (p. 179). Still,
Doyal (1993), discussing human needs argued that human
welfare is related to the kinds of social participation one
has, which in turn depends on the fulfillment of both
physical health and individual autonomy.
How the oppressed groups can become empowered
Although empowerment and oppression can be terms used
in conjunction, they may be seen as terms not in bipolar
positions from each other, but sharing some sort of
interdependence. Empowerment is needed when oppression
exists, as a catalytic device to eliminate or reduce
oppression suffered by some groups. The oppressed groups
may be viewed as depending upon the willingness of dominant
groups to share power, or as lacking mobilization since
they do not know how to use the power they have (Sleeter,
1991, cited Charnofsky, 1971 and Ashcroft, 1987).
When empowerment is thought of as a strategy of change
it implies a new organization of the power distribution.
Through attempts to empower the oppressed, it is possible
100
to envision a more equitable society where all can share
their decision making. For instance, Shor (1992) explained
that in the classroom context an education can be
empowering if it is negotiated among teacher and students,
which does not mean that the teacher will loose his/her
authority.
Although all must be involved in a developmental
strategy to change the uneven relations of power,
empowerment is directed to the segment of the population
which is oppressed. This is so because the oppressed are
the ones who must gain power. The poor, the women and the
racially disadvantaged are commonly thought of as oppressed
groups, since societies have created an unequal
distribution of power based on social markers such as
class, gender and race.
It is important to stress that even though empowerment
can be an ideology, stressed by the intellectual groups of
a society, it cannot be imposed by them on the oppressed
groups. For instance, Johnson (1992) explained that
empowerment may signify an ideology of some non
governmental organizations to endorse the poor in their
conquest of power.
For empowerment to be emancipatory, it cannot remain
only on the level of ideology. It needs to encompass
actions as well. Thus, oppressed groups should be involved
in concrete actions to change their condition and to gain
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power (Johnson, 1992) . Since oppression is a concrete
situation, emerging from the contradiction of oppressor and
oppressed, the transformation of this contradiction can
only be conquered objectively (Freire, 1993) .
The actions intellectual groups may undertake to
empower oppressed groups need to be required by the
oppressed groups, such as providing knowledge and skills
(Sleeter, 1991). And the oppressor can only have
solidarity with the oppressed when his/her action is no
longer sentimental and mushy, in an individual feature, but
when it is an action of love (Freire, 1993).
The fact that one population may have more layers of
oppressive conditions is of special interest because this
overlap increases the population's need to be empowered.
Poor women were seen as the population most in need to be
empowered (Stromquist, 1993). This is the population which
combines the oppression of gender and class, if not of race
as well. Racism has been indeed an additional oppressive
component for women, where slavery was prevalent and in
some locations even under colonial regimes without slavery
(Sen & Grown, 1987) .
Nevertheless, as the experience of suffering from more
layers of oppressive conditions in a population increases
its need to be empowered, so may this overlap augment its
potential to change the status quo. Racism experienced by
women has been advocated as a liberating possibility.
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Sleeter (1991) cited Bluter who stated: "...that women of
color are natural 'agents of transformation' because of
their simultaneous membership in multiple oppressed groups"
(p. 18). Likewise, poor Third World women have been viewed
as potential agents for creating a new social order due to
their combined oppression of class, race, gender and
nationality, which combination is currently understood as
an underdevelopment condition (Antrobus, 1989) .
Although there seems to be a consensus in the
literature that the population to become empowered must be
the less privileged, there is divergence in empowerment's
meanings, goals and the number of dimensions considered.
These diverse conceptualizations make it imperative to
identify which meaning, goals and dimension(s) one refers
to when speaking of empowerment.
Finally, while it appears difficult to determine the
degree to which empowerment dimensions may be interrelated
to one another, it is of special interest that the
conceptualizations of diverse dimensions of empowerment
allow for some independence among them. Thus, the
fulfillment of one dimension of empowerment may or may not
reinforce the fulfillment of another dimension. A
practical example where empowerment is not lived in all
dimensions is in Sleeter's and Grant's (1991) study which
findings--which added yet another dimension to the
empowerment definition— demonstrated that while students
103
could be individually and socially empowered, they lacked
power in institutional terms.
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CHAPTER III
Conceptual Framework That Grounds The Research Questions
The main interest of this study was to explore
whether or not poor Brazilian women who take part in the
activities of a health education program became empowered.
Empowerment was understood as aiming to lead women to both
individual and social transformations. In order to grasp
whether poor women were becoming empowered, it was useful
to assess the dimensions of empowerment (the psychological,
the cognitive, the economical and the political) delineated
by Stromquist (19 93) and (the physical) developed by
Schrijvers (1991). To investigate empowerment in these
dimensions could be one step towards overcoming the
difficulties in the field of health education, i. e., in
spite of an understanding of the need to also address the
social dimensions, implementation of health educational
programs has focused on individual behavior change.
Thus, for the purpose of this study, the definitions
of the five dimensions of empowerment are described below.
Empowerment in the psychological dimension meant either
more beneficial perceptions women begin to have of
themselves, or modifications of their skills to relate to
themselves and/or with others. In the cognitive dimension,
it signified participant women's exerting energy on,
conquering or ameliorating their abilities to learn. In
the economical dimension, it related to participant women's
105
exerting pressure on, acquiring or improving abilities to
gain either money or economic power by learning ways to
make better use of resources. In the political dimension,
it was defined as participant women's exerting pressure
for, gaining or improving their abilities to organize with
other people to fight for a cause. In the physical
dimension, it meant participant women's exerting more
control, acquiring or improving their abilities to control
their own bodies.
Also investigated was whether or not the client
population perceived an improvement in their health and
reproductive health status by participating in the program.
The quest for the health well-being could have been one of
the reasons for joining the health education program, but
was not necessarily one of the reasons for women to
continue their participation in the program. Health was
based on the comprehensive approach which defines it as
mental, physical and social well-being, is concerned with
equity, considers health through a multi-sectoral approach;
and stresses that the client population should become able
to decide for itself and take the lead in health programs
(Rifkin & Walt, 1986). It seemed important to determine
the extent to which the perceptions of change (if any) in
the health well-being prevented or led women to concentrate
their lives in empowering themselves.
In order to investigate whether empowerment was sought
to some degree in the health education program studied, it
was important to determine if the program favored the
characteristics of a comprehensive approach of primary
health care, the one which usually tends to have an agenda
which can empower its participants. In terms of objectives
to be covered by the health education program studied, and
drawing from Molyneux's (1985) distinction between
practical and gender needs, it was expected that the
program had the objective of providing practical gender
needs, such as knowledge and skills about reproductive
health and sexuality, that could further the development of
women as individuals. It was further expected that the
health education program had the aim of addressing
strategic gender needs to change the patriarchal relations
of power imposed on women. Thus, the program studied was
understood as aiming to fulfill the features of a popular
education program where not only individual change was
targeted, but social change was sought (Fink, 1992) . It
should also be an objective of the program to have as a
client population women who are in most need of being
empowered, the poor (Stromquist, 1993).
Taking into account the content to be covered in the
health education program, it was expected that it should
not favor some points of view related to health over others
and that it should address the physical, the mental, and
107
the social aspects of the health well-being (Rifkin & Walt,
1986). In regard to the reproductive health content, the
health education program should have the liberation notion
of reproductive health employed in this study which, as was
previously mentioned, was not limited to women's freedom in
their reproductive years, but encompassed men as well and
involved the:
... the ability to enjoy sexual relations without
fear of infection, unwanted pregnancy, or coercion; to
regulate fertility without risk of unpleasant or
dangerous side effects; to go safely through pregnancy
and childbirth, and to bear and raise healthy
children. (Germain & Antrobus, 1989, p. 18)
Thus, the content in the health education program studied
should involve the three women's reproductive rights as was
delineated by Dixon-Mueller (1993): "the freedom to decide
how many children to have and when (or whether) to have
them; the right to have the information and means to
regulate one's fertility and the right to 'control one's
own body'" (p. 12); in addition to the physical, mental and
social knowledge regarding pregnancy, contraception,
reproductive infections, reproductive diseases, and
reproductive treatment (preventive and curative) in both
men and women.
Considering methodologies, at the classroom level, in
a health education program designed to empower its
participants, negotiations should occur among teacher and
students, which does not mean that the teacher will lose
his/her authority (Shor, 1992) . This applies not only to
schedules, but also to the content of the classes. All
participants (teacher and students) should come to an
agreement by having equal opportunity to discuss their own
preferences or problems. Even though the health education
program should have the specific contents mentioned above
to be transmitted by the teacher, the students must have
enough time and incentive to discuss the relevancy of the
content transmitted according to their own experiences.
According to Freire (1994), the use of small expository
themes is not bad in itself as long as the exposition of
the themes is accompanied by an analysis of it made by both
students and teacher. In an empowering strategy, it is
possible to think of three roles a teacher should have. In
one of these roles, the teacher should share all points of
views for a given content, point out his/her own criticisms
and preferences over the content studied, and encourage
students to be critical of the criticisms and preferences
of the teacher and fellow students. Another role is that
the teacher should promote students' self confidence, since
the lack of it is a feature of the oppressed (Freire,
1994). For that, the teacher can identify individual
difficulties and talents and provide incentives to overcome
the difficulties and to develop talents inside and/or
outside the classroom context. Still another role that a
teacher should perform is to foster independence. For
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instance, in the decision-making process of a classroom, a
teacher could motivate his/her students to make their own
decisions and practice them in the classroom context
instead of always deciding for his/her students.
At the program level for a health program to be
empowering, it should begin by addressing the problems of
the community, utilizing active learning methods which
would not necessarily involve social action, fostering
community participation so that community members could
realize their own needs, and providing information, skills
and reinforcement (Wallerstein & Bernstein, 1988). It is
important to stress that for a health education program to
be empowering it should be in the process of becoming the
responsibility of the community members. For that, the
program should foster collective action such as the
participation inside and outside of the classroom in
meetings related to health issues and in tasks that promote
health for participants and others. The extent to which a
health program can be viewed as a source of empowerment or
domination stems from the degree to which it can lead the
people from the community where it was been implemented to
set their own health agendas and to take the primary
responsibility for the health care of all individuals.
Believing that community participation is the way
through which a program can become the responsibility of
the community members, community participation was granted
110
special focus and assessed through the utilization of
Rifkin's (cited in Stone, 1992} proposed five levels of
community participation, in which community members evolve
gradually from receiving health services and health
education; taking part in program activities through
resource donation (money, land or labor); assuming
managerial responsibility for implementation; monitoring
and evaluating projects; and finally, taking the lead in
program planning and needs assessment.
Because an empowering health education program has as
its target goal of enabling community members to take the
lead in program planning, it was important to check who
played this role in the request of the health education
program. For instance, a program that was established as a
result of a request from community leader(s), as was the
case of research conducted in Porto Alegre studying the
reproductive and socio-economic life of poor women from one
community (Oliveira, Carvalho, Frustock, & Luz, 1992),
would have had more chances of being in the top level of
community participation.
Gender empowerment asks for the transformation of the
uneven distribution of power between women and men within
relationships and institutions (Stromquist, 1993) .
Considering change in relationships, it was interesting to
study the implications to women's relationships with their
male partners in case empowerment was achieved. Since
Ill
Brazil has elements of the patriarchy system which supports
women's submission (Morais, 1968), it was likely that
women's empowerment provoked imbalances to which men may
react.
Concerned with how women interpret different social
institutions, it was interesting to address if there were
any conflicts of empowering women in reproductive terms,
which implied that women should be able to regulate their
fertility with access to contraceptive methods, should have
safe abortions if desired and should seek sexual pleasure
in their relationships. Brazilian cultural norms are
paradoxical. For instance, Brazilian religious values
preached by the Catholic church--which the majority of
Brazilians are affiliated with--usually dictate that women
should only undergo rhythm contraception and should have
sex only for procreation. Still, there is a Brazilian law
that does not permit abortion, and there are few
exceptions. Yet in Brazil there is a great number of
illegal abortions, the use of other contraceptive practices
rather than those allowed by the Catholic church, and an
erotic ideology that values sex for pleasure.
The client and staff populations' opinions of the
Brazilian medical institutions were used to verify the
extent to which these populations evaluated these
institutions as helping or preventing them in their quest
for empowerment. Within these medical institutions and in
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regard to modifications in relationships, it was also
considered, as a sign of empowerment for the client
population if the staff or the client population reported
events of discussions regarding the health information
received, and the treatment proposed in the medical
encounters. The women's ability to discuss the medical
encounter seem to reflect individual empowerment, even if
social issues are not considered, because it challenges the
authoritarian doctor-patient relationship in which most
medical encounters are based and it may also have the
effect of changing the course of treatment, as has happened
in many instances in a study undertaken by Fisher (1987).
Research Questions
1. Did the activities of the health education program
contribute to the empowerment of women in any of the five
dimensions: the psychological, the cognitive, the
economical, the political and the physical?
2. Did the client population perceive improvement in their
health and reproductive health status {mental, physical and
social well-being)?
3. Which objective(s) was(were) emphasized by the
educational activities?
4. What was(were) the content(s) of the health education
program?
5. What was(were) the methodology(ies) used at the
classroom and program levels?
6. What was the level of community participation reached by
the client population? Did reproductive health receive
special consideration to be taught in this community? Was
(were) there other problem(s) that should have received
113
equal or more attention? Which mechanisms did this program
have to reach the client population it was targeted to?
7. if there was empowerment in any of the psychological,
the cognitive, the economical, the political and the
physical dimensions, how did the husbands or male partners
of women react to this empowerment?
8. How did the client and the staff populations perceive
empowerment of women in reproductive terms given the
context of Brazilian cultural sexual norms and the law that
forbids women to undergo abortion?
9. How did the client and staff population perceive the
Brazilian health system? Did the medical encounter(s) the
client population has had (if any) suffer any change after
participation in the program?
Localization And Population Of The Study
At the time of the study, the health education program
was located in two counties peripheric to the city of Rio
de Janeiro in Brazil. The fact that the program was not
situated in the heart of the city meant that these counties
lacked the options of health and education services offered
in the city. Thus, the location of the health education
program was congruent with equity issues since it reached a
population that could not have the same opportunities as
those living in the city. The sites where the health
education program operated were poor and generally
attracted women from Brazilian poor classes. It cannot be
said, though, that women living in this peripheric counties
were poorer than those living in the city of Rio de
Janeiro, since the city is inhabited by women from all
114
social classes who lived in areas that range from rich
districts to slums.
The staff population coordinating health education
programs was not only from administrative positions or from
more advantaged social classes, as usually happens in
institutions of a class-stratified society as Brazil. It
was considered a sign of empowerment that among the staff
emerged were poor women who completed the health education
program.
Research. Design
In the study conducted, the design was naturalistic,
employed ethnographic techniques and attempted to follow
the standards of validity and relevance established by
Martyn Hammersley and described below.
In this study, the social context was understood as
having special importance. Empowerment dimensions
encompass political and economic spheres and the health
definition addresses social well-being. Thus, the
naturalistic design was selected because it could look
beyond the program itself and address the social context.
In field settings it is crucial to understand a
contextual situation surrounding the program to be
evaluated - a circumstance for which
naturalistic/qualitative designs are quite suitable.
The context, which includes type of participants,
locales, different occasions, can interact with a
program in unique ways (Michael & Benson, 1991, p.
24) .
115
In the literature, there are different terminologies
under which qualitative designs are referred to {Lofland &
Lofland, 1984). The naturalistic mode of inquiry is highly
influenced by the disciplines of anthropology and sociology
(Williams, 1986) and uses many of the ethnographic
techniques of these disciplines (Michael & Benson, 1991).
The naturalistic inquiry has been confounded with
ethnography, yet ethnography has been also defined as being
one kind of naturalistic inquiry (Williams, 1986).
However, there are more sources of conceptual
difficulty. There are different kinds of ethnography such
as holistic ethnography and ethnography of communication
(Marshall & Rossman, 1989). Furthermore, standards for
ethnography may mean different things to different authors.
For instance, Wolcott (1987) stated that ethnography
criteria should be based not only on the use of
ethnographic techniques, but also on the use of cultural
interpretation. Yet Hammersley (1990) argued that this
view of ethnography, among other views, does not constitute
criteria for assessment but rather as a means of
assessment, and that ethnography research criteria should
be based on both validity and relevance.
The ethnographic techniques used in this study were
those related to the ones in which ethnography is utilized
as a method. Ethnography as a method implies most of these
elements humans' actions are investigated in natural
116
settings; data are collected in several ways, but
particularly with observations and informal conversations;
data are initially collected and analyzed without
predetermined plans but both processes are systematic; the
emphasis is often in one locale or one group or even one
person; data analysis involves understanding the
connotations and functions of human behaviors specially
through oral descriptions and explanations, and minimally
through statistical analysis and quantification
{Hammersiey, 1990) .
Hammersley (1990) equated validity as being a truth
which means: "...the extent to which an account accurately
represent the social phenomena to which it refers" (p. 57).
Validity claims for ethnography can be assessed through
plausibility (acceptance of the claim by reasonable face
value); by credibility (acceptance of the claim based on:
the features of the problem being studied, the conditions
of the research, the features of the investigator and so
on); and by examining both plausibility and credibility
when a claim is not enough plausible nor credible or even
by requiring further proof (Hammersley, 1990). For
Hammersley (1990), relevance relates to research that can
be both important for problems of the public and that can
increase the present knowledge of the topic it addresses.
Another source of conceptual misunderstanding is that
the naturalistic inquiry has been misunderstood with the
117
term naturalism (Michael & Benson, 1991) . Hammersley's
(1990) stated that naturalism is a methodological
principle, as are understanding and discovery. These
methodological principles may be present alone or in
conjunction within an ethnographic research. Summarizing
the author's descriptions of these principles, the
naturalism connotes the attempt to grasp the phenomena as
they naturally occur with minimal infJuence of the
researcher and attempts to relate events and processes to
the context. Furthermore, the understanding principle
signifies the assumption that human behavior differs from
physical objects and animals, in that it encompasses
interpretation and construction of responses. This
principle views phenomena as culturally construed. Still,
the third principle establishes the need for the research
process be discovery-based, instead of being confined to
predetermined hypotheses. Finally, in this last principle,
the researcher holds as few assumptions as he/she can to
discover the phenomena under investigation. In the present
study, both naturalism and understanding principles were
used.
The naturalistic inquiry was argued as an effective
research strategy for evaluation. Guba and Lincoln (1981)
explained that naturalistic inquiry and educational
evaluation are compatible and desirable when the evaluation
seeks to understand values, demographic features,
118
motivational aspects in a given context. Furthermore,
Patton (1987) affirmed that naturalistic approach is
pertinent to grasp: "...program processes, documenting
variations, and exploring important individual differences
between various participant's experiences and outcomes" (p.
14). Yet, the use of naturalistic inquiry for evaluation
purposes can be problematic. William (1986) when analyzing
if evaluation may have conflicts with the naturalistic
inquiry, identified 13 of them in 510 comparisons between
30 standards for an evaluation and 17 criteria for the
naturalistic approach. Although this author stated that
these conflicts can be serious, he also stated that it is
possible to negotiate them.
Data Collection And Analysis
Patton (1987) referred to the need of addressing nine
questions for the data collection and analysis, named by
him as technical issues: method(s) of inquiry, primary
unit(s) of analysis; sampling strategy; comparisons if any;
kind(s) of data to be collected, from whom, when and using
what instruments; quality and accuracy to be ensured;
concerns about validity and reliability; kind(s) of
analysis to be conducted; kind(s) of statements and
findings that will result from the analysis.
Responding to these questions:
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1. The method of inquiry was naturalistic/ethnographic
because in natural settings it investigated human's actions
and perceptions.
2. The unit of analysis was program participants. This
signified that the emphasis of data collection was placed
on what was occurring for the participants. The data were
gathered from interviews with the client population and the
staff population and observations of the activities of the
organization, the women's project and the classes.
3. The sampling strategy selected the client population
according to the four criteria. The first criterium was to
have women who were program participants in both the urban
and rural sites where this program took place. The
selection of two sites was due to the circumstance that
almost twice the number of women were program participants
in the urban site (so that the program developed one more
class in the urban site) than in the rural site. Still, it
seemed relevant to study both sites because the rural site
appeared to attract poorest women than the urban site and
because the rural site was less accessible than the urban
site. The second criterium was the identification of an
age range of students from the older participants to the
youngest ones. The third criterium was the client
population's participation during classes. The most
talkative and the least talkative women were selected since
it was assumed that women who were least talkative could
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share different points of view related to the program than
the most talkative. The fourth criterium was the
availability for the interview process considering time and
location. Thus, the sampling strategy identified the more
active to the least active participants in educational
class interactions.
Due to the selection process, 13 women from each site
{urban and rural) were interviewed. While in the urban
site, seven women were selected from one class and six
women were selected from the other class, in the rural site
all women were selected from the only class held there.
The ages of the women interviewed in the urban site varied
from 16 to 56 years old being the mean age of the women
interviewed approximately 4 0 years old. Similarly, the
ages of the women interviewed in the rural site oscillated
between 17 to 63 years old, and the mean age of the women
interviewed was about 38 years old. Seven women from each
site were selected as being among the most talkative and
six women from the each site were selected as being among
the least talkative. Only three women to be interviewed
declined acceptance.
For the staff population, the criterion sampling was
to interview the personnel involved with classes and health
educational activities. Because the program studied in Rio
de Janeiro had only one woman who acted as both coordinator
and teacher on staff, other four staff women were
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interviewed in Sao Paulo who acted or have acted as both
teacher and coordinator of similar health educational
programs. The experiences of these four women were
considered relevant to this research because these women
had been part of the client population in health programs
coordinated and taught by the coordinator and teacher of
Rio de Janeiro.
For the educational activities, the criterion sampling
was to observe the activities of the three classes where
all client population met regularly.
4. The client population was examined in terms of date
entered in the program, frequency of participation, reasons
for joining the program and for staying in it. Further
differences that were examined among the client population
were those of personal characteristics--such as the number
of children, the absence of children, employment
conditions, educational background, place of residence,
means of transportation and distance travelled to the
program, marital status, and age--all factors which may
interfere in their participation in the program and in
community participation. On the other hand, the staff
population was examined in light of their past work
occupations. For this population, differences were
examined in their described reason to work in this program,
and their views of possible benefits the client population
may have from participating in the program.
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5. The data were collected from oral interviews and through
fieldwork notes related to observations. Two protocols
were created for the interview process so that all themes
were explored with all women interviewed. These themes
were the ones that could answer the research questions.
The two protocols were translated into Portuguese, which is
the Brazilian official language. The English version of
the protocols is found in the appendices.
The protocol for oral interviews with the client
population explored themes such as like personal
background; employment background; educational background;
background of participation in recreational, social and
political activities; opinions of Brazilian environment
regarding reproductive health and sexuality; Rifkin's
levels of participation; evaluation of perceptions of
health and family responsibilities as it relates not only
to the individual, but also to the general community;
personal life as it relates to reproductive health and
sexuality; and evaluation of outcome of participation in
the program.
The protocol for oral interviews with the staff
population investigated themes such as personal background;
work related questions; educational background, opinions of
Brazilian environment regrading reproductive health and
sexuality; evaluation of perceptions of family
responsibilities; evaluation of perceptions of problems and
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concerns experienced by the client population in regard to
violence, health and reproductive health; Rifkin's levels
of participation.
The process of interviewing took one to two hours and
followed the guidelines previously prepared for both the
client and staff populations. While 26 women from the
client population and the coordinator were interviewed in
Rio de Janeiro, the 4 women from the staff population who
had been former client population were interviewed in Sao
Paulo, while taking part in a program of popular education
and evangelical religiousness.
The interviews were conducted in a variety of settings
such as the rooms in the churches were classes occurred,
the homes of both client and staff populations, the work
sites of both client and staff populations and a religious
university. Notes were taken during the interviews.
The time frame to conduct the interviews and to act as
a participant observer in the educational activities of the
organization was six months. The protocols were considered
to be instruments as well as the researcher. The
researcher being an instrument is pertinent to naturalistic
inquiries (Guba & Lincoln, 1981).
Observations were conducted in six informal visits to
the organization which presently supports the health
education program, two meetings open to the public by the
women's project of religiosity and citizenship that is
124
related to the health education program studied, and in 24
class meetings of the three classes that took place in the
rooms of the churches of both sites.
6. The quality and accuracy of the data were attempted by
providing feedback to the client and staff populations.
Patton (1987) stated: "The giving of feedback can be a
major part of the verification process in fieldwork" (p.
102). The quality and accuracy of data were sought through
restatements in the interviews, a method suggested by
Marshall and Rossman (1989) in order to further understand
the population interviewed.
7. Validity and reliability did not respectively refer to
accuracy of measurement and to consistency of measurement.
According to Hammersley (1990), these meanings of validity
and reliability are quantitative notions that some authors
have advocated to be applicable to ethnographic research.
Instead, and as above stated, validity meant truth and
relevance.
8. The type of analysis conducted was case analysis.
Patton (1987) asserted that a case analysis involves: "to
pull together the data relevant to each case and write a
discrete holistic case study" (147). The case study was
presented thematically considering the program
participants' perceptions regarding reproductive health and
sexuality; the emphasis promoted in the activities of the
organization and the levels of participation of both client
125
and staff populations in health education programs.
Through this analysis it was possible to define, in what
way(s), the educational activities as well as other
activities promoted by the health educational program
empower women. The data analysis sought the understanding
of connotations and functions of human behaviors through
descriptions and explanations.
9. The kinds of statements and findings that resulted from
the analysis were issues contained in the research
questions.
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CHAPTER IV
Organization Description
The nongovernmental organization which presently
supports the health education program studied is located in
two sites of Rio de Janeiro South's region, which are
located about 10 to 25 minutes from the center of the city
of Rio de Janeiro. For the purpose of this study the
fictitious name given to this nongovernmental organization
was ECLECTIC.
According to ECLECTIC'S brochure, which is not
updated, the following information is pertinent to it.
ECLECTIC has been involved with religious studies since
1970 in Sao Paulo and emerged to guestion how religiousness
is associated with the transforming processes of the
Brazilian society. When ECLECTIC moved to Rio de Janeiro,
it was already known for its questioning style. In the
1980's with the political openness, ECLECTIC grew and
opened its horizons; having already put into practice
promotional projects; worked directly with urban poverty,
prostitute women, street children, Blacks, and women;
opened new paths in health and environment; and created a
solid communication program. In order to became relevant
for the 19 90's, ECLECTIC became involved in projects in the
areas of religiousness and citizenship, marginality and
self-confidence, traditions and ethnics; and in core
modalities in research, communication, documentation and
127
information. ECLECTIC has almost 2 00 people as members
that live in diverse parts of the country and as team
workers that develop projects throughout Brazil.
According to other informal sources, ECLECTIC has
expanded its research activities to encompass other themes
rather than religion, does not have a specific church
affiliation, is now involved in projects with street
children, prostitutes, prisoners' families, and AIDS's
victims, and receives financial support mostly from
international funds.
Women's Project Description
The health education program investigated was part of
one of ECLECTIC'S projects in the area of religiousness and
citizenship for and by women.
In ECLECTIC'S brochure, which is outdated, the
following information is presented about the women's
project. This women's project has a female ancient name
for wisdom. For the purpose of this study, the fictitious
name given for this project was the female name MARIA.
MARIA began in 1985 through the biblical and theological
refections of a group of Christian women stressing women's
conditions upon confronting the challenges of society and
the Church; searching to bring awareness, destroy
prejudice, and reestablish self-confidence and dignity of
women through new readings of the Bible and more social
128
action. MARIA has work groups named The Women and The
Land, Sexuality and the Christian Women, and Black Women in
Christian Churches. MARIA helps base community
organizations, publishes materials relevant to women, and
promotes courses, meetings, seminars and researches about
women's participation in Brazilian society.
In addition to the information in ECLECTIC'S brochure,
MARIA has its own brochure. MARIA'S features are as
follow: the biblical and theological reflections emerge
through women's experiences, the work has popular and
ecumenical perspectives, the women come from different
backgrounds and contexts, acting to conquer women's
identity and self-confidence, there is work to organize
women towards the search for their rights and exercising
their citizenship. MARIA aims to deepen the reflection of
God's experiences from women's standpoints -- particularly
women who are poor and oppressed, promote women's awareness
of their value and dignity through new readings of the
Bible, facilitate relationships with women's groups and
projects nationally and internationally, create
bibliographic and educational materials that help the
organizing of women from different backgrounds, and to
create spaces of solidarity among women from diverse
realities and religious practices. MARIA's actions are in
the areas of education, publications, researches, and
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meetings to promote exchanges among women and materials
produced.
Through informal conversations, the following
information was gathered about MARIA. MARIA stresses no
preference to religious affiliation, but rather the
importance of a religious faith that does not oppress
women, an ecumenical congregation and social action
promotion.
It is important to emphasize that the health education
program investigated was not part of MARIA until September
of 1993 . The health education program emphasizing
sexuality and health appeared in 1989 in Sao Paulo
associated with The United Church of Christ. Since 1993
this Church has supported the coordinator of the health
education program to work within the realms of MARIA.
Thus, the support of the health education program by the
MARIA in Brazil is partial and involves the distribution of
educational materials to all the client population and
transportation for the women from the client population who
claim need.
The Health Education Program's Sites
The health education program studied had two sites at
Baixada Fluminense, Rio de Janeiro. Baixada Fluminense
encompasses a vast area, is one of the poorest regions and
has the highest incidence of crime in the city of Rio de
130
Janeiro. One of the sites is located about one hour from
the center of the city of Rio de Janeiro and is an urban
site which is popularly recognized as belonging to Baixada
Fluminense. The center of this urban site can be
characterized by its lack of arborization, its small shops
and a dense population where street vendors hawk their
wares to passerbys. This urban site can be reached by
several bus lines and the train.
The other site is located about two hours from the
center of Rio de Janeiro and is a rural site containing a
small city. This rural site is not unanimously understood
by the inhabitants of Rio de Janeiro as belonging to
Baixada Fluminense. This rural site can be described as
containing elements of both urban and rural settings
because of the existence of a small city. Indeed, some of
the women interviewed in this site did not have a rural
life, working in the small city as domestic workers, or in
schools, cooking. Compared to the urban site, the small
city of the urban site had fewer small shops, street
vendors and pedestrians, and more arborization. Moreover,
the rural site was less accessible by public transportation
than the urban site. Not only were bus lines fewer, but
the hours were of operation were scarce and the train
station was no longer in operation.
The location of the health education program in both
the urban and rural sites was in the centers of the cities
131
of these sites. In the urban site, the program was located
in one of the rooms of a Catholic church. In the rural
site, the program was situated in one of the rooms of a
Methodist church, which is one of the Historical Protestant
Churches. The Catholic church was much larger than the
Methodist church and other social programs were held in the
Catholic church as well.
An important feature of this health education program
is that it is an itinerant program. Once the program
offers the two years of classes, it moves to other
communities so that the client population can take the lead
in developing new health education programs in their
communities. The coordinator of the program stated that
she might help the client population to coordinate new
health education programs, in the initial phase, by meeting
with them monthly to discuss the problems the new
coordinators might have and to provide incentives (moral
and educational materials). She stated that usually these
meetings might take about six months to one year, since the
new health coordinators will soon gain confidence to
coordinate health education programs without her
assistance.
The Health Education Program's Educational Materials
The coordinator is now developing a book on course
content to use in her classes and to give to the women who
132
will coordinate new health education programs. At present,
the client population who take part in the program receive
copies of the content of the course, a handbook entitled
Where there is no doctor? A village health care by David
Werner, blood pressure kits, and two wood models designed
as educational materials, with the design of a woman's
sexual organs and the design of the body's glandular
systems. These were designed by the coordinator and made
by Brazilian street children.
The Health Education Program's Classes
In the urban site the program had two classes . One of
these classes had 14 women and 1 man, while the other class
had 22 women. In the rural site, the program had only one
class with 19 women. The existence of one more class in
the urban site than in the rural was related to the greater
number of women willing to take part of the program in the
urban site than in the rural site.
The three classes had several commonalities. These
classes had the same teacher, the classes took place once a
week on a weekday during the afternoon for two hours and a
half. All the classes started in September, 1993, and were
expected to end by August, 1995. The observed women and
the man have participated in the three classes regularly
since the program started. It was mentioned that a few
women have dropped out from the program, particularly in
133
the initial weeks. Regular participation was required for
graduation. The women who missed more than three classes
could come to class but would not be allowed to graduate as
health educators. The age range of the client population
was large, ranging from adolescent women, to women in
menopause. In all classes, ethnicity and religious
affiliation of the client population were pluralistic and
there were some women who were affiliated with the
particular Church in which classes took place. And in all
classes, there were women who commuted from other
communities as well as those who lived in the communities
where the program was located.
Objectives Of The Health Education Program
The aims of this health education program were
described by the coordinator as the following:
empowerment of women using health education as a
means, build self-esteem/self worth, knowledge of how
their bodies function (as well as their children), in
lieu of the poor health system in Brazil, to train
women to be multipliers, that is, to teach others what
they have learned in the hopes that diseases can be
prevented; for more efficient work in the Health
Pastoral and Children's Pastoral to visit the sick,
aide in their treatment and act as a liaison between
the doctor and the patient, as well as being better
able to orient the family as to the patient's care.
When asked to further elaborate on women's
empowerment, the coordinator stated that it should start by
building self-esteem in order to create capacitation and
134
politization among women. The coordinator also stressed
that for empowerment to occur women had to realize that
they suffer and are oppressed living in a patriarchal
society.
It is important to note that even though the health
education program investigated was designed to train women
as health educators, it allowed a few men to participate.
One of the classes observed had one man participating, and
the presence of another man in a previous class was
mentioned in one of the interviews with the staff
population from Sao Paulo. The presence of one man in one
of the classes was unexpected. If more men can participate
in programs like this, it might lead to empowerment; if
this presence can help to change the gender division of
health care services in a way that the role of community
health workers in the communities will no longer be
confined to women only. As was pointed out by Moser
(1993) :
The community role comprises activities undertaken
primarily by women at the community level, as an
extension of their reproductive role. This is to
ensure the provision and maintenance of scarce
resources of collective consumptions, such as water,
health care and education. It is voluntary unpaid
work, undertaken in 'free time'. The community
politics role in contrast comprises activities
undertaken by men at the community level organizing at
the formal political level. It is usually paid work,
either directly or indirectly, through wage or
increases in status and power, (p. 34)
135
intended Contents Of The Health Education Program
The contents of this health education program were
described by the coordinator of the program as encompassing
causes of illness, the brain, the senses, the respiratory
system, the circulatory system, the urinary system,
reproductive organs and sexuality, the glandular system,
the digestive system, nutrition, pregnancy and birth, how
to care for the infant up to the 1st year, the child from
the 1st to the 5th year, social illnesses or disorders,
first aid measures, and pharmaceutical medication and
natural medication. The physical, mental, spiritual,
social/economic aspects of diseases were mentioned as part
of the contents of the program. Furthermore, the contents
were said to always involve common diseases, causes,
symptoms, treatment and prevention. Still, the contents
were portrayed as emphasizing not only how a system
functioned, but also its connection with other systems.
According to the program coordinator, the content of
reproductive health, which is the focus of this study,
involved how the reproductive system works, male and female
(connection with other systems); understanding of the full
meaning of sexuality, including the understanding of
women's issues; common diseases, causes, symptoms,
treatment and prevention (emphasis on sexually transmitted
diseases/AIDS); family planning, contraceptive methods,
changes in adolescence; changes in menopause/andropause;
136
aging and sexuality; issues concerning gynecology--women's
health issues.
Actual Contents Of The Health Education Program
The teacher's expositions and the discussions of many
of the intended contents were observed in the classes.
Because the researcher was not present during all the
classes in the program, many of the intended contents could
not be observed. Nevertheless, some of the intended
contents not observed were reported in the interviews. In
the classes the teacher brought up issues related to
reproductive health and women's issues, which were the main
interest of this research. These discussions happened
before the interviews took place.
In regard to reproductive health, one of the
evaluation's questionnaires distributed in all three
classes observed is illustrative of the contents raised by
the teacher. The women from the client population were
invited through this questionnaire to reflect upon the
following themes: whether the process of self
valorization, capacitation, awareness was happening;
whether the learning of the sexual organs mechanics was
occurring; if family planning was understood (conception
and contraception); if one's own sexual behavior was
understood (the desire or not to have children, the time to
have children, the number of children desired if any, which
137
method of family planning to use, when to have sex and what
kind of sex to practice, which kind of treatment to expect
from medicine, society and the family); whether there was
awareness of sexual rights, for instance, the right to have
one's own sexual pleasure; whether there was difficulties
of talking about oneself and about words such as lesbian,
masturbation, orgasm, sexual pleasure, etc; if there was a
decrease in shyness about talking about sexuality and sex
with others; whether there was an understanding of the
causes of diseases that affect the sexual organs, and how
to prevent them, including AIDS; whether there was an
understanding of men's genital organs and the diseases that
affect them; whether there was an understanding of the role
men have in the diseases that affect women and vice-versa;
whether there was an awareness of what was oppression in a
male dominated society; whether there was an awareness that
women were oppressed, that is, controlled psychologically,
culturally, and physically by men; if women began to
develop an awareness for how to change this oppression, and
work towards their liberation; whether women were
reflecting over the role of women in society (inside and
outside the home); whether the women were self-valuing
themselves; whether women were aware of any changes they
had undergone in the home with their husbands and children
and outside the home in the community by citing examples;
whether women did not think they had changed at all, and
138
did they know why not. For women who took an active role
in the church, they were further invited to consider the
question "How does the participation in a church contribute
to the continuation of a male dominated society?", what was
the Church's role in women's oppression, and whether the
Bible supported the sex equality today.
Another activity which was observed was the small
groups discussion of women's rights. In this occasion, the
teacher suggested the general theme to be discussed, and
the actual discussion revolved around issues the client
population was interested in. The small groups discussion
rights voiced involved women having the same rights as men
in the labor market, seeing the constitution being
followed, not being a domestic slave, having education,
having vacations and leisure, having access to health care,
having access to housing, having access to good food,
having access to sports, deciding whether to marry, owning
their bodies, having autonomy to come and go, having the
freedom to be heard and to express themselves, organizing
themselves, being able to have a critical awareness, being
respected as people and as women, being respected in their
religiousness and in their churches' duties and being able
to celebrate masses, being able to have women as friends,
and loving and being loved. In these group discussions
there was acceptance of Brazilian constitution regarding
women's rights. In no instance was there a question of
139
whether the Brazilian laws were appropriate or not, but it
was just mentioned that many have not been implemented.
Comparing the urban site with the rural one in regard
to contents discussed, having the same teacher in both
sites contributed to the identical contents exposed. Some
differences emerged from the participant women. One of
these differences was that the rural site was more advanced
than the urban one because a few of the participant women
seldom arrived as late as some of the women from the urban
site. The other difference was that in the rural site
women questioned how to apply the information discussed not
only to themselves but to their children as well. This
difference appeared to be related to the fact that in the
rural site that some women would always bring their
children to the classes, while this was observed only once
in the urban site.
Intended Methodologies Of The Health Education Program
The methodologies of this health education program
were described by the coordinator as encompassing:
Learning through experience where the women give
information according to the experiences with the
diseases they are familiar with in family and
community; emphasis always on prevention through
knowledge of how body functions and physical, social,
political, economical and spiritual causes of
diseases; small groups discussions and tasks to be
shared in: open discussion (full participation),
making of posters and drawings (simplicity and
creativity encouraged through positive and affirmative
criticism), dramatizations, making of dolls with
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organs for use in community talks, games, jigsaw
puzzles, visits from people who have a certain
disease, groups research and/or interviews with
patients or families with certain diseases, slides
when possible; use of learning ideas the women have,
respecting their experience always; the most important
of the methodologies is the one that relates to self
esteem building through field practice: as the course
proceeds, at each level, the women have practice
homework.
Several examples of field practice were provided by
the program coordinator:
examining the throats of their children, taking
pulses, collecting patient histories, reading blood
pressures; as they develop more confidence, giving
talks in their communities on how to control and
prevent TB, or lung health, how to control and prevent
high blood pressure, diabetes; taking their dolls to
give talks on the reproductive system, AIDS
prevention, family planning, child care etc. (this is
done in small groups, pairs of individually); whenever
this is done, there is an evaluation sharing with
positive criticism (part of the self esteem process is
to learn how to accept and give constructive/positive
criticism) ; when possible, a relationship with the
public health clinics as observers; visits to day care
centers for working mothers, to examine the conditions
of the center and the children to see if they are up
to date in their vaccinations, have good teeth etc.
and to see if the center is supplying nutritive diet;
and many more community activities in which they can
share what they have learned.
The book As aaentes educadoras de saude. Breve
historia das experiencias dos grupos de saude (Health
education workers. A brief history of the experiences with
health groups) by Soliani de Lima & Souza (1989) seem to
contain the rationale for the order of the methodologies of
this program. According to this book, the program has
three distinct phases. The first is related to individual
discovery, accomplished through small tasks in the
141
community such as examining patients, conducting research,
measuring blood pressure, and giving health orientations.
In this phase, women begin to be known in their communities
and feel more important and valued. The second phase is
intended to foster the solidarity spirit. With the new
feelings of being able and important that have been
acquired in the first phase, women begin the study of a
woman's body. In this phase, women start to have courage
to talk about themselves, discuss with each other women's
common problems and plan to give lectures in their
community about a woman's body. The third phase is the
compromise with the community and political action. This
compromise begins when women start visiting hospitals and
health clinics and do internships in health clinics.
Through these visits, women make their own evaluation and
exert their role as health workers.
Actual Methodologies Of The Health Education Program
In the classes, it was observed that information was
portrayed through class discussions and through copies of
articles and newspapers containing the content emphasized;
classes set in circles or were divided in small groups to
perform tasks; classes often performed exercises not only
for its health benefits but also to learn measuring
differences of pulse and blood pressure before and after
exercises; in festivities nutritional aspects of food were
142
discussed; any kind of religious devotion happened as the
request of the client population and the pluralistic
religious affiliation of the group was praised by all as
welcome; quizzes were either at home or in class and there
were no grade examinations; individual attention was given
by the teacher to the client population before or after
classes; the client population's suggestions were generally
negotiated with the teacher in terms of changing schedules
and performing additional activities; the teacher
encouraged discussions after exposition of any content
either in the same day or in the next class meeting; the
teacher always praised those who gave their own examples
and provided opportunities for women to express their own
opinions--especially the least talkative women; there was a
strong emphasis by the teacher for participant women
(individually or in groups of two or three) to share
knowledge in their communities of the contents learned in
the classes so that dependence between community health
workers and community members would not be fostered; the
teacher also stressed that women should practice with
themselves, in their families or communities the tasks that
could promote health (visit the gynecologist annually, take
blood pressure, give injections, cook foods that were
healthier, and so on).
Differences between methodologies proposed by the
teacher in the urban site and the rural sites were not
143
observed. Again, having the same teacher in both sites led
to this similarity. However, among the three classes, it
was noticed that one of the classes in the urban site had
more difficulty than the other two classes in forming
groups to share the learned knowledge in their communities
and tended to do so individually. It seemed that this
difficulty was due to the fact these women lived in more
diverse communities than women in the other two classes.
144
The Features Of The Women Interviewed
A) Client population
The women's religious affiliation as shown in table 1
was diverse and Catholic affiliation was the highest
affiliation among the women interviewed. But the number of
women belonging to other religious affiliations was not
insignificant.
Table 1: Women's religious affiliation
Religious
affiliation
Urban site Rural site
Catholic 7 6
Methodist 4 4
Congregagao
Crista no Brasil 1 0
Assembleia de
Deus 0 2
No religion 1 1
Total 13 13
STote: Methodist is one of the-Historical Protestant
Churches and both Congregagao Crista no Brasil and
Assembleia de Deus are Pentecost Protestant Churches.
As religious affiliation of the women interviewed was
pluralistic, so was ethnicity. As can be seen in Table 2,
the race self-definitions were not homogenous among the
women interviewed and in a few cases did not match the
definition the interviewer could give them.
145
Table 2: Women's race self-definitions
Race self
definitions
Urban site Rural site
White 6 5
Mixed Races 6 5
Black 1 3
Total 13 13
Note 1: The women who declared themselves as
from Mixed Races used definitions such as being
'Mulata, Mestiga or Morena'.
No women participating in this program reported to be
from the upper class. A few women from the middle class
did participate in this program. But some of women's self-
reported social classes as shown in Table 3, particularly
in the urban site, as middle class can be questioned in
regard to earning power. If the earning power of a middle
class family from Rio de Janeiro can be defined as between
10 to 30 minimum wages as Carneiro (1987) did in her study,
only one woman from the urban site and two women from the
rural site could be considered as belonging to the middle
class.
Nevertheless, other factors such as property owned and
level of education can contribute to a middle class
definition. Thus, self-reported social classes may
coincide with reality. In any case, it was surprising to
encounter in this study a few women from the middle class
as client population given the objective of the program to
146
be directed to poor women who according to Stromquist
(1993) is the population in the greater need to become
empowered.
Table 3: Women's self-reported social classes
Social class Urban site Rural site
Poor class 7 10
Middle class 6 3
Total 13 13
The women's variation of monthly wages represented by
table 4 demonstrates that women from the rural site, in
general, earned less than women in the urban site. The
mean of monthly wage in the rural site was indeed 42% lower
than the mean in the urban site.
Table 4: Variation of the monthly wages of the
women's families
Variation of
monthly wages
Urban site Rural site
Minimum
monthly
wage
1 salary
($83 .3
dollars)
0.5 salary
($41.6
dollars)
Maximum
monthly
wage
14.3 salaries
($1191.6
dollars)
14 salaries
($1167
dollars)
Mean of
monthly wage
6.2 salaries
($516.6
dollars)
3.6 salaries
($300
dollars)
Considering the family members who actually
contributed to the family income as presented in table 5
below, it was observed that in both sites there were more
families in which the income was a result of the women's
activities rather than their male partners' activities, and
that there were more families in which only the woman or
only the male partner contributed to the income, than
families where everyone contributed.
Table 5: Women's families income contribution
Family income
contribution
Urban site Rural site
Only the woman 5 4
Everyone in the
f amily 4 6
Only the male
partner 3 3
Male partner
and eldest son 1 0
Total 13 13
Considering the families organization of the women
interviewed as shown in table 6, women from the rural site
tended to live less in extended families than those from
the urban site which was surprising. This might be
explained by the circumstance that not all women from the
rural site led a rural life. The presence of more nuclear
families in the rural site may have been the reason why
women who had children took them more often to the classes
than in the urban site.
148
Table 6: Women's families organization
Family organization Urban site Rural site
Nuclear family 5 7
Extended family 5 4
Broken nuclear family 3 2
Total 13 13
Comparing the number of children of both sites, the
rural site had a lower fertility rate than women from the
urban site as displayed in table 7 which was surprising.
This might be related to the fact that not all women from
the rural site had a rural life. The fertility rate and
the family organization seemed interdependent factors in
the population studied. The extended families present in
the urban site were more conducive to a greater number of
children.
The smaller fertility rates of the women interviewed
in both sites, if compared to fertility rates of Brazilian
women for the IBGE's statistics of the 1990's (which was
2.7.), were surprising. These smaller rates may be related
to the eight year gap of this study since IBGE's statistics
were gathered in 1986 and decline of this rate is likely to
have occurred. Still, it is possible that the program may
attract in both sites women who have less or no children
than the average women because of the time needed to attend
the program and to take part in field work activities.
Thus, women participants might be self-selected.
149
Table 7: Women's number of children and fertility rate
Number of children Urban site Rural site
No child 2 2
1 child 3 2
2 children 2 3
3 children 3 2
4 children 4 2
5 children 0 1
6 children 2 0
Fertility rate 2.4 2 .1
As can be seen in Table 8, although all women
interviewed were originally from Brazil, the women
interviewed in the rural site had immigrated more from
other Brazilian States to Rio de Janeiro State than the
women interviewed in the urban site. The identification of
greater migration patterns among the women interviewed in
the rural site perhaps could be associated with the fact
that most women in the rural site reported rural
upbringing, and economic conditions in rural areas tend to
be worse than in urban areas, forcing the rural population
to migrate.
Table 8: Women who were originally from Rio de Janeiro
Place of birth Urban site Rural site
From R.J. 11 6
Not from R.J. 2 7
Total 13 13
150
Most women interviewed were involved in monetary
activities as can be seen in Table 9. The paid activities
women were involved in the urban site included sewing,
pressing clothes, domestic work, office work, waiting
tables, manicure, teaching special education and sales.
Likewise, the paid activities in the rural site women
worked with were sewing, cooking at schools and at home,
agriculture, sales, domestic work, and teaching popular
education in a rural site.
Table 9: Women who work and who do not work for paid
compensation
Paid activities Urban site Rural site
Working 9 10
Not working 4 3
Total 13 13
As is demonstrated in Table 10 most women were also
involved in voluntary activities in the community. This
community involvement might also raise the issue of
participant women being self-selected, since most of them
might be seeking--through program participation--other ways
to continue, improve or increase their activities in their
communities. It is important to note that two women in the
urban site and three women in the rural site did not
initially recognize in the interviews that some of their
activities were voluntary. These five women explained that
151
these activities were not voluntary because they felt
indebted contributing to the communities' welfare becsmse
of theix- relationship with God.
The unpaid activities in the urban site encompassed
sewing; church related activities such as cleaning the
rooms, participating in meetings, teaching others how to
cook, preaching about religious rituals; helping neighbors
in their health care; several school activities such as
teaching other to read and write, and organising school
meetings; and participation in a women's meeting, a
teacher's meeting and a political party.
Similarly, the unpaid activities in the rural site
were church related activities such as participating in
meetings, preaching about religion rituals, and asking
others to donate money for the churches; school activities
such as teaching to read and write; and participation in:
the association of the inhabitants of their rural
communities, a Black awareness meeting, a women's meeting;
and helping neighbors in their health care.
Table 10: Women who work and who do not work for unpaid
activities
Unpaid activities Urban site Rural site
Working 12 11
Not working 1 2
Total 13 13
152
In regard to nonformal education, table 11 shows twice
as many women in the urban site than in the rural site had
been enrolled in nonformal education programs. The
contents of the nonformal education programs in the urban
site were sewing, cooking, nutrition, religious studies,
special education for children and adolescents, painting,
computer, and human sciences courses such as social law,
sociology, and psychology. Two of the women in the urban
site have also participated in seminars about special
education, ecumenical religion, a woman's body and
sexuality. Compared to the women in the urban site, the
women in the rural site had less nonformal education. Only
five women in the rural site have been enrolled in
nonformal education courses with the following contents
sewing, cooking, nutrition, pregnancy and women's studies.
Participation in seminars was not mentioned by women
interviewed in the rural site.
Table 11: Women's nonformal education
Women's nonformal
education
Urban Site Rural Site
Had been enrolled in
other nonformal
education programs 10 5
Had never been
enrolled in
nonformal education
programs 3 8
Total 13 13
153
As can be seen in Table 12, the level of formal
education of the women in the urban site was more
heterogenous than in the rural site. Also, the women in
the urban site had on average gone up to higher levels of
education. In the urban site, four of the women
interviewed said that they were enrolled in formal
schooling, and three of them declared that the health
education program had been the motivational factor for them
to return to school. On the other hand, in the rural site,
although two women stated that they would love to go back
to formal schooling, none of them were enrolled in formal
schooling at the time of the interview.
The level of formal education of most women in both
sites indicates that they are literate. This might imply
that women who are literate are more prone to program
participation than those who are not. In this way, the
issue of women's self-selection need to be raised again.
Still, even though most participant women were poor, their
literacy puts them in an advantaged position vis-a-vis the
illiterate poor women.
154
Table 12: Women's formal education
Women's formal
education
Urban Site Rural Site
No schooling 0 1
1st grade 1 0
2nd grade 0 0
3rd grade 1 0
4th grade 0 5
5th grade 5 5
6th grade 0 1
7th grade 0 0
8th grade 2 0
9th grade 1 0
10th grade 0 0
11th grade 2 1
Finished
university 1 0
Total 13 13
Mote: In Brazil, high school last three years which
means that in the 11th grade students graduate.
The coordinator explained that usually the program has
attracted women who have completed up to the 3rd to 5th
grade of formal schooling. She said that she would like
for the program to attract illiterate women, but that these
women usually have more difficulty participating because
they spend all day working either in factories or in homes
as domestic workers in the urban sites, or on farms in
rural sites. Nevertheless, the coordinator emphasized that
155
even if most women were literate and did not represent the
most oppressed it was great to have a few women who were
working on farms or as domestic workers.
All women interviewed from the client population were
given fictitious names and selected for them being among
the most or least talkative in class participation, as
shown in table 13. It is important to stress that because
the least talkative and the most talkative women from the
client population did not share different points of views
in regard to the program as it was assumed they would,
rating them among the most talkative and least talkative
proved to be irrelevant in this study.
Table 13: Women's characterizations in terms of their
being the most and least talkative women
Urban site Rural site
Josepha (most talkative) Monica (least talkative)
Miriam (most talkative) Marcela (most talkative)
Carmem (least talkative) Silvia (least talkative)
Cleuza (least talkative) Carolina (most talkative)
Antonieta (least talkative) Helena (most talkative)
Clara (most talkative) Lelia (least talkative)
Adriana (most talkative) Eleonora (most talkative)
Sandra (least talkative) Beatriz (most talkative)
Cassandra (most talkative) Katia (least talkative)
Liane (least talkative) Bianca (most talkative)
Marta (least talkative) Carminda (least talkative)
Ana (most talkative) Gabriela (most talkative)
Claudia (most talkative) Gilda (least talkative)
156
B)Staff population
Analyzing the staff population features as presented
in Table 13, it was identified that the five women could be
distinguished among being either nationals or
internationals. The nationals were the Brazilian women and
the Internationals were the North American women.
Nationality, race and level of education were the features
that most distinguished the Brazilians women with the North
American.
Table 14: Staff's socio-demographic features
Features National Staff International
Staff
Level of
formal
education
Less than junior
high school (2nd,
5th and 6th
grades)
Graduate school
Race self
definition
Mixed races White
Nationality Brazilian (Sao
Paulo, Pernambuco
and Bahia)
North American
(The United States
and Canada)
Religious
affiliation
Catholics 1 Catholic and 1
United Church of
Christ
Social class
definition
2 poor class and
1 middle class
1 poor class and 1
middle class
As with some women from the client population, one of
the staff woman's social class definition can be questioned
as belonging to the middle class because her family income
was more than 3 0 minimum wages, which is the higher limit
157
to which Carneiro (1987) defined as being the earning power
of a middle class family.
Studying the variation of the monthly wages of the
staff population as is presented in table 14, it is
important to highlight the fact that the mean of monthly
wage was almost three times higher than the same mean among
the client population of women interviewed in the urban
site and more than five times higher than the same mean
among the client population of women interviewed in the
rural site. That the staff population had a mean of
monthly rate much higher than the mean of the client
population was unexpected because the level of education of
the Brazilian staff population was less than junior high
school level, and because one of the North Americans earned
only one salary.
Table 15: Variation of the monthly wages of
the staff's families
Minimum monthly wage 1 salary
(83.3 dollars)
Maximum monthly wage 42 .3 salaries
($3,571.4 dollars)
Mean of monthly wage 18.5 salaries
($1,541.7 dollars)
If comparisons between client population and staff
population are made, the Nationals of the staff population
share similar features with the client population, with the
exception of the mean of monthly wage. The Internationals
158
of the staff population do not share as many features as
the Nationals do and differ from the client population
mostly in the level of education.
The work activities of the staff population have been
and were the following: missionary work, public school
teacher, church jobs such as educator and health educator
for church programs, nursing, sewing, fund raising, and
making homemade medicines for a community drugstore. In
several of these activities, the women did not receive any
monetary compensation.
As with the client population, women from the staff
population were provided with fictitious names as well.
Margaret was the program coordinator and teacher of the
program studied. Linda, Julieta, Laura and Fatima are the
new health educators who have been part of the client
population in Margaret's past health education programs.
The new health educators reproductive health opinions and
their views of the objectives of the programs they teach
did not always coincide with the ones shared by Margaret.
For that reason they are described below briefly.
Linda is a Catholic Canadian nun who went to graduate
school and has been involved for several years with
missionary work. Linda's objective for the health
education programs she teaches is to promote women's
empowerment. For her, women's empowerment means the
conquest of women's rights. Linda explained that women's
159
empowerment has been fostered in her health education
programs through the sharing of women's collective
experiences. Linda believes that women should have the
information and the right to exert choice regarding
reproductive issues. Linda also mentioned that women's
collective action was needed to promote social change.
Julieta is Catholic and studied until the 5th grade.
Julieta is the woman from the staff population who can be
considered from the upper class. With her family she owns
a sewing factory, where she also works. Julieta also works
for free in the Church and in her community with HIV
groups. Julieta mentioned that her program has the
objective to form new health educators to work in poor
communities. Julieta is in favor of women having free
choice in issues concerning reproductive health and
education to overcome taboos. Although Julieta referred to
the need for new contraceptives methods to be created for
men so that the responsibility for contraception did not
continue to fall only on women, she did not talk about the
need for women to act together in order to change the
social order.
Laura is Catholic, studied until the 2nd grade, works
for free in the community drugstore and at the Church, and
is supported by her son. Laura explained that the
objective of her health education program is to teach women
to know their bodies and for these women to teach other
160
women. Laura's values regarding reproductive health are
not liberating since she is not in favor of women having
free choice in regard to abortion and sterilization. Laura
did not mention the need for social change nor women's
collective action.
Fatima is Catholic and studied until the 6th grade.
Fatima works with her family in construction materials.
Fatima explained that the objective of her health education
program is for women to learn through the exchange of their
experiences the value they have as people and as women so
that they develop political awareness and can fight for
better living conditions and social change. Fatima's
reproductive values are liberating since she believes that
women should have free choice on the issues of abortion and
sterilization and enough knowledge to make good choices.
On the one hand, it can be assumed that Linda's and
Fatima's objectives to the health education programs they
teach involve addressing women's practical and strategic
gender needs. On the other hand, it cannot be inferred
that in Laura's and Julieta health education programs they
address women's strategic gender needs.
Empowerment In The Psychological Dimension: An Unanimous
Path Undertaken
All women interviewed at both sites seemed to be
empowered in the psychological dimension because they
161
reported to happier after participation, than before about
themselves and/or perceived changes in the way they related
to themselves or to others. This unanimous path that is
likely to have been undertaken by all women can be
exemplified by Cleuza's speech. Cleuza is Catholic and 51
years old. She lives with the youngest of three sons,
studied until the 3rd grade, does not work for profit but
receives pensions from a husband and father who are now
dead, and works in the community giving assistance to
patients at their homes and hospital. Cleuza affirmed:
I could not be close to anyone before this program.
With it, my social life is improving. Before this
program, I was either at home or working. Now, I
enjoy going to parties and I seek them, I learned
through this program to have more self confidence in
what I want to do and that I should not escape
problems, but rather confront them. I learned to deal
better with people. I feared people. I do not know
if I was ashamed or I just feared people.
For the psychological empowerment, the process of
changing relationships was described as both in a one way
direction and in two way directions. While Cleuza's speech
accounts only for her initiatives to go to parties,
Bianca's and Josepha's speeches below refer to both theirs
and others' initiatives. Bianca is Catholic, 48 years old,
studied until the 5th grade, lives with her husband and the
two youngest of her four children, has never worked outside
the home but sews at home once a week for paid clients, and
works in the community soliciting donations for her church
and visiting patients. Bianca explained:
162
I became happier due to this program. I feel happier
within myself. Before I thought I had no right to say
anything. Now, I speak even when I am among others
who have higher levels of education and of economic
resources. I feel at ease now. I started to give a
course at the church which before I had neither the
needed courage to give it nor would people have
invited me. People started to see me as someone who
knows something. They make jokes that I will be a
nurse. Even my husband makes these jokes. People
support me more know because they know they can rely
on me.
Josepha is Methodist, 46 years old, lives with two of
her four children and her husband. Josepha works at home
sewing for a big factory. She also works for free in the
Church teaching sewing and coordinating social programs.
Josepha said:
I did not know what was right or wrong. Nowadays, I
feel more secure because I have more knowledge. I
became more free to talk with family and friends who
have also began to value me for what I am learning in
this program.
In other cases, psychological empowerment seemed to
have been propelled in a one way direction by others'
initiatives, not the women's. These were circumstances in
which women reported that their experiences in the program
affected their relationships with their families or their
communities because of the way others started to perceive
or to interact with them. It seemed that women 'gained
status' for taking part in the health education program.
Adriana's speech exemplifies this situation of changes
initiated by others. Adriana is Methodist, 40 years old,
and studied until the 8th grade. Adriana lives with her
163
husband, mother-in-law and one of her two children. She is
the sole supporter of the family, working as a
receptionist. She also works for free in social programs
at her church. Adriana stated: "I started to get requests
from my family for health care and to talk about things
that I do not understand, but that my family thinks I do."
If the psychological empowerment is measured in terms
of degree of relationships, in a few cases, the interaction
of women with their communities could become surprisingly
intense due to their participation in the program. Liane
is 56 years old, lives with two of her three children.
Liane studied only until the 5th grade. Liane was
prematurely retired from the phone company because her work
left her partially deaf. Since her retirement, she works
for free in the community health clinics and hospitals in
meetings and checking blood pressure. Liane reported that
she participates in political activities in the workers'
parties, in her Methodist church and in the mayor's office.
Liane said:
This program is as if the community is also taking
part of it because I teach what I learn here. I feel
happy because people tell me they learn more with my
health explanations to them than with the doctors'
ones .
That all women seemed to be empowered in the
psychological dimension appears to relate to the building
of self-esteem/self worth as an objective of the health
education program. Margaret, the program coordinator and
164
teacher, who has been working in poor communities in Brazil
for over two decades said: "I hope empowerment for these
women will mean to feel good about themselves. Even though
I hope they can use the health knowledge they gained, it
does not matter where they will act."
There were at least three ways that this program
attempted to meet the objective of empowering women in the
psychological dimension. In the classes, it was observed
that when women tended to depreciate themselves for not
accomplishing a task or by expressing not knowing if they
would have the ability to perform a task, the coordinator
stressed their potential and discussed or demonstrated how
they could perform the task.
Another way that the program tried to accomplish
psychological empowerment was by group dynamics that
praised the women's way of being and their accomplishments.
One type of group dynamics was observed. All participant
women (and one man in one of the classes) had to praise
each other in a circle and to listen to everybody's else
praises about themselves. This kind of dynamic helped to
build self-esteem/self worth because women tended to
emphasize what they liked about each other and the
psychological changes the fellow classmates had undergone.
Yet another way that the program attempted to meet this
objective was by engaging in a final group dynamic, in
165
which all the client population would have to praise
themselves in a circle.
Empowerment In The Cognitive Dimension: Another Unanimous
Path Undertaken
Al1 women interviewed reported that they learned
valuable things in this program. The cognitive dimension
appeared to be an unanimous path undertaken by all women.
Some of these women appeared to be so enthusiastic about
exerting their abilities to learn, that they stated their
intention to continue learning by enrolling in other formal
or nonformal educational programs.
Most women interviewed had a learning expectation that
the program could help fulfill. For them, the program was
meeting this learning expectation. A few also mentioned
the teaching expectation the program could support.
Helena's assertion appear to evince both her learning and
teaching expectations. Helena is 32 years old, Catholic
and lives with her husband and three children. Helena
works with her husband in agriculture and she is also
responsible for selling the crop they plant. Helena works
for free in her community as the secretary of a neighbors'
association and affirmed:
I expected to learn in this course and help others.
As I like to learn, I like to teach. The more I
learn, the more I feel motivated to learn more. I am
shy to ask questions, but I learn from other's people
questions. Even though my memory is not great, I
166
still learned in this program. I would like to
improve my memory.
Cassandra's speech appeared to relate to her learning
expectation. Cassandra is 54 years old, Catholic, studied
until the 1st grade, works as a domestic worker and
supports both her husband and one of her five children who
is presently unemployed. Cassandra also works for free in
her community in the singing classes of her church and in a
drugstore making homemade medicines. Cassandra contended:
1 1 1 thought this program would be important to me because I
would learn a lot of things. Because I learned more than I
expected, I now even have greater expectations to learn
more in this program."
There were times when women mentioned the learning
contents. The contents reported were varied as the
examples of Claudia, Silvia and Sandra below demonstrate.
Claudia is 39 years old, Catholic, lives with her mother
and a brother who is exceptional. Together with her mother
Claudia contributes to the family income. Claudia has a
university level of education and teaches special education
and religion in a school. Claudia said that although she
is paid for her work, she works in her school on the
weekends without being paid. Claudia affirmed; "I learned
a lot here. I learned more about arterial pressure and
women's health."
167
Silvia is 17 years old, studied until the 5th grade,
is affiliated with the Assembleia de Deus Church, lives
with her aunt's family, and works as a domestic worker.
Silvia said: "I learned a lot about health, like taking
blood pressure and about children's health problems that a
mother should know. I also learned things that I do not
remember right now."
Sandra is Catholic, 47 years old, lives with her
husband, and studied until the 5th grade. Sandra does not
work for money since she became married 22 years ago, but
works for free in her church, coordinating a group of young
people. Sandra explained: "I learned in this program
things that I did not know such as how the sexual organs
function, contraceptive methods, circulation and
hypertension."
The psychological and cognitive dimensions of the
empowerment process seemed to be very interdependent. Not
only did the learning process seem to lead these women to
feel more valued as persons by themselves and others, but
also the self-esteem improvement was considered a necessary
tool for the learning process. Cleuza seems to be an
example in which she related her nervousness as impeding
her ability to learn and teach. Cleuza, who is widowed and
lives with the youngest of three sons, and works in the
community giving assistance to patients at their homes and
hospital stated:
168
I do not know how to write or teach other about the
things I learned in this program such as depression,
diseases, stroke, temperature and blood pressure. I
expected to learn in this program and be able to teach
others. It is difficult to learn because I feel
nervous and forget. It is difficult to teach others
because I feel nervous when I have to teach health
education in my community. My friends have helped me
but I almost do not talk in the group speeches I
participated. I want to still learn and hope that I
will not feel nervous anymore so that I can teach
others. I will not give up. I many not be able to
teach, but I did improve my skills to help the
patients I have.
Another example of interdependence among the
psychological and cognitive dimensions can be found in
Beatriz's speech. Beatriz's talking ability appeared to be
increased by knowledge and freedom gained. Beatriz is 49
years old, living with her husband, mother and two of her
four children. The family works in agriculture. She is
president of an association of rural producers and helps
ill people in her community. Beatriz contended:
I have more skills to talk with people and to inform
them to prevent high blood pressure and to teach about
food. I feel with more freedom to talk with relatives
and friends. They know I am learning and they respect
my opinion. I told a relative to stop smoking.
The cognitive dimension of empowerment seemed to be
promoted by the program by the combination of diverse
methodologies used since women may learn in different ways.
Still, the fact that different methodologies have been used
in different stages of the program may promote cognitive
empowerment because each step of the program has diverse
requirements. The emphasis on learning through experience,
169
more than on only memorizing contents of themes exposed and
discussed may have led to cognitive empowerment because
women have to link abstract knowledge with the concrete
situations they face. In classes, Margaret, the
coordinator and teacher provided a tip for the women to
handle a memory problem:
When some members of community goes to your home and
ask you some health advice that you do not remember,
you tell the person you will make her/him a coffee and
while you make the coffee you also go to you readings
and study what the person wants to learn.
Finally, and perhaps more importantly, the cognitive
dimension of empowerment seemed to be achieved unanimously
because most women had a learning expectation through their
program participation. It is possible that this learning
expectation acted as a self-fulfilling prophecy.
Empowerment In The Economic Dimension: Productive Labor
Changes Were Not Conquered
Economic empowerment never meant situations where the
women from the client population became involved in the
productive labor activities as a consequence of their
participation in the program. To make the community health
role a paid job does not seem an easy task since the four
new health educators did not receive money for their roles
as health educators.
For a few women, economic empowerment meant becoming
aware of possibilities of gaining money, and to most women,
170
activities in which they saved money by using the resources
they had. Thus, women seem to gain knowledge towards
resources reutilization. In the urban site, four women
contended that they learned mechanisms to utilize the
resources they had in cheaper ways (learned things to
prevent diseases, save with food by knowing how to buy and
cook cheaper nutritious food, and save in stores by knowing
how to research prices), and three women contended that
they could gain money (by charging for taking blood
pressures and giving injections, or because she was
investing in herself with education and should get money
from this investment, and even because she learned that a
woman should impose herself and conquer a professional
role).
Adriana's contention seemed an example of how the
health knowledge gained can become a mechanism for economic
empowerment. Adriana who is the only one who supports her
family as a receptionist and works for free in social
programs at her church said: "By learning how to prevent
diseases as we did here, we helped ourselves economically."
Sandra's assertion appeared to demonstrate how both
the health and food knowledge gained can become vehicles
for economic empowerment. Sandra who does not work since
her marriage and works coordinating a group of young people
in her church stated:
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This program helped us economically because by
preserving our health, we do not spend on medicines.
This program helped me to have better health through
better eating habits. I eat with less oil and salt.
I also have more dietary restrictions now. I learned
to choose food that is more adequate to my health. I
eat less eggs, red meat and liver.
In the rural site, 11 women claimed to have learned
ways to use in cheaper ways the resources they had (learned
to save with food by knowing to buy and cook cheaper
nutritious food, to use natural methods of birth control so
that buying contraceptives was no longer necessary, and to
do homemade medicines so that buying them in the drugstore
was no more needed), and 1 woman affirmed that she could
gain money (by getting a job in a public health clinic
because she studied in this program).
Like Sandra's, Monica's speech seemed an example of
how the food knowledge gained can pave the way towards
economic empowerment and health well being. Monica is
Catholic and 3 5 years old. She lives with her husband and
her daughter. Monica studied until the 5th grade and is a
domestic worker. She supports her husband, who is now
unemployed, and her daughter. Her husband cannot always
work due to heart problems, but even when he works, the
money he makes is only enough to buy his medicines. Monica
was not involved in community activities before
participation in the program. Monica affirmed: "I learned
to save with food, eating with little oil and salt. I now
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eat in a healthy way. I eat vegetables without salt. I no
longer eat greasy meat, and red meat."
Marcela's contention appeared to be an example of how
both the health knowledge gained and program participation
status may lead to economic empowerment. Marcela is 45
years old, affiliated with the Assembleia de Deus Church,
and lives alone since all of her five daughters are
married. Marcela studied until the 4th grade and works for
a school as a cook. Since she has to spend more than half
of her salary (one minimum wage) in transportation,
sometimes she sleeps in the school because she cannot
afford to go home. Marcela explained:
This program might help in my health and so I do not
need to spend money. Because I am being more
respected in my community due to my program
participation, this program might also help me to get
a job in the community health clinic or even at
another school. I have been trying to get a transfer
to not spend so much in transportation and have not
been able to.
Eleonora's speech seemed to be another example in
which the food and health knowledge gained may be a gateway
towards economic empowerment. Eleonora is 45 years old,
Catholic, studied until the 4th grade, works for profit
cooking in a school and at home and for free in the church,
where she is involved with baptisms. Eleonora used to
participate in a neighbors' association but stopped when
the president was murdered. Eleonora affirmed: "I use less
oil and sugar. I learned to use vegetables peels. I no
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longer buy medicines in the drugstore because I learned
good things for my health using homemade medicines."
The economic dimension of empowerment relating to
saving money seemed to be fostered by class festivities, in
which nutritious aspects of food were mentioned, placing
emphasis on saving money. On these occasions discussions
were relating to not consuming unnecessary amounts of
protein, which is more expensive than other kinds of food
such as vegetables and grains. Still, it was also observed
during class discussions that under certain circumstances
doctors and pharmacies prescribed and charged for
unnecessary drugs and exams. These discussions can
contribute to women's empowerment since they learn that
physicians and pharmacies may be working in the interests
of capitalization. Through the interviews many women
discussed what they learned about homemade medicines
through the program. This class content which emphasized
homemade medicines appeared be a vehicle for women's
empowerment.
It was interesting to note that almost three times as
many women from the rural site than the urban site reported
to be empowered by resources reutilization. This fact may
be associated with the circumstance that rural women had in
average a greater need to save money since their families'
monthly income was 42% lower than in the urban site.
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Economic empowerment never meant to these women that
they would be engaged in productive labor activities, and
this can be associated with their expectations and
experiences of unpaid community activities and the lack of
paid positions for health educators.
Nevertheless, the fact that a few women already
envisioned possibilities of gaining money through this
program shows that these women were in the process of
becoming economically empowered, given their interest in
changing the community health role into a paid one.
Economic empowerment was also not neglected by Margaret,
the coordinator and teacher of the program, because she
explained in a conversation that: "It is a conflict for me
to teach women to be health educators if they will work for
free."
Empowerment In The Political Dimension: The Least Conquered
Dimension
The political dimension was a process that seemed to
be undertaken by very few women from the client population.
As previously mentioned even among the staff population,
two of the new health educators did not appear politically
empowered.
Most interviewed women appeared to be political
unaware. These women seemed to be relying on themselves
individually to think and resolve problems, that collective
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thinking or actions seemed foreign. When these women were
asked about group experiences, individual cases were
reported. The irony seemed to be that these women reported
having a high level of cooperation in their communities but
they were acting individually towards the collective well
being .
With the few exceptions mentioned below from the
client population, the women who had histories of political
struggles either failed to see how health education could
be linked to other political issues they were dealing with
or reported that they did not want to deal with political
issues because their past political struggles had not been
success ful.
A few of the women interviewed (one in the urban site
and three in the rural site) said that through program
participation they became active in struggles for
improvements of the health clinics of their communities.
That there were more women in the rural site than in the
urban site taking part of these activities was surprising
since it did not coincide with Oakley's (1989) findings in
the Americas where urban communities compared to the rural
ones, were more likely to take part in community
involvement for health development. It seemed that for
Liane knowledge and status gained through program
participation enabled collective actions.
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Liane was prematurely retired and works for free in
the community health clinics and hospitals. Liane reported
to have political activities in the workers' parties, in
her Methodist church and in a mayor's office, and affirmed:
Due to this program, I have been going as part of a
committee to the mayor's office to complain about the
community's health clinic because it lacks materials,
and the competence of the nurses and physicians should
be questioned. I am more respected now in the mayor's
office because I take part of this health education
program.
For Bianca and Monica it appeared that collective
actions emerged through knowledge gained but there was a
greater expectation of working collectively with class
mates. Bianca, whose main work activities are in the
community, asking for donations for her church and visiting
patients, and who did not have any past of political
activities said:
I have been visiting my community health clinic in
order to evaluate the appropriateness of vaccination
and if the health professionals are doing their job
well. I am participating in this program together
with other women from the same community so that in
the end we can change things.
And Monica, who is a domestic worker supporting her
family and has not been involved in communities and
political activities before participation in the program
contended:
I am interviewing workers in my community health
clinic. I want to see the exams they do and if this
clinic does follow ups. We (pointing to two fellow
class mates) are taking this program, and we will work
together to improve our community.
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For Katia it appeared that collective action emerged
through knowledge gained and political experience. Katia,
26 years old, does not have religion, lives with her
husband and two children. Katia studied until the 5th
grade. Katia works as a domestic worker and supports her
family. Katia explained that she had been involved in the
past in political activities to support a candidate which
she did not personally like, but she did it in exchange of
a personal favor in order to get her husband an expensive
health device to walk, because he is disabled. Katia said:
"I am evaluating how my community health clinic works as
consequence of my participation in the program."
In addition to these women who are willing to improve
their communities' health clinics, Carolina is said to have
a political activity due to her participation in the
program. Carolina, 21 years old, Catholic, lives with her
parents and 6 of her 11 brothers and sisters. Carolina has
completed high school and has been working as a popular
educator with rural issues for two years. Carolina has
been volunteering to teach children at her church and to
teach adults at a school on Sundays since her high school
years. Carolina seemed to be the an example of using
health and political knowledge to foster collective
actions. Carolina said: "I am coordinating a group of
five women to discuss with them both health and political
knowledge learned in this program in order to exert
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pressure to change the health conditions of the community
where we all live."
And political awareness is likely to have increased
through this program, at least for Clara. Clara is
Catholic, 25 years old, lives with her parents, two
brothers and her daughter. She is currently unemployed.
Clara participates in a women's movement as a vice
president. Clara has completed high school and takes
extension courses in sociology, psychology and social law.
Clara affirmed:
I did not imagine that this program would have this
aspect of making oneself feel more of a citizen. This
program went beyond my expectations. I expected to
learn about health which I did, but now my
expectations are greater since health encompasses a
greater responsibility. Health needs political
interventions. There is a need to report the things
that go wrong in the health clinics and hospitals.
People that have health education should not just
think in terms of a cure, but in intervention by
pressuring the political public power.
Considering the political dimension of empowerment,
the health education program seemed to have promoted this
kind of empowerment for only a few women, most of whom were
already politicized or at least politically aware. This
outcome can be related to the fact that political action is
the last stage to be conquered in this program which is
still on course. This outcome can also be associated with
the fact that despite the teacher's emphasis on bringing up
discussions of concrete situations in which women could use
their abilities to exert political power to change the
health situation of their communities, it may still be
necessary, for the teacher to work together with the women
towards political change by being a model of action.
Finally, this outcome can be due to a common observed way
of solving conflicts by thinking and acting individually,
not in collective ways. For instance, there was a general
consensus among most women interviewed from the client
population that women should have individual autonomy to
solve the conflicts of the Churches' doctrines and problems
related to women's reproductive health such as abortion,
sterilization and sexuality. But very few women
interviewed contended that this was a matter that in
addition to individual autonomy, needs government and
health system changes towards allowing and providing: (1)
abortion and sterilization, {2) health information and
contraceptives to women, (3) incentives to medical research
so that new methods of contraceptives can be created for
both men and women that will seek to take away the
responsibility of contraception from women's hands, as well
as to place a high priority on the health well-being of
users.
Empowerment In The Physical Dimension: Changes In Women's
Sexuality
Empowerment in the physical dimension was for most
women related to having found better ways to deal with
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their sexuality. While in the urban site, eight women gave
indications that participation in the program led them to
control their bodies; in the rural site, nine women
provided such indications. The control of their bodies did
not always mean that women have improved their sexual
lives, since for two women in the urban site gaining
control meant abstinence and saying no to their husbands.
The notion of control of the body appeared in women's
discourses. Adriana, who supports her family as a
receptionist and who works for free in social programs at
her church said: "I began to own my body. It is a growing
process". And Cleuza, who is widowed and lives with the
youngest of three sons, and works in the community giving
assistance to patients at their homes and hospital
contended:
Before I worried that I did not have sexual pleasure
and felt I was ill. Now, I know it was foolish to
feel I was ill. I learned to deal with my sexual
pleasure and to feel good about it. Before I felt
ashamed about my sexual desire. Now I learned to feel
in control.
The awakening of women's need for their own sexual
pleasure in relationships was also reported. Carmem's,
Bianca's, Gabriela's and Miriam's contentions below seem
examples of this awakening. Carmem is Methodist and 3 8
years old. Carmem lives with her husband, her four
children and a niece. Carmem sews dolls for a living and
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does not work in the community. She has studied until the
5th grade and affirmed:
I did not have any concerns related to sexuality
before this program and now I have. Now, I no longer
think it is positive to have a partner who just thinks
of his own sexual pleasure, because it affects the
relationship in the long run. I fear to be alone now,
without someone to share pleasure and love, but I will
face it if it has to happen. I no longer have a
sexual life with my husband although we live in the
same house. He started to drink too much for some
time now. I grew up, he did not. I grew up as a
human being, as a woman. Then, he lost his dominance
over me that his wife had to be with him sexually.
Bianca, whose main work activities are in the
community asking donations for her church and visiting
patients explained:
1 used to think that sex was only for men's pleasure.
With this program I learned that it is for my pleasure
too. I started to invite my husband to have sex,
where as before only my husband would invite me. I
used to be suffocated in our relationship, but now I
feel owning my body.
Gabriela is 39 years old and lives with her male
partner and three children. Gabriela studied until the 5th
grade. Gabriela works in sales and used to work in
political activities but stopped because it is hard for
people to get together and fight for a cause. Gabriela
contended: "I learned to have more freedom in my sexual
life by saying yes and no and exactly what I want. Before
this program I never made clear to my male partner what I
wanted."
Miriam is 48 years old and studied until the 5th
grade. Miriam lives with her husband and two children.
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She works pressing clothes. Miriam also works for free
cleaning the church and taking care of children. She said:
"I decided to assume that my sexual life was not good and I
eliminated it. I used to live over my husband's dominance.
I feel better to assume to myself that our relationship is
not good. 1 1
The psychological dimension and the physical dimension
of empowerment sometimes appeared as interdependent in
women's speeches. Women's ability to discuss sex appeared
as reflecting both psychological and physical empowerment.
This ability seemed to be present in the speeches provided
by Helena, Katia and Monica. Helena who works with her
husband in agriculture and is the secretary of a neighbors'
association stated:
I was more reserved since I had fear to talk with
people. Now, I know how to defend myself when others
are mean to me. I talk more with my kids. I tell
them the truth now. I used to tell them half-truths.
I was more reserved with my mother and father too. I
am talking more with them and even teaching my sister
who is getting married about sexuality. Now, my
father opened up to me. With my opening up about
sexuality, my parents opened up to me regarding their
sexuality.
Katia works as a domestic worker and supports her
family. Katia has been involved in political activities in
exchange for a personal favor. Katia contended: "Today, I
do not have too much inhibition as I did before when I
talked about sex. Before, I was embarrassed. I am much
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more sure when I talk about health too. People now listen
to me and give me attention."
Monica, who supports her husband and daughter as a
domestic worker explained: "My sexual life has changed
with this program. My husband and I started talking. We
are learning to know each other which has affected
positively our sexual life. We lost our shyness to talk
about sex too."
In only two instances, women reported having improved
their physical conditions through the program (a breast
cancer situation and an uterus infection case) . Except for
these two cases, all the other women did not have any
physical problems regarding their reproductive health
during the time they have been in the program. Some women
reported having had problems before the program.
The health education program appeared to have
contributed to women's physical empowerment by discussions
and reflections women had of reproductive health taking
into consideration issues such as sexuality, women's
rights, gender roles, need for affection in relationships
with male partners, contradictions of religious affiliation
and church participation in the emancipation of women. It
is important to note that the group dynamics in which these
discussions unfolded were initiated with examples of
anonymous individuals. It was observed in classes that
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most women, after discussing these anonymous individuals,
were eager to share their own experiences.
The program also promoted empowerment of women's
physical conditions by discussions of women's and men's
reproductive health issues and through the requirement that
all women--with the exception of the adolescents
participant women who were not sexually active--had to
visit a gynecologist annually.
Desire To Learn Takes Priority Over Health. Improvement
The client population perceived improvement in their
health and reproductive health status. Most women
interviewed (13 from the urban site and 11 from the rural
site) had stated that their participation in the program
had improved their general health. Reasons given for
improvements were related to mental and physical well
being, and not the social well being. Interviewed women
from the urban site have learned to eat better, practice
exercise, deal better with psychological issues, treat skin
diseases and diabetes. Interviewed women in rural site
acquired knowledge in controlling high blood pressure,
dealing with psychological problems, treating circulation
problems, eating better, practicing exercises, and doing
home medicines. As mentioned before, 17 women (8 in the
urban site and 9 in the rural site) improved their
reproductive health.
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Although women were enthusiastic about their own
health improvement, the quest for personal health well
being was not the major concern for the client population
to take part in the program. In both sites most women (11
in the urban site and 12 in the rural site) joined the
program because of their desire to learn, and some of these
women further reported their wishes to practice what was
learned in their communities (by teaching others or by
offering their health services).
Reproductive health and health problems were reported
on very few occasions as being the reason for joining the
health education program. In the urban site, two women
stated that they joined the program hoping to improve their
health (one of them for experienced back problems and the
other had breast cancer). In the rural site, one woman
stated that she came to the program to improve her health
due to a circulatory problem.
All women interviewed, regardless of perceived health
improvement or not, were unanimous in stating that they
were willing to continue their participation in the
program. Still, in classrooms, listening to informal talks
among the client population and talking with them, it was
perceived that their enthusiasm for participating in the
program was related to their discoveries that they could
learn, and feel valued in their capacities (learning,
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teaching, offering health services) by themselves and by
others.
Community Participation: Women's Unstructured Initiatives
It was analyzed Rifkin's {cited in Stone, 1992)
proposed five levels of community participation, wherein
community members evolve gradually from receiving health
services and health education; taking part in program
activities through resource donation (money, land or
labor); assuming managerial responsibility for
implementation; monitoring and evaluating projects; and
taking the lead in program planning and needs assessment.
In regard to these five levels, the first impression
was that the level reached by the client population was
weak, remaining little beyond the first one: namely, the
one in which community members received health education.
Nevertheless, because this health education program
included practices outside the classroom, it can be said
that the client population's community participation
existed more as unstructured initiatives. All women
interviewed in both sites were discussing some of the
health contents learned in the program, individually or in
groups of two or three, in their communities. Still, many
women (nine in the urban site and eight in the rural site)
were practicing informal needs assessment of their
communities' health problems. Furthermore, many women were
187
already developing a health community role due to their
participation in the program insofar as they were being
requested to practice what they learned in the program by
offering unpaid health services to their families and
communities. In the urban site, taking into consideration
the women interviewed, seven started giving health advices,
five began to take blood pressures, one started taking
temperatures, one became responsible for a homemade
medicine drugstore, and one started to donate medicines.
In the rural site, considering the women interviewed, three
began to provide health advices, eight started to take
blood pressures, two began to give injections, and one said
that she was taking temperatures. Finally, as previously
mentioned four women were taking actions for improvements
in their communities' health clinics.
There were signs that the level of community
participation reached by these women might increase.
First, many of the women interviewed planned to be
coordinators of health education programs in the near
future. Second, the existence of new health educators
constituted by women who had been client population
represents 'successful histories' of women who learned to
operate in more structured initiatives in their
communities. Indeed, when the new health educators
interviewed were asked about their participation, they
performed at much higher levels of participation than the
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client population. Third, most women interviewed from the
client population had other kinds of community
participation not related to the health education program.
Community activities are important for two reasons.
The first reason is that it was emphasized by the staff of
MARIA directly involved with the advertising and selecting
of the client population of the health education program
that women's eagerness to take part in the program was
related to past works developed in these communities with
the help of the personnel of MARIA, when credibility with
the client population was established. Second, three of
the new health educators asserted that women who were
client population and had histories of community activities
were the most prone to becoming new coordinators of health
education programs.
Implementation Of The Health Education Program
According to some women of the staff of MARIA, the
health education program studied was known previously to
operate within the realms of MARIA and was considered a
program that met MARIA'S aims in their work with
communities. The selection of the sites for the health
education program were in communities that MARIA has worked
with. In the urban site, personnel from MARIA who worked
with women's groups and base communities advertised the
program to the women from this community. Likewise, in the
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rural site, another member of MARIA'S staff working in a
project with women and land, advertised the program in the
rural community.
From the perspective of the staff of MARIA it seemed
that a health education program emphasizing health and
sexuality was a felt need of poor women in general, but
other needs were also equally important. This is so
because MARIA has several programs for poor women,
addressing diverse needs. And in two of MARIA'S meetings
open to the public, emphasis was given to the several needs
poor women have. From the perspective of the client
population, it appeared that the health education program
was a felt need since all people (not only the women
interviewed) discussed in the classes their enthusiasm
about it because they learned essential things to improve
their lives.
Male Partners' Reactions To Women's Empowerment As Diverse
Three women from the urban site and five from the
rural site did not have male partners while taking part in
the health education program. In general, male partners
did not react negatively to women's participation in the
program. In the urban site, only three women reported
negative reactions from their male partners and in the
rural site only one woman reported negative reactions from
her male partner. The male partner's negative reactions
190
seem to be related to women's empowerment in the
psychological and cognitive dimensions. When some women
seem to be changed by becoming more assertive of their
rights some of their male partners reacted negatively by
devaluing women's efforts or ways of being. Miriam who
works pressing clothes and for free cleaning the church and
taking care of children reported the following negative
reaction of her husband:
My husband just thinks of bad things. He thought I
was not competent to learn. When I started to learn,
my husband began his conflict, but did not accept my
change, of becoming a free, independent women who is
growing, no longer performing domestic works which
are, by the way, not valued. My husband wanted a
woman always in humiliation to him. Today I do not
care to be accepted by my husband.
Carmem also experienced a negative reaction from her
husband. Carmem sews dolls for a living and does not work
in the community. She reported her husband's reaction as:
He does not like my attending the program. My husband
already came three times to see me in this program.
But I learned to respect myself as a woman. He
complains that I come here to do nothing. He also
complains that I went back to school. I do not care
for him anymore. I learned to do what I want. I want
to help my children learn a new culture where women
are not submissive to men instead of learning the old
fashioned culture that my husband values.
Gabriela works in sales and used to work in political
activities but stopped because it is hard for people to get
together and fight for a cause. Gabriela said in regard to
her male partner's reaction:
My male partner questions himself if he should have
allowed me to participate in this program because he
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thinks I changed a lot, becoming very independent.
With this program I became interested in having my own
schedule and autonomy and my husband feels threatened
with my independence. All men, irrespective of social
class, want to dominate women.
And Adriana who supports her family as a receptionist
and works for free in social programs at her Church
explained that her husband had the following reaction:
My husband does not support me to come to this
program. My husband thinks it is silly to be taking
classes. He believes its is just an excuse to leave
the home. He tells it is not worthwhile to study
something that I will not apply working later.
The positive reactions of most male partners were
related to the fact that these partners saw these women
empowered in the cognitive dimensions since the women were
assumed to be learning something valuable in terms of
health for the women themselves, for the women's families,
and for these women's paid or voluntary work in the
communities. It seemed that no conflict emerged here
because male partner's positive reactions can be associated
with women improving performance in gender roles either at
home, work or community.
Clara, who lives with her parents, two brothers and
her daughter, is currently unemployed and participates in a
women's movement as a vice president affirmed:
My male partner likes my attending the program because
when he has doubts of health issues, he asks me. He
even likes to make copies of the copies I get in this
program. He also likes because when I have a health
problem, the program is a place for me to talk.
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Cassandra works as a domestic worker supporting both
her husband and one of her five children. Cassandra works
for free in her community in her church and in a drugstore
making homemade medicines. Cassandra said: "My husband is
happy because I am learning how to make medications. He
complains of school work and church activities, but not of
this health education program. He complains but I do
everything."
Ana is 34 year old, lives alone but has a daughter
from a previous marriage. Ana completed high school and
works going from home to home spreading pesticides. Ana
does not have any community activity and contended:
My male partner likes this program because it is
related to health so that it can broaden the knowledge
and help. He does not object to me discussing
sexuality in this program, but he does object if I
discuss it with other friends.
Lelia is Methodist and 43 years old. Lelia studied
until the 4th grade. Lelia lives with her husband and two
daughters. Lelia does not work for money and does not have
community activity, but she helps her sister to take care
of her children. Lelia said: "My husband likes what I
learn in this program because I tell him, our children,
neighbors and parents."
Marta's case is perhaps the clearer example of a
situation where her husband's positive reaction is only
related to perceiving Marta gaining skills to improve her
gender role. Marta is 28 years old, Catholic and studied
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until the 8th grade. Marta supports her husband and two
children by working in sales. She also works for free in
the church's catechism and said:
My husband likes me to take part in this program
because he works in a drugstore, so it is closer to
what he does. But he complains that the teacher is
feminist. He complains because now I believe a woman
needs to have her profession. Before I was in doubt.
My husband never liked me to work or study outside our
home. But because his job is unstable--now he is
unemployed, I have been trying to negotiate with him
to work and study and this program gives me strength
for this negotiation.
In two instances, the male partner's reactions
appeared associated with women's empowerment in both the
psychological and cognitive dimension. Through this
empowerment male partners valued women's assertiveness.
This was the case of Helena. Helena, who works with her
husband in agriculture and is the secretary of a neighbors'
association contended: "My husband feels safer because I
feel safer. Before we would always run to the hospital and
now there is lot of things that I learned that we do not
need to run and then we feel safer."
And Bianca also experienced a positive reaction from
her husband. Bianca, whose main work activities are in the
community asking for donations for the church and visiting
patients explained:
My husband likes my participation in this program
because he thinks I learned to liberate myself. He
thought, as everybody else that I was dumb. I always
liked to help other people, but then people used to
give orders to me. Now I still like to help people
but when I want, not because they give orders.
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In the other two cases, the male partners' positive
reactions seem to be associated with the women's physical
empowerment. On these two occasions women learned to
understand more about their bodies and to discuss sex.
Josepha is one of these examples. Josepha, whose basic
activities are sewing and teaching sewing for free, has
already changed from having a Catholic religious
affiliation to have a Methodist one. Josepha said:
My husband's reaction has been wonderful to my
participation since he gives great support. In this
program, I learned to take better care of my body, to
feel happier and that to talk about the body and about
sexual pleasure are not sins. I had Catholic
education and thought that many things were sins. I
started to relate better with my husband when I
started to talk about sexual pleasure. To talk more
with him in general helped us.
And Carminda is another example of a positive outcome
related to physical empowerment. Carminda is Methodist and
studied until the 6th grade. Carminda lives with her
husband, children, mother, sister and nephew. Carminda
sews for the Brazilian Carnival schools and has no
community activities. Carminda contended:
My husband saw the improvement in my relationship with
him and with our kids. I learned to accept and
respect people from my family as they are instead of
wanting to change them. My husband used to make sex
only for his own pleasure. He did not talk with me
about sex because he was raised on the farm. After I
started to learn about my body and talk with him about
sex, I began to have sexual pleasure again in our
relationship.
Because most partner's reactions through program
participation are related to perceiving women improving
195
their gender roles, the extent to which some of the women's
themselves had this same perception or whether they used
this possibility as a good excuse for participation should
be questioned.
Still, the issue of women's self selection can also be
raised here. Not only there were eight women in this
population who did not have partners and should be freer to
participate than other women, but there were women whose
male partners seemed to be very supportive. Even the women
who had conflicts with their male partners for program
participation have participated regularly, once a week for
over a year.
Religious Affiliation As Not Determinant Of Opinions
Related To Abortion And Sterilization
It cannot be said that the religiousness of the women
interviewed played a major role in their decision to favor
or to be against abortion or sterilization. The
religiousness of the women interviewed was varied, but
their opinions in favor or against abortion could not be
inferred by this diverse affiliation. In the urban site,
seven women (three Catholics, two Methodists, one without
religion, and one affiliated with Congregagao Crista no
Brasil) were in favor of abortion, while six women (four
Catholics and two Methodists) were against it. In the
rural site, three women (three Catholics) were in favor of
196
abortion, eight women were against it {two Catholics, four
Methodists, one without religion and two from the
Assembleia de Deus) and one Catholic woman said she had no
opinion. In regard to the five women from the staff
population, only one Catholic woman was against abortion.
Sterilization was much more favored than abortion by
the women interviewed. In the urban site, 11 women were in
favor of sterilization (6 Catholics, 3 Methodists, 1
without religion, and 1 affiliated with the Pentecost
Protestant Churches named Congregagao Crista no Brasil) and
2 were against it (1 Catholic and 1 Methodist). In the
rural site, 10 women were in favor of sterilization {4
Catholics, 3 Methodists, 1 without religion and 2 from the
Assembleia de Deus Church), 1 Catholic woman and 1
Methodist women were against sterilization and 1 Catholic
woman said she had no opinion. Considering the 5 women
from the staff population, only 1 Catholic woman reported
being against sterilization.
Health. Education Program Changing Women's Points Of View
In some instances, the program was cited as having
changed some of women's views regarding abortion and
sterilization.
Bianca, whose main work activities are in the
community asking for donations for the church and visiting
patients contended: "I was against abortion due to the
197
preaching of the Church. With this program, I realized
that there are situations in which there is need for it.
The body belongs to the person."
Eleonora is Black, works by cooking at home and at a
school", and works for free at the church. She contended:
Before my participation in this program and in a group
that studies Black's and women's discriminations in
the political, religious and home spheres, I was in
favor of abortion and sterilization. Now, I believe
there is no need. I think my religious consciousness
has grown and I do not accept abortion. Yet, I am not
in favor to have children without conditions. I am
not in favor of abortion because there are means of
contraception that do not kill. I am not in favor of
sterilization because Black people are getting more
sterilized than the White. Everything that is bad
falls on the Negro race (drugs, sterilization). I
think that there are some people interested for the
Negro race to stop growing. There are 13, 14 years
old Black girls being sterilized and I cannot be in
favor of that.
While Eleonora's speech is different than Bianca's
because the former gave a more detailed account of her
opinions and discussed sterilization in addition to
abortion, both Bianca's and Eleonora's opinions seemed to
have been changed because they reflected upon their
religious education and were exposed to different
circumstances surrounding the issues of abortion.
Conflicts Of A Liberation Notion Of Reproductive Health
With Brazilian Cultural Norms
Some of the interviews are explicit in detailing the
conflict of empowering women in reproductive terms in the
198
context of Brazilian cultural norms. Linda is originally
from Canada and has been a nun for several years doing
missionary activities and is a new health educator. She
said:
In Brazil the poorer the women, the more submissive
they are. Women here are very oppressed, enslaved by
their children and husbands. Women here do not even
know the possibilities of fighting for their rights,
especially the ones who are domestic workers. They
fear very much what people think.
Margaret, the coordinator and teacher of the program
who is North American and has worked over two decades in
Brazil contended:
This is a patriarchal country. Sex within marriage is
for men to enjoy and women to endure. Because it is a
Catholic country, women's self-esteem comes from
reproduction. There is a double morality in Brazil.
Men can have sex outside the marriage and women are
considered prostitutes if they do so... This program
brings challenges to women. When you teach women'
issues and reproductive health, they question their
doctors and husbands and they learn their rights. If
this program does not cause conflict to women, it did
not reach them.
It was interesting to note that the conflict of a
liberation notion of reproductive health may be present in
the staff population. Laura, one of the new health
educators who is Catholic and was against abortion and
sterilization affirmed: "In Brazil it is terrible because
there is too much sexual freedom. People meet each other
and soon are in bed."
199
Other themes not related to abortion or sterilization
discussed in the health education program were raised as
being conflictive to the client population's upbringing.
Clara lives with her parents, two brothers and her
daughter, is currently unemployed and participates in a
women's movement as a vice president. Clara stated:
This program is against values that my family tried to
instill in me, but not that I had. I do not think
that girls should not know about menstruation as it
was hidden from me by my mother who now wants me to
hide it from my daughter. I always thought women had
to have pleasure in sexual relationships but I was not
taught that. Still, I always thought men and women in
a relationship had to respect one another in their
search for sexual pleasure, but I was not taught that.
Cleuza, who is widowed and lives with the youngest of
three sons, and works in the community giving assistance to
patients at their homes and hospital explained:
In the beginning I was embarrassed to take part in
this program because there was a lot of things related
to sexuality and to a woman's body that I did not
know. My parents never taught me anything and I went
up to the 3rd grade only.
Carminda, who sews for the Brazilian Carnival schools
and has no community activities stated:
You know, my religious education cannot lead me to
think that prostitution and homosexual behavior are
natural as my peers in this program view them. I
learned that they were sins. God wrote it very clear
in the writings that they were sins. Sex is to be
lived as a pure thing and not as only for pleasure.
The discussion of the above conflicts demonstrate that
a liberation notion of reproductive health cannot easily be
accepted by women where cultural norms diverge from this
200
notion. Acceptance of this notion may occur in some areas
and not in others. For instance, Carminda, who regained
sexual pleasure within her marriage is the one who is
against sexual pleasure as an end in itself in other kinds
of relationships.
Personal Conflicts Emerged Through Program Participation
Women reported on some occasions the conflicts they
endured while participating in this program. It was noted
that some women were sad because their male partners did
not change as they did. Carolina, who has been working as
a popular educator with rural issues for two years and also
volunteers teaching children at her church and adults at a
school said:
I think that the religious preaching of virginity is a
way to control a woman's body that has existed for a
long time. Because of this program, I feel more
advanced and no longer believe in this preaching. The
problem is that my boyfriend is more backwards than
myself.
And Cassandra, who works as a domestic worker
supporting both her husband and one of her five children
and works for free in her church, as well as in a drugstore
making homemade medicines affirmed: "With this program I
learned about sexuality, but my husband did not. So no
change happened. My husband is too rude and drinks. Then,
I feel like not being willing towards him."
201
Other women reported some anxiety when they realized
that they should act in different ways than they were used
to. Gabriela, who works in sales and used to work in
political activities but stopped because it is hard for
people to get together and fight for a cause explained:
Being part of this program and another one about woman
and citizenship I started to feel in conflict with my
own changes. My male partner realized that I was not
so dependent on him anymore. I did not even notice at
first that there was too much of a change in myself.
Yet, now I realize that I also used to repress my
children and I feel bad about it.
Clara, who lives with her parents, two brothers and
her daughter, is currently unemployed and participates in a
women's movement as a vice president stated:
Men suffer too much with the history of orgasm. Women
do not suffer because they can fake. I never felt
shy, but I began with this program to open up to men's
problems. I try now to talk with my male partners.
Before, I used to think that they should resolve their
problems alone.
Other women reported sadness over the fact that they
were learning too late to change their lives and that they
wished they had participated in this program much earlier
in their lives. Lelia, who does not work for money and
does not have community activity, but helps her sister
taking care of her children affirmed: "I would like to have
participated in this program 20 years ago to have benefited
more from it.1 1
Liane, who was prematurely retired and works for free
in the community health clinics and hospitals explicated:
202
With this program I learned that dialogue is necessary
in a relationship. I got married without any
affective guidance, just the religious one. If I had
participated in this program before, my life would
have been better. My husband was like an animal who
wanted to have sex without any concern for my sexual
pleasure. He used to come home just to have sex, to
get money and to beat me. He also had children with
other women. Because of this marriage, I never wanted
a new marriage and I have been separated for 17 years
now. I now work a lot and do not worry about my
sexual life. I have a fiancee, but I do not want to
get involved sexually with him. It is fine as it is.
He gives me the love I want from a distance.
The personal conflicts women reported to be
experiencing in this program evince women's frustrations
and women's awareness of the need to change their personal
behaviors.
Conflicts Of The Program Being Situated In The Rooms Of
Churches
Some women expressed conflicts which others had over
the content of women's issues and sexuality being discussed
through the health education program within the rooms of
the churches. Josepha, whose basic activities are sewing
and teaching sewing for free, and who has already changed
from having a Catholic religious affiliation to have a
Methodist one said:
I might have to leave my Methodist Church which
suggested that I take this health education program
because I cannot teach sexuality there. The Methodist
Church which referred me did not know what I was going
to learn, they thought I was going to learn only about
health issues, not women's issues as well. Anyway, I
have another church that has already accepted me to
teach there.
203
Antonieta is 16 years old and Catholic. Antonieta
lives with her parents, brother and sister. She works
during the day selling ice cream with her father. She
studies at night and is in the 9th grade. Antonieta
teaches religion in the church. Antonieta affirmed: "A man
from my church was against this program because he thought
it was absurd to discuss the women's bodies issues within
the Church's realms."
Julieta, who is a new health educator and whose family
income can be considered from an upper class family said:
I suffered with the new priest that arrived in my
Catholic Church while I was teaching my first health
education program. This new priest just taught
materialistic things, such as the rebuilding of the
Church. He did not value social programs like mine
and wanted to eliminate them. This priest also did
not like the fact that I taught the program without
him having a say in it. I became very disappointed
with the Catholic Church because it ordained a priest
like him. I do not know if I will have energy to
teach a new class after this experience.
Even though these above conflicts were reported, the
program studied had successfully operated once a week for a
year and a half in the rooms of two churches. The two
rooms of these churches can be thought of as self-selected
social spaces because of the credibility that was
previously established with the populations allowed the
program to exist. Thus, this suggests that in some
occasions it is possible to overcome conflicts and to
attempt women's empowerment in social spaces not commonly
thought of as spaces for social change.
204
The Brazilian Health System Perceived As Precarious
Even though there were no health services provided by
the health education program, the client population
discussed with the coordinator the: health services to be
sought in the Brazilian public health system, ways to deal
with the problems of the system, what could be changed and
what they could do as citizens to foster change.
Considering the women interviewed in the urban site,
10 of them perceived the Brazilian health system as very
precarious, 2 of them emphasized that some health
institutions were good, while others were precarious, and 1
woman emphasized that the public, not the private health
system was very good. Considering the women interviewed in
the rural site, 6 of them affirmed that the Brazilian
health system was precarious, 4 of them contended that some
of the Brazilian health institutions were good, while
others were precarious (1 of these women emphasized that
only the private institutions were good), and 3 women
emphasized that the Brazilian health system was very good.
In both sites, the complaints these women had about the
health system was related (in hierarchical and descending
order of mentioning the problem) to: precarious medical
treatments, a government that does not care about health
issues, the lack of medication health institutions had,
time spent for treatment, the emphasis on medical
specialization care instead of primary health care,
205
patients' fault in dirtying the hospitals, and lack of
adequate medical information. In regard to the staff
population, all women perceived the Brazilian health system
as very precarious. Among their explanations for the ills
of the system, the women pointed out the: lack of material
and human resources, bad working conditions, poor pay for
the doctors, poor education the doctors and nurses
received, the division of private and public systems where
only the former was good, bad medical treatments, a
government that doesn't care since in the Ministry of
Health the people in charge were not always involved in
health professions, and were subject to corruption.
Women's Health Decision-Making: Another Path Being
Undertaken
Most of the interviewed women from the client
population reported that their medical encounters changed
after their participation in the health education program.
Thus, women's health decision-making was another path being
undertaken by these women.
*
Among the women interviewed m the urban srte, 10
reported that their medical encounters had changed, 2 said
that their medical encounters had not changed, and 1
declared having not been to a physician since her
participation in the program. Among the women interviewed
in the rural site, 8 contended that their medical
206
encounters had changed, 2 declared that there was no change
in their medical encounters, and 3 affirmed that they had
no medical encounter since the program had started. In
both sites, the changes were related (in hierarchical and
descending order of mentioning the change) to the fact that
these women started to question the physicians, to talk
more with their physicians, to feel more at ease in their
medical encounters, to know how to explain and understand
more the issues being talked about and to feel they had
control of their bodies.
Women's health decision-making seemed to be related to
psychological, cognitive and physical empowerment. Clara
and Gabriela seemed to be examples of how the psychological
empowerment influenced medical encounters. Clara, who
lives with her parents, two brothers and her daughter, is
currently unemployed and participates in a women's movement
as a vice president stated said:
My relationship with my physician has changed
somewhat. With this program I talk more and I learned
to question. I have more confidence in the things
that I say to question him. Even though my physician
says that he is the only one who has knowledge, I
questioned him about that.
Gabriela, who works in sales and used to work in
political activities but stopped because it is hard for
people to get together and fight for a cause contended:
My medical encounters changed because now I ask when I
feel there is something wrong. I was misdiagnosed in
one of my last visits to a gynecologist and I went for
a second opinion. It appeared that the gynecologist
207
who misdiagnosed me used to explore patients giving
wrong diagnosis. She was making money from expensive
health exams.
Claudia and Josepha are likely to be cases where their
medical encounters appear to have changed due to women's
cognitive empowerment. Claudia, who has university level
of education and teaches special education and religion in
a school affirmed:
My medical encounter has changed because I have more
knowledge about women's health issues. So, it became
easier to speak with a doctor, to listen to him, and
to read between lines. We have to be smart to deal
with doctors.
Josepha, whose basic activities are sewing and
teaching sewing for free, has already changed from having a
Catholic religious affiliation to have a Methodist one.
Josepha said:
Before this program I did not talk with the
physicians. I did not even read the drugs guideline.
Now I question everything. Before I would think that
the knowledge was only the physician's responsibility.
Now with the knowledge gained in this program I think
the responsibility is mine too as a patient and a
health educator.
Gilda and Lelia seemed to be examples of situations
where their medical encounters were changed due to their
physical empowerment. Gilda is Methodist and 63 years old.
Gilda has never gone to school. Gilda is widowed and lives
with her mother and two sons. Gilda does not work for
money but receives a pension from her husband who died.
Gilda visits homes in the community to ask for donations
for her church and contended:
208
My second visit to a gynecologist in my life was
required due to my participation in this program. It
was different than the first because now I do not feel
so ashamed, so locked and so difficult. It might be,
for this new feeling of seeing things related to
sexuality in an open way that I felt at ease with this
visit. Now, I also see the need for going to a
gynecologist.
Lelia does not work for money and does not have
community activity, but she helps her sister to take care
of her children. She contended:
I learned in this program to know my body and
sexuality. I was shy before. My gynecologist noticed
the difference since I was relaxed in my last visit. I
did not tell her I was in this program.
The above accounts of changes in medical encounters
reflect women's initiatives, not the physicians. It was
not surprising that these changes seemed to reflect only
women's initiatives. In only two cases women reported that
their physicians were aware of women's participation in the
health education program.
However, it was surprising the high incidence of
reported changes in medical encounters since most of these
women were poor and should not have similar background with
their physicians's who are likely to be mostly from
Brazilian upper classes.
Findings Interconnectedness
There seemed to be some interconnectedness among the
findings. On a few occasions, women's speeches evinced
that the psychological, cognitive and physical dimensions
209
of empowerment shared interconnectedness. Psychological
empowerment was perceived as linked to cognitive and
physical empowerment. Likewise, cognitive empowerment was
viewed as associated with psychological and physical
empowerment. Still, physical empowerment was seen as a
consequence of either psychological and/or cognitive
empowerment.
But in many of women's discourses there were no
perceptions of interdependence among different dimensions
of empowerment. For instance, Miriam, Carmem, Gabriela,
and Adriana who suffered negative reactions from their male
partners for program participation did not relate these
reactions to their physical empowerment (which they stated
had occurred) but to their psychological and/or cognitive
empowerment. These women's lack of association of their
physical empowerment might mean that it had no connection
with their psychological and cognitive empowerment or even
that these women did not perceive or report this
connection.
It is also possible that women's lack of association
of empowerment connections on some occasions versus the
association in other circumstances might also mean that a
dimension of empowerment can be interdependent with other
dimensions in some of women's change processes but not in
all of them.
210
In this study, there also appeared to be an
association of male partners' reactions to the outcomes of
women's empowerment in this program. Since most women were
not empowered in the economic and political dimensions,
most male partners' positive reactions may be linked to
perceiving that the patriarchal relations of power were not
threatened. Perhaps for a greater threat to be perceived,
it is germane that women become economically and
politically empowered.
Still, there appeared to be an association with
women's self-selection for program participation and the
site selection. It might not be by chance that women from
the rural site compared to the women from the urban site
seemed to be and become more politically empowered. The
women from the rural site tended to experience more layers
of oppressive conditions which in turn increased their
potential for changing the status quo.
211
CHAPTER V
Discussion
Empowerment outcomes encountered
On the one hand, the findings were not related to an
objective measure of change but to women's self reported
perceptions. Thus, these findings can be questioned as to
whether change occurred, since women's perceptions of them
might not be always accurate. On the other hand,
methodologies to study women's empowerment might not ask
for objective measures because changes or lack of them seem
relevant if they are perceived by the women who report
them.
Given that these findings were valid accounts of
women's changes, all Brazilian women who were interviewed
as client population participating in the activities of the
health education program studied appeared to be empowered
in at least in two dimensions. All women reported to be
empowered both in the psychological and the cognitive
dimensions by stating that they were relating better with
themselves and/or others and exerting their abilities to
learn. Most of these women also seemed to be empowered in
the physical dimension since they reported having learned
to deal better with their sexuality and a few have improved
their health conditions. Many of these women are likely to
have been empowered in the economic dimension when this
meant making better use of their resources, but none of
212
these women seemed to have become empowered in the
economical dimension when it signified becoming involved in
productive labor activities. A few women thought of
possibilities of transforming the community health
activities into paid ones and for that they could be
thought of at least as being aware of economic empowerment.
And only a few women appeared to have increased their
empowerment in the political dimension--by attempting
through the knowledge and status gained in the program--to
intervene in their communities to change the state of
affairs. On a few occasions, women's speeches evinced the
interdependence of empowerment dimensions.
In addition to individual change, gender empowerment
seeks the change of uneven distribution of power between
men and women in relationships and institutions
{Stromquist, 1993). Some women from the client population
were able to promote change in some of the relationships
they had with their male partners and physicians.
Contrary to the expectation that male partners would
react negatively to women's empowerment if it was achieved,
heterogenous reactions were reported by some of the women.
The male partners' reactions were reported to be positive
in situations where women were perceived as more assertive,
the sexuality of the couple improved or women were assumed
to be improving their reproductive role to take better care
of themselves, the family and the community. The negative
213
reactions from male partners were reported to have occurred
when women were seen by them as having more autonomy or
more assertive of their rights or threatening their male
dominance.
Most women reported changes in their medical
encounters. These changes related to women questioning
their physicians, talking more with them, feeling more at
ease in the encounters, knowing how to explain and
understand more the things that were being talked about,
and feeling they had control of their bodies. The high
incidence of these changes among the women was surprising
given the fact that the majority of these women were poor,
and they did not share any similarity to the physicians's
background--who are assumed to be mostly from middle or
upper Brazilian classes. The similarity between patients
and physicians has been contended to be a factor that
promotes women's ability to became active in the medical
decision-making process (Cockerman, 1993, cited Bouton et
al.)
Social institutional change was not reported. But
perhaps this might still occur through the participation of
women in some organizations. Some women said that they
became more respected or heard in organizations they were
involved with due to participation in the program. And a
few women reported that they began to be active in
214
interventions that they thought could effect change in the
health clinic communities.
Even though most women were very aware of the barriers
the Brazilian health system could present for the general
population to provide basic health needs, very few women
voiced changes in government policies or in the health
system that might be needed, and that both could undertake
in order that women can live a liberating notion of
reproductive health, such as being allowed to be sterilized
or have abortion.
The program's features
The health education program studied leaned towards
the characteristics of a comprehensive approach of primary
health care by offering a full range of health themes which
involved the physical, mental, spiritual and social
dimensions. In regard to the reproductive health content,
the health education program had a liberation notion of
reproductive health employed in this study. The program
also had the agenda of empowering its participants using
health education as a mean. The program sought for the
client population to take the lead in health decisions and
programs in their communities by becoming community health
educators.
Because the coordinator defined women's empowerment
and reproductive health in terms of objectives and intended
contents broadly, it was difficult at first to infer the
extent to which the program addressed strategic gender
needs and the liberation notion of reproductive health
before observations took place. Only through class
observations was it possible to be assured that in this
program, the sought after empowerment addressed both
individual and social changes and that the kind of
reproductive health notion it emphasized was liberating.
The actual contents discussed in classes provided practical
and strategic gender needs as defined by Molyneux's (1985).
Thus, it was provided knowledge and skills about
reproductive health and sexuality, that could develop women
as individuals; and the program also questioned how to
change the patriarchal relations of power imposed on women
by society in general and particularly by the family and
the Church. Therefore, the program studied fulfilled the
features of a popular education program which according to
Fink (1992), aimed at individual and social changes.
Empowerment was sought through a combination of
diverse methodologies. At the classroom level,
negotiations happened among teacher and students, without
the teacher losing her authority. The health education
program had both broad and specific contents that were
transmitted by the teacher. These themes were discussed by
the client population in light of their own experiences.
The teacher shared all points of views of a given content,
216
pointing out her own criticisms and preferences over the
content discussed, and supporting students whenever they
were critical of her or other fellow students' criticisms
and preferences. The teacher used diverse methodologies to
promote students' self confidence and independence.
At the program level, the health program followed
Wallerstein's and Bernstein's {1988) recommendations:
begin with the problems of the community; utilize active
learning methods, emphasizing when possible field work
practice; foster community participation so that community
members can realize their own needs; and provide
information, skills and reinforcement.
The program addressed the need for collective action
through the suggestions that all participants should teach
health education in their communities and exert political
pressure in the communities health clinics.
Communities activities: Are they empowering to women?
Due to participation of the program, all participant
women were teaching health education in their communities
and only a few were beginning to exert pressure to change
their communities health clinics. Most client population
did not seem yet to be political empowered.
Community activities not related to the program were
reported by most women. These activities were unstructured
and unpaid. Although these activities seem to have the
217
prospect of becoming more structured and health oriented as
has happened with the new health educators, they were
unpaid. Still, the fact that two of the new health
educators did not report exerting any political role even
when teaching since they only addressed women's practical
needs, showed us that becoming a health educator through
this program may not necessarily mean that women will work
towards women's strategic gender needs. Thus, the
development of a community health role such as a health
educator, may be questioned as to its role in leading to
the empowerment of women, if this role is not used to
question and exert pressure to change the status quo.
Moser (1993) explained that women's health care unpaid
activities, as well as others' activities in the community
can derive from their reproductive role. In this way, it
may argued that most women from this study are not working
towards complete empowerment if they do not eventually
became economically and politically empowered through the
acquisition of a community health role.
Need for credibility in top down initiated programs
Considering the actors who requested the
implementation of the health education program in both
sites, this program was not established as a result of
requests from community leaders, as was the case in Porto
Alegre (Oliveira, Carvalho, Frustock, & Luz, 1992).
218
Therefore, most women in both sites were, as expected, at
the bottom level of community participation. Nevertheless,
the program was well accepted by the client population and
attracted it due to the past works of MARIA, which
established credibility with women from the client
populat ion.
Desire to learn, not health improvement
The desire to learn, rather than the quest for the
health well-being was the main reason to join and continue
participation in the health education program. Even when
women perceived to have improved their health or
reproductive health conditions by participating, they
continued to state that their participation was mostly
related to their learning experience. Nevertheless, their
perceptions of change in their health well-being were
reported as helping, never preventing, them to concentrate
their lives on empowering themselves.
Religious practices as not monolithic
The diversity of religious affiliations encountered in
the sites studied reflects both Prandi's and Pierucci's
(1994) data that Rio de Janeiro is the least Catholic
Brazilian State, and Fernandes' (1992) findings that in the
farthest areas away from the city of Rio de Janeiro, there
may be found a smaller percentage of Catholic and higher
219
percentage of Evangelic affiliations. Thus, from the
standpoint of studying social spaces where ecumenical
congregations are among the most diverse in Brazil, the
sites studied were ideal.
That religious affiliation did not determine opinions
regarding sterilization, abortion and sexuality relate to
the fact that values and practices can be diverse even
among those adhering to the same religious denomination.
As Nunes (1992) reminded us, the Catholic Church is not
monolithic. We might assume that the Methodist or the
other Protestant Churches should not be monolithic as well.
Furthermore, ecumenical congregations may share different
practices. Although in the sites studied ecumenical
congregations were portrayed as welcome and no conflict was
noticed or reported, it is possible that conflicts did not
emerge because in the sites studied women were respectful
towards the religious affiliations others had.
Conflicts of Brazilian cultural norms and living a
liberation notion of reproductive health
Most women in this study tend to agree that women
should have individual autonomy to resolve the conflicts of
the Churches' doctrines versus issues of abortion,
sterilization and sexuality. Similarly, Nunes's (1994)
study found that Catholic women from Ecclesial Base
Communities tended to justify their contraceptive practices
220
in light of their need for individual autonomy. These
findings are worrisome insofar as by focusing 'only' on
individual autonomy, the responsibility falls entirely on
the individual for solutions. This may take away the
attention form the ills of the social structure.
Religious values or education were identified as
posing some difficulties for a few of the client population
and one new health educator to live up to a liberation
notion of reproductive health. Thus, participation in this
program as a client population, and even becoming a health
educator, did not necessarily lead women to endorse a
liberation notion of reproductive health.
In addition to religiousness, other conflicts of
living a liberating reproductive health notion given
Brazilian cultural norms were identified. The cultural
conflicts women from the staff and the client population
raised related to the: parents' lack of discussion with
their children about sexuality and women's bodies issues,
double sexual morality for men and women, women's self
esteem stemming from reproduction, submission of women--
especially the ones from the poor class, women not being
allowed to have sexual pleasure, and sex being condemned as
simply for pleasure. The personal conflicts experienced by
the client population were the lack of change in their
husbands, anxiety about their own behaviors and whether or
*
not they should change, and learning too late so that they
221
could not change their past. The conflicts of a program
being located in the rooms of churches were voiced by two
women from the client population, when related to the
teaching of sexuality and women's body issues. And a new
health educator addressed the conflict of a priest not
valuing social programs and programs that were not
initiated by him. The conflicts experienced by women in
this program suggests that it is imperative that programs
that attempt to raise women's empowerment find ways to
support women to face the conflicts that may emerge.
Recommendations For Future Research
As with past experiences with health education
programs, individual behavioral change was easier promoted
than was social change. This study showed that in addition
to individual behavior change, it was possible for
relationship changes to be initiated by women.
Because neither collective awareness nor actions were
not conquered dimensions by most women from the client
population, and taking into account Stromquist's (1994)
analysis of a study in Chile in which she concluded that
empowerment is time and labor consuming, future research
may look into the last stages of programs that are not only
intensive but extensive in their approaches to promote
empowerment. Still, future research may look into
histories of politicized poor women to understand what
222
circumstances of their lives and what kind of social
activities they were involved in that contributed to their
political awareness and activities, since these may be
generated outside a program setting.
La Belle (1986) asserted that in Latin America the
existence of popular education programs depends on the
combination of goals directed to social change with those
that support the social order. Likewise, the program
studied combined the goals to give women practical and
strategic gender needs. More research is needed in the
outcomes of combining goals that can be seen at times as
antagonistic for this program seemed to have promoted mixed
results among the new four health educators and the client
population. Among the new health educators there were two
women who seemed to work by providing only practical gender
needs and two women who appeared to provide the strategic
ones, in addition to the practical gender needs. Among the
client population, there were only a few women who seemed
to be using the knowledge gained in the program towards
collective action for social change.
Methodological Recommendation For Studies Of Empowerment
In methodologies that examine empowerment, the
researcher should attempt to be attentive to the power
imbalances that may arise between the researcher and the
researched. In this study, the researcher tried to respect
223
the authority of Margaret (the teacher and coordinator) and
to establish a rapport with Margaret in which negotiations
could occur. Margaret was very helpful insofar as she used
the researcher's presence in meetings to let the women
participants know they could feel valued because there was
a stranger willing to be with them and to get to know them.
In regard to the other women participants, the
researcher also attempted to establish a good rapport with
them. For that, it seemed advisable that a researcher seek
interactions with the women not only to learn from the
program and the women participants but simply to be with
them. It is suggested that a researcher should be as
responsive as possible to the level of the women's needs of
interaction. For instance in this study, after the
interview, Cassandra asked the researcher to call her at
her work once in a while, just to say hello. Another
example was Helena who asked the researcher to contribute
with money to her children's school which was recently
vandalized. Responding to these requests helps to ensure
good support.
Another important recommendation is that the
researcher should follow the spirit of the program. For
example, the health education program itself did not give
quizzes of the content learned. Thus, the researcher
emphasized that during the interview process, content would
not be tested but could be discussed if women felt at ease
224
to do so. This was stressed in the hope that women would
feel at ease to describe whatever their experiences were.
Another example that followed the spirit of the program was
that during some interactions and interviews, it was felt
necessary to reassure women's value as Margaret did. This
was always done with the women who doubted that the
researcher could learn from their experiences.
During interactions it seemed advisable that the
researcher could share with the women participants personal
curiosities they have. In this study, the researcher
shared curiosities about life in the United States compared
to life in Brazil, what mode of transportation the
researcher used to arrive at the program, where the
researcher now lived, and where the researcher was
originally from. Sharing these curiosities seemed a path
to strengthen some of the relationships.
On the other hand, on the occasions that the
researcher was asked opinions about the issues related to
the study being conducted, it was not advisable to share
them not only because it could influence the outcome of
women's responses, but also because all opinions have to be
valid. The opinions of the researcher are not an important
issue to be discussed because they are not more or less
valid than the ones the women had. This was always
stressed in order to validate women participants own
opinions.
225
Finally, it seemed advisable that the findings should
be shared with the women participants. In this study, a
promise was made to send an English copy to the coordinator
and a summarized version in Portuguese to the participant
women who are interested.
Conclusion
The health education program studied seemed successful
in conquering its objective of training women who will
indeed act as health educators in their communities. It
appeared also that the health education program has been
very successful in empowering women in the psychological,
cognitive and physical dimensions using health education as
a means.
Because the economic and political dimensions of
empowerment seemed to be less conquered dimensions among
the client population and two of the new health educators
interviewed, it is suggested that this program add to the
efforts to empower women in these dimensions so that
women's strategic gender needs can be fully addressed.
However, it is recognized that for these additional
efforts more financial resources may be needed and these
may be difficult to obtain, since at present the program
operates with only one teacher who is the coordinator, and
financial resources to run the program are minimal.
By adding to the few reports in the literature of
feminist groups working with health education, lastly it
should be said that this program seemed to be an experience
that helped women to challenge their lives and to provide
them with new horizons. But this challenge evoked many
times conflicts that are not a comfortable experience.
227
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Appendices
A)Protocol for oral interviews with the client population
Personal background
. Age
. Religious background if any
. Ethnicity
. Social class
. Place of birth
. Place of residence
How long have you lived in this area?
. Do you have children?
If yes, how many? What are their ages?
. Who lives in your house?
. How much would you guess is the average income of your
family?
Who contributes to this income?
Employment background
. Have you ever worked?
If you have worked, what was (were) the activity
(activities) in which you have worked?
. Do you work at home for monetary compensation?
If yes, how many hours a week? And for how long have you
had this job?
. Do you work outside your home for monetary compensation?
If yes, how many hours a week? And for how long have you
had this job?
. Do you work outside your home without monetary
compensation?
If yes, how many hours a week? And for how long have you
had this job?
. If you work outside your home, how long does it take you
to get to your job? How many means of transportation do
you use?
252
Educational background
. Have you ever been to school?
If yes, up to which level?
. Have you ever participated in an adult educational
program(s) other than this one?
If yes, for how long, what was(were) its(their) goal(s)
and where was(were) it(they) located?
Background of participation in recreational, social and
political activities
. Do you participate or have you participated in the past
in any recreational activity? What kind (s)? Where at?
. Do you participate or have you participated in the past
in any social activity? What kind(s)? Where at?
. Do you participate or have you participated in the past
in any political activity? What kind(s)? Where at?
. Is there any problem you have that may prevent you from
participating in an activity outside the home or to come
on a regular basis to this program?
. How does your family (male companion, relatives and
children) react to your participation in activities
outside your home?
Opinions of Brazilian environment regarding reproductive
health and sexuality
. How would you describe Brazilian law (prohibition for
abortion) and government restrictions (contraceptive
availability and lack of options) regarding reproductive
health? What do you think about them?
. How would you describe the Brazilian health care system?
What do you think about it?
. How would you describe Brazilian cultural values
regarding sexual behavior? What do you think about them?
Reasons to participate in health educational program
. How did you hear about this present health education
program you are taking part in?
. Why did you seek participation in this program?
. Why do you continue to participate in this program?
253
. How long does it take you to come to this program? How
far is it from the place you live?
. How long have you been participating in this program?
And how often do you participate?
. Have you ever participated in other kind(s) of health
education program(s)? If yes, how similar or different
is this present program from the one(s) you experienced
before?
. Which was(were) your initial expectation(s) of this
program when you first came? Did you meet any of them?
Is(are) your expectation(s) different now than from the
time when you joined the program?
. Is there any change you would like to make to improve the
program in which you are participating?
Rifkin's levels of participation
Identify which level(s) the client is involved in by
asking questions related to them:
. Do you receive health services and health education?
. Do you take part in program activities through resource
donations (money, land or labor)?
. Do you assume managerial responsibility for
implementation of health education and/or health
programs?
. Do you monitor and evaluate projects?
. Do you lead in program planning and needs assessment?
Evaluation of perceptions of health and family
responsibilities as it relates not only to the individual,
but also to the general community
. Is(are) there health problem(s) and/or concern(s)
experienced by you and your friends that take part in
this program?
. Is(are) there reproductive health problem(s) and/or
concerns experienced by you and your friends that take
part in this program?
. Is(are) the violent problem(s) and/or concern(s)
experienced by you and your friends that take part in
this program?
254
Who do you think should be responsible for the economic
welfare of the family?
Who do you think should be responsible for the health
welfare of the family?
Personal life as it relates to reproductive health and
sexuality
. What is your marital status now and what was it in the
past? If any relationship(s), describe the length of
present and past relationship(s)?
. Do you have or have you had in the past any reproductive
health concern(s) or problem(s)? If yes, which one(s)?
Given a history of involvement with male partner(s) ask:
A)Do you share of have you shared with partner concerns
related to your or partner's reproductive health?
If yes, which one(s)?
Ask specifically any dimension missed if respondent does
not include in her answer any of the dimensions related
to reproductive health (sexual desires, sexual pleasure
and initiative in sexual activities), reproductive
infections in both partners, reproductive treatments
(preventive and curative), contraception, pregnancy,
family planning decisions.
. Do you have or have you had in the past any concern
regarding your sexual life? If yes, which one (s)?
. Have you had different sexual partners?
If answer is yes, did experience(s) differ in sharing
reproductive health concern(s)? If yes, cite examples
and possible reason(s):
. Do you have or have you had physician(s) for reproductive
health care?
Given the respondent has had physician(s) for
reproductive health care treatment:
A)Has(have) your physician(s) been male or female?
B) Have you experienced treatment by different
physicians?
If yes, did you feel difference in treatment?
If difference was experienced in treatment, cite examples
and possible reason(s).
255
C) Do you share with your physician(s) your concerns
related to your reproductive health and the reproductive
health of your partner(s)?
D) Do you go or have you gone to reproductive health
treatment accompanied by male partner(s)?
E) Do you have or have you had in the past any
difficulty regarding medical treatment(s) related to
your reproductive health?
Evaluation of outcome of participation in the program
. Have you learned anything participating in this program?
If yes, what have you learned? Cite examples:
. After participating in this program, are you more aware
of what you could do to prevent reproductive health
problems?
. Have you learned in this program anything that might help
you to be better off economically? If yes, what?
. With your participation in this program have you become
involved in other activities (social, political,
recreational, voluntary work, work)? If yes, name them:
. Have you changed as a person in any way due to the
participation in this program? If yes, how so?
. Has your health status improved because of taking part in
this program? If it did, in which way(s)? And if it
did, do you feel more likely to continue participation in
this program or less likely?
. With your participation in this program has your sexual
life changed in anyway? Have your feelings about your
sexual life changed? If there was any change are you more
likely to continue participation in this program or less
likely?
. With your participation in this program have your medical
encounter(s) changed in anyway? Have your feelings about
medical encounter(s) changed in anyway? If there was any
change are you more likely to continue participation in
this program or less likely?
. With your participation in this program, did you learn
about other places other than here that you can go to
seek help and/or get acquainted with people that will
help you in reproductive health problems, sexual concerns
or medical encounters- If yes, cite examples:
256
. Did your relationships with friends and family change in
any way after participating in this program?
. Have you experienced any conflict for having taken part
in this program? If yes, which one(s)?
. Do you think the things you learned through this program
related to reproductive health go against values you have
or have had?
. If the respondent has or has had a male partner during
participation in the program, what does or did he think
about your participation in the program?
B)Protocol for oral interviews with the staff population
Personal Background
. Age
. Religious background if any
. Ethnicity
. Social class
. Place of birth
. Place of residence
How long have you lived in this area?
Work related questions
. How did you become interested in working in this program?
. When did you start working here?
. How many hours a week do you work here?
. Do you work for any other organization(s}? If so, which
one (s) ? ' •
. In the past have you worked in a different job{s)? If so,
what kind(s) of activities have your worked with?
. Have you ever worked in adult educational programs other
than this one?
If yes, for how long, what were their goals and where
were they located?
257
Educational background
. Did you go to school?
If yes, up to which level?
Opinions of Brazilian environment regradinq reproductive
health and sexuality
. How would you describe Brazilian law (prohibition of
abortion) and government (restriction and lack of
availability of contraception) regarding reproductive
health? What do you think about them?
. How would you describe the Brazilian health care system?
What do you think about it?
. How would you describe Brazilian cultural values
regarding sexual behavior? What do you think about them?
Evaluation of perceptions of family responsibilities
. Who do you think should be responsible for the economic
welfare of the family?
. Who do you think should be responsible for the health
welfare of the family?
Evaluation of perceptions of problems and concerns
experienced by the client population in regard to violence,
health and reproductive health
. Is(are) there health problem(s) experienced by the client
population?
. Is(are) there violent problem(s) experienced by the
client population?
. Is(are) there reproductive health problem(s) and/or
concern(s) experienced by this client population? If yes,
what is it or what are they?
. Is(are) there complain(s) by the client population
related to their reproductive health?
Ask specifically any dimension missed if respondent does
not include in her answer any of the dimensions related
to reproductive health (sexual desires, sexual pleasure
and initiative in sexual activities), reproductive
infections in both partners, reproductive treatments
(preventive and curative), contraception, pregnancy,
family planning decisions.
258
. Do you think the client population voices its feelings
and concerns related to reproductive health when dealing
with male partners?
. Do you think the client population voices its feelings
and concerns related to reproductive health when treated
by physicians?
. Do you think the client population voices its feelings
and concerns about reproductive health in this program?
. Do you think there is(are) similar problem(s) experienced
by the client population? If yes, what is it or what are
they?
Still, in affirmative cases does the client population
report it as only unique to their individual lives or as
a common problem for many women?
. Does the client population report any difficulty sharing
with male partners reproductive health concerns or
problems?
. Does the client population report any difficulty sharing
with physicians reproductive health concerns or problems?
. Does the client population report any difficulty sharing
with the staff population reproductive health concerns or
problems?
. Do you think this program benefits the client population?
If yes, in what way(s)? Cite examples.
. Do you know other activities inside and outside the home
that the client population is engaged in? If yes, what
is it or are they?
. Is(are) there any characteristic(s) of the client
population that may make"them more prone to participation
in this program?
. Is(are) there any characteristic(s) of the client
population that may make lead them to benefit from this
program?
. Which women does this program encourage to become part of
the health educational activities of this program?
. How does this organization try to reach its client
population?
259
. Do you think there are women who should be benefiting
more from this program than the ones who are enrolled?
. Does this organization give any incentives for women to
participate?
. Do you think this program raises any conflict for the
client population ?
. What do you think could be different in this
organization?
Rifkin's levels of participation
Identify which level(s) the staff population is involved
in by asking questions related to them:
. Do you receive health services and health education?
. Do you take part in program activities through resource
donations (money, land or labor)?
. Do you assume managerial responsibility for
implementation of health education and/or health
programs?
. Do you monitor and evaluate projects?
. Do you lead in program planning and needs assessment?

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Asset Metadata

Creator Felix De Sousa, Isabela Cabral (author)

Core Title Can Reproductive Health Education Empower Women? A Brazilian Qualitative Study

Degree Doctor of Philosophy

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, health,OAI-PMH Harvest,women's studies

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Stromquist, Nelly P. (committee chair), Ransford, H. Edward (committee member), Rideout, William M., Jr. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-603833

Unique identifier UC11226817

Identifier 9616959.pdf (filename),usctheses-c20-603833 (legacy record id)

Legacy Identifier 9616959.pdf

Dmrecord 603833

Document Type Dissertation

Rights Felix De Sousa, Isabela Cabral

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

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