Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
Educating women on sexual health and reproductive rights: A case study of a prevention program in Peru
(USC Thesis Other)
Educating women on sexual health and reproductive rights: A case study of a prevention program in Peru
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
EDUCATING WOMEN ON SEXUAL HEALTH AND
REPRODUCTIVE RIGHTS:
A CASE STUDY OF A PREVENTION PROGRAM IN PERU
Copyright 2002
by
Jennifer Blythe Vega
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements of the Degree
DOCTOR OF PHILOSOPHY
(EDUCATION)
December 2002
Jennifer Blythe Vega
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMI Number: 3093926
UMI
UMI Microform 3093926
Copyright 2003 by ProQuest Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company
300 North Zeeb Road
P.O. Box 1346
Ann Arbor, Ml 48106-1346
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, written by
J e n n i f e r B l y t h e V e g a
under the direction o f h e.T dissertation committee, and
approved by all its members, has been presented to and
accepted by the Director o f Graduate and Professional
Programs, in partial fulfillment o f the requirements for the
degree o f
DOCTOR OF PHILOSOPHY
Director
Date December 18. 2002
Dissertation Gtommittee
Chair
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
DEDICATION
Esta tesis esta dedicada a todas las madres cuidadoras del Peru, cuales me
abrieron sus casas, sus vidas, y experiencias. Sin el valioso apoyo de ustedes este
proyecto no se ubiese podido realizar. Gracias para su incondicional y vailiozo
apoyo, su amistad, y su paciencia hacia mi persona. Por todo eso nunca las
olvidare.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ACKNOWLEDGMENTS
This dissertation has been an incredible process, one I will never forget, that
has taken me across the world and changed my life completely. There are so many
people who have been instrumental in making this possible. I would like to thank
Dr. Nelly P. Stromquist, my advisor, for all of her thoughtful input, patience, and
encouragement in making this dissertation complete. I would also like to thank my
committee members, Dr. William M. Rideout, Jr. and Dr. Hilary Schor, for their
time and support in this process.
I would also like to thank my family and friends here in the States who have
put up with my stress and craziness and loved me and supported me throughout,
especially Sheila and Javier Vega, Amy, Nick and Hailey Pritchett, and Patrick
Vega. I would also like to thank GianMarco La Sema for his patience and support
throughout this process.
My friends have been instrumental, I cannot name each of you here, but I
must mention some of my advisors, editors, and true support system members.
Thank you especially to Drs. Marta Soto, Jennifer Johnson, and Shereen Fogel for
letting me know I could get it done. I have made life-long friends and am truly
blessed.
Finally, to my family and new friends in Lima, who supported me with a
place to live and opened their hearts and homes to me. Thank you especially to
Patricia and Memo Guzman and family, Rosa and Roberto Guzman and family,
and Susana Arambulo Vega, you are my home away from home. To the madres
iii
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cuidadoras in Lima and throughout Peru, this project would not be here without
you. I also must thank the wonderful people from PROMUDEH and UNFPA who
became my mentors and wonderful friends, especially Nancy Melgar, Celia
Aldana, Gladys Seminario, Maria Pfa Validivia, and Ivan Amezqufta. Thank you,
thank you, thank you.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TABLE OF CONTENTS
DEDICATION................................................................................................................ii
ACKNOWLEDGEMENTS......................................................................................... iii
TABLE OF CONTENTS...............................................................................................v
LIST OF TABLES AND FIGURES......................................................................... viii
ACRONYMS AND ABBREVIATIONS—GLOSSARY OF TERMS....................ix
ABSTRACT..................................................................................................................xii
I. INTRODUCTION.......................................................................................................1
Background of Topic..................................................................................................... 2
Purpose of Study.............................................................................................................4
Statement of Problem..................................................................................................... 6
Significance of Problem................................................................................................. 8
Assumptions.................................................................................................................... 9
Limitations...................................................................................................................... 9
II. REVIEW OF THE LITERATURE........................................................................ 11
Historical Findings on the Spread of HIV/AIDS with Women................................11
Theoretical Frameworks Of HIV/AIDS Prevention Programs.................................35
HIV/AIDS Prevention/Education Programs.............................................................. 52
Current Research on Effective Intervention Programs............................................. 65
Sociocultural and Socioeconomic Considerations in the Spread of HIV/AIDS 82
Condom Use and Female-Controlled Prevention Methods......................................88
HIV/AIDS Prevention Policies................................................................................... 91
Conclusion.................................................................................................................... 93
III. METHODOLOGY................................................................................................ 96
Setting............................................................................................................................99
Research Design..........................................................................................................103
Organization of Study.................................................................................................104
Time Line.....................................................................................................................118
Interpretation............................................................................................................... 120
Validity and Reliability.............................................................................................. 121
Summary......................................................................................................................122
v
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
IV. PROGRAM DESCRIPTION AND OVERVIEW 123
Introduction..................................................................................................................123
Current Information on Sexual Health and AIDS in Peru.......................................123
Programs in Peru Dealing with Sexual Health and AIDS.......................................125
Ministerio de Promocion de la Mujer and Desarrollo Humano (PROMUDEH).. 137
System of the Ministry of Women (PROMUDEH).................................................142
Summary......................................................................................................................145
Wawa W asi..................................................................................................................146
Observation of Wawa Wasis......................................................................................150
Reproductive Health Project Description.................................................................162
Goals and Objectives of the Reproductive Health Course...................................... 163
Conclusion...................................................................................................................165
V. FINDINGS........................................................................................................... 167
Introduction..................................................................................................................167
Section One
Training begins for the Coordinators........................................................................ 168
Feedback From the Coordinators...............................................................................185
Course Implementation for the Madres Cuidadoras Introductions.........................192
Section Two
Analysis of Intervention Outcomes...........................................................................220
Knowledge of Sexual Health and Reproductive Rights.......................................... 220
Sociocultural Messages: Gender Roles and Machismo.......................................... 225
Condom Use and Behavioral Change.......................................................................229
Access to Health Care and Information....................................................................232
The Government’s Responsibility............................................................................ 236
Social Interaction: Communicating the Message.....................................................238
Nonformal learning vis-a-vis Informal Education...................................................243
Multiplier Effect..........................................................................................................244
Socioeconomic Situation............................................................................................245
Evaluation Results from Calandria...........................................................................247
Section Three
Life Realities............................................................................................................... 254
Lima-Callao................................................................................................................254
Huancavelica...............................................................................................................287
Conclusion.................................................................................................................. 296
Interviews with the Madres and Padres Usuarios...................................................302
v i
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Section Four
Sustainability of the Sexual Health and Reproductive Rights Course...................313
VI. SUMMARY AND RECOMMENDATIONS.................................................316
Overview..................................................................................................................... 316
Summary of the Research Questions........................................................................316
Recommendations...................................................................................................... 329
References................................................................................................................... 333
Appendices.................................................................................................................. 343
Appendix I-- Organization of PROMUDEH .......................................................... 343
Appendix II— Organizational Chart..........................................................................344
Appendix HI— Reproductive Health Course Modules............................................. 345
vii
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
LIST OF TABLES AND FIGURES
Table 1-- Variables to be assessed in formative research......................................... 69
Table 2-- Cairo recommendations for action............................................................. 87
Table 3— Demographics of participants in the sexual health and reproductive
rights course............................................................................................... 117
Table 4— Time-Line of Research Study...................................................................119
viii
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ACRONYMS AND ABBREVIATIONS
ACNM— American College of Nurse Midwives
AIDS— Acquired Immune Deficiency Syndrome
CHE— Community Health Educators
CHUSA—Church Human Services AIDS Prevention Program
COOPOP—National Office of Popular Cooperation
ENDES—Encuesta Demografica y de Salud Familiar; Demographic and Family
Health Investigation
FHI— Family Health International
FIDA-K—International Federation of Women Lawyers, Kenya
FRESH— Focusing Resources on Effective School Health
GRIDS— Gay Related Immune Deficiency Syndrome
IEC—information, education, and communication
ILO—International Labor Organization
INEI—Instituto Nacional de Estadistica e Informatica; National Institute of
Statistics and Information
INPPARES—Instituto Peruano de Patemidad Responsible; Peruvian Institute for
Responsible Parenthood
JSI—John Snow, Inc.
KABP—knowledge, attitudes, beliefs, and practices
KAP— knowledge, attitude, and practice
LDHMT— Lusaka District Health Management Team
MSF— Medecins Sans Frontieres; Doctors without Borders
MINS A—Ministerio del Salud; Ministry of Health
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
MAP—Monitoring the AIDS Pandemic
NPP—National Population Plan
NRC— National Research Council
ONUS IDA—Latin American United Nations Programme on AIDS
PAR—Support Program for Emergency Zones
PATH— Program for Appropriate Technology in Health
PRONAA—Programa Nacional de Apoyo Alimentario; National Program of
Nutritional Assistance
PROCETTS—Programa de Control de Enfermedades de Transmission Sexual and
SIDA; Program for Control of Sexually Transmitted Diseases and AIDS
PROMUDEH—Ministerio de Promotion de la Mujer y del Desarollo Humano;
Ministry of the Advancement of Women and Human Development
PTAs—parent teacher associations
SEATS—Family Planning Service Expansion and Technical Support
TPC-ICP— Tripartite Commission ICPD Programme of Action Implementation
USAID—United States Aid for International Development
UNFPA—United Nations Population Fund
UNAIDS—Joint United Nations Programme on AIDS
SISMU—Integrated Reproductive Health Services
STDS—sexually transmitted diseases
STI—sexually transmitted infections
Glossary
Bien-estar—well-being
Combi—bus
x
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Comedor popular—community public kitchen
Comunales—community child care center
Entre Amigos—Among Friends
Familiares—family child care homes
Hogares Educativos Comunitarios—Community Education Homes
Institucionales—institutional child care center
Mate de coca—coca leaf tea
Mini—van bus
Madre cuidadora—child care provider
Madre/padre usuario—parents who utilize child care program
Ninez con Esperanza—Hopeful Kids
Programa Nacional Wawa Wasi (National Wawa Wasi Program)—child care
program within PROMUDEH
pueblos jovenes—low-income neighborhoods
soroche—altitude sickness
Sistema Nacional de Casas de Ninos Wawa Wasi—National System of Homes for
Children Wawa Wasi
Vaso de Leche—Glass of Milk assistance program
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ABSTRACT
This study examines a sexual health and reproductive rights education
program, implemented by the Ministry of Women and the United Nations
Population Fund, for low-income women in three regions of Peru. The course
included four modules of gender relations, sexuality, sexual health and
reproductive rights, and family violence. The first phase of the study involved
interviews with administrators, directors, and program coordinators followed by
course observations and participant surveys. The second and third phases included
in-depth interviews with the participants.
The evaluation includes analysis of the participants’ knowledge of sexual
health and reproductive rights, issues of gender roles and machismo, condom use
and behavioral change, access to health care and information, communication about
HIV/AIDS, and program sustainability. Follow-up interviews and observations
with the course participants and the impact of the course on their daily lives is
examined. Finally, recommendations are made on best practices to consider in
further HIV/AIDS education programming.
This study found that the short-term intervention was not effective in
providing avenues for empowerment or improving negotiation skills necessary for
creating behavioral change or enhancing communication about sexual health.
Although the participants did increase their basic knowledge and awareness of
sexual health issues, the inherent problem of machismo and pre-determined gender
roles did not allow women to voice their rights. The program did not provide
xii
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
condoms, and lack of access to condoms and essential health care was a major
barrier to negotiation and communication. Many of the participants were able to
communicate the new information and messages to community members, friends,
and family, but lacked ongoing support and resources. In addition, the peer
education model was often in conflict with the role of the women as childcare
providers, which was their primary responsibility.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER ONE
INTRODUCTION
The most recent report from the United Nations Programme on HIV/AIDS
(UN AIDS/S WHO, 2001) found that 40 million people were living with HIV/AIDS
by December 2001; an estimated 46% (18.5 million) of these were women. Five
million people were newly infected with HIV in 2001; of these 2 million were
women and 800,000 children (p.l). Although the majority of cases in the past were
found in homosexual men and drug users, the current trend shows an increase in the
number of heterosexual women infected with the disease. In Peru, the country of
this research focus, of the 53,000 people living with HIV/AIDS by the end of 2001,
13,000 (25%) were women (UNAIDS, 2001). The impact of AIDS has become a
startling and swiftly increasing epidemic around the globe that is quickly
overcoming other epidemic tragedies such as drought, war, famine, and malaria,
through loss of life, ramifications on society and the economic impact on every
country. The most striking effect of this epidemic is the impact of the disease on
women. With the social, cultural, and traditional patterns of gender inequality seen
throughout highly patriarchal societies, women have been placed in a mode of
powerlessness to fight this disease and the spread of a costly and deadly epidemic
around the world. Prevention programs and education on HIV/AIDS now become
a necessity in all countries to fight the spread of this disease.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Background of Topic
The first cases of AIDS were found in the early 1980s by doctors in the
United States through an increasingly noticed rare form of pneumonia. Karposi’s
sarcoma, a rare form of cancer, was also on the rise. The immune systems of
patients were unable to combat these diseases. Since the first records of these cases
were found in homosexual men, the new disease was labeled Gay Related Immune
Deficiency Syndrome (GRIDS). However, as the disease was soon found in people
aside from homosexual men, the name was termed in the US, in 1982, of Acquired
Immune Deficiency Syndrome (AIDS) (Barnett and Blaikie, 1992).
The disease quickly became known and found in other parts of the world,
increasingly among heterosexuals, and most recently has had a dramatic impact on
developing countries and on women and the poor. The reasons for this have been
attributed to both socioeconomic and sociocultural factors and also to biological
factors for women. In fact, the majority of AIDS cases worldwide are through
heterosexual transmission. Socioeconomic status has been associated with
increased participation in “high risk” sexual behavior and women have increasingly
suffered consequences due to economic conditions (Weniger & Berkley, 1996).
Women are also impacted by the disease due to the lack of power they have in
relationships resulting from prescribed gender roles and the inability to negotiate
safe sex practices.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Prevention through Education
One of the most important findings of the UNAIDS report (1998) is that
prevention does work and that well-designed and focused programs can be
effective. “The best prevention campaigns work simultaneously on many levels—
increasing knowledge of HIV and how to avoid it; creating an environment where
safer sexual or drug-taking behaviors can be discussed and acted upon; providing
services such as HIV testing, treatment for other sexually transmitted disease
(which if left untreated greatly magnify the risk of HIV transmission) and access to
cheap condoms and clean injection equipment; and helping people to acquire the
skills they need to protect themselves and their partners” (UNAIDS, 1998, p. 26).
Structural changes along with changes in the law and employment are
recommended as well. Also important is making information available to young
people, making drug taking safer through needle exchanges, condom distribution,
education and treatment programs, increased counseling and testing, and access to
antiretroviral therapy, especially for women who are pregnant or breastfeeding.
What has been learned from the past ten years of AIDS intervention? The
most striking concern is that although women have more recently been included in
prevention programs, attention has not been paid to the fact that they have been
placed in a powerless role against AIDS. Programs targeting increasing women’s
knowledge about HIV, and promoting behavioral change and access and education
on condom use assume that women have the power to influence their partner’s
behavior and to express their sexual roles freely. But, social and cultural influences
3
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have forced women into an environment where this is not the case. Three areas that
HIV education programs have not focused on include: socially and culturally
established gender roles, women’s sexuality and power relations, and women’s
empowerment.
With current statistics and increasing numbers of women affected by AIDS
throughout the world, it is important that prevention through education becomes the
forefront of effective programs and of governmental campaigns. This research is a
case study of a sexual health and reproductive rights educational prevention
program for women in Peru with a specific focus on HIV/AIDS. The study will
evaluate the knowledge, beliefs, attitudes, and practices of women before and after
intervention. Further, the impact of gender roles and inequalities associated with
constraints in power will be evaluated as to their effect on sociocultural risk factors.
Finally, the results will consider biological, behavioral, and psychological
outcomes of the intervention.
Purpose of Study
Many international development agencies are currently working in
communities worldwide to educate and promote safe sex behavior and to protect
the health of women, the most rapidly increasing population that is infected with
HIV/AIDS. This research project is a case study in Peru on issues surrounding
community health. The specific focus is on low-income women in Peru, with the
goal of understanding the attitudes and behaviors of Latin American women in
order to reach this population in regards to education and dissemination of
4
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
information regarding HIV/AIDS. This particular population was chosen due to
the socioeconomic and sociocultural factors that place them in high-risk situations
as discussed in the relevant research.
Effective prevention programs must not only educate women on the disease
and its mitigating factors, but must consider the sociocultural impact of gender
roles and sexual relations and the power of women to create behavioral change.
These programs must also target men and provide effective interventions that
incorporate an understanding of gender roles and power structures. The literature
shows that knowledge of transmission and risks of contracting HIV are not direct
indicators of behavioral change for women but, that social, cultural, and economic
factors contribute highly to the ability to negotiate safe sex practice. The 1996
study conducted by Encuesta Demografica y de Salud Familiar (ENDES) in Peru,
found that awareness of the existence of ADDS was very high amongst women
(85.5%) as well as men (75.7%). This rate was much higher than knowledge of
other sexually transmitted diseases, such as knowledge of gonorrhea (40% of
women and 21% of men) or of genital herpes (3% of women and 1% of men). The
knowledge of AIDS was higher for those in urban regions (88%) than rural (41%)
and increased with the level of education, from 22% for those without education to
94% for those with higher education (PROMUDEH, 1996, p. 24). However, all
these data represent high knowledge of AIDS; they do not address knowledge of
methods of protection. Further, as mentioned earlier the rates of AIDS infection
have continued to increase for Peruvian women in comparison to men.
5
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Statement of Problem
The problem to be investigated is the functioning and impact of sexual
health and reproductive rights education program on the knowledge, beliefs,
attitudes, and practices of Peruvian women. For a program to be effective,
behavioral change must occur with an increase in knowledge. However,
sociocultural factors may inhibit the results of the prevention program due to
prescribed gender roles which effect the power women have to negotiate safe sex
practices.
Research shows that effective programs must educate on the transmission of
HIV/AIDS, while promoting the reduction or elimination of risk behaviors.
Women and girls can be empowered by: “(1) increasing their knowledge about
their bodies and sexuality, as well as about HIV and other STIS, and (2) improving
their skills in using condoms and negotiating safe sexual behaviors with their
partners” (Gupta et al., 1996, p. 224). Further, incorporating research that looks at
the “realities of women’s lives” and examines gender roles and the social,
economic, and cultural factors which impact sexual attitudes is an essential part of
effective programs (p. 224).
One thing learned from current research is that education is not enough, but
that creating an environment that fosters empowerment, taking an active stance
against socially construed gender roles, and confronting sexual power dynamics
can help to promote a woman’s ability to control her own body and reduce risks
associated with HIV (Ankrah, 1996, Gupta, 2000). “Empowerment seeks to
6
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
combine and expand both consciousness-raising and participation so that
individuals not only may understand their society and the place they currently have
in it, but may undertake efforts to modify social relations” (Stromquist, 1994, p.
266). Applying this definition of empowerment to HIV education, both women and
men must become part of the dialogue. Women should take an active role in the
development and discussion of HIV. They must have a central role in changing the
socially prescribed gender roles and powerlessness that has increased their risks of
HIV infection. Men should also understand and develop their own awareness of
the sexual power struggle and the dynamics of social and cultural constraints
related to gender relations.
Researchers and projects must also take into consideration a very important
resource: those people who have been successful in protecting themselves from
AIDS. How are certain people able to protect themselves? Why and when do
some men use condoms? And, how are some women able to say no? What makes
the difference with those people who have effectively remained safe from this
disease? It is an urgent aspect to consider in researching prevention trends to target
those who have been successful and who have made behavioral changes in their
lives.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Questions to be Answered
The research seeks to answer the following questions:
1. Does the sexual health and reproductive rights educational program provide a
context for empowerment in the framework of the research recommendations
(Cairo Agenda)?
2. Did the women increase their knowledge of sexual health and reproductive
rights as a result of the program intervention?
3. Was the sexual and reproductive behavior effected by the program intervention?
4. Are the participants able to communicate the information to others?
5. Is the project sustainable? Over what period of time? And, with what level of
commitment from key agencies?
Significance of Problem
Since the mid-1980s, significant research has been conducted on
HIV/AIDS. This research initially focused on homosexual transmission and was
centered on the United States. In the 1990s increasing attention was paid to
developing countries, such as those in sub-Saharan Africa and Asia where the
impact has been most striking. Although newer research has focused on the
increase of the epidemic with women, very little has been completed on developing
countries in Latin America and with Latinas. With the epidemic patterns of disease
in countries such as sub-Saharan Africa, other developing countries may want to
utilize key research findings to control the spread of the disease before it becomes
8
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
an epidemic. This is vital to the research in Peru, as the statistics readily show
increasing infection rates since 1983, and especially an increase in rates for women.
Assumptions
The main assumptions from relevant research are that an effective
prevention program will not only increase knowledge and awareness of HIV/AIDS,
but will have positive behavioral change outcomes. There are many social and
cultural constraints to discussing sexual behavior and safe-sex practices. Women
are particularly impacted by these constraints due to sociocultural and
socioeconomic conditions. The position of women in regards to gender roles and
equity will impact the outcomes of the prevention and possibilities for negotiating
safe sex practice. Further, governmental policy and intervention are key to
controlling the spread of the epidemic.
Limitations
The major limitation to this study is the sensitive nature of the topic.
Participants may not be comfortable addressing sexual behaviors, especially those
that place them at risk, with a researcher. Further, an outside researcher faces
cultural and trust limitations The organizational culture as well as the social culture
will take time to understand and to develop relationships. Often communities and
agencies are suspicious of “outsiders” who come into their homes to deposit their
pre-set models and beliefs. The researcher will have to establish trust within the
agency and with the participants in order to receive honest and credible responses
and interactions.
9
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Other limitations include the sustainability of the program. As the course
workshops were a pilot study prior to implementation of the full-scale program, the
pilot study was short-term (two-months) and short-lived. As a result, the ongoing
long-term effects of the program could not fully be determined. In addition, the
full implementation never took effect due to governmental changes resulting in
termination of the course.
There were several limitations with the survey given to respondents prior to
and following the training. A total of 50 women took the survey prior to the
workshop and only 13 completed the post survey. Due to the small comparable
sample size no significant tests could be completed, but meanings will be discussed
in the analysis section.
10
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER TWO
REVIEW OF THE LITERATURE
Historical Findings on the Spread of HIV/AIDS with Women
The most rapidly increasing population infected with HIV worldwide is
women. Women are biologically, epidemiologically, and socially more susceptible
to HIV infection (Chiriboga, 1997). In Africa, women have suffered most from the
ADDS epidemic, whereas in Asia and Latin America, increasing infection rates
among women have just recently become evident. In the United States, women
living in poverty, and increasingly, African-American and Latin American women
are infected with HIV. In Africa, Asia, and Latin America, women are rapidly
becoming the majority of new HIV cases each year. Drug use and heterosexual
contact are the main causes of infection. The barriers to women using effective
safe sex practices, such as condoms, are attributed to economic reasons, fear of
losing their partner, and increased rates of domestic violence (O’Leary and
Jemmott, 1995).
Latin American women in the US are most affected by infection rates,
increasing dramatically due to transmission from injection drug use to heterosexual
contact. Although little research has been conducted on this population, data have
suggested that Latin American women are less knowledgeable than other women
about how HIV is transmitted, are more likely them other women to
“underestimate” their personal risk, and that socioeconomic, cultural, and religious
factors influence the increased infection rates (Fernandez , 1995).
11
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In looking at the historical epidemiology of women with HIV/AIDS in
developing countries, we should consider three core issues: gender roles in the
society, sexuality and power relations, and the sociocultural and socioeconomic
barriers that place women in positions of powerlessness. These will be discussed
through a glimpse at the lives of women in Africa, Asia, and Latin America. This
chapter will also focus on the current research on effective HIV/AIDS prevention
programming, the social and cultural impact on HIV/AIDS, and the effects of
condom use and other prevention methods.
Women in Africa
When discussing the effects that AIDS has had on women in developing
countries, it is important to consider the history of the epidemic on women in sub-
Saharan Africa, as this region has suffered the greatest impact and is where a
majority of AIDS research has been completed. The history of the spread of the
disease, as well as the response on a national and local level, are invaluable
resources in determining best practice and establishing effective program goals.
“The AIDS epidemic is effecting a crippling blow on African women. The
World Health Organization (WHO) reports that in 1993, more that 4 million
African women were infected with HIV. Although an HIV prevalence rate as low
as 5 per 100,000 infected women of the childbearing ages of 15 to 49 is found in
some Easter European, Asian, and Pacific bound countries, African women are
infected at rates as high as 2,500 per 100,000” (Ankrah, et al., 1994, p. 534). By
12
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2001, 28.1 million people were infected with HIV in Africa, while in sub-Saharan
Africa up to 55% of those infected were women (UNAIDS/WHO, 2001, p.2).
In a study by the Population Crisis Committee of Washington, DC, a
measurement of the well being of women, including health, marriage and children,
education, employment, and social equality, ranked 18 countries in the African
region as poor, very poor, or extremely poor on a scale of 100 points. “The
underlying reasons for the low women’s status in Africa are tradition and culture,
illiteracy and ignorance, and poverty, with the limitations they all place on
women’s lives” (Harrison, 1997 p. 644). Several studies have linked education to
maternal mortality rates, and secondary education has been related to lower
population growth rates. In fact, “female education is judged by the World Bank
experts as being the ‘most influential investment’ with high financial returns”
(Harrison, 1997, p. 645). Harrison points out that when people’s basic needs are
met, such as food, water and housing, women’s health is improved:
The impact of AIDS is distinct for each broad category of people
affected by the disease. Where African woman and children are
concerned, this is so because their roles, functions and rights in
society differ from those of men. African women, through
reproduction and production, are inextricably linked to the survival
and development of Africa. The health, development and, number
of African children influence the present and future quality of life of
African communities. Whether children reach their full potential
relates to the early nurturance by the mother. Whenever women
suffer from HIV infection and AIDS, children are increasingly likely
to suffer (Ankrah, et al., 1994, p. 533).
Ankrah, et al. (1994), describe the sociocultural factors which contribute to
women having a role of “subordination to men” (p. 534). In highly patriarchal
13
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
societies, emphasis is placed on childbearing, and female sexuality is placed under
a “double standard.” Women are expected to be virgins at marriage and to remain
faithful to the husband, where the opposite is true for men. In many societies,
women have little access to land and little rights to children or property if their
husbands should leave or die.
Distinguishing women in four categories (young women, women who are
wives and mothers, women with multiple partners, and women as survivors)
Ankrah, et al. (1994), define the effect of AIDS as it relates to each group of
women. Young women represent the highest infection rates (up to one-half of the
HIV-infected population was under 25 years, according to the WHO). The first set
of factors contributing to this epidemic are “sociocultural pressures” including
traditions such as polygamy or older men seeking younger wives, pressures for
early marriage and childbearing, the inability to refuse sex with a husband or
partner, rape, and the economic needs which result in multiple partners or economic
sexual arrangements. The second group of factors is also based on the social
context, but at a more personal level, through the toleration of premarital sex, early
age of marriage, unwanted pregnancies, and lack of sex education. In fact, one
study in South Africa found that of secondary school students (in four school
districts), 75% of students reported having sexual intercourse, but only 11% had
ever used a condom (p. 536).
Women who are wives and mothers present a unique set of issues based on
the sociocultural expectations and pressures placed upon them. Married women,
14
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
especially, those in polygamous relationships, are most likely to be infected by the
husband. Due to the social pressure to bear children and to remain in a submissive
role, women who say no to sex, do not bear children, or whose children die, are
likely to be abandoned by the husband and blamed by the family. A lack of
education contributes to this cycle of repression and hopelessness.
Prostitutes and women with multiple partners represent a group of women
who have not only been blamed for the spread of AIDS but who have also received
little support or advocacy. Again, economic needs have forced many women into
prostitution. Other African women have multiple sex partners to assist in
supplementing their income.
Women who are survivors, whose husbands have died of AIDS, or elderly
women who become infected because their husbands continue to have intercourse
with younger women have a double burden as the survivor. Widows must now
provide for the children, become the sole economic providers, and in rural areas
continue to produce food for the family. Due to cultural traditions, when widowed,
many women lose all rights to children, land, and family connections. Often if
women have contracted the disease themselves, they face the burden of finding a
home for their children.
Repeatedly in the research on the effect of AIDS on women in Africa
(Renaud, 1997, Ankrah, 1996, Clark, 1996, Kiragu, 1996), the social and economic
barriers that women face are designated as a leading cause of the spread of this
epidemic among women. In Renaud’s (1997) study of women in a prostitute
15
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community and their response to the AIDS epidemic, she discusses the position of
women in Senegal as defined in part by the Muslim religion. Traditionally men are
given many more rights than women upon whom many restrictions are placed.
Girls receive less education than boys do, as women spend more time in the fields
and men need education to find jobs.
According to Kiragu (1996), the burgeoning epidemic among women in
Africa is based on social and cultural inequality and must be confronted at the
policy level. With the increasing rates of infection among women, the inequalities
in social, cultural, economic, and basic personal rights for women must be brought
to the forefront:
Gender inequality of all kinds increases women’s vulnerability to
HIV infection in three closely linked ways. First, lack of economic
opportunity for women, enshrined in social-cultural practices and
reinforced by the legal system, leads to dependence on men, whose
interests do not always coincide with women’s need to protect
themselves. Second, depriving women of the right to autonomy and
control over their own bodies also deprives them of their right to
refuse sex and to demand safer sex practices by men. Third, some
cultural practices, many either protected by or ignored by the law,
are directly and immediately dangerous and can lead to HIV
infection. The solution is to empower women through legal reform
to take advantage of economic opportunity, to determine when and
with whom they will have sex, and to refuse cultural practices that
endanger them (p. 1).
According to the International Federation of Women Lawyers in Kenya
(FIDA-K), one of the gravely inherent gender inequalities in Africa is domestic
violence, which is not only a common practice, but is condoned in many African
societies. Living in fear, these abused women have little say over control of their
own bodies, increasing the likeliness of HIV infection. A second is marital rape,
16
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
which in most countries is not recognized as a violation of the law, again increasing
the risk of infection since women do not have the power to say no to sex. Wife
inheritance is a tribal tradition where the widow is required to remarry within the
husband’s family. Due to economic conditions, many women must abide by this
tradition that inhibits the woman’s right to choose a partner and increases the risk
of transmission. In many areas, women are not allowed to own or inherit property.
“This is a prime example of how gender discrimination within the culture works its
way into the financial structure, perpetuating women’s economic dependence on
men and ultimately limiting their ability to control their personal and sexual lives”
(Kiragu, p. 2). In this type of patriarchal culture, if the husband dies, the land,
children, and possessions become property of the husband’s family.
Female genital mutilation (FGM) is yet another form of gender
discrimination, which allows men to “own” a woman’s body and deny her of any
form of sexual pleasure. This practice increases chances for HIV infection through
use of un-sterile instruments during the surgery and increased genital abrasions
which make women more vulnerable to contracting the disease. Young women and
girls are highly at-risk when they are married at an early age or against their will to
older men who believe these young girls are less likely to be HIV infected. This is
also one of the most common reasons for girls leaving school at an early age.
Commercial sex-workers are highly at-risk of HIV and can not report abuse or
violence due to the criminal aspects of sex work (Kiragu, 1996).
17
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Women in Africa have been the most hard-hit by the AIDS epidemic. In a
patriarchal society, with little rights to land, economic security, and health rights,
let alone the right to protect their bodies, these women have had a challenging
fight. Women are dependent economically on men to provide not only food but
also the basic right to own land. In communities where beating of wives and rape
is considered part of daily life, the manifestations of a disease such as AIDS are
insurmountable. The discrimination against women and the grave gender
inequalities must be faced by policymakers, community members, educators, and
within the health care system itself in order to protect and empower women to
protect themselves. Just providing women with condoms is not enough. Women
must have the capability to protect themselves and the basic human rights to
provide for themselves. Women are placed in double jeopardy from this epidemic.
They are not only more susceptible to AIDS, but they also have the burden of
providing for the sick, the orphaned, their children, and themselves.
Women in Asia
Asia, and especially Asian women, has been largely forgotten in the
research and prevention of HIV/AIDS. This is largely due to the low comparative
infection rates, wherein only three Asian countries have over a 2% HIV infection
rate (Thailand, Cambodia, and Myanmar). In addition, those infected have been
overwhelmingly commercial sex workers, men having sex with men, and
intravenous drug users, so current interventions have focused on these
communities. Only recently have infection rates been noticed through heterosexual
18
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
contact, especially in conjunction with increased migration due to economic need.
However, it is extremely important to note that with the incredible population rate
of China and India, if even one percent of the population were infected with HIV,
the sheer numbers would be outstanding (MAP, 2000). Asia is as extremely diverse
as the countries, religions, and cultures that make up the region. Therefore,
generalizations about Asia as a whole in regards to HIV/AIDS transmission can
only be suggestive of the true inter-country situations. However, throughout the
region, heterosexual transmission rates are among the lowest and there are many
commonalties in the status of women in regards to their increased susceptibly.
Women in South Asia suffer from poor economic, social, cultural, and
educational conditions. There is a predominant lack of adequate health care,
creating even more vulnerable conditions for women. Women are extremely
susceptible to transmission of HIV/AIDS due to lack of power in their
relationships, determined by extremely rigid gender roles and expectations for
women as wives and mothers. Lack of economic independence, including
increased mobility of male partners, has increased the risks facing Asian women.
Trafficking and violence against women and young girls is a serious problem
throughout many Asian countries, and these problems point to the extent to which
women have little or no say over their bodies, let alone the ability to negotiate their
sexual rights and needs.
Research and intervention on HIV/AIDS in Asia has largely focused on the
commercial sex industry and those utilizing that industry. New trends show that
19
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
heterosexual transmission of HIV is increasing as women are being infected by
their partners who visit sex workers. Therefore, AIDS interventions thus far have
been focused on the “bad” disease spread by the behavior of “bad” women, and as a
result a severe social stigma has been attached to the disease. An example of such
labeling of the disease is the Philippines, where the government has helped to
perpetuate this negative stigma. As a result, many women have found themselves
unemployed due to closures of sex industry locations. The Catholic Church has
been a predominant force in the discussion, citing the condemnation of “Premarital
sex, Promiscuity, and Prostitution” (the three P’s) (Law, 1998). The sex industry is
an essential part of many Asian women’s lives, as it provides their only outlet for
economic support. This places women at increased risk of contracting STDS and
AIDS. Women have little control over their bodies and limited skills for negotiating
condom use. However, Cambodia and Thailand have been recognized as two
countries in the region with successful intervention campaigns. Thailand’s “100
percent condom” program in the commercial sex industry is one such highly
effective intervention.
In general, sex and sexual health are “taboo” subjects in Asia and especially
among Asian women. In many South Asian communities, “prevailing religious,
cultural and social beliefs often restrict open discussion about sex amongst South
Asians. Discussions about HIV/AIDS are further limited because this issue is
perceived to be a western phenomenon linked with homosexuality, drug use, and
promiscuity” (ASAP, 2001, p. 131). Women in these circumstances have become
20
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
increasingly susceptible to AIDS as many have never heard of nor seen a condom
let alone have adequate information about STDS and AIDS.
The taboos surrounding HIV/AIDS in South Asian communities
often extend to other aspects of women’s sexual and reproductive
health as well, including infertility, other sexually transmitted
diseases, and sexual abuse. This is not only true amongst South
Asian communities, in the Indian sub-continent, and in the Afro-
Caribbean Diaspora, but also amongst South Asians settled in the
West. Young South Asian women are often at a disadvantage
because their parents may not give them permission to attend sex
education classes, assuming that it will promote promiscuity. The
double standard about dating and premarital sex continues to exist
and women are expected to remain chaste, while men are tacitly
permitted to have multiple partners. It is not surprising then that
women are unwilling to bring up sensitive issues like safer sex or
HIV/AIDS (ASAP, 2001, p. 132).
Like women in Africa, Asian women are often dependent on their spouses for
financial and economic support and have little power for negotiation of condom use
or for safe sex issues.
In Mongolia, as in most other Asian countries, AIDS is seen as a “foreign”
disease, and many, increasingly those who are younger, uneducated, unemployed,
and unmarried have never heard of the disease (Tsetsgee, 2000).
“In Bangladesh, sexual behavior is a domain of privacy and
confidentiality. The initial reaction of rigid Bangladesh society to an
open discussion of reproductive health education or education on
sex and HIV/AIDS is influenced by myths, misconceptions, taboos
and discrimination leading to social rejection. Sex is a forbidden
subject for students and teenagers; teachers totally skip the chapter
on reproductive health. There is no welcoming place where they can
discuss the issue in a free and friendly atmosphere” (UNAIDS,
2001, p. 1).
Rural women especially face low socioeconomic conditions and are often
uneducated, making them highly dependent on male partners. A recent study in
21
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Bangladesh on family planning found that rural women had both positive and
negative results. The women enjoyed benefits of decreased economic pressure due
to smaller family size, better health due to less stress on their bodies from
childbirth, and increased harmony in their home lives. On the negative side, they
reported physical problems with contraceptive methods, criticism and social stigma
from not following traditionally prescribed social norms, and “emotional distress”
associated with sterilization and abortion decisions. The study found that
empowerment in family planning choices did not result in empowerment in other
areas of their lives, and in many cases it left the women more isolated due to
sociocultural norms (Schuler, et al., 1996).
Women in the Philippines also face serious unmet needs in regards to
reproductive and sexual health care. According to Jimexez-David and Talian
(2002), the gaps in gender inequality begin at a young age for Filipino women.
Young girls do not receive equal access to resources, including education, and have
greater responsibilities in their homes. This continues into adolescence, where
young girls are expected to wait until marriage for sex; however, the pregnancy rate
of teens is one in 15. STDS place women at extremely high risk, whereas in most
Asian countries women are viewed as the “carriers” who infect men. In addition,
young women have the highest HIV infection rates in the Philippines. Violence
against women is extremely common including increasing rates of rape. Abortion
is illegal and is often performed under unsanitary conditions. Family planning is
22
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
lacking, there is lack of access to contraceptive methods, and maternal death rates
are high.
Korean women are also impacted by inequity in social and economic
conditions since the status of women is very low. Young women have a dual role
as wife and mother that they must share with their careers. Men often value
traditional gender roles, placing increased work on the Korean women. “There is a
lag between the country’s employment system, which asks women for a
commitment to work, and societal expectations, which define women as primary
caregivers for children” (FHI, 2002, p. 1). The roles of Korean women have
changed during the past several years, going from the traditional role of
“unconditional sacrifice” for their children to a more modem role taken on by
professional women. This change has also placed an increased conflict on Korean
women’s ability to adapt to their new role. In addition, women exhibit low self
esteem due to this changing role, and gender stereotypes are common (FHI, 2002).
Physical mobility in Asia is a newer phenomenon that is perpetuating the
spread of HIV, especially among women. As a result of rapid economic change,
economic growth has created large disparities between rural and urban areas well as
agricultural and industrial areas. As people begin to migrate in order to seek better
economic conditions, the health care and educational sectors have been unable to
respond to the changing needs. Those who are highly mobile are more likely to be
exposed to high-risk environments and to bring this risk home with them. In
addition, more and more women have joined these migratory forces. This is often
23
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
due to trafficking of women and children into the slave and sex work industry
(Bain, 1998). Myanmar, Cambodia, India, and Thailand are some of the countries
where illegal trafficking of women and girls for sex work has increased the threat
of HIV.
The issue of trafficking and sex work in Asia is an extremely serious
problem in the event of HIV/AIDS transmission that places Asian women at great
risk. Those who are affected are mostly uneducated and poor women and girls who
find themselves in the sex industry either illegally or through their choice due to
severe economic conditions. In order to help their families some girls become
prostitutes. In other cases, their families sell them to the sex industry. The
“devadasis” in rural India are an example of such discrimination which places
women in extremely risky situations. Their families dedicate these women at an
early age to devote their lives to worship of “goddesses”. This is largely as a result
of poor economic conditions of the family, rendering them unable to pay a dowry
for marriage. These women have often been forced into sex work to provide their
source of income. They have little education and knowledge about HIV/AIDS or
prevention, they are rarely away from their work at home, and they are restricted as
to their social, emotional, and educational outlets (Dadian, 1997).
In China, the heterosexual increase in the spread of HIV is a result of
increased mobility of the population, high risk behaviors (intravenous drug use,
prostitution, homosexuality), blood transfusions, and “the sexual revolution with
changes in the patterns of sexual behavior and increased pre- and extra-marital sex,
24
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
casual sex, and multiple sex partners among the younger generation” (Bain, 1998,
p. 562). There are many factors that inhibit the use of condoms as a form of
protection against AIDS and STDS in China. These include poor production of
condoms, lack of availability, and cultural fear. Behavioral patterns contribute to
the risk through representation of “masculinity”, poor health care, and lack of sex
education. In fact, there are a myriad of “sprays” that are advertised in China as
methods of protection from AIDS, and they are even approved by the Ministry of
Health. HIV/AIDS is viewed as resulting from homosexuality and promiscuity
(Dikotter, 1997).
Laos has also suffered increased infection rates due to the high mobilization
of the population as migrant workers have relationships with local women, the
majority of whom are uneducated and lacking health services (Bain, 1998). In both
cases, women are placed in risky situations, as they are unable to negotiate or
demand safe sex while their partners are placing them at high-risk of infection.
In India HIV/AIDS infection rates are increasing from urban to rural areas
and from high-risk groups to the general population. Additionally, one in four
cases are found in women (NACO, 1998). NACO found that several factors
contribute to the increase in HIV infections, including decline in moral values,
increased mobility, increased use of the commercial sex industry, and population
increases resulting in poorer economic conditions. Women often feel that they have
no need to seek out sexual health care; they have limited sex, and there are stringent
taboos about sexuality and STDS. Furthermore, women are not comfortable with
25
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
male doctors and female doctors are almost non-existent (NACO, 1998). Women in
India face high maternal mortality rates, poor quality of health care, low education,
and high illiteracy rates which contribute to their feelings of powerlessness in their
lives and relationships.
As of now, heterosexual transmission rates of HIV/AIDS remain low in
Asia and for Asian women. However, this trend may not continue as women are
increasingly placed at risk due to economic conditions, mobility, and sociocultural
gender roles. Women in Asia have little opportunity or support for appropriate
health care and education about sexual health, reproductive rights, and HIV/AIDS.
Female sex workers are at extreme risk of contracting HIV due to lack of
education, access to condoms, and lack of power in their roles with their clients.
Violence and a social stigma on contraceptive use enhance these issues and further
drive the problem, as do cultural attitudes about women’s rights. In countries
where women can be sold or traded into sex work and are often forced
economically into this position, they have little power to negotiate or demand safe
and sanitary treatment and conditions. Women then are placed in extremely risky
situations which may result in a steady increase in the heterosexual transmission of
HIV in Asia.
Women in Latin America and the Caribbean
In Latin America and the Caribbean, women have increasingly been
infected with HIV; by 2001, of the 1.8 million infected, 30% were women in Latin
America and 50% in the Caribbean (UNAIDS/WHO, 2001, p.3). Although initial
26
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
infections were seen predominantly in homosexual males, recent trends show major
increases in heterosexual transmission, specifically affecting women. Women in
Latin America are more susceptible to HIV infections due to the sociocultural
practices that relegate women to subordinate roles in their communities, with their
families, and with their partners. Machismo is one such factor, propagating the
belief that men are dominant and should control the lives of women. Men in Latin
America often have sexual partners outside of marriage, and violence toward
women is very high (Rafaelli and Pranke, 1995). There is a direct connection
between infection rates and poverty rates, low educational rates, and lack of health
services, which are all common problems among women in Latin American
countries. Other factors contributing to increasing infection rates in Latin American
include poverty amongst certain social groups, migration, an expanding
commercial sex industry, illegal drug use, violence and alcoholism, and
vulnerability of young women (Vandale, et al., 1997).
The predominance of research on women has been completed in African
countries, although some research is beginning to consider women in Latin
American countries. Brazil is one country in Latin America where the HIV
epidemic has been strong and a number of programs have been implemented.
Women in Brazil have increasingly been infected with HIV in proportion to male
infection rates (from 36:1 in 1985 to 4:1 in 1994) (Klein-Alonso, 1996, p. 150).
The sociocultural traditions of sexual relationships in Brazil border on the
traditional and the progressive. Women have restrictive social roles while it is still
27
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
considered “normal” for a man to have a wife and a “lover.” On a more
progressive side, “Women Police Stations” (WPS) have been created for women
who are being discriminated against sexually; however, the majority of cases are
dropped. Sex is not openly discussed among couples, and the woman is considered
responsible for contraception. Further, men may rate their “masculinity” through
their sexual relations and power in these relations (Klein-Alonso, 1996).
In the study by Klein-Alonso (1996) in Brazil, she found that the
representations of gender roles were culturally prescribed for women and men. A
woman should get married and have children, should not enjoy sex prior to
marriage, should not “show interest” in a man, should not make more money than
her husband, and should not discuss “feelings and emotions,” including those about
sex. Men, on the other hand, can be aggressive but should not express feelings,
should not partake in household chores, should not show public affection, and do
not associate sex with love. These descriptions indicate the wide discrepancy in
expected gender roles culturally prescribed on a social level.
The highest increase in the numbers of HIV infections in Brazil was found
among married women with children. Therefore, a recent decision in Sao Paulo
was to increase the use of the female-condom while convincing women that their
husbands are putting them at risk. “Latin-style machismo leaves women with little
bargaining power” and results in lower use of condoms (McDaniels, 1998, p. 8).
Women fear violence and losing their partner if they insist on safe sex practices.
This recent study found that Latin American men were very likely to have sexual
28
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
relations outside of marriage, with 49 percent of men and only 14 percent of
women admitting to affairs (p. 8). This puts women at an increasingly higher risk
level for AIDS infection, as married women are more likely to become infected by
their husbands.
In Haiti, HIV infection rates are among the highest in the world, with an
over 4% infection rate in adults (UNAIDS, 2001). The strongest implication for
women is that infection rates for women among the HIV population increased from
10% in 1980 to 50% in 1993. In Haiti, women’s health is a serious concern that
coincides with extremely high poverty rates, high migration, low economic status,
and low education rates. In addition, as men have emigrated for economic reasons,
women have increasingly been placed in the role as the sole economic provider for
the household. This places women in serious jeopardy of economic, social, and
health problems. Women in these severe economic conditions often seek out new
male partners for financial support to assist with the children they have from prior
relationships. Maternal mortality rates and adolescent pregnancy rates are high, and
the average number of children is 4.8. Only 50% of women have access to health
care, and the use of contraceptives is a low 18% across the country (Adams, et al.,
1998). In addition, domestic violence rates including rape are very high, and “more
than 70% of the female population have experienced some form of violence, of
which 37% is sexual in nature” (p. 37). However, few incidents are ever reported,
as “many women do not know they have right to bring charges against their
aggressors and that they have the right not to be beaten by their spouses” (p. 37).
29
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Women in Haiti lack advocacy and support for family planning and
reproductive health. As noted by the increasing HIV infection rates, women have
been placed in a powerless role due to lack of education, financial independence,
and support. Women have little participation in governance and decision-making
in any level of their lives. “The social role of Haitian women is to be wives,
mothers, and homemakers. Men frequently comment that women are too weak to
participate in politics. Women’s status in Haiti is extremely low. Women lack
confidence to speak out at meetings; they are unaware of their basic human rights;
and economically, politically, and socially they occupy the lowest social position in
Haitian society” (Adams, et al., p. 37).
Mexico is another country where lack of rights for women and an inability
to negotiate with their partners places them at increased risk of HIV transmission.
In a recent workshop on sexual health for women in Mexico (Rojas and Lopez,
1997), participants discussed several impediments to equality of health and HIV
education for women. Some of the major problems found were that male doctors
usually make the decisions about women’s health, and doctors are often resistant or
lack the background for effective HIV education. In addition:
• An important part of the female population is home-based and
does not have access to the information on AIDS through
institutions such as schools or within the health sector.
• The information on men’s sexuality is scarce, and even less is
known of women’s sexuality. Therefore, many myths and
stereotypes surround both men’s and women’s sexual behavior,
leading to difficulties in knowing how best to change that
behavior.
• The use of inappropriate technical language makes it difficult for
the general population to understand the messages about
30
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
HIV/AIDS. Therefore, it is important that the characteristics and
language of the population be taken into account (p. 17).
In addition, in regards to sexual health, there is a long-term cultural inequality for
women, and Mexican society is resistant to changing these roles. Education and
resources are scarce for women and for reproductive health and gender issues
(Rojas and Lopez, 1998).
In Argentina, younger women, especially those living in poverty, have
increasingly become infected with HIV/AIDS. Argentina has a long history of
discriminatory practices and social stigma designed toward certain religious, racial,
and sexual groups. Contraceptive methods and family planning were prohibited
until 1986, sexual education has been resisted, and abortion is illegal. Poverty and
resistance from conservative and religious sectors against condom use also places
women at great risk of HIV infection. Officials have basically ignored the risk of
AIDS to women, as they associate the disease with promiscuity, homosexuality,
and drug use. Sexual and reproductive health is not adequate or available to most
women, and condoms are not used nor distributed through the health care system
(Bianco, 1997).
In a national study of sexual behavior and HIV in Argentina (Frontera,
1995), women were found to be at high risk of infection. The majority of
respondents stated that they received most of their information about AIDS from
television (38%), followed by magazines (30%). Women were also highly likely to
get information from friends (18%) (p. 36). The majority of men reported they did
use condoms, but the majority of women stated they did not. Men reported they
31
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
did not use condoms mostly because they had a stable partner, that they did not
know why they did not use a condom, or that the condom bothered them. Women
also reported they did not use condoms because they had a stable partner. The
majority of men and women stated that the government was doing a “bad” job of
dealing with HIV in the country (Frontera, 1995). This information indicates that
women continue to be placed in high-risk situations due to lack of information as
well as ability or perceived need to use condoms.
Chile faces problems similar to Argentina, with an increased infection rate
of 4:1 for women to men by 1994, and with the majority of women contracting
HIV through heterosexual contact in their own homes. The general belief in Chile
is that women infected by HIV have multiple sex partners or risky sexual histories,
but the data do not support these beliefs. There is low contraceptive use as
exemplified by high rates of illegal abortion and adolescent pregnancy. This is
seen as a result of lack of information and education, lack of available and adequate
health care, and cultural barriers. These cultural issues include the acceptance of
extramarital relationships for men and the lack of ability to communicate about
sexually transmitted diseases. Traditional gender roles do not allow women to
negotiate with their partners about safe sex practices (Manmquez, 1997).
A 1996 study of AIDS in Chile found that 85% of respondents had not used
a condom in sexual relations during the previous month. In fact, only 59% of men
and 33% of women interviewed had ever used a condom. Reasons for lack of
condom use included that it was unnecessary (47%), that they did not like it (10%),
32
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
that it bothered them (5%), that it diminished pleasure (4%), that it was only
necessary with “easy” women (3%), and that they were embarrassed (2%)
(Mendez, 1996, p. 36). The study also found lack of knowledge about AIDS and
its transmission and a strong belief in myths surrounding AIDS (Mendez, 1996).
This indicates lack of education and communication about AIDS among the
community. Women were much less likely to use a condom and to protect
themselves against contracting the disease.
Studies of Latin American women residing in the United States support the
sociocultural norms that increase sexual behavior risks. Gender roles include
“double standards” for Latin American women. They lack knowledge of sexual
health and their bodies and can not discuss sexual matters such as condom use. On
the other hand, men are expected to have outside sexual relations. Married Latin
American women were found to be less likely to use condoms (14%) than non-
Latinas (26%) (Maldonado, 1991). Women then have little room for negotiation
and no power to discuss concerns of protection and contraceptive use.
Women in Latin American and Caribbean countries are increasingly
susceptible to HIV infections, as the disease moves from one of men having sex
with men and illegal drug use to that of heterosexual contact. Sociocultural
practices which predicate violence against women, machismo, and lack of health
services and education place women at extremely high risk in these countries.
Women are justifiably in fear of voicing their rights due to threats of violence from
their partners. Poverty and lack of access to adequate education further inhibit the
33
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ability to demand safe sex or adequate health care. The socially stratified gender
roles render women in a position where they are vulnerable to HIV infections from
their partner’s outside sexual relations and their own inability to request safe sex.
Women are placed in a powerless role in their relationships, and this is further
intensified by lack of education, poverty, poor health care systems, and inequality
in gender roles. Infection rates for Latin American and Caribbean women will
continue to rise until these threats can be confronted and diminished.
Summary
Women in Africa, Asia, and Latin America make up the most rapidly
increasing population infected with the HIV virus. This infection rate can be
attributed to the discriminatory practices that render women helpless to controlling
their own bodies and making decisions in their daily lives. Poor socioeconomic
conditions require women in many countries in Africa, Asia, and Latin America to
depend on men for financial support, placing women in vulnerable positions where
they are often forced to provide sex for economic need. Sociocultural norms in
these regions also determine women’s gender roles that often discriminate and
render women in positions of inequality. Many women in these regions do not
have access to education, medical care, economic resources, or adequate
information on sexual health and reproductive rights. Women become powerless
over decisions about their bodies and unable to negotiate safe sex with their
partners. Women are expected to be wives and mothers and play these roles
without discussion or ability to change their socially prescribed position. In many
34
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cases, especially in African, Asian, and Latin American countries, women have no
political voice to demand equal treatment and access to adequate resources. When
a woman cannot negotiate or make decisions about sex or her body she becomes
more susceptible to contracting HIV and other STDS. Due to the defenseless role
of many women, they will continue to be at high risk for contracting the disease
until societies and communities change current practices. The situation can change
when women become empowered to recognize and change the norms and
conditions that continually place them in vulnerable situations. Power in
relationships and in the struggle for equality in education, health care, political
voice, reproductive choice, and against violence is essential for women to create
empowering environments where women can make safe choices about their lives
and their bodies. Through this power, women can protect themselves from
continuing to become victims of AIDS.
Theoretical Frameworks of HIV/AIDS Prevention Programs
HIV/AIDS prevention programs have been designed and evaluated based on
a number of theoretical frameworks; from social and behavioral theory to
communication theory, each has had an effect on the conceptual framework of
educational interventions. The main area of concern mentioned repeatedly in
research is the lack of attention these theories pay to human sexuality, and much
later to gender relations. As the epidemic has expanded, theory-based interventions
have also re-framed program design and basis for evaluation. This section will
provide an overview of the theoretical basis for prevention programs.
35
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Gillies (1996) examined prevention programs based on social and
behavioral theories. The main concern with these programs has been “reliance on
quantitative survey research, lack of exploration in to the social context of
behavior, limited discussion of national and local policies, limited evaluation,
inadequate consideration of diverse processes for preventing HIV infection, and
poor elaboration of concepts of sexuality” (p. 131). In models examined from
1991-1993, the majority were based on psychological theory followed by sociology
and social psychology. The psychological approaches focused on “individual
determinant of sexual behavior and assuming that behavior is rational,” whereas the
social approach examines within and between group behavior and “emphasizes”
individual behavior (p. 136). The psychological theories did not prove to be
effective in HIV education and have led to focus on a more sociological approach
as well as combined theoretical frameworks.
Other theories have drawn from social science and have taken enhanced
approaches to intervention. Social construction theory has contributed to more of a
cultural understanding of behavior concerning “the emotional significance of
certain sexual acts and the wider systems of meanings that made these behaviors
important” (p. 139). Systems theory has also played a role in prevention, especially
in Africa, monitoring the migrant work lifestyle and behaviors of truckers and sex
workers. Gillies suggests that although the original social science theories have
been weak in areas, combining these theories with other models such as political
36
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
science, justice, and political democracy theories can help to enrich program
models.
These frameworks have varied among regional areas, and especially in
developing countries. Webb (1997) provides an overview of theoretical approaches
to AIDS prevention in Africa. Initial research in the 1980s was based on “bio-
anthropological” approaches, searching for meaning in “deviant” sexual behaviors
and investigating cultural issues. These approaches tended to reinforce “cultural
and gender stereotypes of assumed black sexual (and female) immorality” (p. 29).
Bio-medical approaches tended to over-generalize cultural practices such as ritual
cleansing or polygamy. Due to these concerns, recent theories have taken political
and economic structures into consideration in relation to understanding the
epidemiology of HIV/AIDS. Structural analysis then began to consider that
“structural conditions will result in a certain behavioral pattern in any given area”
(p. 31). This approach is found to be “deterministic” in nature and does not provide
explanation for local difference. This assumes that based on the structural
situations, both political and economic, people will behave in particular ways. It
does not consider cultural or regional distinctions that allow people varying
freedoms or opportunities.
As research shifted in Africa in the early 1990s, the political economy
perspective began to replace the behavioral and anthropological approaches. Webb
states that this created movement toward examination of structural rather than
individual behavior, but has not provided further understanding of HIV
37
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
epidemiology or implications for program design. As a result, the political ecology
approach has been developed based on themes of Realism, Structuration, and
Marxism. The underlying belief relies on social structure combined with biological
causes of the epidemic. This new framework is linked to the shift to qualitative
rather than quantitative research for determining causal relations. Webb further
reports that structuration theory has played a more active role in examining sexual
motivation and how HIV is transmitted within these activities. In addition,
geographical research has contributed to cartography and “spatial aspects” of the
AIDS epidemic. Although, geographical approaches have not contributed directly
to educational frameworks, they have provided social and epidemic mapping
components to the understanding of the epidemic.
In the United States the initial responses to preventative measures were
developed through the public health system based on behavioral science and
communication theories; approaches that were not clearly established or understood
in public health arenas in the early 1980’s (Rosenberg et al., 1997). These
behavioral approaches sought to understand the causes for sexual behavior in order
to influence change. Educational programs must “be consistent, intensive,
systematic, and combined with other strategies” in order to modify behavior (p.
179). Research would seek to understand how and why people behave certain
ways, what are the outcomes of the behavior, how can it be changed, and the
effectiveness of intervention. However, most health care workers were not trained
38
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
in or knowledgeable about behavioral change theories and the health care system
was not prepared for dramatic conceptual restructuring.
In combination with many of these programs, media and communication
campaigns have been highly utilized in prevention programs. Many of the initial
media campaigns were based on fearful messages about AIDS. Netter (1992)
described three phases to media interventions and reporting on the epidemic. In the
first phase, the “fear and ignorance,” at the beginning of contact with the disease
relays messages similar to those initially found in the United States referring to the
“gay plague.” Many of the myths of government cover-up and those that place
blame on cultural or social groups are disseminated in this phase. The media has
responded by exploiting these myths and by promoting representations of fear in
reporting. In the second phase, acceptance of the disease has occurred and fear has
lessened. Usually, journalists report more responsibly, providing good and
accurate information to the public. The third phase is a more recent reaction seen
in North America and beginning in developing countries. The media views AIDS
as “a key public issue deserving of serious treatment and policy review” (p. 247).
AIDS becomes more of a serious and regular consideration for media coverage on a
national and local level.
As the media clearly plays an active role in portraying the AIDS messages
to the community, what should their role as educators become? Netter argues
against the position of journalists as educators: they are not trained as educators,
their job is purely informatory not educational, media has been ineffective in other
39
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
health campaigns such as cigarette smoking, and misinformation is likely to be
disseminated. As most AIDS research has found, education alone is not enough to
deter behavior or to end the epidemic, but the media can play an effective role in
providing information. However, AIDS educators should not rely on media for a
source of information or view them as partners in the prevention campaign and
should instead find ways to work cohesively with the media for best practices in
prevention.
On the research and evaluation aspects of prevention, many of the
methodological approaches have been based on the social science approaches to
prevention. The knowledge, attitudes, beliefs, and practices (KABP) surveys have
been highly utilized in quantifying an understanding of sexual behavior. In the
early stages of research in the 1980’s, surveys were designed around the general
population through national survey research. Demographic and health surveys
(DHS) were initially utilized in family planning and sexuality research (Gillies,
1996). These types of evaluations are limited due to lack of data quality, limited
contribution to understanding the epidemic, and lack of applicability to program
design. Focusing these evaluations on specific populations, such as sex workers or
migrant workers, has proven more useful in design and applicability.
As research surrounding the HIV/AIDS epidemic has evolved,
methodologies have focused less on quantitative behavior and more on qualitative
studies. Qualitative studies have considered “social, cultural, political, and
economic factors and have relied less on psychological theories (Gillies, p. 146).
40
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In evaluations from 1991-1994, theoretical frameworks have considered more
social construction, sociology, and anthropology for design of research and as
approaches to understanding sexual behavior.
The theoretical approaches attributed to HIV education have evolved over
the past ten years of the epidemic, both in program design and evaluation. A move
from psychological theories with a focus on the individual to combined structural
theories with more of a focus on political and economic structures has taken place.
These frameworks have also shifted evaluation from quantitative surveys of human
sexuality based on demographic regions to more qualitative studies focused on
individual sexual behavior and external factors that may inhibit these behaviors.
However, these theories continue to evolve in the current face of the epidemic and
have just begun to consider the social ramifications associated with the increasing
numbers of women infected with HIV/AIDS.
Main Concepts o f Reality/Sexual Relations
Research in the prevention of AIDS has led to the realization that there is
little understanding of human sexuality. Without an understanding of the nature of
sexual relations and how behavior is determined in these relations, little
opportunity for behavioral change can occur. Many AIDS education programs
have failed to recognize these factors when providing education for both women
and men. “Currently, four basic recommendations form the core of most programs
preventing sexual transmission of HIV: abstain from sexual intercourse; practice
mutual monogamy; use condoms consistently and correctly; and access appropriate
41
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
treatment for other sexually transmitted infections” (Gupta et al., 1996, p. 216).
These do not consider the basis of human sexuality and/or discuss the limitations
effecting real sexual practices and the mitigating factors that contribute to
relationships. Abstinence and monogamy are strongly based on behavioral change,
requiring serious limitations on sexual practices, without considering the basis and
needs that underlie sexual relationships. These four recommendations do not pay
attention to gender roles, power roles in sexual relationships, or the social,
economic, and cultural manifestations that influence sexual behaviors.
In general, most HIV education programs leave power relations out of the
discussion and provide “gender neutral” interventions. These do not consider
social processes, sexual relations between men and women, and women’s ability to
utilize preventative behaviors (Campbell, 1999). Campbell (1999) applies Miller’s
“Self in Relational Theory” approach to HIV prevention, where women place a
greater meaning on relationships than men, resulting in increased risk for initiating
change in these relationships. According to this theory, sex is something a woman
“gives” to a man and the ability to negotiate safe-sex behavior would require
women to move away from this role and to become more assertive in sexual
communication. Women, then, “must act contrary to their socialization as the
subordinates of men” which requires them to change culturally and socially
prescribed behaviors (p. 85). AIDS prevention programs also base protection on
“mutual monogamy”. However, this may actually be dangerous for women who
maintain monogamous relationships, when their partners do not. If a woman
42
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
believes both are practicing monogamy, she may not protect herself appropriately
and would be less likely to communicate contraceptive or preventive needs.
Intervention programs have also ignored cultural variables that effect a
woman’s ability to negotiate safe-sex behaviors. “Women fail to reduce their risk
because the necessary behavioral changes may involve real or perceived threats to
their economic survival, their relationship, and their culturally sanctioned roles”
(Campbell, p. 92). Programs that merely prescribe abstinence, for instance, forget
that economic and cultural needs may outweigh the ability to communicate or
negotiate about safe sex. Therefore, HIV education programs must take cultural
and gender specific issues into consideration when designing and implementing
intervention and messages associated with those interventions.
In addition, most programs have focused on either gender neutral education
(designed for either men or women) or on educating women to create behavioral
change, yet the importance of the male partner’s behavioral change has not been
emphasized. This approach requires women to take responsibility for changing
their partner’s behavior, although power relations already place women in a
subordinate role. Programs often target women because they are “easier to reach”
and programs are provided in places where women more often attend (i.e. family
planning clinics, welfare offices). Programs designed for intervention with women
only assume that women have control in these relationships and that women can
change male behaviors. Instead, male sexuality and gender roles must also be part
of the structure and design of intervention programs. These programs and research
43
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
agendas must consider men’s reproductive health, masculinity, and sexual
relationships of men (Campbell, 1999). They must provide gender sensitive
approaches to education, while providing intervention appropriate to the needs of
both partners in sexual relationships.
As mentioned earlier, most programs base interventions for HIV prevention
on four recommendations, each requiring behavioral change. These educational
interventions include messages that assume women can change their behavior
without social or partner support. The messages are in the form of a list of “do’s
and don’ts,” for example: “refrain from multiple sex partners, use condoms, and
treat and control STDS” (Cash, 1996, p. 314). These messages focus on behavioral
change without consideration for social, cultural, or power relationships. The first
message creates an assumption that “only promiscuous women get AIDS”, the
second assumes women have the power to influence their partners to use condoms,
and the third assumes that women have access to health care and education on
STDS, when in reality, women lack power in relationships and in many areas lack
any information regarding or access to adequate health care (Cash, p. 314, 315).
Cash (1996) points out that these messages have been highly ineffective in
interventions for men as well. In many developing regions of the world, men also
do not have access to health care and prevention, including condoms. “These
messages are unrealistic for the millions of men living in communities where
customary values, expectations, and behavior are at odds with the messages” (p.
316).
44
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In sum, the educational messages and recommendations designed by most
HIV prevention programs have not been effective in creating behavioral change by
not recognizing the social and cultural manifestations that underlie sexual
relationships. Little is known about human sexuality and the conditions necessary
for adequate prevention campaigns. It is essential, however, that education go
beyond these messages and incorporate social, cultural, economic, and gender
issues into the discussion of prevention. Furthermore, both men and women must
be included in the HIV prevention dialogue.
Empowerment
As with sexuality and gender relations, HIV/AIDS education programs have
paid little attention to issues of women’s empowerment. Although research on
nonformal education programs has included recommendations for incorporating
empowerment into educational interventions for women, little has been done to
address these issues in the HIV education arena. An understanding of
empowerment and the components necessary for transformation of women into
roles that allow power in relationships is essential for creating effective education
programs.
Webb (1997) defines empowerment as “the link between context and the
individual” and applies two variables in relation to HIV education:
• “Behavioral empowerment allows girls and women to have more control over
their sexual activity, either through resisting sexual advances or through
negotiating safe sex. It is the increase in the decision making ability of the
45
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women, so rendering them less vulnerable to infection, as the incidence of
unsafe sex is reduced.
• Structural empowerment is the reduction of economic dependence on men, and
the improvement of women’s sociolegal status” (p. 209).
Thus, empowerment takes on two forms, the first being individual and allowing
women the power to negotiate and communicate about their sexual needs and
desires. This creates an environment where women are able to control their own
bodies and to effectively protect themselves from unsafe situations. Again, women
can make their own choices for control of their bodies and are less likely to be
involved in at-risk behavior. The second is more systematic, in that it changes
outside forces that drive women into positions of subordination, due to economic
needs. This empowers women to provide for themselves economically, resulting in
removal of the economic needs for sexual relationships. This can occur on an
individual level, or when considering structural empowerment, on a collective
level. This type of collective empowerment would require a long-term approach
that allows for recognition and understanding of the structural forces that contribute
to oppressive conditions. A program that seeks to create this structural awareness
would focus on a more “conscious-raising approach” that would create
opportunities for collective awareness and change.
There are many underlying factors that contribute to the spread of
HIV/AIDS in developing countries. The socioeconomic and sociocultural factors
are instrumental in contributing to this disease, especially related to the status of
46
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women in these countries. These issues contribute greatly to the main issues that
make women more susceptible to HIV infection: lack of power or control over their
bodies, playing a subordinate role in sexual relationships, and socially prescribed
gender roles. These factors lead to increased risk for women in contracting HIV and
other STDS.
HIV education programs vis-a-vis the messages they provide, have largely
left women’s empowerment out of the prevention dialogue. In designing
educational interventions that require behavioral change, the social, economic, and
cultural conditions of women have not been considered as to the impact they have
on sexual relations. Empowerment of women in cognitive, psychological,
economic, and political areas allows them the ability to control their own lives and
their own bodies. When women are no longer dependent on sexual relationships to
provide their physical and economic well being, they will be able to negotiate and
communicate, both prerequisites for effective protection from HIV/AIDS.
The Feminist Perspective of HIV Education Programs
What has been learned from the past ten years of AIDS intervention? The
most striking concern is that although women have more recently been included in
prevention programs, attention has not been paid to the fact that they have been
placed in a powerless role against AIDS. Programs targeting increasing women’s
knowledge about HIV, promoting behavioral change, and giving access to and
education about condom use, assume that women have the power to influence their
partner’s behavior and to express their sexual roles freely. However, social and
47
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cultural influences have forced women into an environment where this is not the
case. Three areas that HIV education programs have not focused on are socially
and culturally established gender roles, women’s sexuality and power relations, and
women’s empowerment.
Feminist theories of education can, and have, contributed to the design and
effectiveness of HIV/AIDS education programs. Feminist theories can hope to
shape and define a clear thinking of gender, or gender roles, and determine an
empowerment model. In examining women in development (WID) models,
Maguire (1984) presents the applicability of a feminist perspective to WID from
three theories: radical feminism, Marxist feminism, and socialist feminism. These
can be constructive in determining HIV education as well.
Radical feminism “argues that the primary motivating force of history has
been men’s striving for domination and power over women” (p. 26). The power
relations between men and women are “biologically based” leading to oppression
of women. The biggest criticisms are the lack of attention to sex versus gender and
the lack of attention to culture or class. Marxist feminism looks less at gender
relations and at “economic or class relations as the primary oppression” (p. 28).
So, rather than focusing on gender relations, they view the women’s production and
ability to contribute economically as the essential determinant of oppression. The
criticism of this theory is the lack of attention to power through gender relations.
Finally, social feminism considers sex, race, and class in the causes of oppression
both in society and within family structures (Maguire, 1984).
48
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
As these feminist theories relate to WID, they can also relate to concerns of
power and gender relations in HIV education. Maguire specifically considers
social feminism in the realm of nonformal education and in the structural designs
that oppress women, with a focus on how relationships between women and men
are necessary for transforming these structures.
Social feminism forces recognize that within those structures
women do not live, work, love, and play in isolation. Women exist
in dynamic and concrete relations with men. Feminist analysis
legitimizes attention to those relations, particularly to differences of
power and privilege. Feminism asserts that not only must structures
be transformed to allow ordinary women and men dignity and
control, but concurrently women and men need to transform the
relations between them (p. 33).
In examining HIV education, then, feminist theory would contribute attention to the
power and gender relations that affect women’s ability to negotiate sexual behavior
and to communicate in relationships. It would recognize the importance of the
education of men as well and their need for knowledge of the conditions of women
and causes for subordination. Educational programs would also consider the
transformation of relationships and the empowerment of women to take an active
role in these transformations.
Schneider and Stoller (1995) describe four ways that feminist approaches
have already contributed to HIV prevention. First, “recognition that AIDS is a
pandemic.” This has helped to recognize the effect of the epidemic on women,
created “alliances” on an international level, and brought a level of awareness of
cultural and class differences among women (p. 3). Second, feminist leaders in the
HIV crisis prescribe “sustained attention to the social relations of race, class,
49
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sexuality, and culture” (p. 4). These issues consider social and political inequalities
as well as those related to access to health care, education, and the legal system.
Inequalities due to racial and class distinctions are also part of this discussion. The
third theme is the “processes of feminist social change” (p. 5). This pays attention
to the actual conditions of women’s lives and views women as “actors pursuing
creative and effective strategies which invariably challenge, even if indirectly,
relations of gender inequality and women’s enforced passivity” focusing on the
empowerment of women to change these conditions (p. 5). This is created through
process of “individual and group survival” and fostering institutional change (p. 6).
Finally, an “emphasis on women’s skills and activities” is seen as an essential core
of HIV education. The social processes and practices that women engage in on a
daily basis are core elements of their ability to motivate change both individually
and politically.
Feminist theory has contributed to the HIV dialogue by considering culture
and class when examining social and political inequalities and focused on
empowerment and economic security as factors required for successful
intervention. In order for education to reach women, successful programs would
first include educational material about the: transmission of AIDS and other STDS,
how to use and access condoms, sexuality and women’s sexual health, reproductive
health and family planning, communication and information sharing, partner
negotiation, identifying risk behavior, individual and family health, and right to
health education (Cash, 1996). Second, consider the process of education from
50
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
both an organizational and process perspective. Organizations should consider peer
educators and vertical models of education. The learning process should look at
communication levels and should: “appeal to emotions, giving participants a
personal stake in the outcome; build skills and enable participants to practice new
or unfamiliar behaviors and; enable participants to share experiences that give rise
to new solutions” (p. 325). Finally, the context of the intervention includes a safe
and open environment fostering discussion and paying attention to women’s
schedules and locations.
In addition, effective research would pay attention to comparison of
“theory-based intervention strategies” in controlled settings, violence in
relationships focusing on reversing the “feminization of poverty” for women to
become empowered, controlling other STDS, and improving sex education and
drug-use prevention” (O’Leary and Jemmott, 1995, p. 257).
In essence, effective intervention from a feminist perspective would go well
beyond educating women on the risks associated with HIV/AIDS. These programs
would focus on the social and cultural constraints that place women in subordinate
roles, fostering an open dialogue among both women and men as to transforming
these conditions. The economic deprivation of women would be addressed through
combining courses with currently functioning economic development programs, or
incorporating skill-building activities into prevention programs. Effective
programs would create opportunities for empowerment of women that go beyond
sexual roles and relationships, but that allow examination of the political and social
51
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
structures which constrain women’s sexual, social, and economic rights. Finally,
these programs would offer space for nurturing realization of these conditions and
the ability to create change on both the individual and social levels.
Summary
Current HIV/AIDS education programs have not addressed issues of power,
gender relationships, or the empowerment of women necessary for understanding
the dynamics of the sexual behavior associated with women and the HIV/AIDS
epidemic. Feminist theory can contribute greatly to this dilemma by recognizing
the social, cultural, and gender inequalities that guide women’s inability to protect
themselves from this epidemic. Further, recommendations for effective
programming must incorporate theory while paying attention to those social and
political manifestations that drive the subordination of women in these contexts.
HIV/AIDS Prevention/Education Programs
By the end of 2001, there were an estimated global total of 40 million adults
and children living with HIV/AIDS. An estimated 5 million adults and children
were newly infected with HIV in 2001 alone, 2 million of whom were women.
Globally, 800,000 children were infected with HIV in 2001, through breastfeeding
or the birthing process. AIDS has become a top ten leading cause of death
worldwide (UNAIDS/WHO, 2001, p. 1).
It is useful to look at several recent nonformal HIV/AIDS education and
family planning programs to understand the successes and weaknesses in current
methodologies as well as the program dynamics. The program descriptions will
52
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
help to analyze the attention that has or has not been paid to the core issues of
empowerment, gender roles, and sexuality. A description of programs in the
United States and Africa will help to outline the objectives current programs seek
and obtain. Also, the type of provider is important to understand based on the
desire to focus on gender issues. Religious organizations, government supported
agencies, and community-based non-governmental organizations (NGOs) may each
have a differing viewpoint on incorporating gender into the discussion. These
programs where chosen for review as to the relationship to the Peruvian program
through the focus on the train the trainer model, peer educators, and on women.
Church Human Services AIDS Prevention Program (CHUSA)
The Church of Uganda established the Church Human Services ADDS
Prevention Program (CHUSA) in 1992. The religious organization and World
Learning, Inc., an NGO, support this program. The program participants are adult
women and men and families in the church community. CHUSA provides training
for educators from the Church leaders to community members, or Community
Health Educators (CHE). The CHE becomes a community peer educator,
providing outreach, counseling, and education for community members. The
program also provides condom distribution within the community. CHUSA’s
objectives are to create behavioral change, improve the reproductive efficiency of
the community, and improve community health through preventive measures. This
project was short-term as funding ended in 1995 (CHS, 1995).
53
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Evaluation and Program Features
Evaluation was established at the onset of the program through knowledge,
attitude and practice surveys (KAP) distributed in two of the target communities.
To define program effectiveness, the evaluators looked at the number of
community members reached by CHEs, increase in condom use, increase in
abstinence, decrease in multiple partners, and increased knowledge about HIV.
The program had several strong features, including the CHE or peer educators, the
dedication to community outreach, and the evaluative component. Weaknesses in
the program were found in the lack of follow-up provided to each community
contact, the inability to provide outreach in remote areas, the lack of condom
supplies, and the unavailability of HIV tests due to access and cost issues (CHS,
1995, Ruteikara, 1996).
Analysis from a Gender Perspective
This model nonformal education (NFE) program can be projected in the
typology presented by Petherbridge-Hemandez (1990). This adds a new dimension
to the typology where CHUSA might be classified as a religious-transformative
program. With a religious orientation, the program presents a transformative
objective in the behavioral change aspects. One outcome of the CHUSA project, as
evidenced by the Church, was that the program created an opportunity for an “open
and positive dialogue” between the Church and public health workers, which
resulted in behavioral change as well as promotion of the educational message
(CHS, p. ii). However, the Church has often been left out of the discourse by both
54
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
medical professionals and the government, due to religious misconceptions or
political constraints (Ruteikara, 1996). Fernandez (1985) looks at these polarities
when examining the relationships in which NGOs base their orientation. CHUSA
can obviously be classified due to its close relationship with the Church, but how
does it define its relationship vis-a-vis the political or educational dimension.
The evaluators note that the “majority of trained Community Health
Educators were men and it is culturally more acceptable for men to talk to their
fellow men about sensitive subjects such as sex and condoms than it is for a man to
discuss these things with a woman” (CHS, p. 10). The educational approach was
for reproductive efficiency within the community by eliminating a major health
problem. This approach in relation to women seeks to improve health, nutrition,
and family planning to create change within the household. The problem with
CHUSA is that it did not seek to combine other approaches with its educational
model in respect to women. For example, an empowerment model could help to
increase knowledge of the external factors facing women in Uganda. When
empowered, women have the voice to control their own bodies and their own
futures. However, CHUSA presents a horizontal relation in dialogue and appears
to have missed on the conscientization opportunities. Again, CHUSA failed to
engage the community in the “collective awareness” of their conditions.
Further, the lack of costly and local HIV testing discouraged community
members from getting tested. As the Church now attempted to require HIV testing
prior to marriage, people had to travel long distances twice, to test and get results
55
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
(CHS, 1995). Again, the structural violence associated with AIDS epidemic in
Uganda comes to the forefront of the learning process, where testing and
prevention are inaccessible to these communities. This knowledge could create an
emancipatory effect leading to community mobilization against these structural
forces. It does not appear that CHUSA was able to create a link between the
increased skills and knowledge of the oppressive conditions as presented in popular
education programs. For these types of process changes, the program would need
to create an opportunity for community members to understand the true oppressive
conditions and to realize the lack of resources to meet the basic needs necessary to
protect themselves. CHUSA presents the beginnings of an effective intervention
model, but much more can be done to improve the opportunities for
“consciousness-raising” in the community.
Sisters with a Vision
A second program, located in inner city South Central Los Angeles, was
created by Drew University and supported by the Los Angeles County Office of
AIDS Programs and Policy. The program has functioned since 1996 and provides
services for African-American women ages 14-44. The program provides HIV
education, HIV testing, counseling, health clinic visits, condom distribution, and
completion certificates and incentives. The objectives are to promote behavioral
change and skills building, reduce risks of infection, and educate women about
HIV. The educational intervention is designed as a five-hour program given over
five weeks. Women are required to sign a 30-60 day “safe sex” contract, and
56
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
follow-up counseling is provided if necessary. A university professor and
researcher provides the educational program.
Evaluation and Program. Features
Evaluation was also established as part of the design. Pre- and post KAP
surveys were designed and distributed by the university, but had not yet been
evaluated. Success of the intervention is currently measured by increase in self
esteem and knowledge. Strong program features include the free HIV testing,
condom handouts, and completion certificates and incentives. The safe sex
contract also provides an innovative design incorporating commitment from
program participants. Major weaknesses are in the funding as this an entirely
grant-based program.
Analysis from a Gender Perspective
Originating from a university-based practice, the organization has
community-based education as its goal. Dependence on grant funding does create
some dependence on institutional regulations and guidelines, however the link with
the university appears as more of a help than a hindrance to its success. The
“internal characteristics” of this project are similar to many of those described by
Fernandes (1985). This project was indeed started by the vision of a single person,
with one funded project becoming the basis for the organization. A continual
struggle to provide and find funding sources plays a major role in the continuance
of the organization. The community connection with local churches and businesses
57
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
is one area where a lack of participation is felt, and further interaction can be
focused.
A culturally sensitive approach to prevention education, along with a trusted
instructor, are important factors for effective intervention. There is a lot of fear,
mistrust, and misinformation still within the African American community
regarding the AIDS epidemic. However, the information gained in the courses is
accurate information, displacing of the myths. The curriculum model and
methodology appear to be appropriate interventions for this community.
Sustainability is a major concern: since the interviews are so close to the end of the
intervention, it is difficult to ensure that there is no “decay” in attitudes or behavior
(Coyle, et al., 1991). The issue of continued change is important, especially if a
woman returns to drugs or life on the streets. Since many of women were
prostitutes or traded their bodies for drugs, it is important to understand if the
behavioral change can continue in a new setting.
Positive attitudes toward the use of condoms and knowledge of the
technical use of condoms increased. The condom handouts and female condoms
create a positive social exchange regarding use. Proper technical use was
demonstrated on several occasions, with participants modeling as well. A few of
the women had tried the female condom and most say they were willing to try it.
Some still have a difficult time presenting this to their partners since they believe
they are now in monogamous relationships; they do not feel they have to utilize
these prevention methods.
58
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
There is a concern that there are no current outlets for support or continued
education once women leave the program. This lack of continuance and support
could lead to the “decay” in newly learned behavior as mentioned above. Again,
one of the greatest barriers to behavioral change is the inability to talk with partners
or encourage them to practice safe sex. This hindrance increases with low self
esteem or dependence on the partner. Knowledge gain and positive attitudes about
condom use are apparent results of the course, but without the continued support,
what happens when a partner does not want to use prevention? The women were
excited about trying new things like the female condom. When a partner reports it
is uncomfortable or brings up issues of trust, the women may be faced with
daunting decisions.
Family Planning Service Expansion and Technical Support (SEATS) Project
The Family Planning Service Expansion and Technical Support (SEATS)
Project was created in 1995 “to expand the development of, access to, and use of
quality family planning and reproductive health services in currently underserved
populations and ensure that unmet demand for these services was addressed
through the provision of appropriate financial, technical, and human resources”
(Newton, N., 2000, p. vii). The project began initially in Zambia and extended to
several other countries. Funded in part by USAID, the project is managed by John
Snow, Inc. (JSI) an international public health management consulting firm
(Newton, 2000). Other partners are the American College of Nurse Midwives
(ACNM), American Manufacturer’s’ Export Group, AVSC International,
59
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Initiatives, Inc., the Program for Appropriate Technology in Health (PATH), World
Education, and USAID Missions. One of the particular targets on youth ages 10-
19 years of age (or as defined by the particular country), especially in urban
settings. The components of the youth outreach were combining multiple
interventions, provision of clinical services, promoting collaboration on local,
national, and international levels, involving youth at each phase, outreach and peer
education, utilization of currently functioning programs, community mobilization
and advocacy, and sustainability of programs.
Main objectives to the SEATS program are:
• Access to sustainable, quality reproductive health services that meet the
needs of both women and men throughout their lives and that emphasize
health promotion and prevention, but also include therapeutic care.
• Knowledge and skills required to make good use of that knowledge
when making decisions that affect reproductive health.
• An enabling socioeconomic and legislative environment that supports
access to family planning and encourages healthy behavior (p. 4).
SEATS began the program in several African countries as well as Albania,
Cambodia, and Russia. The Zambia project began in 1997, targeting youth ages 10
to 24 in urban areas. Working with the Lusaka District Health Management Team
(LDHMT), who had been focused on youth reproductive health since 1996, the
SEATS program sought to enrich and expand current programs.
Evaluation and Program Features
An initial evaluation was conducted in two communities to determine the
needs of the youth in these areas. The “participatory” nature of the evaluation
allowed community members to organize and assess their specific needs. The
60
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
results found that youth in the communities were participating in high-risk sexual
behavior and that misinformation regarding reproductive health was common.
In collaboration with community members, existing youth centers and safe
and private areas (Youth Comers) in existing clinics became the center for
provision of reproductive health services for youth. Peer educators participated in
training and became integral in establishing many of the youth centers. They also
played a leading role in ongoing evaluation and data gathering. Over 18,000 young
people were reached through individual counseling, group activities, distribution of
contraceptives, and through the youth centers. Evaluations indicate that peer
educators became an increasing source of reproductive health information for
youth, and that use of youth clinics increased. Young people did prefer meeting
with the peer educators to nurses in the clinics. However, they did report concerns
with lack of privacy, hours of operation, and need for additional medications.
Further, the community found a need for more peer educators, that knowledge
among youth regarding reproductive health remained low, and that parents had
concerns about youth interventions.
Analysis from a Gender Perspective
The SEATS project initially took an “action-research” approach that is key
to the development of consciousness-raising community approaches to change. By
including the community and in fact allowing them a leading role in the evaluation
of the needs of youth, they fostered an environment where community members
could decide their own process. Action-research “begins with the principal that
61
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
people already know a great deal about their own situations. It builds on this
knowledge, using structured exercises and social interaction to develop a ‘critical
consciousness’ about human behavior and the causes of social phenomena”
(Schoepf, 1995. The project also sought to mobilize the community through
collaboration of Neighborhood Health Committee actions, school Anti-AIDS clubs,
PTAs and business (Newton, 2000).
Another important aspect was the use of peer educators, group discussions
and youth centers. These can foster dialogue by incorporating a process approach
to learning, where rather than merely “banking” information into participants
minds, it allows for an “active dialogue” of what it happening in their lives (La
Belle, 1986, p. 68). Peer educators were both male and female who were trained on
HIV issues. Youth centers provide a comfortable atmosphere for youth to attend
and participate without the social stigma associated with visiting a “health clinic.”
The peer educators also took on an emancipatory role in their own learning
and development. They became leaders in the fundraising and resource building
for youth centers. They also took active roles in the ongoing evaluations of the
programs. Although the program did not have an obvious gender component to its
design, it was effective in reaching many girls. However, it is not clear how or if
empowerment and gender roles were part of these discussions. It does appear that
the participatory design did allow for dialogue to begin in these important areas.
62
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Summary
In evaluating each of these programs it is possible to consider several
factors that enhance or are lacking from design and implementation. First, most of
the programs lack sustainability due to funding sources or commitment. The Los
Angeles program has created some continuity due to dedication of the staff to
provide support and search for funding. The funding sources for the Los Angeles
project are linked with the government. The other programs appear on the surface
more autonomous in nature, however the attention to donor agencies may have an
impact on programming. In regards to transmission of knowledge most of the
programs present a top-down approach to learning and intervention. The SEATS
project did incorporate community assessment in its design. As a result of the
program design, most of the programs follow a prescriptive approach to learning
where the instructor or leader instills knowledge, a “banking” model as described
by Freire (1997). Finally, these learning approaches predominantly focused on
individual change with little attention to system change in the structural or
empowerment levels. The SEATS project did promote some system change with
the goals of increased access to health care and legislative change. However, the
change most noted was creation of youth outreach centers.
Each of these programs provides insight to the current setting of HIV/AIDS
education and intervention programs. By design, many programs are neglecting
urgent concerns and needs of communities. Effective programs must consider the
implications of effective programs and pay attention to weaknesses from outreach
63
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to the actual education components. Both internal and external aspects of each
program should be evaluated and assessed for effectiveness prior to implementation
of new interventions. Attention must be paid to the key issues in the development
of women from an empowerment perspective, taking into consideration the
sociocultural implications of gender and power relations.
In considering these programs, it appears they do include women in the
intervention but do not necessarily involve women in the process of design or often
implementation. A clear gender focus is not established in the programs that
include empowering women in their relationships. Access to condoms and
knowledge on how to use condoms is a first step, but intervention should move
beyond access to include successful negotiation. Inclusion of the community and
use of peer educators is a successful model, but again these efforts should include
gender-sensitive and inclusive methodologies. Using men in the outreach to speak
to women whom already face rigid gender discrimination may not be the most
effective approach. Rather, involving men in the process would seem to be more
valuable to long-term success. Empowerment should be the focus of effective
intervention, which does not seem to be the case for any of these programs. This
empowerment education includes a focus on the social and cultural constraints that
place women in high-risk situations. Safe sex negotiation and increased power in
gender relations are essential to the success of HIV/AIDS intervention.
64
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Current Research on Effective Intervention Programs
Some of the key agencies that have completed intensive research across the
world on HIV/AIDS demographics and prevention programs have targeted
successful intervention components. Three of the recognized leaders in the field
are the Joint United Nations Programme on HIV/AIDS (UNAIDS), and Monitoring
the AIDS Pandemic (MAP), and the National Research Council (NRC).
UN AIDS is a collaborative program with UNICEF, UNDP, the United
Nations Population Fund (UNFPA), UNESCO, World Health Organization
(WHO), and the World Bank, which began in 1996. This program has several
guiding principles for supporting a long-term and sustainable response, technical
soundness, focus on vulnerable populations including women, providing a
supportive model, human rights, participation and partnership, national autonomy,
and complementing current research. “UN AIDS is the first programme of the
United Nations system to have NGO representation on its governing body.” The
main strategies areas are to provide country support and “international best
practice” (UNAIDS, 1997).
UN AIDS completed a worldwide study in cooperation with WHO in 1997
which made several suggestions for education programs. The report found that
prevention does work and that well-designed and focused programs can be
effective. “The best prevention campaigns work simultaneously on many levels—
increasing knowledge of HIV and how to avoid it; creating an environment where
safer sexual or drug-taking behaviors can be discussed and acted upon; providing
65
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
services such as HIV testing, treatment for other sexually transmitted disease
(which if left untreated greatly magnify the risk of HIV transmission) and access to
cheap condoms and clean injection equipment; and helping people to acquire the
skills they need to protect themselves and their partners” (UNAIDS, 1998, p. 26).
Structural changes along with changes in the law and employment are
recommended as well. Also important is making information available to young
people, making drug taking safer through needle exchanges, condom distribution,
education and treatment programs, increased counseling and testing, and access to
antiretroviral therapy, especially for women who are pregnant or breastfeeding.
The second lead agency, MAP, started in 1996 as a joint program with
Family Health International (FHI), Harvard School of Public Health and UNAIDS.
Comprised of health and research specialists around the world, MAP conducted a
symposium in 1998 focusing on the “status and trends” of the HIV epidemic
(MAP, 1998, p. 1). The MAP Network (1998) found major gaps in the knowledge
within countries of the at-risk behaviors, the quality of the data and the utilization
of resources. Recommendations include:
• understanding country specific HIV prevalence through combined
epidemiological and behavioral research;
• ensuring behavioral research directly contributes to policies, programs, and
support;
• linking behavioral research to the context of the prevention program, not
waiting to implement programs for research results, but utilizing research for
program improvement;
• improvement and expansion of behavioral assessments to “compliment” other
process, data, and outcomes;
• minimizing the interaction between TB and HIV;
• data collection and analysis specific to programs targeting migrant, refugees,
and internally displaced persons;
66
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
• support, care, and program provision for orphans;
• increased data on occupational exposure for health care workers; and
• focused collection and analyzing of data for HIV/AIDS therapies and their links
to prevention.
Finally, the NRC (which includes members from the National Academy of
Science, National Academy of Engineering, and Institute of Medicine) has been
working on evaluation programs since 1916, with a goal of “furthering knowledge
and of advising the federal government” (Coyle et al., 1991, p. ii). The NRC
makes several key recommendations for combating the current AIDS epidemic in
Africa:
• Basic surveillance systems for monitoring the prevalence and incidence of
STDS and HIV must be strengthened and expanded.
• An increase in research funding for the development of social and behavioral
interventions aimed at protecting women and adolescents, especially girls, from
infection deserves highest priority.
• More evaluation research is needed to correlate process and outcome
indicators—such as reported condom sales and behavior change—with
reductions in HIV incidence or prevalence.
• Research on mitigating the impact of the disease should focus on the needs of
people with HIV/AIDS.
• Linkages between sub-Saharan African institutions and international research
centers must be established on a wide range of activities, including teaching,
research, and faculty and student exchanges. International donors should
seriously consider establishing a sub-Saharan African AIDS research institution
with a strong behavioral and social science element (Cohen & Trussell, 1996).
Looking at these three lead agencies in the realm of AIDS research, how
have they incorporated issues of gender into the dialogue? Each of these agencies
have recognized that women are at greatest risk of infections, yet they do not
discuss issues of power in sexual relations or gender issues in their
recommendations. UNAIDS mentions acquiring skills to protect selves and
partners, but these skills differ greatly dependent on gender and cultural power
67
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
relations. MAP mentions recommendations for migrants and refugees (which may
include women), but women are not specifically mentioned. If research on
behavior is to influence policy then issues of power and subordination of women
must be a part of that dialogue. None of the recommendations take into account
gender differences or the interest of gathering differential data based on cultural,
social, or gender status. The NRC does mention protection of women and girls
through research on social and behavioral issues. These must then take into
consideration sexuality of women and sexual relationships to fully understand the
social ramifications. Also, men should be included in this research to determine
interventions required from both perspectives.
Other research has been completed which evaluates current AIDS education
programs and made recommendations as to objectives, program content,
components, and evaluation. When evaluating essential features in an HIV/AIDS
program it is also important to take these recommendations into consideration.
First, Lamptey and Coates (1994) analyzed several community-based
intervention programs in Africa and summarize successful strategies. The basic
principles of prevention programs are to adapt programs to local conditions,
“programs implemented in a specific community must go through a development
process to ensure that they will work in that particular location” (p. 515). As
outlined in Table 1, they found that a number of variables must be assessed prior to
program implementation.
68
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 1
Variables to be assessed in formative research
Interpersonal factors
Knowledge, attitudes, perception, and skills
Interpersonal processes
Formal and informal social networks and social support systems
Institutional factors
Social institutions with formal and informal rules and regulations
Social factors
Relationships among organizations and institutions
Public policy
Local, state, and national laws and policies
Material impediments
Availability of resources and institutions for programs
Note: from Lamptey and Coates (1994). Community-based AIDS interventions in Africa. In Max
Essex, Souleymane Mboup, Phyllis J. Kanki, & Mbowa R. Kalengayi (Eds.), AIDS in Africa (pp. 513-531).
New York: Raven Press Ltd.
Other principles that they found to be of utmost importance in program
development were targeting the audience most at-risk of infection, building local
support and capacity, the need for community involvement to create sustainability,
and support for interventions through local and national policy. They also outlined
successful intervention strategies currently in-use in Africa. These strategies were
behavioral, including reducing the number of partners, correct condom use and
improved health awareness, and biomedical which reduce STDS, immunize, and
provide treatment for HIV and AIDS. Behavioral interventions could be clinical
through small group training and counseling or directed at the community level
through mass media interventions and peer education strategies.
Two other studies, Hope (1995) and Clark (1996), promote “primary
prevention” as the only method for combating this disease. According to Hope,
programs that “change sexual behavior and control the spread of other sexually
69
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
transmitted diseases” have proven to be most effective in slowing the spread of
AIDS. He proposes “promotion of condom use, education about the benefits of
sexual partner reduction, and social marketing campaigns promoting AIDS
awareness” (p. 88). Clark (1996) recommends a model program in South Africa to
provide an outline for the entire continent, including sexual education for youth,
effective treatment for patients with STDS, mass communication programs,
increasing access to condoms, and appropriate care and support for both infected
women and men.
Although these recommendations seem to get at the urgent objectives, they
do not provide specific components necessary for effective intervention with
women. As Ankrah (1996) so deftly points out, many prevention programs have
left women out of the process due to the lack of power women have to say no.
“Because so many standard prevention approaches fail to reach them, women
remain far more ignorant about the epidemic than they should (be) after more than
ten years of HIV programming—with deadly consequences” (Ankrah, 1996).
Suggested is an empowerment approach for women that incorporates gaining
control economically, socially, and over their sexual lives. Funding for “gender-
sensitive” prevention programs is a must. Support from the international women’s
movement to strengthen the battle against “domestic violence, trafficking of girls
and young women, better health, improved educational and economic
opportunities, and equality under the law” are essential to this struggle against
deadly consequences (Ankrah, 1996).
70
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
When considering this type of empowerment approach, the underlying
social and cultural factors that effect women and girls must be addressed in order to
create an environment that allows change. Gupta et al. (1996) make several
recommendations for effective intervention programs that include women to foster
behavioral change:
• Help to empower adolescent girls and women by (1) increasing their knowledge
about their bodies and sexuality, as well as about HIV and other STIS, and (2)
improving their skills in using condoms and negotiating safe sexual behaviors
with their partners. Provide girls and women with opportunities for group
interactions to model new behaviors, share personal experiences, and develop a
critical consciousness about their sexual roles.
• Design programs for adolescent boys and men that promote sexual and family
responsibility.
• Fund participatory action research that (1) examines the cultural, economic, and
social factors related to sexuality and gender relations; and (2) ensures a strong
focus on the realities of women’s lives” (p.224).
These program objectives pay attention to the need for empowerment, while
considering the social, cultural, and economic constraints placing women in roles
of powerlessness. Involving men in the discussion and education helps to promote
awareness of the social conditions of women. However, joint programming for
women and men does not necessarily provide the most empowering environment
for women and can instead inhibit women from participating freely. Therefore,
programs should consider educating men and women separately, followed by
opportunities for dialogue. This may also lead to a “consciousness-raising”
opportunity for both men and women regarding the political and economic
structures that support these conditions. Again, this type of process would require a
71
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
long-term systematic approach to realization of the conditions of oppression to
encourage confronting these conditions.
It has become evident that education about HIV and AIDS transmission and
risk behaviors is not enough to create behavioral change and prevent the spread of
AIDS among women. As outlined by Stein (1998):
1) programs that provide information only have not been shown to affect behavior;
2) programs that combine content on values with information on how to avoid
infection and that attend to developing skill needed to avoid, cope with, or leave
high-risk situations delay the start of or reduce the likelihood that young people
will engage in high-risk behaviors;
3) programs that make use of peer educators and support groups seem to be
effective in motivating students to demonstrate their newly acquired knowledge
and skills;
4) program effectiveness is linked to duration and intensity with one-shot
counseling sessions that are associated with HIV-testing showing little if any
effect in modifying behaviors;
5) programs that are targeted to specific groups, with content shaped to
accommodate differences in age, gender, geography, race, sexual orientation,
and language differences are more likely to accomplish their goals than are
programs that fail to take account of group differences; and
6) programs that make use of realistic messages that address the experiences of the
targeted group are more effective that watered-down versions of reality (p.
138).
Therefore, objectives must pay attention to not only providing information about
HIV, but provide useful techniques for communication and negotiation. These
should also focus on holistic approaches that take into consideration cultural,
social, and gender differences when providing effective intervention messages.
In addition to these objectives, from a feminist perspective of nonformal
education, the programs must incorporate women’s empowerment. Empowerment
can be defined as providing opportunity for “consciousness raising” of society’s
conditions with the ability to create change in these situations (Stromquist, 1994, p.
72
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
26). Programs, then, would provide venues for empowerment in cognitive,
psychological, economic, and political areas (Stromquist, 1996). Applying these
ideas to the HIV prevention methodology, programs that involve women in the
assessment of needs and program design can help them develop an understanding
of their role in society and create a consciousness-raising effect. Helping to decide
their personal needs provides women with a measure of satisfaction that they have
some determination of their future. In order for this type of conscious raising to
occur, a long-term collective approach is necessary. The intervention would include
a process that allows for recognition of oppressive conditions and the structural
forces in place that contribute to these conditions. In addition, programs that add
economic development, even a small project, assist women in seeing possibilities
for creating their own economic contributions. This would also create an
opportunity for collective thinking and a path for mobilization efforts.
Curriculum and Content
In addressing ADDS education for women and girls, we must to consider
appropriate curriculum and gender sensitive messages in intervention efforts. As
AIDS education has progressed there has been a movement from the negative
messages and “scare tactics” to more gender sensitive and empowerment
approaches. A recent UNESCO study (2002) focused on gender relations in HIV
preventative education taking on the objectives of “1) to develop a gender
perspective on HIV preventative education; 2) to review existing educational
strategies and IEC (information, education, and communication) materials; and 3)
73
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to develop empowering educational strategies and gender sensitive IEC materials”
(Medel-Anonuevo, 2002, p. xvii). One of the main findings was that gender must
be clearly defined in regards to: “the difference between sex and gender, gender as
a social construct, and HIV as a gender issue” (p. 2). The concept of gender has
been used in AIDS programming without a clear perspective and universal
understanding of its meaning and how it plays a part in the AIDS pandemic.
In order to develop “empowering educational strategies and gender
sensitive IEC materials” UNESCO makes several recommendations (p. 17). First,
in regards to objectives when developing AIDS intervention programs, the quality
of the material should be measured by the “7Cs”: captivating, clarifying the
benefits, comprehensive, correct, clear, culturally appropriate, and care for women.
The second objective is to focus on risk factors including individual, biological,
and societal, the target audience both primary and secondary, and the important
characteristics of the audience including economic, geographic, and social factors,
and desired behavioral change including attitudes to be promoted in the process. In
addition, preparation of materials should be clearly analyzed according to the “7Cs”
and to the appropriateness of the inherent messages. Finally, materials should be
fully tested prior to use.
The study further found that current IEC material is inappropriate for
dealing with gender issues.
1) Most materials are inappropriate because they are based on the
premises that women would be in control of their sexual
practice. In reality most women lack power to determine where,
when, and how sex takes place.
74
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2) Many safer sex messages emphasize the need to use condoms,
but this reinforces women’s dependence on men to protect their
health.
3) Women do not learn from IEC about how to ask the right
questions at the right time to assess their personal risk (e.g. to
check if the partner is an intravenous drug user, bisexual, or has
other partners).
4) Messages should be supportive, positive, and meaningful.
5) In the few cases IEC give messages to women to protect
themselves, the scenarios do not face up to the real difficulties. It
is one thing to ask a casual partner to use a condom; it is another
thing to ask a man who has sworn fidelity to you and has been
with you for years.
6) Women often accept what their partners have done wrong
against them, and at most, they regretfully shake their heads.
7) Innovative resources and appropriate messages are needed to
support women in violent relationships (pp. 36-37).
Finally, the UNESCO project recommends that HIV prevention consider six
elements in regards to “GENDER”. Effective intervention should focus on gender
awareness and sensitivity, educational strategies that are not only participatory but
develop a “comprehensive gender sensitive strategy”, networking on national,
regional, and local levels, development of materials as a continual process,
inclusive evaluation and monitoring, and comprehensive research on gender and
AIDS (pp. 41-43).
In reaching women in HIV/AIDS education programs, as mentioned Cash
(1996) suggests several content areas to be included in the teaching or “classroom.”
Although some of these may seem obvious, many have been left out of education
program for women. Content should include: “AIDS and its transmission; STDS
and their transmission; acquiring and using condoms; sexuality and women’s
sexual health; reproductive health and family planning; communication and
75
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
information sharing; partner negotiation; identifying risk behavior; one’s health and
the health of others; and right to health education” (p. 320-21). Among these the
ability to communicate is most important. Women need an opportunity to express
their ideas in a variety of ways including individual and group settings in order to
successfully negotiate behavior. Also important is material design, including types
of print design and use of graduation certificates or diplomas. In addition to
increasing knowledge, this content allows for an understanding of women’s health,
which is a first step in recognizing personal needs. Program content that includes
communication and negotiation skills goes beyond the traditional educational
methods, incorporating opportunities to practice new behaviors. Integrating
discussion of health rights, may provide the avenue for “consciousness raising” of
the societal conditions enforced on women. However, these must include men in
the dialogue in order to promote understanding on a societal level.
The “FRESH” model-Focusing Resources on Effective School Health- is an
additional curriculum development from the past years of AIDS research.
Developed by UNESCO, UNICEF, WHO, and the World Bank (2000) as partners
in taking a “FRESH” start to school health, the program focuses on the importance
of health in the education system. The important components include, “health
related school policies, provision of safe water and sanitation, skills based health
education, and school based health and nutrition services” (p.3). The skills based
health education should focus on “development of knowledge, attitudes, values,
and life skills needed to make and act on the most appropriate and positive health
76
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
related decisions. Health in this context extends beyond physical health to include
psychosocial and environmental health issues” (p. 7). In addition the “development
of attitudes related to gender equity and respect between girls and boys, of skills
such as dealing with peer pressure, is central to effective skills-based health
education and positive psycho-social environments” (p. 8).
Regarding adolescents, there is concern about content of courses that should
focus on abstinence only or promoting safe-sex behaviors. The most effective
courses with youth should increase knowledge of HIV transmission, improve
negotiation and coping skills, and encourage communication with peers outside of
the classroom environment (Stein, 1998). The SEATS (2000) project also
recommends providing programs that incorporate community support for
reproductive health programs and including parents and community to provide
input in the activities (Newton, 2000). In fact, research has shown that knowledge
of safe sex behavior does not encourage youth to become sexually active at an
earlier age (Stein, 1998). And, in the case of Senegal, increasing knowledge of
HIV/AIDS infection and transmission has actually promoted a later age of first
sexual experience (UNAIDS, 1998).
Fostering Knowledge in the Classroom
Cash (1996) provides several recommendations for fostering learning in the
“classroom” of an HIV/AIDS education program. She states that participatory and
reflective processes are required to enhance communication. “Narratives (stories),
discussions, role playing, dramatizations, games, simulations, and other group
77
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
process techniques that rely on the popular culture” are most effective in creating
an open level of communication and participation (p. 324). Women need to be able
to talk to each other and with men in their own language and forms of
communication or expression. The learning process should also:
• “Appeal to the emotions, giving participants a personal stake in the outcome;
• Build skills and enable participants to practice new or unfamiliar behaviors;
• Enable participants to share experiences that give rise to new solutions” (Cash,
p. 325).
Use of comic books and novels have proven helpful in fostering communication
among women. Role-playing or “practicing” talking to partners also assist women
in practicing what they might say in the real situation.
These methods are appropriate to HIV education, and have proven
successful in evaluations of nonformal education programs. Utilization of group
dialogue allows women an opportunity to share feelings and concerns in a safe
environment, where many women may have never had the opportunity to discuss
these issues. Promoting this dialogue through use of stories or plays has been
utilized successfully in literacy programs as well as HIV interventions.
Single-Sex or Co-Educational Courses
In confronting the AIDS epidemic it is essential that education is conducted
for anyone who is at risk of contraction regardless of sex, ethnicity, or social
background. Many of the recommendations mentioned previously look at
intervention programs in relation to the objectives without consideration to who is
receiving the services. In most cases, what women need versus what men need in
an education program varies greatly. Many programs have targeted specific
78
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
populations by gender. In the case of enhancing communication surrounding
HIV/AIDS it is suggested that the best programs center around groups involving
only women and those involving both men and women (Cash, 1996). Women only
groups allow better opportunities for free dialogue. When programs include both
women and men the conditions can further contribute to issues of power and
discrimination. If women are not free to express their thoughts and ideas due to
social forces, then they will not be able to do so in joint programming. Programs
should instead focus on separate interventions that lead to enhanced opportunities
for dialogue, lessening the threat of violence or discrimination. Effective design of
women only groups include peer-led discussions and open and participatory groups
where women feel comfortable to share their stories, concerns, and questions.
For example, the AIDSCAP program in Kenya studied the effect of female
condom use with women. This program involved support groups and group
discussion for the women and for their male partners. Women ages 18 to 40 years
were recruited through women’s networks from a variety of educational and
socioeconomic backgrounds. The women met in focus groups both prior to and
following the four month intervention and participated in individual evaluative
interviews (Mwakisha, 1996). Following the intervention, focus groups were also
held with the male partners to determine their reactions to the program.
The study was designed to examine the “influence of various social, cultural
and economic factors on acceptability and the degree to which women feel use of a
female-controlled method increases their power within a relationship” (p. 2).
79
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Unlike other studies of contraceptive devices, this study focused on the women’s
opinions in hopes to promote negotiation and power from the decisions of with
whom to participate in sexual relationships. The study utilized peer support in
efforts to enhance communication among women. A focus group with male
partners was also conducted after the women had completed the program. The
majority of the men spoke favorably about the female condom, although some were
concerned when their partners brought the device home. One partner did become
violent after being approached with the new contraceptive method. An important
finding of this study is that even though the women met separately from men it did
increase their confidence and ability to communicate with sexual partners
(Mwakisha, 1996).
Other programs have also met with men separately from women.
Workplace programs, condom outreach at local hotels and bars, and “men-only”
health clinics have been utilized in reaching men (Onyango, 1997). It seems that
the best interventions target both men and women separately and together. Women
must have a safe and comfortable environment to share and learn about sexuality
and health, but men must also be involved in similar interventions. The program
should include a gender-sensitive approach to the educational content and
eventually combine these efforts to include both men and women in joint learning
environments.
80
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Programming Considerations
The programming considerations are extremely important in reaching
women, especially considering work schedules, family life, and location of the
intervention programs. These considerations include location, time, and
accessibility. As suggested in the SEATS (2000) project on youth reproductive
care, adolescents need an environment where they feel safe. Barriers to programs
include the location of the intervention and the educators they meet once they are at
the program. Youth are fearful that they will be seen or recognized in the
community when entering a program, so youth centers that offer many activities in
addition to reproductive education are most effective. Further, the use of peer
educators provides a more comfortable atmosphere that fosters communication and
education (Newton, 2000).
In providing educational programs for women the location and environment
are essential. Women must also feel “safe” in order to promote education and
communication. Again, a center for women or location that provides other
activities as well may assist in getting women to attend. Meetings need to take
place at times when working women and mothers are able to attend, and childcare
should be considered. As with younger women, peer educators have proven most
successful in promoting communication (Cash, 1996). These programs should also
consider literacy levels and provide materials for those who may not be able to read
or write.
81
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Timelines for interventions have varied greatly. Programs with as little as
15 hours of intervention have proven to increase knowledge and decrease risk. In
the most effective cases, programs that were “continuous and repetitive” provided
the best opportunities for behavioral change (Stein, 1998). It seems the best
programs would provide ongoing support and education for women as new needs
arise, as well as providing continual opportunities for outreach and communication
among women.
Summary
Effective HIV/AIDS education programs should be open to the cultural and
social conditions of the environment in which they intervene. Although many
programs base their methodology on increase in knowledge, this alone has not
proven to be adequate for decreasing at-risk behavior. Instead, programs must
address the social, cultural, gender, and political issues which contribute to sexual
relations and increase the risks of contracting HIV. When women and men are
both included in intervention (separately then together) and women are supported
in an environment that allows for open discussion and fosters empowering
situations, then opportunity for change is most likely to occur.
Sociocultural and Socioeconomic Implications in the Spread of HIV/AIDS
There are many underlying factors that contribute to the spread of
HIV/AIDS in developing countries. The socioeconomic and sociocultural factors
are instrumental in contributing to this disease, especially with women and related
to the status of women in these countries. These issues contribute greatly to the
82
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
main issues that make women more susceptible to HIV infection: lack of power or
control over their bodies, playing a subordinate role in sexual relationships, and
following socially prescribed gender roles. These factors lead to increased risk for
women in contracting HIV and other STDS.
As women struggle with poor economic conditions they are often forced to
subject themselves to risky situations. According to Gupta, Weiss and Whelan,
(1996) some women in developing countries have turned to “sexually networking”
as a result of the dire economic circumstances following the economic recession in
the 1980s. This includes turning to men who offer money, goods or other
assistance in turn for sex, providing sex in return for rent with “slum lords”, and/or
remaining in a “nonmonogamous” relationship with a male partner due to the
financial security the relationship provides. Each of these situations increases the
sexual risk of women and increases their vulnerability. Several studies have found
that women are less likely to ask their partner to use a condom in these situations
due to fear of violence or being left without financial support (Gupta et al., 1996).
The study by Whelan (1996) among pregnant women found a high inverse
correlation between women’s status and gender equality and HIV infection rates: as
women’s status and equality increased the infection rates decreased. Status was
measured by “health, family status, education, employment, and social equality”.
Gender equality was measured by “life expectancy, marital status (widowed
divorce, separated), literacy, share of paid employment, and social equality” (Gupta
et al., p. 222). The results indicate that social equality as well as economic status of
83
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women have an impact on women’s vulnerability, power, and ability to negotiate
sexual rights.
Not only does infection risk relate to the socioeconomic status of women,
but the ADDS epidemic has a direct impact on economic conditions for women. Just
as the AIDS epidemic has put increased economic costs on developing countries,
the epidemic has created an increasing economic burden for women, especially for
women who are the caretakers of those with the disease and are left to take care of
the family once a husband or relative has died from AIDS. The disease has left
increasingly negative human, social, and economic costs particularly in Africa
(Hope, 1995). The human costs are seen in the decrease in population growth rates
and increase in child death rates. The social costs can be viewed in the increasing
number of orphans, single-female households and child-headed households, and the
increasing cost burden on extended families caring for relatives. Finally, economic
costs are those direct costs associated with hospitals, doctors, and medications and
indirect cost related to losses in the labor force and productivity.
Sociocultural factors also greatly impact the vulnerability of women in
sexual relationships and their ability to negotiate safe-sex practices. In many
countries the “ideal” attitudes about women surround virginity, innocence, and
motherhood (Gupta et al., 1996). If a woman is knowledgeable about sex then she
is seen as less virtuous; the man should supply the information about sex. For men,
on the other hand, it is acceptable to have multiple sex partners and to engage in
84
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sexual activity outside of a relationship. These conditions again contribute greatly
to increasing the risk associate with contraction of STDS.
In considering these social factors, gender relations come to the forefront of
intervention concerns for women. As has been mentioned, women have little
control over their own reproduction and “lack the power to control their partners’
sexual behavior” (Rojas & Lopez, 1997, p. 3). Women can have all the knowledge
about safe sex that is available, but still lack the power in relationships with men.
Programs that target women leave men out of the discussion, so they assume
women have power of negotiation. Men control women’s sexuality from the
doctors in the clinics (the majority have traditionally been men) to economic
control in the household. Both men and women need to be part of the HIV/AIDS
discussion to promote gender awareness, the “power gap” in relation to women and
men must be raised, culture and social circumstances must be taken into
consideration and “consciousness-raising” should be added as a component to
educational interventions (Rojas & Lopez, 1997). However, educating women and
men together does not necessarily provide the most empowering environment for
women. So, programs should seek to develop innovative programs that educate
men and women separately, then provide opportunities for joint dialogue. In
addition, in order to allow for a true conscious-raising component, a long-term
program would allow for understanding of social circumstances and structural
practices that render participants into situations of oppression.
85
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Power becomes a central issue in the struggle for women to protect
themselves against AIDS. Empowerment and gender sensitive programs then
become vital in prevention. Empowerment then can be looked at in four areas:
cognitive, psychological, economic, and political (Stromquist, 1994 & 1996). A
cognitive approach to empowerment ensures women have an “understanding of
their conditions of subordination and the causes of such conditions.” In the
psychological realm women develop “feelings that [they] can act to improve their
condition.” If women are “able to engage in a productive activity that will allow
them some degree of financial independence” they can create economic
empowerment (Stromquist, 1994, p. 267). Finally, political empowerment allows
women to understand their “conditions and rights” and leads to opportunities for
mobilization (Stromquist, 1996, p. 237). Applying these ideas to the HIV
prevention methodology, programs that involve women in the assessment of needs
and program design can help them to have an understanding of their role in society
and create lead to empowerment.
Options for incorporating these issues in HIV intervention programs are to
have an impact on women’s socioeconomic status through “linking” up with
current programs that deal with economic issues for women. Providing AIDS
intervention at an agricultural promotion or microenterprise training program,
places two essential development interventions together and saves AIDS programs
from having to design programs on their own which could be costly and time
consuming. In addition, AIDS programs should “advocate for improvements in
86
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women’s access to education and productive resources” to improve socioeconomic
conditions (Gupta, 1995, p. 4).
The Cairo Program of Action (1994) presents a conceptual framework
(Table 2) for effective AIDS intervention through empowerment and improvement
in socioeconomic conditions (Malhotra & Mehra, 1999). This framework is
important to consider in program development as it delineates the crucial factors
required in empowering women, leading to improved reproductive health.
Table 2
Cairo Recommendations for Action
PRECONDITIONS
Socioeconomic Factors in
Women’s
“Empowerment”
•
Access to
employment and
income
•
Poverty reduction
•
Access to skills,
education,
information
•
Increased political
voice
•
Elimination of
violence
Mediating Factors in
“Empowering” Women
• Ability to affect
reproductive choices
• Ability to access
services and
information______
• Ability to negotiate
safer sex
• Reduced wanted
fertility__________
• Reduced motivations
for exposure to risk
— ^
GOALS
Reproductive Health
and Population
•
Recognition of
individual
reproductive rights
and choice
•
Reduced risk of
STDS and AIDS
•
Lower maternal and
child mortality
•
Improved quality
of care
•
Reduced fertility
levels
•
Increased
contraceptive use
Note: from Malhotra and Mehra (1999). Fulfilling the Cairo commitment: Enhancing women’s economic and
social options for better reproductive health. Washington, DC: International Center for Research on Women.
As governments worldwide have accepted the Cairo Agenda, this framework
becomes even more prominent in addressing quality programs at a national level
87
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
(Gupta, 2000). This framework shows how socioeconomic conditions play a direct
role in empowering women to make informed decisions on reproductive health.
The model illustrates how socioeconomic conditions play a direct
relationship with AIDS infection risks for women. Without access to sufficient
economic conditions, education and political decision-making, women have little
opportunity to negotiate control of their bodies, their health, or their reproductive
rights. The literature indicates that addition of cultural issues to this conceptual
framework is essential as these concerns vary dependent on cultural values and
norms associated with sexuality and gender equity. For example, focus on
virginity, age of first sexual onset, female genital mutilation, and age of marriage
are all issues which vary by social culture and can have a significant impact on
power relations and sexuality.
Condom Use and Female-Controlled Prevention Methods
Use of condoms as a barrier to HIV infection has been one of the constant
variables in intervention programs. Research has shown that as condom use
increases, HIV infection rates decrease. However, use of condoms has been
focused on the ability of women to “coerce” their partners and influence their
partner’s behavior. With the little power that women have in sexual relations, this
seems to be an impossible task without attention to recognition of gender roles for
both women and men. It is interesting that little training has been done with men
%
on how to effectively use condoms, but has instead focused on women with an
assumption that women have control of both contraceptive and reproductive
88
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
decisions. Very little has been done to improve access or availability of “women-
controlled” prevention methods (such as the Reality female condom) instead
relying on traditional male controlled methods. Furthermore, condom use
programs have not taken into consideration women’s desire for children or
sexuality of women. Education and access alone are not sufficient to allowing
women to negotiate safe sex.
In considering condoms as one of the effective methods of HIV prevention,
research should consider the reasons condoms are not used. Studies conducted in
the United States found that even thought 20% of sexually active women reported
they had used a condom at some time, of these one in five had not used a condom
during the last sexual occasion, and that among African-American and white
American men, ages 20 to 39, only “27 percent of sexually active men had used a
condom in the 4 weeks before the interview” (Ehrhardt, 1996, p. 259). The reasons
that men did not use condoms ranged from embarrassment of purchasing condoms
to the idea that their partner might lose trust. These types of barriers to condom use
must be considered when implementing current prevention programs.
Condom interventions were found to be effective in prevention of
HIV/ADDS if the use of condoms was accepted and the condoms were used
correctly, and always. Approaches to distribution of condoms should include
availability to those in need and through peer education. Condom marketing is also
important through promotion or peer education. Several programs have been
successful when peers were utilized or non-traditional marketing has taken place.
89
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
However, sustainability has been a major problem in condom marketing projects.
Provision of an adequate supply of condoms as well as ensuring the “logistics” of
care and distribution are important aspects of successful interventions. Finally,
programs must target STD reduction and education to ensure effective intervention
(Lamptey & Coates, 1994).
Introduction of women-controlled prevention methods for HIV can improve
the ability of women to protect themselves and reduce their risk of infections. Due
to many of the sociocultural effects and the inability of women to negotiate safe sex
practice with male partners, utilizing methods that women can choose and control
can greatly reduce infection risks. Although research has been conducted on
effective methods, the existing methods have not been fully tested for safety and
are therefore not available on the global market (Elias et al., 1996). The most
effective method has been the newly introduced “Reality” female condom.
However, this type of condom is costly and has not been widely distributed in
developing countries.
Sobo (1995) completed a study of condom use among African American
women in Cleveland, Ohio. Following focus groups, interviews and
questionnaires, she found that among this population “unsafe sex occurs most
frequently among socially isolated women who derive self-esteem and status
mainly from having conjugal partnerships with men” (p. 72). Although these
findings cannot necessarily be generalized across ethnic groups or geographic
areas, her finding suggest that “gender may well be more important than ethnicity
90
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and geography in the production of personal AIDS-risk denial” (p. 72). Erhardt
(1996) makes several recommendations for improving the likelihood of condom
use; including men in condom program design, including negotiation issues in
programs with women, provision of new women-controlled barrier methods, and
consideration of variation in personal risk and needs based on age and
developmental stages.
HIV/AIDS Prevention Policies
As has been suggested in research and recommendations on HIV
intervention programs, involvement on the governmental level can have a positive
impact on infection rates. What has happened in many policies, however, is that
the specific impact on women has not been taken in to consideration. For example,
women’s reproductive rights must be measured in relation to condom campaigns
and mandated HIV reporting laws. However, with the impact the epidemic has
had on a social and economic level in developing countries, policies must be
created that are sensitive to gender while promoting knowledge and access to
intervention and health care.
Governmental intervention and policies have been linked to successful
intervention in countries where infection rates have improved. Two countries that
have been successful are Uganda and Senegal. These successful programs include
governmental support in collaboration with religious leaders, community leaders,
educational institutions, and local NGOs. Uganda, one of the first countries to
launch a national campaign fighting AIDS, is also one of the first to show a
91
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
positive trend, from 13% infection rates in 1994, dropping to 9.5% in 1997.
Prevention programs developed with the assistance of religious and tribal leaders,
included school programs and community counseling (UNAIDS, 1998, p. 12). In
Senegal, the government worked with religious and community leaders to promote
and provide sex-education in elementary school, treatment for STDS, and
promotion of condom use. The infection rates in Dakar have stayed as low as 2%.
Increased condom use has been one of the greatest impact in Senegal (p. 27).
However, these interventions must include policies that directly target
issues concerning women. These policies must consider new methods of “women-
controlled” prevention products, in addition to community involvement,
empowerment and “the end to the oppressive policies and practices that place
women at a great risk of HIV infection” (Gollub, 1995, p. 72).
Women-controlled products would include the female-condom or other methods
that women can control and make decisions regarding their own sexual health.
Mann and Tarantola (1996), present several considerations for national government
interventions surrounding AIDS: “1) voicing commitment; 2) translating
commitment into action; 3) coalition building; 4) planning and coordinating; 5)
managing; 6) responding to prevention needs; 7) responding to care needs; 8)
securing financial resources; 9) sustaining the effort, 10) evaluating progress; and
11) evaluating impact” (p. 315). In a survey of 118 countries, those currently
experiencing high levels of HIV infection found that government officials in these
countries were likely to “voice commitment” (60%), Latin America reported the
92
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
lowest number of national AIDS advisory committees (53%), most programs were
coordinated by ministries of health, less than half (48%) had decentralized
programs that 70% had conducted some kind of a prevention assessment and 81%
had evaluated their governmental program (pp. 315-325).
Further research indicates that for policy agendas to be successful they must
consider, the socioeconomic impact on women, provide access to information for
women, confront “women’s vulnerability”, improve health care reform, include
men in the education process, increase “women-controlled” barrier methods, focus
research on ways women’s behavioral change is impeded by outside forces, and
focus on legal and political status of women (Ankrah and Long, 1996).
Conclusion
HIV and AIDS have now become a pandemic around the world, is
increasingly threatening women. Although much research has focused on women
in African and the horrific numbers affected by AIDS, women in Asia, Latin
America, and the United States are now at-risk for steadily and rapidly increasing
infection rates. Discriminatory practices, socially prescribed gender roles, poverty,
lack of education, and poor health care are all factors that have led to the vulnerable
situation for women and this disease.
As theories have evolved since the onset of AIDS, research has begun to
focus more on the qualitative approach to understanding behavioral practices and
human sexuality. In order to reach women, intervention efforts should focus on
power relations and gender sensitive educational approaches. Current AIDS
93
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
prevention messages have not been effective in dealing with the social and cultural
issues that place women in high-risk situations. Instead, education and intervention
should focus on empowering women to negotiate safe sex and to demand access to
education and health care. The structural barriers to economic independence and
the behavioral barriers to negotiation in relationships should become an additional
focus of intervention efforts.
From a feminist perspective on HIV/AIDS intervention and education,
power and gender relations become keys to women’s empowerment. Economic
security is an urgent consideration for women to be fully empowered in their lives.
Intervention programs then move past education to access and use of condoms,
sexuality and sexual health, negotiation skills, addressing risky behavior, and rights
to education and adequate health care. Women then become empowered not only in
their relationships, but as equal voices in their communities and in the political
arena.
Assessing and evaluating current programs will help to gain a clear
understanding of effective intervention methods. Major agencies involved in AIDS
interventions need to include women in their focus and efforts. Programs should
consider gender sensitive methods in their education interventions that include
clear understanding of gender and incorporate the “7Cs” of gender sensitive
prevention techniques. Men must also come to the table in educational
interventions in order to fully address the social and cultural practices that render
women vulnerable to HIV infections. Programs should consider women’s safety as
94
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
well as accommodate women with resources such as childcare to assist in their
participation.
Evaluation of successful programs should look at behavioral change that
addresses the social and cultural constraints placed on women by society. These
programs would include both women and men in transforming these issues in
separate, then joint intervention efforts to foster empowerment. Sociocultural and
socioeconomic practices that place women in powerless roles in their relationships
should be addressed and eliminated in order to empower women. Access to
condoms, including the female-controlled methods, and skills for condom
negotiation are essential to intervention efforts. Finally, government support
through policy and practice becomes important in fully addressing intervention on a
countrywide level.
As shown in current HIV/AIDS research some progress has been made over
the past several years of this worldwide pandemic. However, where women are
concerned there are still leaps to be made in prevention and education. This is
evident in the increasing infection rates for women around the world,
predominately related to poor economic conditions, lack of education, and health
care. Efforts thus far have not fully considered the vulnerability and extreme risk
to women in an effective way to diminish this risk. Women must be empowered to
fight this disease which can only be done through confronting the social and
economic barriers that render them helpless to increasing infection rates.
95
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER THREE
METHODOLOGY
This project is case study of a health education course, “Reproductive
Health in the Program, Community Care Homes-Wawa Wasi,” provided by the
Ministry of the Advancement of Women and Human Development in Peru
(PROMUDEH) and funded by the United Nations Population Fund (UNFPA). The
program implemented a reproductive health care course into several existing
departmental programs within the Ministry of Women. The purpose of this
dissertation is to evaluate the effectiveness of the sexual and reproductive rights
course in the Wawa Wasi child care program within PROMUDEH.
Investigation of a reproductive and sexual health program for disadvantaged
women, identification of important variables of an effective program, and
generation of hypothesis for further research of best practice in prevention and
education are the purpose of the current research (Marshall and Rossman, 1995).
This study addresses the research questions of “what is happening in this program,
what are the salient themes, patterns, categories in the participants’ meaning
structures, and how are these patterns linked with one another?” (Marshall and
Rossman, 1995, p. 41). In this context, interviews, survey questionnaires, focus
groups, and observations are the basis of the research design.
Although the program deals with a variety of themes surrounding sexual
health and reproductive rights, a particular focus of the research is on the
HIV/AIDS prevention module. Successful AIDS intervention and education
96
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
programs must move beyond a description of transmission to include discussion of
condoms, sexuality, sexual health, communication strategies, negotiation, and
rights. This program was chosen as it attempts to include these themes in the basic
modules of sexual health and reproductive rights, sexuality, family violence, and
gender relations. With these concepts in mind, this program seeks to capture the
major program recommendations in its educational components.
As the needs surrounding HIV/AIDS intervention programs have changed
since the onset of the epidemic, so have the research methodologies studying
transmission of this disease. In the early stages, research was focused on different
communities’ attitudes toward sexual relations as well as the behavior of their
members. To gather this information, predominantly large-scale quantitative
surveys have been utilized. These knowledge, attitudes, beliefs and practices
(KABP) surveys focused on behavioral change but did not consider “effective
intervention” (Parker, 1996). However, these types of surveys are seen to be
effective when combined with other evaluative approaches. More recently,
qualitative studies have come to the forefront, examining “sexual
culture... structures of power in gender relations and the experience of sexual
violence and discrimination” (p. 137).
Gillies (1996) looked at several qualitative research studies conducted
since 1991. In this evaluation she found that “psychology did not provide the
dominant conceptual framework and that questions related not only to individuals,
but also to social, cultural, political and economic factors. In the questions asked,
97
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
there is a new emphasis on the complexity of sexual life, associated with the
challenge of developing innovative responses for effective HIV prevention” (p.
146). These issues are important foci for future research.
The NRC (1991) recommends the case study approach as most appropriate
in evaluating the type of nonformal education programs conducted by community-
based organizations. Case studies can be quite successful, especially as initial
evaluative methods. Looking at the design, program components and outcomes is
key to the case study approach. Also included are:
• the target groups and subgroups being served;
• how individuals learn about services and what other services are
available to them;
• how a CBO learns about and reaches out to individuals, engages
them in receiving services, and limits attrition from the project;
• what services of educational material are delivered, by whom,
how often, to whom, and in what context;
• the accuracy and timelines of the education or risk reduction
information selected groups receive; and
• how funds are used (Coyle et al., p. 87).
However, these components are only part of the larger design of an effective
evaluation, focusing on the design issues. It is important to consider who
participates and how they are being served if we are to understand a broader picture
of the entire intervention.
As discussed above, most research indicates that a combination of
qualitative and
quantitative studies are best in evaluating AIDS prevention programs. As many
studies have undertaken large quantitative examinations, researchers are now taking
into consideration smaller qualitative studies that take a closer look at the
98
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
knowledge, attitudes, beliefs, and practices of program participants and the
community. Smith and Debus (1992) also recommend that a qualitative approach
include in-depth interviews and observation as essential aspects of evaluation.
Interviews can be individual over a course of several days or in the focus group
format. Observation can be combined with interviews over the length of a course.
The qualitative study will include interviews, focus groups, and observations. This
approach will help to triangulate the data and ensure reliability.
Setting
The “Reproductive Health Program in the Community Care Homes—Wawa
Wasi” is a program developed by PROMUDEH with the UNFPA to improve the
sexual and reproductive health of the country, promote sexual and reproductive
rights, and to reduce gender gaps that exist based on social status and geographic
area. The educational project on the reproductive health of women was
implemented in the existing Wawa Wasi childcare program as a method of
educating women on a small-scale effort with hopes for an eventual large-scale
result. Wawa Wasi is a government subsidized day care program for children ages
0-5 years. Madres cuidadoras (day care providers) in poor urban and rural areas
provide low cost and no cost day care and food programs for children of working
parents {madres and padres usuarios).
This program was chosen as it is a good opportunity to study a newly
designed and implemented sexual health program with an HIV/AIDS component.
It provides an invaluable opportunity to evaluate the concept and program
99
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
components. This program is supported by PROMUDEH, supplying an
opportunity to research a government-based project, and how the government may
or may not take an active role in the intervention needs of the community.
PROMUDEH provides services for women and families who are struggling
financially or emotionally. The sexual health course targets the women who receive
these services. The course within the Wawa Wasi program sought to:
1. contribute to the practice of the sexual and reproductive rights of women and
men, promoting the availability and use of services, as well as improving the
access and quality of sexual and reproductive health services nationwide
according to the needs of the population;
2. contribute to reducing unwanted pregnancy and abortion and STDS and AIDS
in adolescents, promoting the adoption of healthy behavior and self-care of
reproductive and sexual health;
3. contribute to facilitating the implementation of the political/legal and
institutional framework of sexual and reproductive health of the country, to
promote the self care of sexual and reproductive health, and the practice of
sexual and reproductive rights (UNFPA, 1998).
The sexual health and reproductive rights course consists of four modules
written by PROMUDEH and UNFPA for the Wawa Wasi program. The four
modules include the topics of: Saying NO to Family Violence, Improving Gender
Relations, Sexual and Reproductive Health, and Knowing and Protecting our
100
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Sexual and Reproductive Rights. This study focuses on evaluating the effectiveness
of the sexual and reproductive health module.
Although the central office is located in the metropolitan area of Lima, the
project was developed to provide outreach to rural areas and to the pueblos jovenes
(low-income neighborhoods) in the surrounding areas. The educational component
took place during a two-month period (July and August 2000) in four suburbs of
Lima, the rural mountain area of Huancavelica, and the Amazon basin area of
Huanuco. The initial training of area coordinators occurred over a one-week period
in Lima. During this time, twelve program coordinators from all three regions
participated in in-depth training and four courses. Once trained on the modules, the
coordinators returned to their respective regions to simulate the program for the
madres cuidadoras. The module implementation occurred first in four areas of
Lima, followed by the other two regions. Each course was conducted over a four-
day period and approximately 15-18 madres cuidadoras each participated in two of
the four modules. Once the project was completed, the modules were to be
evaluated and redesigned by Calandria, an outside evaluation agency.
As one of the goals of the program was to improve the sexual and
reproductive health of the community, the agencies hoped that the madres
cuidadoras would transfer the knowledge gained through the modules to the
madres and padres usuarios. This was designed to take place in informal settings
during visits to the Wawa Wasis through discussions that occur there. The
nonformal design of the educational component was intended to initiate informal
101
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
education among the participants establishing a “multiplier effect” among the
madres and padres usuarios and the community. Within this design, the madres
cuidadoras have informal and often fleeting meetings with the madres usuarias
which can hinder the process. However, the advantages to this type of process
include the opportunities created by this type of regular contact.
Questions to be Answered
This research project will answer the following questions through analysis
of the sexual health and reproductive rights modules implemented in the Wawa
Wasi program with a goal of further understanding the effectiveness of the
educational intervention.
1. Does the sexual health and reproductive rights educational program provide a
context for empowerment in the framework of the research recommendations
(Cairo Agenda)?
• Does it educate and inform about social relations, sexuality, negotiation, and
bargaining practices? Does it educate about sexual knowledge and rights?
• Does it provide skills for negotiating male-based contraceptives and the ability
to demand safe sex? Does it provide communication skills?
• Are women provided access to employment and income?
• Do women have access to medical care and prevention?
• Is social support provided?
• Are women provided an opportunity for increased political voice?
• Does the program seek to eliminate violence against women?
102
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2. Did the women increase their knowledge of sexual health and reproductive
rights as a result of the program intervention?
• What did they learn?
• Did this knowledge have an effect on their attitudes, beliefs and practices?
• Did any increased knowledge remain over a period of time?
3. Was the sexual and reproductive behavior effected by the program intervention?
• Did condom use increase?
• Was there any behavioral change in regards to sexual practices?
4. Were the participants able to communicate the information to others?
• With whom did they communicate (children, spouses, friends, madres/padres
usuarios)?
• What were they able to communicate?
• How did communication take place? In what context?
5. Is the project sustainable? Over what period of time? And, with what level of
commitment from key agencies?
Research Design
The primary data collection methods included observations, interviews,
focus groups, surveys, and review of documents. An overview of each method will
be provided. As described in methodological recommendations mentioned
previously, both interviews and observations are important aspects of a qualitative
case study. Both were utilized to understand fully the design, program
components, and outcomes and to evaluate who is being served, how they are
103
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
reached, the context of the program, who provides the education and materials, and
the information provided. This case study follows a “process evaluation” approach,
looking at the questions of what occurred in the program and for whom and how
(Coyle et al., 1991). Process evaluations incorporate observations, surveys, and
record reviews to assess the “how and how well the delivery goals of the program
are being met” (p. 17). It is important that the evaluation actually measure the
goals designed by the program.
Organization of Study
This dissertation focuses on the ministry of women’s (PROMUDEH)
implementation of the reproductive health program and particularly its HIV/AIDS
education component. The project was initially designed to target four
PROMUDEH programs: the Agency of Promotion of Childhood and Adolescence,
Promotion of Women, the National Literacy Program, and the National Wawa
Wasi Program. However, the program was only fully initiated in the Wawa Wasi
program, which is the focus of this study.
This research began with information gathering and interviews with
directors from all four of the PROMUDEH programs. The information gleaned
contributed to understanding the depth of the implementation of the sexual health
education materials, as well as the design and program objectives. Interviews
focused on the implementation of the modules and the design of the educational
modules. During the implementation phase of the project, surveys were utilized for
demographic data, combined with observations, focus groups, and interviews
104
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
measuring the knowledge, attitudes, beliefs, and practices of program participants
prior to and following intervention. Throughout this time, individual interviews
with course participants, administrators, and educators were conducted to further
assess the practice and results of the education program. According to current
research when evaluating HIV intervention it is essential to determine whether
knowledge is sustained. Therefore four months following the educational
intervention, interviews and observations were conducted with participants and
educators to analyze how knowledge, attitudes, belief, and practices have changed
or remained the same with time. A final phase of the study occurred over a four-
month period one year after the initial course was given including additional
interviews and observations.
The interviews and observations served to address the components as
described by NRC (1991): who is being served, how participants are reached and
what is provided, the type of outreach, engagement, and retention in the project, the
context of the educational materials (who, how, where, how often), and relevancy
and accuracy of the education.
Participants
The participants in this study came from four different groups. The first
were administrators and directors of PROMUDEH and Wawa Wasi program. The
second group consists of the regional coordinators for the Wawa Wasi program.
The final groups were the madres cuidadoras and madres and padres usuarios.
105
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The administrators and directors were chosen for their participation in the
sexual health and reproductive rights program in PROMUDEH. Four consultants
who were hired by UNFPA and PROMUDEH served as the main informants.
They were each responsible for the implementation of the modules in their
respective programs. The consultant for the Wawa Wasi program served as the key
informant for the overall project.
The regional coordinators who participated in the study were those who
were chosen by PROMUDEH for the module implementation. Twelve
coordinators from five regions of Peru: Lima-Callao, Huanuco, Huancavelica,
Cerro de Pasco, and Huancayo participated in the weeklong workshop in Lima.
These coordinators were the center of the module observations and focus groups
were conducted following the workshops. Two coordinators each from Lima,
Huancavelica, and Huanuco served as participants for the actual implementation
phase of the workshops. They were chosen by the Wawa Wasi consultant for their
participation. They were observed at length during the implementation of the
modules in each of their regions. In addition, they were interviewed informally
prior to and following the workshops.
The madres cuidadoras who participated in the study were those who were
able to attend the module workshops. These consisted of approximately 18 women
at each of the simultaneous workshops held in the three regions. Of those in
attendance, 50 completed the pre-survey and only thirteen completed the post
survey. I had hoped to have a higher rate of completion for the post-surveys,
106
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
however time constraints only allowed for those who participated in the focus
groups to complete the survey. Therefore due to concerns of validity, only pre
survey information can be utilized and presented.
In addition, six madres cuidadoras were chosen to participate in the in-
depth observations conducted over the one-year time period. The regional
coordinators in Lima selected the participants. The researcher had hoped to have
ten such participants, however only eight madres cuidadoras were accessible and
willing to participate, two of whom dropped out of the study at a later date as one
moved and one left the Wawa Wasi program. Three more women were
interviewed following the course modules in Huancavelica.
The final interviews with the madres and padres usuarios were based on
their availability as contacted in the Wawa Wasi homes of the six madres
cuidadoras. Again, the researcher had hoped to have many more interviews,
however due to the sensitive nature of the subject, confidentiality, and the time
constraints of the interviewees only seven madres and padres usuarios were
interviewed.
Observations
Two types of observations were conducted during the length of the study,
course observations during the implementation of the modules and home
observations in the Wawa Wasi locations. Observations were initially conducted
during the “train the trainer” phase which occurred in Lima, prior to the
initialization of the course modules. Then observations were conducted during
107
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
each of the program courses in Lima, Huanuco, and Huancavelica. In addition,
observations were conducted following the program intervention with the madres
cuidadoras in the Wawa Wasi homes. The course observations were utilized to
gain a sense of what happened with the women in the program, how they interacted
with each other and the agency, how they presented themselves, how the material
was presented to them, and the madres’ response to the intervention. The course
observations were initially centered on the decision to get to know the “setting and
people”, establishing rapport and comfort level, and introducing the project (Taylor
and Bogden, 1984, p. 32-34). These happened during the Train-the-Trainer phase
in Lima and during the initial meetings in each of the regions. Observations helped
to understand the course dynamics. As the course progressed, the observations
helped to assess the context of the education program, the actual participation
levels, how communication occurred, and learning outcomes. Observations also
provided a method of determining levels of empowerment and negotiation, if any,
that women gained from the intervention. It also provided an avenue for assessing
how the program objectives were actually met in the classroom.
Second, observations were conducted in eleven homes in Lima, eleven
homes in Huancavelica, and five homes in Huanuco. The observations in the
Wawa Wasi homes were designed to gain an understanding of the daily lives of the
madres cuidadoras and their interactions with their families, friends, and the
madres and padres usuarios. Both the issues of the informal education process and
empowerment were assessed during the home observations. These looked at the
108
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
type of negotiation the madres cuidadoras have with their families, partners, and
madres and padres usuarios. How is power relegated within these relationships
and did participation in the program have any impact on these power and gender
relationships?
In addition, further observations in the Wawa Wasi homes in Lima took
place during the period four months following the course intervention. The initial
observations occurred over a two-month time frame followed by a four-month
phase, where each home was observed on a regular basis during various hours of
the madres cuidadoras’ day. These observations were based on feminist
empowerment theories to consider the level of cognitive, psychological, economic,
and political voice that the madres cuidadoras have in their own daily lives and in
the lives of those they interact with on a daily basis (Stromquist, 1994 & 1996).
These observations sought to determine the level, if any, of informal education that
occurred as a result of the sexual health training. Observations included the madres
and padres usuarios as they interacted in the Wawa Wasi homes to determine the
impact, if any, of these informal processes.
Interviews
Throughout the research project interviews were conducted with a number
of key players in the program. PROMUDEH and UNFPA administrators, program
coordinators, madres cuidadoras, and madres and padres usuarios were
interviewed during the length of the course and following time period.
109
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Initial interviews were conducted prior to the implementation of the
modules with administrators and directors of the three PROMUDEH programs.
Key administrators and the actual program leaders and educators within
PROMUDEH and UNFPA were selected for the elite interviews due to their
position in the organization, as well as experience with the modules and concepts
of the program (Marshall and Rossman, 1995). Open-ended interviews, focusing
on knowledge and the historical background of the program were utilized. The
interviews began with a “grand tour” question and led to specific questions as the
interviews proceeded (Tierney, 1991). The interviews helped to assess the goals of
the program, the design of the modules and the commitment of both agencies to the
full implementation of the modules. These also served to determine commitment
of the agencies and the sustainability of the project.
Once the initial observations of the course took place and a general
understanding of the dynamics and components of the intervention was gleaned,
interviews were scheduled with program coordinators, participants, and
administrators. Interviews were conducted throughout the length of the project with
the participants both in the Wawa Wasi homes and in the classroom. Six in-depth
interviews were conducted with the madres cuidadoras in the Wawa Wasi homes
in Lima, and three were conducted in Huancavelica. In-depth/open-ended
interviews had a goal of understanding the knowledge, beliefs, attitudes, and
practices of the women. The interviews utilized open-ended questions in an
exploratory approach to the experience of learning in the prevention program
110
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
(Kvale, 1996). The interview includes a “protocol of general questions that need to
be covered”, however, the interviews followed the path of interest as led by the
interviewee (Tierney, 1991, p. 9). The goal of the interview was to explore the
background and education each participant brings to the program, the general
knowledge of HIV/AIDS prevention, the view of themselves as an at risk person,
the current at risk behaviors, program expectations, and explore knowledge gained
and possibilities of behavioral change as a result of participation in the course.
General interview questions included:
• How did the participant find out about the program and why did she choose to
participate?
• What are the participant’s expectations from the course and does she feel the
course is meeting those objectives?
• What type of knowledge regarding HIV/AIDS did the participant have prior to
the program?
• What is the participant’s current knowledge of HIV/AIDS, its transmission and
risk of infections? Also, what knowledge does she have about effective
prevention methods?
• What prevention methods does the participant currently use and what may she
use in the future? What ways are available to negotiate sex relations?
• What are the barriers for the participant to negotiating safe sex behavior with
current or future partners?
I l l
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In an effort to understand their personal lives and any impact of the
intervention, the interviews also elicited information about the participant’s
experiences outside of the learning environment. Their personal experiences and
life descriptions helped to determine if the program had any personal effects.
Questions guided the interview toward a look into the daily lives of the women and
the cultural and social roles in which they participate.
Each interviewee was provided with an outline describing the purpose of
the study, the background of the research project, the length of the interview, and
discussion of confidentiality (Tierney, 1991). The interviews were confidential;
names were not used on the data sheets or in the final report. Information obtained
during interviews was utilized solely for the research project.
In addition, during the four-month and one-year follow-up, interviews were
conducted with participants, coordinators, and administrators. These interviews
took place over two time periods (two months and four months), with six of the
women initially interviewed in Lima, to further assess the impact of the education
and how the knowledge, beliefs, attitudes, and practices of the women had changed
or remained the same over time. These interviews, along with the observations,
focused on the real life experiences of the madres cuidadoras and the social and
cultural influences that determine their daily lives. Empowerment issues formed
the central role of these interviews, based on the Cairo Program of Action
conceptual framework for how socioeconomic conditions play a direct role in
empowering women to make informed decisions on reproductive health (Malhorta
112
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
& Mehra, 1999). The interviews also sought to evaluate any informal education
processes that may have occurred following the initial education program.
In addition, during the final phase of the dissertation research the madres
cuidadoras and madres and padres usuarios were interviewed to further assess the
informal education and communication processes. These interviews focused on the
relationships between the madres cuidadoras and the madres and padres usuarios,
focusing on the context and reality of these relationships. This helped to determine
if the program objectives of a “multiplier effect” of the educational component had
occurred. The level of communication and any learning that may have taken place
was evaluated through this informal access component.
Interviews also occurred during the four month follow-up and continued
during the final phase with program administrators from both PROMUDEH and
UNFPA as well as the Wawa Wasi coordinators. These interviews helped to assess
sustainability and commitment from the departmental level. Due to governmental
changes, very few of the initial PROMUDEH administrators remained available for
interviews. However, those still working with the project were contacted and
interviewed as well as those evaluating the program from UNFPA. The future of
the project is yet undetermined and will continue to be evaluated through this
interview process.
Focus Groups
Focus groups were also part of the initial evaluation of the four educational
modules. Focus groups were conducted with the twelve program coordinators
113
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
following the initial training component. The focus groups were designed to elicit
feedback on the materials presented as well as to evaluate the attitudes and beliefs
of the coordinators in regards to the course objectives. The trainers’ comfort levels
with the topics of sex and sexuality were discussed as part of the focus groups in
determining how easily they could facilitate further educational programs in their
respective regions.
Focus groups with the madres cuidadoras were also conducted the day
following each of the modules. These sought to elicit feedback on the content and
understandability of the information as well as the interest level. The focus groups
also provided a means of understanding the participant’s current understanding of
sexual health and reproductive rights. The ability to process and reverberate the
information provided in the course was an important aspect of the focus groups.
This helped to determine if the participants could share the information accurately
with others and if their circumstances allowed for such sharing of sensitive
information. The participants were able to ask questions, provide responses, and to
further process the information they had received in the preceding days. This also
provided an opportunity to share their experiences in relationships with partners,
friends and family in regards to the sensitive topics of sex and sexuality.
The focus groups were transcribed and analyzed. During the following
months the transcriptions were coded to determine common themes and elicit
general information from the participants. These findings are presented and
discussed in chapter four.
114
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Surveys
In addition to interviews, pre- and post-surveys were designed for purposes
of the dissertation and distributed to project participants prior to and immediately
following the course. The initial surveys served as a baseline needs assessment as
to knowledge, attitudes, practices, and beliefs (KABP). Pre- and post-surveys were
completed by program participants in all three regions immediately prior to and
following the course. The surveys focused on the goals of the program as well as
the content of the four modules. Questions looked at knowledge of sexual health,
HIV/AIDS, and comfort levels with personal health. These also included questions
of availability of medical care, access and ability to use condoms, and opportunities
to discuss personal concerns surrounding these issues. Economic and social
support was also touched upon in the surveys.
The first part of the surveys included descriptive information of the madres
cuidadoras who participated in the workshops and completed the pre and post
surveys. Of those participating in the workshop, fifty women completed the pre
survey. Only those who participated in the focus groups were asked on completed
the post-surveys, of which thirteen completed the survey. And, the six madres
cuidadoras from Lima completed the survey four months following the
intervention. Of the fifty women completing the pre-survey, I looked at
educational level, age of participant, number of children and marital status (see
Table 3).
115
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In Lima, the half of the women had completed university education. Two
women (10%) had completed primary education, 8 women (40%) had completed
secondary school education, and 10 (50%) had completed university education.
The average age of participants in Lima was 42.5 years with an age range of 24
years to 71 years of age. The participants had an average number of children of
3.04. Four women (18.2%) had no children, one (4.5%) had one child, four women
(18.2%) had two children, four (18.2%) had three children, three (13.6%) had four
children, four (18.2%) with five children, and one each with six (4.5%) and eight
(4.5%) children. The majority of women in Lima, 14 (66.7%) were married, four
(19%) were single, two (9.5%) were cohabiting, and one (4.8%) was separated.
In Huancavelica, the average educational level of the participants was
completion of secondary school. Three women (25%) had completed primary
school, eight (40%) had completed secondary school, two (16.7%) had completed
some university, and four (33.3%) had completed university education. The
average age of participant in Huancavelica was 30.6 years of age with a range of 18
years to 56 years of age. The average number of children per participant was 2.58.
Five women in Huancavelica had no children (41.7%), one (4.5%) with two
children, three (25%) with three children, and one each with five (8.3%), seven
(8.3%) and eight (8.3%) children. The majority of women (50%) were single, four
were married (33.3%), one (8.3%) was cohabiting, and one was widowed (8.3%).
The participants in Huanuco had an average educational level of secondary
school. Four women (25%) had completed primary school, eleven (68.8%) had
116
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
completed secondary education, and one (6.3%) had completed university
education. The average age in Huanuco was 28.7 years with a range from 18 years
to 47 years old. The women had an average number of children of 2.75. Three
women (18.8%) with one child each, five (31.3%) with two children, four (25%)
with three children, three (18.8%) with four children, and one (6.3%) with seven
children. Seven of the women in Huanuco (46.7%) were married, seven (46.7%)
were cohabiting and one (6.7%) was separated.
Table 3
Demographics of participants in the sexual health and reproductive rights course
Lima Huancavelica Huanuco Total
M arital Status
Single 4 6 0 10
Married 14 4 7 21
Cohabiting 2 1 7 10
Separated 1 0 1 2
Widowed 1 1 0 2
Educational Level
Primary 2 3 4 9
Secondary 8 3 11 22
Some university 0 2 0 2
University 10 4 1 15
Age
18-25 2 6 5 13
26-40 5 4 9 18
41-60 13 2 2 17
61-71 1 0 0 1
Number of Children
None 4 5 0 9
1-3 9 4 12 25
4-6 8 1 3 12
7-8 1 2 1 4
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
These demographics provide a broad range of ages, educational levels, and
family background to assess the effectiveness of the program. The groups were
also quite similar in age, educational level and number of children.
Review o f Documents
A review of documents supplements the interviews and observations by
providing essential information on program history. Program descriptions,
including funding sources and dates, fact sheets on each program, advertising
material, and course material each contribute to content analysis of the
methodology of this dissertation and goals of the intervention program. This also
provides an overall picture of the project and delineates facts and policies (Marshall
and Rossman, 1995). Program components and objectives were determined by
review of the documents and materials utilized in the program design proposals.
These were compared and contrasted with observations and interview findings in
efforts to triangulate data.
Further review of documents included PROMUDEH policies on HIV/AIDS
intervention as well as other governmental-related policies. This served to
determine the attitude and commitment of the Peruvian government to an
HIV/AIDS campaign. Data analysis of historical infection rates and current
infection rates supplement the materials.
Time Line
The recommendations from the NRC on data collection include visits to the
program for three to four days conducted by a team of specialists (i.e. educator,
118
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
evaluation specialist). They recommend interviews with staff, administration,
program or community leaders, and five to ten participants in the program (Coyle
et al„ 1991).
Table 4
Time-Line of Research Study
December 1999- May-August 2000 December 2000- April-August 2001
January 2000 January 2001
• Initial contact
•
Interviews • Interviews • Final
with with with key interviews with
PROMUDEH PROMUDEH informants administrators
• Establish directors and and
commitment
•
Document administrators coordinators
from the review • In-depth • Final in-depth
ministry •
Interviews interviews interviews with
with other and the Lima
agency observations Wawa Wasis
administrators with the
• Interviews
•
Observations
Wawa Wasis
with madres
of Wawa
in Lima
and padres
Wasis • Four-month usuarias
•
Training for
the
coordinators
follow-up
surveys
•
Implementatio
n of the
research
modules in
the three
regions
•
Focus groups
•
Pre and post
surveys
•
Initial phase
of interview
with madres
cuidadoras
119
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Recommendations for effective AIDS intervention research include pre- and post
intervention surveys, ongoing interviews and observations, and follow-up surveys
several months after program completion. The time spent in the field is dependent
on the time necessary to establish credibility, an understanding of program
dynamics, and actual intervention timelines.
The time frame occurred during three phases over one-year time period (see
Table 4). The initial collection of data took place from May 2000 through August
2000. An additional two months were spent in December 2000 and January 2001.
During this time follow-up surveys and post-interviews were conducted. In
addition, the researcher returned for further interviews with the madres cuidadoras
and madres usuarias May 2001 through August 2001.
Interpretation
Comprehensive notes were taken during all interviews and observations to
include description and direct quotations. A cover sheet, including background of
the interviewee and an overview of topics covered, was completed directly
following the interview. Focus group data was transcribed and notes were
summarized within 24 hours. The data is presented in a descriptive manner,
pointing out themes and patterns where noticed. The interview data was
triangulated with the observations and review of documents to locate salient
patterns and themes and their links (Tiemey, 1991, Marshall and Rossman, 1995).
The data gathering process took place throughout the project period. The data were
continually analyzed during this process.
120
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Validity and Reliability
An important consideration in any research study is validity. Validity
questions how accurate are research findings.
Establishing validity requires determining the extent to which
conclusions effectively represent empirical reality and assessing
whether constructs devised by researchers represent or measure the
categories of human experience that occur (LeCompte & Goetz,
1982, p. 32).
Two aspects to be considered are internal validity (“authentic representations of
some reality”) and external validity or how comparable the study is across groups
(p. 32). When measuring internal validity, we can ask does the researcher “actually
observe or measure what they are observing or measuring?” External validity
questions “to what extent are the abstract constructs and postulates generated,
refined or tested by scientific researchers applicable across groups?” (p. 43).
To ensure measures are as valid as possible, this research study utilized
methods of triangulation of data and data gathering methods, construct validity by
“operating within a conscious context of theory-building”, and face validity by
ensuring accuracy through “member checks” and continual feedback (Lather, 1986,
p. 270-71). Specific methods included listening openly to all informants, ensuring
accuracy in note taking, writing soon after the investigation begins, focusing
writing on what was actually said, “reporting fully”, “being candid”, allowing
121
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
colleagues to provide feedback to methods and writing, and “achieving balance” in
the field and in writing (Wolcott, 1990, ppl27-133).
In efforts to establish legitimacy, I was introduced to the participants as a
student researcher from the University of Southern California, but the exact details
of the research were not disclosed. This minimizes the chance that participants
discussed issues they believed I want to hear, or to hide things that they may not
want me to know (Taylor and Bogden, 1984).
Summary
This research presents a case study that takes an in-depth look how issues of
gender, empowerment, and sexuality operate as components of a nonformal sexual
health and reproductive rights education program. Findings of the study will help
to provide a better understanding of current sex education and reproductive
practices in Peru, governmental policy regarding HIV/AIDS education and
prevention, sociocultural attitudes toward dissemination of information and gender
dynamics, socioeconomic implications, change in knowledge, practice, attitudes,
and beliefs of women, and prevalence of high-risk behavior amongst women.
122.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 4
PROGRAM DESCRIPTION AND OVERVIEW
Introduction
In this chapter, I will discuss the background and goals of the
PROMUDEH/UNFPA sexual health and reproductive rights project. First, I will
present current data on sexual health in Peru. I will also discuss the organization of
PROMUDEH and the programs within this governmental organization that are
working on sexual health issues followed by a description of the Wawa Wasi
course and observations of the Wawa Wasi homes in the three regions of this study.
I will then provide an overview of programs in Peru that address sexual health,
reproductive rights, and HIV and AIDS. This overview will help to gain an
understanding of the PROMUDEH project, the women who work in and participate
in the program, and the current situation of sexual health intervention in Peru.
Current Information on Sexual Health and AIDS in Peru
Considering the impact of a sexual and reproductive health intervention
program in Peru, an understanding of the demographics of the area will help to
assess whether the intervention fully addresses the social and economical
constructs of the country. The average fertility rate in 2000 was 3.1, with an infant
mortality rate of 43 per 1000 births. In 1996, 35.8% of married women reported
using no method of contraception, 6% used birth control pills, 12% IUD, 4%
condoms, 9% were sterilized, 9% used other modem methods, and 23% used
traditional methods (USAID, 1998, pp. A-41, A-46, A-62). According to the
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
National Institute of Statistics and Information (INEI), the total number of married
women using contraceptives increased from 57% in 1992 to 69% in 2000. The
number of those using traditional contraceptive methods decreased from 26% to
19% respectively. Of those using modem methods, 14.8% used injections, 12.3%
had their fallopian tubes tied, 9.1% IUD, 6.7% pills, 6.2% condoms, and 1.3%
other methods (INEI, 2000). It is not clear why this increase occurred, unless it
was based on increased communication on contraceptives addressed by the current
intervention programs that will be described later in the chapter.
The maternal mortality rate in Peru is 265 for every 100,000 births; one of
the highest in the region. A study conducted by the Alan Guttmacher Institute
(1997) looked at pregnancy and abortion issues in Peru. They found that of all
pregnancies, 40% were wanted, 30% were unwanted, and 30% resulted in an
induced abortion; indicating that 60% of all pregnancies in the country were
unwanted. Of every 100 women who induce abortion, 47 have complications and
20 are hospitalized for these complications (INEI, 1997). These data indicate that
contraceptive use may not be adequate and that ability to negotiate wanted
pregnancy does not occur. These issues are both indicators of high HIV prevalence
rates that place women at high risk.
As stated previously, 48,000 people in Peru are infected with HIV or AIDS,
25% of whom are women. The majority of those infected are men between the
ages of 20 to 39 years of age (55%). The majority of women infected are also
between 20 and 39 years of age. In addition, domestic violence is a serious
124
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
problem in the country with 38.9% of women in relationships reporting some
physical violence in their relationship and 67% reporting psychological violence.
Of these 19.4% report violence as a frequent occurrence (INEI, 2000).
Programs in Peru Dealing with Sexual Health and AIDS
This dissertation also included an in-depth search for programs in Peru
currently dealing with sexual health and AIDS issues. The review of programs was
designed to assess the level of intervention, if any, occurring at the time of the
PROMUDEH training and to determine any coordinated efforts at education and
prevention. This search was completed through the interviews with administrators,
consultants, and coordinators at PROMUDEH and other agencies, the madres
cuidadoras, and the madres usuarias. Programs known and recognized by
community members would have the best advertising and possible attendance.
Therefore, the programs discussed are those recommended and known by
participants in the dissertation research. In addition, any programs I located while
in Peru or through general research are included in the discussion.
The programs dealing with women’s health include United Nations
organizations, other international organizations, government agencies, feminist
organizations, and religious organizations. The level and types of participation
include small courses to large full-country interventions, including formal,
nonformal, and informal methods of teaching. Through the research, contact was
made with several of these programs whose descriptions are included below.
However, this list is far from exhaustive of the programs in Peru that may be
125
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
dealing with these issues. The main limitation to providing a more complete list is
that there is no central mechanism available to provide information on these types
of programs. I found very little communication occurring between the different
ministries that were often dealing with similar issues and little communication
among most agencies on women’s health issues or AIDS. Although many
participants I interviewed were familiar with other projects around Peru and many
had worked for some of the other agencies in the past, they reported few joint
ventures or meetings leading to combined outreach attempts.
United Nations Programs
United Nations Population Fund (UNFPA)
The United Nations Population Fund (UNFPA) was the lead agency on the
PROMUDEH Wawa Wasi program. UNFPA has worked in Peru for twenty years.
For the sexual health and reproductive rights program with PROMUDEH, UNFPA
contributed over $370,000 for a three-year intervention. They served a
coordinating and evaluative role in the program. In addition, the director proposes
$20 million for the five-year period (2001-2005) for reproductive health,
population and development strategies, advocacy, and program coordination.
During the previous years (1997-2001) UNFPA participated with $15 million to
Peru in support of reproductive health, technical assistance for family planning,
men’s reproductive health, and national reproductive health and reproductive rights
programs. The main accomplishments were:
a) creation of a training and supervision model for reproductive
health, developed in conjunction with national universities, taking
126
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
into account cultural and regional particularities. Five universities in
different regions of the country will use the training module to
provide in-service training on reproductive health to Ministry of
Health personnel; and b) the incorporation of sex education in the
school curricula through support for the National Sex Education
Programme (NSEP). With UNFPA support, 49,000 primary and
secondary school teachers were trained on sex education and over 3
million school children have received sex education since the
programme was launched in 1996 (UNFPA, 2000, p.5).
UNFPA also participated in the development of the National Population
Plan (NPP) and worked in advocacy for reproductive health, reproductive rights,
gender equity and women’s empowerment. This work included formation of a
Tripartite Commission for the follow-up of the ICPD Programme of Action
Implementation in Peru (TPC-ICP). They also provided workshops, seminars, and
research studies based on these issues. UNFPA was also responsible for the
development of the National Reproductive Health and Family Planning Programme
and the National Plan for Equal Opportunities for Men and Women 2000-2005
(UNFPA, 2001).
United Nations Joint Program on AIDS (UNAIDS)
UNAIDS also plays an active role in the AIDS intervention programs in
Peru. As UNAIDS serves in a leadership role for the eight leading agencies
(UNICEF, UNDP, UNFPA, UNESCO, ILO, WHO, the World Bank, and UNDCP),
in the regions it functions through one of these lead agencies. UNAIDS regional
work is coordinated by a country program advisor (CPA). In the case of Peru, the
UNAIDS country office is stationed out of the UNDP office in Lima led by an
InterCountry Program Advisor who covers Bolivia, Ecuador and Peru (UNAIDS,
127
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2002). UNDP focuses its work in Peru on support of democratic governance, fight
against poverty, energy and environment, technology, information, and
communication, and prevention of factors that threaten society including natural
disasters and HIV/AIDS. UNDP works directly with and through participation in
ONUSIDA (UNAIDS in Latin America) to strengthen the country’s efforts against
HIV/AIDS. This includes project support and information campaigns concentrated
on vulnerable groups. The major results have been planning events on AIDS
awareness including World AIDS Day events and concert, radio public service
announcements, and a national marathon against drug use (UNDP, 2002).
UNAIDS work in Peru is generally centered on surveillance efforts and
collaboration with the MINSA PROCETTS program. These actions appear to be
solely supportive in nature with little new development or intervention efforts.
Recently, protesters in Lima declared there was a lack of treatment for those living
with AIDS. Their concern resulted from perceived lack of support by the MINSA
and UNAIDS in Peru. The Peruvian Health Minister declined support of the
UNAIDS universal access program and the UNAIDS representative for Peru stated
that no access program for antiretroviral therapy was planned for Peru. Protesters
felt that both the MOH and UNAIDS had to take a more active role in support of
those living with AIDS in Peru (Stem, 2001).
128
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Other International Agencies
Doctors Without Borders/Medecins Sans Frontieres (MSF)
MSF has worked in Peru since 1985 focusing on the prevention of
communicable diseases, a leading cause of mortality in Peru. In the past few years,
MSF has added HIV/AIDS to its agenda in Lima. The program in Lima focuses on
reducing STDS and HIV/AIDS and improving access to and quality of health care.
The outreach includes basic care, staff training, and public education. MSF has
sponsored AIDS fairs in Lima and with local organizations in Cuzco, Ayacucho,
and Iquitos. An HIV prevention focused program is located within the local
Lurigancho prison that includes support and counseling for those living with
HIV/AIDS. In the Lima districts of San Juan de Miraflores, Villa Maria del
Triunfo, Villa el Salvador and Chorrillos, MSF works closely with the MINSA
PROCETTS program on prevention efforts, including training of community health
workers and public health staff. MSF also began a sexual health and reproductive
rights for children and teens in the Lima district of Villa El Salvador. The project
“Entre Amigos” (Among Friends) works with pregnant teens and abused children
(MSF, 2001).
United States Agency for International Development (USAID)
USAID provided Peru with approximately $750 thousand in 2001 to
support HIV/AIDS intervention efforts. USAID has supported surveillance
programs for STDS and AIDS. Activities also include “strengthening laboratory
diagnostic capacity, supporting the study of the relationship between tuberculosis
129
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and HIV/AIDS; disseminating information, education, and communication
materials; and training peer health educators” (TvT Associates, 2002, p.3). USAID
also works in support of the MINSA PROCETTS program on HIV/AIDS
intervention efforts.
Peruvian Government Programs
Programa de Control de Enfermedades de Transmission Sexual and SIDA
(PROCETTS)—Ministry of Health (MINSA)
The Programa de Control de Enfermedades de Transmission Sexual and
SIDA (PROCETTS) through the Ministry of Health (MINSA) was a recognized
program by the PROMUDEH and UNFPA staff. The program objectives are
controlling STDS/HIV/AIDS in Peru through reduction of transmission of
STDS/HIV, lessening the individual, social and economic impact of STDS/HIV,
and strengthening the resources against STDS and AIDS (MINSA, 2000). The
priorities for services are those people currently living with HIV/AIDS, high-risk
groups, especially men and women with multiple partners or those practicing
unprotected sex, followed by the general population. PROCETTS is working in 33
regions to inform and provides infrastructure and resources for those at risk of
contracting STDS/AIDS (MINSA, 2000).
Feminist Organizations
Flora Tristan-El Centro de la Mujer Peruana
Flora Tristan is one of the feminist organizations in Peru currently dealing
with the issues of women’s health. The objectives of the organization are to
130
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
improve the situation of women citizens in the political process and development
processes resulting in gender equity and justice. This includes promotion of the
sexual and reproductive rights of women (Flora Tristan, 1999). Since 1990, they
have focused on two of the poorest districts in Lima at the various Vaso de Leche
(Glass of Milk) program locations to bring the Servicio Integral de Salud
Reproductiva (Integrated Reproductive Health Services, SISMU) program to
women in the community. This work includes developing district strategies for
provision of information, education, communication, and advocacy for women’s
organizations and health agencies; investigating and creating a work plan for the
health agencies and women’s organizations on basic health; a reproductive health
program which includes alternative health options for women; and many other
projects. They also work with adolescents, in the universities and on issues of
maternal mortality and unsafe abortions (Flora Tristan, 1999).
The director described the current programs and introduced me to other
research projects dealing with AIDS. She stated that the organization of Flora
Tristan is a feminist program that has existed for 20 years. The three main goals of
the organization are human rights, sexual health and reproductive rights, and rural
development. She described several current projects including a joint program with
the local University of San Marcos. An additional research project on family
violence and reproductive health is located in Lima and Cuzco. However, they are
currently spending more attention on the issue of illegal and unsafe abortions in
Peru. She stated the organization did work on projects with MINSA and
131
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
PROMUDEH dealing with HIV/AIDS, but they were not doing any direct
intervention on this issue. Much of its current research and project work deals with
the Cairo agenda and the recommendations, which is relevant to this research
project and the goals of the educational intervention.
El Movimiento Manuela Ramos
Manuela Ramos is a feminist organization that has worked in Peru for equal
rights between men and women and the development of the country since 1978.
With offices in seven cities, including the capital of Lima, its main job is the
“assessment, investigation, diffusion and defense of legal, economic, social and
reproductive rights of the women from the diverse cultures that live in Peru”
(Manuela Ramos, 2002).
Bien-estar (Well-being) is one of its main projects dealing with health and
sexual and reproductive rights. In 1989, Manuela Ramos began to provide health,
legal, and business services to the women in Peru through the Community Clinic
for Women’s Health in Ollantay, San Juan de Miraflores. The need for this
intervention grew and in 1997, Manuela Ramos established a larger and more
amplified location, the Casa del Bien-estar, the first multi-service center for
women. With a team of 15 health promoters the clinic provides education and
prevention on a variety of health topics including family planning, gynecological
cancer, and reproductive infections. The Casa del Bien-estar first serves as a
health clinic for women, but also provides services for legal orientation on family
132
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
violence and divorce and services for economic support and small businesses in the
form of credit and training (Manuela Ramos, 1998).
Reprosalud a second major program that is funded in part by USAID and
focuses on the sexual and reproductive health of women. However, as the
participants decide on the topics, the program has little or no direct focus on
HIV/AIDS. In this case, the design to include community self-assessment works
against the inclusion of AIDS in the curriculum. Over 700 health promoters, 200 of
which are men, have provided services for over 23,000 people. The director
described the Reprosalud program, which has worked in nine regions since 1995.
The program provides education for both men and women on areas of sexual
health. They have reached over 89,000 women and 46,000 men since the
implementation of the project. At the start of the program the Ministry of Health
coordinated a diagnosis of the situation in each district. From the 1993 census,
they chose the districts where more the 70% of the population lacked basic
necessities of life. From there, they searched for existing women’s organizations in
each district that were accessible and near a health center. They ruled out zones
that were still highly affected by terrorism (working in these zones later in the
project). These zones include Ancash, Huancavelica, Ayacucho, San Martin, La
Libertad, Puo, Ucayali, and Lima (Manuela Ramos, 2000).
Once the zones were established, presentations were made to local women’s
organizations to ask for their participation. These groups then created a self-
diagnosis of the needs in their respective region, taking into consideration
133
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
maternity rates, birth and death rates, relationships of girls and families, etc. These
self-diagnoses found that the major problems were vaginal infections at 40% and
number of children at 35%. In the mountain regions one of the main issues was a
problem with pregnancy or birth.
The methodology is to train the women and men in the community to
provide information to others. Once the community members are trained they go
out and present at clinics and meetings with community members. Different
communities are trained on different topics depending on the needs assessment.
For example, in the jungle area of Pucallpa, teen pregnancy was one of the major
problems, so they are trained on this issue. Manuela Ramos has developed
modules for the promoters, who in turn train others. The modules contain a variety
of pictures and are designed for those who are illiterate. There is also an
evaluative exam at the end of the training. The evaluative results were over 80%
correct answers for both men and women in each area. AIDS is only a very small
part of the topic and is actually discussed more with teens.
Asociacion de Comunicadores Sociales— Calandria
Calandria is the feminist agency conducting the evaluative part of the
PROMUDEH project. Calandria has produced numerous publications on women’s
issues and feminist theories. Publications include the validation for the modules for
the PROMUDEH project which will be discussed in the data analysis section
(Aldana, et al., 2000). According to an interview with one of the main researchers
(2001), Calandria is a NGO specializing on communication and development.
134
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Calandria was created in 1983, by a group of professors and students from the
University of Lima. Initially, its work focused on the production of a radio
program that intended to give support to the newly created women's grassroots
organizations. Throughout the years, new areas of work were developed.
Now, Calandria is organized in four main areas divided into two centers and
two departments: the Media Production Center, Research Center, the Civil Society
Department, and the Local Development Department. The Media Production
Centre specializes in the production of media such as video programs, radio
programs, and printed material (booklets, comics, posters, manuals, etc). They also
design and organize activities such as "video plazas" (showing videos in streets and
squares organizing a debate about them afterwards). The Research Center designs
and applies surveys on different topics, especially on democracy and citizenship
issues. They also do work on qualitative research, through studies of knowledge,
attitudes, and practices (KAP) (Aldana, 2001, personal communication).
Calandria has developed numerous video resources on AIDS. Some of those
viewed included a fictional story on a schoolgirl who contracts AIDS from her
boyfriend. Another followed three couples making decisions about sex and whether
or not to use condoms. They also have developed commercials on condom use and
several articles on condoms and AIDS. These videos are used for presentations
with youth groups and in various training.
135
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Religious Organizations
There are several religious organizations in Peru dealing with HIV/AIDS
intervention. However, only one will be described below, as I was able to access
only this program.
Hogar de Buen Pastor— Good Shepherd Assembly of God— Shelter
The Hogar de Buen Pastor is a residential living center for children and
mothers infected with AIDS. This program is a church-based program. They
provide housing for orphans of AIDS as well as mothers with infants. The
residence is a very large converted church and school, standing two stories tall with
long hallways surrounding a central courtyard and garden. The organization
accepts women and children with AIDS only; they are unable to help those with
other diseases such as tuberculosis. The staff consists of two medics, eight nurses,
one accountant, one social worker, a volunteer psychologist and a pastor. They
survive financially from donations.
The clients are referred to the shelter through hospitals. The director stated
she had contact with social workers in the local hospitals that referred poor families
with AIDS to the program. She informed me that the same religious organization
ran one other home which had space for more children and ten adults. At that time,
there were two women and eight children living in the Hogar de Buen Pastor.
Intervention efforts of the agency involve HIV infected women in
discussions about he disease and how it spreads. They do not have any prevention
programs. They plan for the assistant social worker to provide talks in the local
136
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
schools in the future. Their greatest problem is in the need for volunteers to help
with beds, food, and to work with the children.
Summary
The review of these agencies and organizations providing sexual health and
reproductive rights programming allows for a review of some current programs in
Peru, especially in regards to HIV/AIDS programming. This shows that there is
international, local government, feminist and religious organization support for
these themes. The outreach from each program is recognized within the
community as participants in the PROMUDEH organization recommended each of
these programs. As presented in the overview, most of these programs focus on
educating women and the community on sexual health issues. AIDS is not
necessarily a priority for any of the programs, except for PROCETTS, but is
touched upon through the outreach and intervention. During this analysis, no other
programs were located that had a direct focus on AIDS prevention. One of the
concerns of agency members was the lack of coordinated efforts between programs
and the lack of a central informational mechanism that would allow for a holistic
understanding of intervention efforts. As reported by the PROMUDEH leaders,
government agencies had not coordinated efforts or control methods to develop a
clearer picture of the overall programs in the country.
Ministerio de Promocion de la Mujer and Desarrollo Humano (PROMUDEH)
Although several organizations are working on issues of sexual health and
AIDS, the project to which I had the most access that was working most directly on
137
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
AIDS was in PROMUDEH through the Wawa Wasi program, sponsored by
UNFPA. I did gain access and entry into this program, but obtaining that access
was a major barrier to implementation of the dissertation research. The following
provides a thick description of the access process.
Making Contact: Getting in the Door
In establishing access to the program, I first had to get through a maze of
bureaucracy to reach the actual people with whom I would work. I think it is
important to understand this process in order to fully recognize the government’s
perception of this program. My initial contact with PROMUDEH was in December
1999. I gained access to a meeting with the vice-minister of PROMUDEH through
contact with a mutual friend. On the meeting date, I headed into central Lima
several blocks from the Plaza de Armas where the presidential palace and other
major governmental offices are located. The area is highly business oriented; the
streets are crowded with pedestrians and taxis. The office is located in a tall cold
concrete building. After passing through high gates, showing my identification to
the guard, and through a metal detector, I was required to leave my ID with the
front desk in exchange for a visitor’s pass.
One of the first things I noticed was that all of the women working at
reception were wearing uniforms of pink blouses and gray skirts. What was most
interesting was that throughout the building most women were in the same uniform,
but the men were not wearing the pink shirts. This pointed to possible issues of
gender discrimination in that women were required to wear the uniform with the
138
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
gender assigning color, but men were allowed to wear clothing of their choice. I
was led through an open area where several women dressed in traditional Indian
clothing were selling a variety of artwork and sweaters. Proceeding up the elevator
I was met at the door by security who escorted me to a waiting area. In this waiting
area I noticed three indigenous women dressed in traditional clothing seated as if
also waiting for a meeting. After about half an hour I was shown into the vice-
minister’s office. The office was large and tastefully decorated in modem western
style. The vice-minister welcomed me and I began to present my research needs.
This meeting lasted approximately fifteen minutes as I explained my project. The
vice-minister was very supportive of my project and welcomed me to complete my
work with PROMUDEH. We left the office and I was introduced to his advisor
who would be my ongoing contact for the project. She gave me her card and asked
me to keep in contact with her regarding my project.
I returned to the US and kept in email contact with the advisor over the next
few months until my return for my research and data collection in May 2000. I met
with her immediately and updated her on my objectives and how I hoped to be
involved with PROMUDEH. Wearing the traditional pink uniform of the office,
she explained that they had several programs touching on AIDS, but not dealing
directly with the topic, however they were now trying to incorporate this theme into
the programs. She said she would set up meetings for me with the directors of the
different programs to see where the best place would be. She shared with me a
directory of the various programs and the themes they covered.
139
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In the following days, I met with several administrators within
PROMUDEH who introduced me to the various programs. The current project
dealing with sexual health and reproductive rights was a joint grant with UNFPA,
which was being piloted in four programs: Children and Adolescents, Promotion of
Women, Literacy, and Wawa Wasi. Four consultants had been contracted to
develop modules and evaluate their effectiveness. I met with these four consultants
to get an overview of the project and assess if they would be appropriate areas for
my project. In the Children and Adolescents program, the consultant was in the
process of developing the modules and did not plan to begin for three months. The
second program, for the Promotion of Women, works with women leaders around
Lima. They provide more of a referral service for sexual and reproductive health
and were not directly dealing with these issues. The consultant for the Literacy
program was able to share the modules in development, but also did not plan to
begin for at least six months.
Finally, I met with the coordinator for the Wawa Wasi Program. The project
would first work with the Wawa Wasi coordinators from different regions who are
each responsible for 15-16 Wawa Wasis with at most eight children in each home.
They then planned to provide the course for the madres cuidadoras and the madres
and padres usuarios. The course would start in two months; however, the pilot
course would begin in two weeks. Approximately twenty coordinators would come
to Lima for training, and then they would begin the pilot in three provinces. The
purpose was the validation of the modules and revision of the manuals. This
140
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
project was available for me to evaluate and it was appropriate for my research
goals in that it addressed the issues of sexual health and reproductive rights with a
focus on HIV/AIDS, and would take place during the proposed research timeline.
Gaining Confidence
During the next few weeks, I spent time developing relationships with the
key agents and understanding the design and goals of the Wawa Wasi program. I
also had to gain trust with the consultant and leaders to ensure my participation in
the project. After several visits and calls from the vice-minister’s office I was
finally allowed access to the program. This Wawa Wasi consultant, Nancy, actually
became my closest confidante throughout my research, but she still needed
convincing before she agreed to my participation.
The training with coordinators from five regions (Cerro de Pasco, Huanuco,
Huancayo, Huancavelica, and Lima) began the next week. Set in the Hotel Savoy in
downtown Lima, the intensive training lasted four days. Nancy encouraged me to
spend as much time as possible with the coordinators as they would provide the
direct contacts I needed with the madres cuidadoras and they would have the final
decisions to invite me to the course implementation in their respective regions. By
the second day, Nancy and the other administrators separated themselves from the
coordinators allowing me to get to know them one on one during lunch, breaks, and
the training. The women soon were filled with questions of the United States, my
work, my university, and various other topics. We began to build trust during the
following days. It seemed that I quickly became considered an “expert” on AIDS
141
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
due to the nature of my research. I spent extensive time talking and meeting with
the coordinators. Confidence was gained through the interactions and conversations
that ensued over the following days. As the coordinators began to understand my
project, they wanted to provide assistance where possible. I was invited to attend a
visit to the local Wawa Wasis in Lima, and by the end of the training each of the
coordinators excitedly offered their assistance and encouraged me to visit their
respective regions and classes. Confidence had been obtained and I could now
embark on the rest of my research journey.
System of the Ministry of Women (PROMUDEH)
Now in the project and ready to begin my direct research, I needed to spend
time learning about the organization and find out what else was happening in Peru
around these themes. I began a review of documents from those that had been
provided to me and spent time in the PROMUDEH library. PROMUDEH was
created in October 1996 by the government of President Alberto Fujimori under
legislative decree to support women and families, to improve equal opportunities
for women, to promote activities that improve human rights, and to give priority to
at-risk children. The vision of PROMUDEH is to create a great cultural change
where men and women share the same opportunities and become owners of their
own destiny, under an ambiance of peace, democracy, and solidarity. The mission
of PROMUDEH is to inform and advance women and the community, prioritizing
those in extreme poverty, through the promoters and basic social organizations, in
142
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
order to better standards of life (PROMUDEH, 2000). The five main objectives of
the Ministry are to:
a. Improve the equality and access of employment, health, and education.
b. Reinforce the role of the woman and family in society, through programs
oriented toward their development and fight against poverty.
c. Formulate and execute policy action oriented toward preventing, attending,
promoting, and rehabilitating children of an age to be considered at-risk.
d. Provide incentives for civic values and behavioral norms, according to ethic
and moral principals, solidarity, and peace.
e. Improve the access to information, culture, recreation, and sports as methods of
personal and collective support (PROMUDEH, 2000, p.l).
The programs dealing with sexual health and reproductive rights were the main
interest of my research. There are several programs within PROMUDEH dealing
with these topics. However, PROMUDEH is involved in many other activities
outside of health. The organizational flowchart (Attachment I) shows the overall
programs within the PROMUDEH governance. The following programs deal with
the sexual health and reproductive rights in some form. Those working on the
UNFPA curriculum are Children and Adolescents, Promotion of Women, Literacy,
and Wawa Wasi. The PROMUDEH programs including a focus on sexual health
include the following:
• National Literacy Program—teaches reading and writing for women and men
through content including health, sex education, prevention of family violence,
143
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and citizenship and rights. The literacy program is newly involved in the
UNFPA sexual health training, where the consultant is currently in the process
of developing course modules.
• National Wawa Wasi Program—provides basic services of care and nutrition
for children between six months and three years of age. The Wawa Wasi
program is involved in the UNFPA sexual health and reproductive rights
training. The modules have been developed and the consultants will complete a
pilot study in three regions that will be evaluated in the following chapters.
• Office of the Promotion of Children and Adolescents—ensures adequate
psychosocial support for children and adolescents for healthy social and family
lives. The department includes the offices of Adoptions, Children’s Defense,
National Plan of Action for Infancy, and Plan for Working Children. This
program is in the process of developing modules through UNFPA funded
program.
• Office of the Promotion of Women—provides programs that permit the support
of women organized for equal opportunity. Includes offices of Family
Violence Prevention, Pro-Mujer which focuses on local and social agencies to
help support services including sexual health, citizenship, and family violence,
Warmi Wasi which brings education and information to rural and poor women
on sexual health and domestic violence, Women and Citizenship, Gender and
Human Development, and Prevention and Treatment of Drugs. This
department has completed two courses on prevention of family violence for 135
144
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
participants, one video addressing prevention of family violence for 2,500
viewers, and a one-day event for the “Day for No Violence Against Women”
reaching 400 people. They are also involved in the development of modules for
the UNFPA funded curriculum.
Summary
The preceding information describes the objectives and departments within
the ministry, including a brief overview of the goals of each department. Several
departments have current programming that deals with the issues of sexual health
and reproductive rights of women. As mentioned, four of these departments are
directly involved with the PROMUDEH/UNFPA program and are in the process of
developing modules and designing curriculum for implementation of the
workshops. The Wawa Wasi is the first of the programs to implement the modules
and will serve as the focus of this study.
The sexual health and reproductive rights program was chosen for its
accessibility but also for the program design which appeared to exemplify the
recommendations for effective intervention. As discussed previously, an effective
HIV/AIDS intervention program with women would include material beyond the
discussion of AIDS. A successful program would include: transmission of AIDS
and other STDS, use of and access to condoms, sexuality and women’s sexual
health, reproductive health and family planning, communication and information
sharing, partner negotiation, identifying risk behavior, individual and family health,
and right to health education (Cash, 1996). In addition, according to the Cairo
145
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
recommendations an effective program would seek to empower women through
equitable social and economic development in order to make clear changes in
reproductive choices (Malhotra and Mehra, 1999). The PROMUDEH program was
organized around four central topics of sexual and reproductive rights, sexuality,
gender relations, and family violence. In addition, through the Wawa Wasi
program, the participants had some access to economic and educational resources.
This seemed to create an ideal model for effective AIDS intervention according to
the research recommendations.
Wawa Wasi
The Wawa Wasi program was developed in 1993 under the Ministry of
Education. Wawa Wasi is a childcare program. Day care providers (madres
cuidadoras) in poor urban and rural areas provide low cost and no cost day care
and nutritional programs for children and families. This program, initially entitled
Hogares Educativos Comunitarios (Community Education Homes), was funded by
UNICEF and designed to provide integral attention to children three years old and
under. In 1994, with financial assistance from the Inter-American Development
Bank, the European Union, UNICEF, and the World Nutrition Program, the
Sistema Nacional de Casas de Ninos Wawa Wasi (National System of Houses for
Children Wawa Wasi) was bom. In 1996, the program was transferred to
PROMUDEH as it fit within the mission, methods, and objectives of this new
ministry. With the governmental Plan of Action for Infancy (1996) approved,
several operational strategies for Wawa Wasi were changed; and with continued
146
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
support from the Bank and assistance from Japan, the final contract for financing
the National Wawa Wasi Program was completed in January 1999 (PROMUDEH,
2000).
Wawa Wasis are located in private homes, community centers, and in
institutions. The private homes, called “ familiares, ” provide care for up to eight
children between the ages of six months and three years of age. The program
provides equipment, stimulation materials, training and technical assistance. The
community Wawa Wasis (comunales) are located in community properties, built by
the ministry or the community themselves. The community Wawa Wasis are built
on a larger scale to provide care for 16,24, 32 or more children, depending on the
size and number of women providing care rather than the limit of eight children in
a private home. Wawa Wasis can also function in institutional settings
(institucionales) such as businesses, associations, or universities (PROMUDEH, El
Wawa Wasi, 1999).
Each Wawa Wasi is attended by a mother from the community (madre
cuidadora), who is responsible for the care and support of the children in her care.
These women are selected and supervised by an area coordinator and are trained by
PROMUDEH. The madres cuidadoras are required to provide nutrition, health,
and stimulation for the children in their care. Wawa Wasis function in 23
departments of Peru, supervised by a headquarters director and the area
coordinators. In 1999, there were 1,071 family and 3 community Wawa Wasis,
providing care for 11,736 children. This jumped to 2,965 family and 250
147
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community homes, providing care for 28,476 children in 2001. The number of
madres cuidadoras went from 1,467 in 1999 to 3,530 in 2001 (PROMUDEH,
2001).
During my research, I was able to visit each of the three types of Wawa
Wasis, familiares, comunales, and institucionales in three distinct regions of Peru:
Lima, Huancavelica, and Huanuco. Clear variances in the programs were observed
by region and type of home. There were also distinct differences in resources
available to the madres cuidadoras varying again by location which will be
described by region below. The madres usuarias who utilize the child care are
mostly working mothers who can not afford basic care for their children. The
majority work in the markets, in agriculture, as vendors on the streets or buses,
and/or as house servants. Most have very little education and are living in situations
of poverty.
The director of the Wawa Wasi Program provided me with a prior research
report (PROMUDEH, 1999) that gathered information directly pertaining to the
madres cuidadoras’ and madres usuarias’ knowledge of AIDS and use of
contraceptives. The data from 1999, found that amongst the madres cuidadoras
57.5% used some form of contraceptives and 42.5% did not. Although 74% of
those questioned were aware of the existence of AIDS, “only 24% knew of the
existence of sexually transmitted diseases, of these the most recognized were
gonorrhea and syphilis. They were aware that these were transmitted through
148
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
sexual contact and the form of prevention most recognized was to have only one
partner” (p. 30).
In the case of the madres usuarias, the average age of initial sexual activity
was 15 years. Their knowledge of sexual health involved only contraceptive
methods, of those the most common were IUD, injections, pills, condoms, the
rhythm method, and tying of fallopian tubes. However, the women were most
likely to use the rhythm method or pills for contraceptive methods. The majority
had no knowledge of sexually transmitted diseases (76%) and although they knew
of the existence of AIDS (69%), they did not know how it was contracted (p.36).
The sexual health and reproductive rights course was designed to become
one of the training workshops that the madres cuidadoras participate in on a
regular basis. As prior training focused on the care and well being of the children,
this was one of the first attempts to focus on the health of the madres cuidadoras
and the madres usuarias. The madres cuidadoras would participate in the four
modules on sexual and reproductive health rights, sexuality, family violence and
improving gender relations. This had a goal of then multiplying the training and
information through the madres cuidadoras communicating the messages to the
madres usuarias. The Wawa Wasi program was chosen for implementation of the
modules as its participants are women who may not have other outlets for
communication and education on these health issues. In addition, the madres
cuidadoras in the mere design of their job and interactions with the madres
usuarias were placed in an opportune position to relay the information and training.
149
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Observation of Wawa Wasis
This section provides a description of the Wawa Wasi homes in each of the
three regions of the module implementation. Before and during the workshops,
observations were made in a number of Wawa Wasis in each region. These
observations had a goal of understanding the scope of the Wawa Wasi and the daily
tasks and lives of the madres cuidadoras. This was also designed to evaluate any
differences in the regional areas and the support from the ministry. In addition, it
allowed for a glimpse into the life realities of the madres usuarias and their
relationships with the madres cuidadoras. This information will be utilized in the
analysis and evaluation of the modules and their impact on the participants as well
as long-term effects of communication and dissemination of the educational
components. Thick description of the observations is provided to gain a glimpse
into the reality of life in the regions.
Lima-Callao
Lima, the capital of Peru, is a large metropolitan area with over eight
million inhabitants. It serves as the first location for initiation of the sexual health
and reproductive rights workshops. Lima is divided into several regions that vary
greatly in size and standard of living. There are 1,224 Wawa Wasis in Lima
serving 9,792 children (PROMUDEH, 2001). According to the 1993 national
census, less than 25% of the population of Lima was living in poverty, however
35% of the population was living below standards of basic necessities of life.
Callao is a smaller district that borders Lima. It is a separate district, but is basically
150
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
part of the adjacent metropolitan Lima. The district offices in Lima supervise the
Wawa Wasi homes in Callao. Callao is made-up of a large fishing area and also
hosts a naval reserve. It also contains one of the poorest neighborhoods in the area,
rampant with drug use and gangs. Callao has 220 Wawa Wasis, providing care for
1,464 children. Almost 35% of the population in Callao live below the standards of
basic needs (PROMUDEH 2001). In 2001, 33% of those living in Lima and Callao
were living in poverty and 3% of those in extreme poverty. In these two areas,
26% of the population lives with unsatisfactory basic needs (INEI, 2001).
In Lima, I spent time in both private and communal Wawa Wasis,
observing the daily interactions and in interviews with the madres cuidadoras and
madres and padres usuarios. My first visit was in a communal Wawa Wasi outside
of the city of Lima located in a pueblo joven of San Juan de Lurigancho. I was
invited to attend the visit with the ten coordinators visiting from the regions and
two directors from PROMUDEH. The neighborhood was surrounded by large dirt
hills covered with makeshift houses, lacking electricity and running water.
Unpaved and uneven dirt roads marked the entrance to the community; the small
taxis took us only to the edge from where we walked to our destination. Stray dogs
ran alongside us barking and begging for food as we made our way through a maze
of unmarked streets and houses. After finally arriving at the Wawa Wasi coated in
bright green paint, I saw the PROMUDEH Wawa Wasi sign which read: “Ninez
con Esperanza” (Hopeful Kids).
151
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Three madres cuidadoras dressed in pink Wawa Wasi aprons and several
children excitedly greeted us at the door. They led us in for a tour of the newly
constructed site. Colorful educational materials and cartoons flanked the walls,
three small “child-size” tables with miniature chairs decorated the main floor, cots
and toy areas ran along the walls. The madres cuidadoras explained to us that this
Wawa Wasi was brand new and that the ministra of PROMUDEH had come for the
grand opening. They showed us photographs of the opening party and of the events
and parades they had thus far for the children. The women were all local women
from the community and expressed contentment in their job with the Wawa Wasi.
The building also had a small bathroom and low sinks for the children to wash their
hands. The children were dressed in bright and warm clothing, although slightly
mismatched and dirty, appropriate for the winter weather. PROMUDEH provided
the tables, chairs, toys, and all of the necessities for the daycare center.
Walking to the adjoining building, I entered my first comedor popular.
This comedor was different than the norm, in that it specifically provided food for
the Wawa Wasi children. Four cooks showed us around the locale. Large pots
boiled in the kitchen with potatoes and rice. Nutritional charts were posted on every
wall of the large entryway and eating area. The comedor provides a morning snack
of milk and cereal or other meal and an afternoon lunch for the Wawa Wasi. There
are also several private homes and a community center where they provide lunch
and snacks.
152
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Off again, our group walked deeper into the neighborhood to the second
community Wawa Wasi. On arrival, this center appeared very different from the
first. It was surrounded by a white metal fence and painted a soft blue with a large
sign boasting: “Working for a New San Juan”. This center was indeed different, in
that the community members themselves constructed it. Upon seeing the success of
the first center, the community decided that an additional center was needed to
provide needed services for the children. The Wawa Wasi program provided
financial support for such endeavors and the second community Wawa Wasi was
constructed in San Juan.
From here we walked again, across a very busy street, crowded with buses
and taxis to visit a private Wawa Wasi. The home was very small, with mud stone
walls. The Wawa Wasi was located in the front of the house, very dark and cold.
Posters about nutrition and the Wawa Wasi were posted on the walls. There were
several toys and a small table and chairs and a cot in the back of the room. The
madres cuidadoras greeted us and invited us to sit and visit with the children. Five
children played with puzzles and blocks and a few were reading books. This home
was consistent with the type of Wawa Wasi found in the pueblos jovenes. Most of
the families worked long hours and had few options for childcare. PROMUDEH
provided assistance with educational toys, beds, and a table with eight chairs. The
two programs of the comedores populares and Vaso de Leche, both assist with
nutritional meals for the children. However, these are not available in all areas of
Lima but are based on the poverty level of each region. In Lima and Callao, the
153
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
madres cuidadoras receive additional funding directly from the parents, whereas in
the provinces PROMUDEH provides direct funding to the madres cuidadoras on a
monthly basis. I found the funding in Lima on the part of the parents to range from
one sol to three soles per day (30 US cents to one dollar).
I visited several other private Wawa Wasi homes during my field research.
In-depth descriptions are included in the observation section of each of the women
who participated in my study. The type of home and level of poverty varied greatly
by community in Lima and Callao. However, a common thread was the
capabilities of the madres cuidadoras as centers of information for their respective
communities. Regardless of area, the homes seemed to serve as a resource center
for everything from food to health to a place to just visit and talk.
Huancavelica
Huancavelica is the second setting of the Wawa Wasi sexual education and
reproductive rights courses. Set within the lustrous central Andes mountain region,
Huancavelica is 3700 meters above sea level. Mate de coca (coca leaf tea) is a
daily requirement to fight off soroche (altitude sickness) which affects most all
visitors. The residents are a cultural mix of the traditional Quechua Indian families
and the more “modem” younger families. There is no direct access to
Huancavelica by air or bus, only in collective taxi, so the journey from Lima was
quite an experience. Few tourists visit this area and for most I was the first
foreigner (let alone English speaking person) they had met.
154
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Huancavelica has a poverty rate of 88% and an extreme poverty rate of
74%. Almost 87% of the population live without basic necessities of life (INEI,
2001). There are 71 Wawa Wasis in Huancavelica, providing day care for 568
children (PROMUDEH, 2001). The majority of people employed work in
manufacturing industries and in mining.
The day before the class began, Nancy, Pia and Ivan from UNFPA and I
headed out on a six hour bus ride to Huancayo, the largest city nearby
Huancavelica. Celia from Calandria would meet us later that night. This trip took
us high into the Andes mountains arriving to Huancayo in the early evening. The
following morning the search for our ride to Huancavelica began. We headed to the
bus station where we were told taxis would be located. After several minutes of
haggling with the owner, we found a taxi that would take us on the last leg of our
journey.
The windy road was unpaved and in extremely poor condition. The ride to
our destination was four hours of treacherous turns and near passes with large
trucks heading in the opposite direction. But, the scenery through this trek was
amazing. The road heads through small villages, across rivers, and through valleys
and mountains that are absolutely breathtaking. The turn into the valley above
Huancavelica was the most amazing of all, as you see the small town nestled in the
center of the mountains. The location itself made Huancavelica subject to the
horrific terrorism that plagued Peru during the past decade. As we learned during
our visit, the number of widowed women was among the highest in the country.
155
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The streets were busy with people attending to their work, carry goods or small
children. We stopped in front of our hotel in the plaza de armas. The hotel was
the best in the town, but being under construction, had no electricity or hot water
for our first days. In the midst of the winter season and high in the mountains, it
was colder than I had ever expected.
The class began that day in a small community room just off from the plaza
de armas. The following day we were invited to visit the Wawa Wasi homes of the
participants. That morning, bundled up for the freezing temperatures, several of us
started on the tour. Walking through town we headed down narrow cracked streets
until we arrived at the Rio Ichu. Crossing a small and crowded footbridge, we
found ourselves in a very different area of the city than we had seen thus far. The
streets were now unpaved dirt roads that led up higher into the mountains. Small
brick houses with dirt floors were closely set to one another, children played in the
streets, and llamas crossed our paths on several occasions.
Upon entering the first of nine Wawa Wasis we would visit that day, we
were greeted by even children, cheeks rosy and burned from the cold, and the
madre cuidadora, dressed in the now familiar Wawa Wasi smock. As in Lima,
PROMUDEH provided the home with a child-size table and chairs, a small cot, and
educational toys. The children were also each provided a plastic drinking glass
decorated with the Wawa Wasi logo. The area coordinator’s own children were in
this Wawa Wasi. We spent time in each of the homes, talking with the madres
cuidadoras and playing with the children. In this region, the madres cuidadoras
156
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
receive direct funding from the government in support of the daycare program,
unlike in Lima where the madres are solely dependent on direct funds from the
parents. The monthly salary was 90 soles (about $25 USD). Several of the women
said they also receive some payment from the parents, perhaps two to five soles per
week (less than $2 USD). Most of the parents work in mining, agriculture or the
local markets, so their resources were extremely limited. The parents would often
give eggs or flour when they were able. Others might come and clean or do
laundry one day to provide additional support.
The Wawa Wasis in this area were also supported by a comedor that
provided breakfast and lunch for over 160 children in the various day care centers.
The six cooks were cutting and boiling potatoes in large metal pots. They proudly
offered us a taste of the gelatin they had made for snacks that day. The comedor
provided food solely for the Wawa Wasis, but was adjacent to the comedor popular
that provided food for the community. The comedor was located at the peak of the
small mountain community. In the distance we could see several women and
children washing clothes in the river. In the opposite direction, a view of the entire
city set in the valley could be seen.
Later that day, we were able to visit an institutional Wawa Wasi at the local
university. The university was located outside of the city itself, halfway up a local
mountain. Accessible by taxi or foot, we saw numerous students making the trek
up the hill. Here, two women cared for the children of university students in a very
small converted classroom. The children were provided meals from the university
157
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cafeteria. The room was dark and damp, but toys and colorful posters and
children’s artwork decorated the walls. A crib was located in the back area. In this
case, the students provided a weekly fee to help fund the center, a necessity for the
families while in classes or studying.
Huanuco
Huanuco was the third region that would participate in the sexual health and
reproductive rights classes during this time frame. Huanuco, considered part of the
central highlands region of Peru, rests in a large valley along the Huallaga River.
Much more modem than Huancavelica, there are several parks, museums, and
archeological sites. The major park boasted colorful rides and toys for children.
Shopping areas and restaurants surround the plaza de armas. Above the town there
is a large well-groomed park with a children’s playground that overlooks the entire
valley. Surrounding the town, numerous pueblos jovenes clutter the mountains,
accessible only by narrow dirt roads. Only a two hour drive to the jungle region of
Tingo Maria, Huanuco’s climate is humid and very hot although the highland rains
are common.
Huanuco has a poverty rate of 79% and an extreme poverty rate of 62%.
Over 78% of the population live without the basic necessities of life. There are 28
Wawa Wasis in Huanuco serving 224 children. The majority of people are
employed in agriculture followed by tourism and mining.
During the visits to the Wawa Wasis, we set off in taxis to the nearby hills
and pueblos jovenes. The taxi left us high in the region in a maze of dirt roads and
158
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
dried out riverbeds. Children were running through the streets and several women
sat in front of makeshift houses selling fruit and drinks. The first site was the first
local community Wawa Wasi under construction. The floor plan was the same as
the other community sites visited in Lima. They hoped to have the building done
in the next few months. The first private home was a few blocks away. Eight
children played and colored around the familiar Wawa Wasi table. The walls were
brightly decorated with white paint and pictures of colorful cartoon characters. The
madre cuidadora explained to us that her daughter had painted the walls for the
children. The front room was converted into the day care area in which the madre
had taken extra care to provide a bright ambiance for the children.
The next home was a shared area for two Wawa Wasis, with a total of
sixteen children. The madres had created a joint venture out of one area and
combined their resources. The children played happily around the table, eating
crackers and juice. The madres explained that each of the local homes had access
to a comedor that provided the daily food for the children. Most of the homes had
dirt floors and rested on the side of the mountain. The children were from the local
neighborhood. In two of the homes, several of the children had contracted
chickenpox and were recuperating in the Wawa Wasis. It appeared that the
chickenpox was spreading among the homes and at least three children were
already sick. As in the other regions, the madres cuidadoras worked together and
helped each other with food and taking care of the children when someone was sick
159
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
or with other issues. It seemed to be a “close-knit” community with shared
information and resources.
Summary
These observations of the Wawa Wasi homes served to create a clearer
vision of the Wawa Wasi program itself and of the life realities of the madres
cuidadoras. This also focused on the implementation of the sexual health and
reproductive rights program and the impact it did or did not have in the women’s
daily lives. Also, the opportunities they have for voicing their new knowledge and
the environment for this type of interaction. Visiting homes in the three regions
allowed for a comparative view of the socioeconomic and sociocultural makeup of
each community. This helped to provide a basic introduction to the women and
their relationship to with their families, the children, the madres cuidadoras, and
the PROMUDEH program. There were regional differences in the culture of the
communities, from the large metropolitan area of Lima to the rural mountain and
jungle cities. These differences were seen in the amount of support received from
the parents and from the Wawa Wasi program. The regions received much more
support both physically and financially from PROMUDEH. In Lima, the women
are dependent on the resources of the parents.
In Huancavelica, the madres seem to receive much more emotional support
from the coordinators and the other madres cuidadoras. There were at least fifteen
homes set together in the small community and the comedor provided a central
resource. This closeness in proximity allowed for increased opportunities for
160
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
interaction among the madres, which could provide avenues for communicating the
themes in the workshops. This also provided them with closer personal
relationships, as they seemed to know and understand each other’s family and
home situations better than those in the other regions do. There was a strong sense
of support for the Quechua speaking women, most of whom were illiterate. This
was seen through the visits as well as in the training. In Huanuco, the environment
also allowed for this close type of relationship between the madres cuidadoras.
Each of the women was personally connected through proximity as the homes are
closely located. This also brought a strong sense of social support between the
madres. In both cases, as the madres usuarias were part of their community and
neighborhood, this seemed to provide a closer relationship with the madres.
In Lima, this support seemed to come much more from the immediate
neighborhood. The Wawa Wasis in Lima were physically separate due their
metropolitan location. Each home belonged to a different community with a
different physical and cultural make-up. In these cases, the women appeared to get
this social support from their family, friends, and neighbors who were not related to
the Wawa Wasi program. They depend more on the monthly meetings to get in
touch with the other madres. The women in the study each presented as leaders and
resource hubs within their own communities, providing support for their
neighborhood. They received less financial support from the Wawa Wasi program
itself and needed to go to their community for this support. However, the Wawa
Wasi homes in the pueblos jovenes in Lima seemed to mirror more of the
161
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community-style program in the regions. This is due to the close proximity of the
homes, creating their own central hub and support group.
Reproductive Health Project Description
The UNFPA/PROMUDEH project was based on the “train the trainer”
model of outreach. The training was based on the top-down model, where the
knowledge and information are disseminated from the directors to the coordinators,
to the madres cuidadoras and eventually to the madres and padres usuarios. The
ideology is that this nonformal education program would lead to informal teaching
from the madres cuidadoras to the madres usuarias resulting in a “multiplier
effect” of the dissemination of information to the community. In fact, the initial
UNFPA proposal showed and expected outreach of training 12,500 madres
cuidadoras who in turn would outreach to 90,000 madres usuarias.
Attachment II shows the actual training model. UNFPA and PROMUDEH
are the overseeing agencies for the reproductive health project, providing funding,
coordination and development of modules. The four programs directly involved
are Children and Adolescents, Promotion of Women, Wawa Wasi, and Literacy.
Each program has a consultant based in the PROMUDEH offices, but paid out of
the UNFPA grant funds. The director of the Wawa Wasi program works directly
with UNFPA to coordinate efforts. In turn, the consultant is placed at PROMUDEH
to work in between the director and coordinators in the field. She would develop
the modules and provide direct training to the coordinators in Lima. She also works
with the evaluating agency, Calandria, to organize the evaluative component.
162
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The coordinators from each region are trained on the reproductive health
modules in Lima. From there, they return to their regions to teach the madres
cuidadoras. At this point, the informal education component begins and the
madres cuidadoras are expected to share the new knowledge with the madres
usuarias. An underlying effect is sharing the information with their families,
children, and friends, which will be discussed in detail in the chapter on findings.
Goals and Objectives of the Reproductive Health Course
The reproductive health project has several goals and objectives. The
course modules are developed around four main topics: Knowing and Protecting
Our Sexual and Reproductive Rights, Talking About Our Sexuality, Improving
Gender Relations, and Saying No to Family Violence. Each module has specific
objectives, themes, and indicators of success (Attachment HI). Each module
includes activities and information for the trainers and come with a workbook for
participants.
The first module, Knowing and Protecting Our Sexual and Reproductive
Rights, focuses on the following objectives: 1) recognize sexuality as a way of
exercising of rights, 2) assume naturally and with conviction the necessities and
requirements to exercise their sexual and reproductive rights, and 3) develop
actions for the promotion and permanence of their sexual and reproductive rights.
Activities include defining rights and citizenship, defining sexual rights, discussing
health rights and requirements from the government. Success indicators are to be
163
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
able to define, recognize, and demand sexual and reproductive health rights as
citizens to their partners and the government.
The second module focusing in Talking About Our Sexuality has as its
objectives that participants will: 1) recognize sexuality as an important dimension
in the lives of all people and identify its biological, psychological, and social
components, 2) value positively sexuality and assume its expressions naturally, and
3) promote an integral vision of sexuality and exercise it responsibly and
pleasantly. This module involves activities around the differences between sex and
sexuality, male and female sexual organs, sexual development, contraceptive
methods, pregnancy, STDS and AIDS, and self-esteem. Indicators of success
include the ability to recognize and identify the components of sexuality, identify
male and female sexual organs, indicate conditions of safe sex, and accept and
appreciate their own bodies and sexuality.
The next module deals with Improving Gender Relations. The main
objectives are that participants will be able to: 1) recognize the social construction
of gender roles, identifying the stereotypes that create and maintain them, 2)
assume a critical attitude toward gender stereotypes and equal values for men and
women, and 3) promote equal gender relations in immediate environment and
communities. Activities in this module include identifying gender roles and sexual
identity and the social agents that create these roles, discussing how these roles are
developed, and defining equality. Determinates for success are that participants are
able to define and identify sexual roles and stereotypes, specifically in social and
164
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
institutional norms and they way they are communicated. They should be able to
promote gender equity and find appropriate messages that promote equality.
The final module, Saying No to Family Violence, has three main objectives:
1) recognize sexuality as an important dimension in the lives of all people and
identify the biological, psychological, and social components, 2) assume a critical
attitude about the actions of family violence and the social and cultural conceptions
that they sustain, and 3) develop actions that prevent family violence and
disseminate the norms for protection and existing social services. The activities
include understanding family violence rates in Peru, the causes and consequences,
and discussing identification and prevention. Successful participants will be able to
recognize family violence incidents, support prevention actions, and orient families
in their community on these cases.
Each module contained a set of activities with a coordinating workbook that
allowed participants to reach the set indicators. The coordinators participated in the
activities then reproduced these activities in the field.
Conclusion
In Peru, social and economic constructs have placed women at increasing
risk of HIV infections; with 25% of all those infected being women. Although
several programs currently deal with sexual health and reproductive issues for
women, many of those do not include HIV/AIDS in the design. There are no
holistic intervention efforts within or amongst programs or any clear concerted
effort at the governmental level, especially concerning women. PROMUDEH does
165
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have several programs that include sexual health and reproductive rights issues in
their purview that address these issues with women. However, none has a specific
focus or inclusion of HIV/AIDS issues.
The sexual health and reproductive rights course designed by PROMUDEH
and UNFPA does include specific AIDS education within the modules. The
program takes place through the madres cuidadoras and coordinators of the Wawa
Wasi childcare program in efforts to reach out to the community through a train-
the-trainer model and peer educators. The modules focus on gender relations,
family violence, sexual health and reproductive rights, and sexuality.
The following chapter will focus on implementation of the modules and
impact on the women involved in the program. This includes analysis of the effects
on the women on a long-term basis.
166
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER FIVE
FINDINGS
Introduction
This chapter provides a detailed analysis of the data and findings from the
case study of the PROMUDEH sexual health and reproductive rights program.
Observations of the workshop and training of the coordinators will be discussed,
including their feedback from focus groups. This will be followed by discussion of
the implementation of the modules in the three regions and analysis of the
intervention. Themes that emerge from the course will be evaluated in detail
through the observations, focus groups, interviews, and surveys. In-depth
interviews with the madres cuidadoras in Lima over the following one-year time
frame will be evaluated and discussed in relation to the goals of the intervention
program and the research questions of this study. Interviews with the madres and
padres usuarias will also be utilized to further evaluate the program and
communication of the topics. Finally, sustainability of the project will be analyzed.
This chapter will be separated into four main sections: first, description and
observation of the courses; second, a discussion of the major outcomes of the
courses; next, a discussion of the long-term observations of the madres cuidadoras,
followed by interviews with the madres and padres usuarios; and finally a
discussion of problems with program sustainability.
167
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Section One
Training Begins for the Coordinators
In July 2000, the course workshop began with the regional coordinators in
Lima. Twelve coordinators came from five regions of Peru including, Lima-
Callao, Huanuco, Huancavelica, Cerro de Pasco, and Huancayo. The workshops
took place over a four-day period. The first day was an introduction to the course
and overview on sexual and reproductive health. The second day covered the
modules on gender and sexuality. Part two of sexuality and sexual and
reproductive rights modules were held on day three. Day four included the module
on family violence and a final course evaluation. Each day began at 8 a.m., with
lunch included, and ended at 5:30 p.m. Each coordinator completed a workshop
evaluation at the end of each day.
The training was held in Hotel Savoy, in downtown Lima, a few blocks
from the PROMUDEH offices. The meetings were held in the basement of the
hotel. The room was dark and obscure with black chairs arranged in a half circle.
Four long tables with red tablecloths lined the back of the room. Large white
sheets of paper were taped to the side wall and a white board was located toward
the front. Water, cups, crackers, and writing pens were located on a small sign-in
table. On the first morning, the coordinators were dressed casually in jeans with
jackets and sandals. Lively salsa music was playing on a radio in the background.
168
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Day One—Course Overview and Introduction to Methodology
The first day of training includes the course introduction and overview on
educational methodology. Activities include a welcome and overview of the
program, identification of sexual health and reproductive rights, the role of the
facilitator, adult education methodology, learning techniques, and overview of
materials.
On the first morning, the coordinators are working in small groups at the
tables. Nancy is moving around the room, assessing their progress. Each group
receives a small sign with the words, “social drama, lecture, workshop, group
discussion and brainstorm”, and is asked to move to the front of the room to tape up
the signs under the appropriate technique posted on the wall. The coordinators are
very engrossed in their work, talking amongst themselves and concentrating on the
written material. As they finish, they move back to the center half circle and sit
down. Nancy asks if they are done and points to the signs on the wall. Two of the
women get up and begin hanging small signs that include the different techniques
below each large sign. They appear excited about their work and give each other a
“high five” clap after placing signs in the appropriate locations.
At this point, Nancy begins to give direction to the groups. She calls them
all to the center circle several times. Finally, she explains the difference between
social drama, a real situation, and role-play. They begin to talk about different
methods of teaching such as social drama, workshop, lecture, group discussion, and
brainstorming. They also discuss the advantages and disadvantages of each
169
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
method. One by one the women go to the front of the room to discuss their
answers; some are shy and some are very outspoken. All applaud after each one
completes her explanation.
During this time, two men enter the room and sit and observe. I later find
that they are from the UNFPA office and will be observing the process and
evaluation. The women have numerous questions for Nancy as they continue
working even as people enter or leave the room. There is a long discussion on the
meaning of “brainstorm.” The coordinators express concern that they will be unable
to successfully practice these techniques with the madres cuidadoras as they are
not yet confident on the topics and their ability to process and share the materials.
Nancy explains that over the next four days they will be testing the material to see
if it works or not. The coordinators will give their input on the modules and
materials, which will be revised before they are used in the field. She describes the
main topics of each module and explains they will each only teach one of the four
in their respective region.
The four modules are then handed out to the coordinators. Nancy goes
through the books and the three main parts including the techniques they will use in
their workshops. Their homework for the evening is to read each section and make
revisions. They will also need to notify Nancy on the types of materials they need,
as they will replicate the training in the regions. She stresses they will need to be
ready to go out and train by the end of the week, with all of the materials necessary.
170
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The coordinators are all very quiet at this point; a few ask questions on the time
frame. They day ended with the written evaluation of day one and comments.
Summary
This first day served mostly as an introductory setting for the coordinators
and the PROMUDEH trainers. All of the key researchers met the coordinators and
helped to provide the setting and environment for the rest of the week. This training
focused on teaching techniques for the coordinators that are in line with the
methodologies recommended through relevant literature. The coordinators voiced
concern about their lack of knowledge of the topics and their ability to share the
materials in the field. The following days would need to focus on their confidence
and provide them with adequate materials for completing this task.
Day Two— Gender and Sexuality
The second day includes the topics of gender and sexuality. The gender
activities include identifying sexuality, gender roles, socializing agents and gender
stereotypes, equality in human relations, and incorporation in daily life. Activities
pertaining to sexuality include concepts of sexuality, sexual organs, and ability to
incorporate the material in daily life.
All twelve coordinators are seated on chairs in a half circle in the middle of
the room. Today, Lilian from PROMUDEH leads the training. There are two
UNFPA representatives seated at the back and side observing the workshop with
Nancy. The coordinators appear very interested in the topic, as they listen intently
and take notes. They seem a bit more casual and comfortable as they are now
171
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
oriented to the workshop and requirements. The coordinators are broken into two
groups, working on scenes dealing with gender roles. Each group draws a diagram
of the daily routines of “Rosa” and “Jose”. They discuss the different gender roles
of the family and discover Rosa plays a triple role in the family as housekeeper,
mother, and wife. This activity touches on the realization of gender roles in the
society in attempts to begin recognition and understanding of the consequences of
these socially prescribed roles. When one of the coordinators asks a role specific
question, the leader responds that it is a very good and appropriate question, but
that they must be careful with questions when working with those not at the same
social level. This indicates that some of the madres cuidadoras may need fuller
explanations of concepts in order to fully grasp the meanings and interpretations
and touches again upon the social and cultural constraints in the communities.
During the morning break, Nancy introduces me to several of the
coordinators. They are very happy to work with me and help me with my project.
They return to the workshop, singing a song. The coordinators are all clapping and
dancing, laughing about the children’s song. The next topic is about social
stereotypes, and they work in groups on categorizing gender roles of boys and girls.
The coordinators are somewhat confused by the task, stating that many of the
descriptions are traditional roles and no longer take place. When they return to the
main group they discuss socialization of these gender roles. This is a first step at
dealing with gender awareness and the discrimination against women in the
society. Throughout the day, they continue to sing songs for “icebreakers”, and
172
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
focus on equality and gender as outlined in the course modules (Attachment HI).
Later, they are required to do their own skits on gender stereotypes. One group sets
up a scene with two children fighting, the girl’s mother yells at her for playing
football “it is not ladylike”, but the boy’s mother is not mad at all. This points to
the different gender roles and expectations of the children. The second skit begins
with a young girl in the house when her father gets home from work. He tells her to
bring his clothes and food. The mother comes home and yells at the girl and they
both complain. The girl finally remarks, “Why did I have to be a girl?” These
gender messages are presented, but not discussed as to the way they influence
women and men and place women in subordinate roles, contributing to conditions
of discrimination. These would need to be fully internalized in order for the women
to recognize these constraints and to empower women to change these messages.
During the lunch break, Nancy asks me to sit at the table with the
coordinators; she and the other trainer sit at the next table. The coordinators begin
to open up with me and ask me questions about my research. They are very excited
to learn more about the United States, especially about job opportunities there. I
find out that all of the coordinators have university education and many have
teaching credentials. They are each responsible for 18 Wawa Wasis that they visit
on a monthly basis. They also provide monthly training for the madres cuidadoras
and additional training for the madres usuarias. They describe their perspective
regions and the differences in the communities.
173
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The second half of the day is focused on sex and sexuality. The
coordinators have an easy time finding definitions and figuring out most of the
exercises. They play several more games, in which they are active and playful.
When they are asked to draw the internal and external male and female organs, a
few appear a bit nervous. The leader asks them why it is important to know the
proper names. A few turn red in the face, there is nervous laughter. The
coordinators express concern that the madres will not know the proper names, but
will need to use common names for the body parts. The coordinators have many
questions in this section about the functioning of the male organs. They also
discuss cervical cancer and the importance of a yearly gynecological exam. The
coordinators state that the madres believe that each time they have the exam, it
takes part of their skin inside and they will soon not have any left. The leader
points to the importance of teaching them the facts about sexual health.
There is also extensive discussion about the age of first menstruation. Many
girls in their communities do not hear about menstruation from their parents, and
when they begin their menses in school, they have no idea what is happening. The
coordinators state they each heard about sex first from their school teachers and
that sex and sexuality are topics in school. They mention that before it was very
embarrassing to talk about these themes. The final task of the day is to create a
poster about the day’s topics. The leader gives feedback on the messages in each of
the posters. For example, one is a picture of a pregnant woman and the madres
may get the message that they will only be happy if they are pregnant. The
174
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
coordinators must understand the full implications of the messages they send and
the way that the madres cuidadoras interpret these concepts. The coordinators
need to recognize these types of gender sensitive messages in order to address the
issues of gender with the madres. These messages can serve to have an
empowering role with the women to address and change these gender roles.
Summary
This training day touches on the modules of gender and the first part of
sexuality. As they participate in the activities and information, the focus is on how
they will present the materials in the field. The women actively discuss social roles
and stereotypes. The use of role-playing and case scenarios helps to provide safe
avenues for expressing these issues as they relate to the community. They have a
good understanding of the sexual organs. Most of the questions raised are about
male sexual organs and health. This is a theme that was reiterated in the regions, as
the women have little education on male sexual health. Another major issue was
that of the lack of education about sexual health for women. The personal stories
about the lack of information about menstruation and the trauma that comes with it
are discussed by the coordinators and supported by the stories from the madres
cuidadoras.
Several themes arise around the implementation of the training with the
madres cuidadoras in the regions. The coordinators discuss the learning styles of
the madres and which activities and methodologies would be most effective. They
also talk about the type of language they will need to use and how they will need to
175
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
modify the activities to fit the specific culture of their region. They bring up the
lack of information and misconceptions that are common in their communities and
amongst both the madres cuidadoras and usuarias. They will have to confront
these during the training through expression of appropriate message. They discuss
the importance of ensuring that these messages are socially and culturally
appropriate. What is missing is that the messages must also be gender appropriate
in order to touch upon and address power in relationships. Through these messages
and realization of their conditions the women can become empowered to address
these issues.
Day Three—Sexuality Part 11 and Sexual Health and Reproductive Rights
The third day focuses on a continuation of sexuality and begins the module
on sexual health and reproductive rights. The major activities include sexual
development, sexual and reproductive health, STDS and AIDS, self-esteem, and
incorporation of the themes. Under the second session the activities include the
concept of rights, citizenship, rights of sexuality, sexual and reproductive rights,
legal and governmental rights and responsibilities, and incorporation of the themes
in daily life.
On day three the workshop starts a bit late, as the observers and I help set
up chairs and clean the room. The coordinators tell me that they were up late the
previous night working on developing the materials that they will take with them
when they return to the regions. Several stated they were concerned that they would
not be sufficiently prepared to lead the workshop with the madres cuidadoras when
176
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
they return. They do not feel they have enough information and are not
knowledgeable enough on subjects such as sexual health. They request a VCR and
videos, but Nancy is doubtful whether they will even have access to electricity in
the regions. She also confronts them on being late that morning, especially those
from Lima, and asks everyone to respect the time. There is a lack of support and
resources for the coordinators that will impact their ability to address and process
the information in the field. This has an effect on the quality and ongoing support
of the training.
The morning workshop is a continuance of the sexuality module. They
begin with a game and move on to discuss problems women in the regions face
with these issues of sexuality. The coordinators bring up adolescent pregnancy,
high fertility rates, and girls getting married at a young age as some of the problems
they observe in their regions.
The module also covers condom use and safe sex. Two of the coordinators
comment that they had “strong” husbands who would not let them use condoms.
One coordinator got pregnant because her husband would not agree to buy
condoms and she did not want to use birth control pills. They are concerned about
how forceful the madres can be with their husbands and how they will be able to
pass on the information. The assumption is that women have control in their
relationships and will be able to successfully negotiate and communicate with their
partners. However, as shown by the coordinators and later with the madres, this
control is perceived as they express little control over their bodies or in their
177
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
relationships. One coordinator states that it is important to think about protection
even when you are pregnant for issues of STDS. One problem they have found in
the mountain regions is that the “campesinos” are getting their tubes tied after
giving birth because “they don’t understand what is happening”, indicating that
they are receiving unwanted operations. The coordinators express concern that
they will not be able to handle such issues. The training now has an opportunity to
address the subordinate roles that women have in society rendering them unable to
have power over their own bodies. However, the training falls short of addressing
these issues. Nancy suggests they invite a specialist to lead this part of the module.
One woman states, “well, we understand, but not everything perfectly.” They also
discuss how to handle condoms safely and about other methods, like the new
female condom, which no one has seen. They are very surprised that it can be
reused and washed. One woman also mentions that the Institute for Reproduction
and Health (INPARES) is giving free Norplant implants for the rest of the month at
the health clinics. The implementation of the female condom is a step toward
addressing negotiation factors with the women, but the lack of access and ability to
communicate remain untouched.
The coordinators have several comments about the health clinics and
question the quality of the training they provide. They feel that the training is “at
too high a level, it’s boring and the women have to wait too long.” For example,
the Wawa Wasi and Ministry of Health need to work closer on this type of training;
they should be required to send information to the madres cuidadoras on a monthly
178
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
basis. One other major misconception arises over breastfeeding. The coordinators
ask about the milk that comes during the first few days and the difference between
what comes later. The women in their communities say that the first milk is not
good for the baby and it should be thrown out, but the coordinators are not sure this
is true. They also ask why it is important for a woman to wait 45 days after giving
birth to have sex. Nancy explains it is mostly for health reasons and they need to
explain to the madres to use protection, as most will have sex within one week.
This is due to the fact that the women have little control over their bodies and lack
the ability to negotiate with their partners. The training does not provide the women
with the skills to negotiate in these situations.
The afternoon group is about STDS and AIDS. Nancy defines the types of
diseases and how they spread. She states that many women feel they are safe if
they are only with their partner, but this is wrong when it comes to STDS. They
discuss anal sex and how it is easier to contract AIDS through anal intercourse.
They coordinators feel that this is a common problem in Peru, especially for
women in their communities who have had many children. These women are
unable to control their bodies or make decisions about their sexual desires, let alone
protect themselves from disease. This can only occur when the women are
empowered to negotiate and communicate with their partners, which the training
does not provide. Nancy states that this is one reason why the cases of AIDS in
women are increasing in Peru, because most are women who contracted the disease
in their own homes. The coordinators have numerous questions: “If you are HIV
179
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
positive can you give it to anyone? Is it true you can get it in your own house?
What about if you wash with soap? Can you get it from kissing? What if you have
blood on your mouth? How long can you live with the virus?” Nancy is able to
answer most questions, but it is clear there were many misconceptions about AIDS
among the coordinators. They continue to have questions, but the questions remain
unanswered, as Nancy has to move on to the next topic due to time constraints.
Therefore, there is no opportunity to discuss how to empower the women to
successfully negotiate and protect themselves from HIV infection.
The next module about sexual health and reproductive rights begins. The
coordinators participate in an activity to define their rights. The coordinators appear
to be getting tired and a bit bored. Many talk amongst themselves and yawn during
the final presentations. The time frame for the workshop is very long and the
information may get lost as a result. They discuss what it means to be a citizen:
“over 18 years of age, a person who has responsibilities and rights, you can elect
your representatives and government, ability to participate in political action and
projects”.
They now relate the rights of a citizen to the final topics of self-esteem and
sexuality. After a review of the difference between sex and sexuality, they write
their own definitions of their rights and place them in writing on the wall: “The
right to know and respect our own bodies. The right to sexual education. The right
to exercise our sexuality with autonomy. The right to exercise our sexuality
independently from reproduction.” They discuss these as inherent rights of being a
180
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
citizen. Although the coordinators are able to recognize their rights, there is no
connection to their lives. This would be an excellent opportunity for empowerment
in the political realm in order to assert and demand their rights as women.
The next activity involves self-esteem as each woman has to walk to the
front of the room and look at her body in a large mirror. Some appear shy, looking
quickly and walking away, others see this more as a game and spend time prancing
in front of the mirror. They then move on to an activity where they each have to
write down their sexual likes and dislikes. Five topics are placed on the board: “I
like to be kissed on...and I like to kiss on...” “I like to be caressed on... and I like
to caress on...” “My sexual or romantic fantasy is...” Each coordinator writes
down her answers on note cards which are then collected and placed under each
category on the wall. Nancy reads out the answers and the women laugh and cheer
at the various comments and ideas. Finally, Nancy discusses four more sexual
rights: “The right to liberal election of maternity. Participation of men and women
with equal responsibility in the raising of their children. Access to sexual and
reproductive health services. To participate as a citizen in the formulation of
politics and programs for population and support.” The coordinators read the
statements out loud and express their agreement with these rights. They agree but
this assumes they have the power to express and assert these rights. The day ends
as the coordinators again fill out their daily evaluation forms.
181
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Summary
Day three focuses on the modules of sexuality part two and sexual health
and reproductive rights. The coordinators enthusiastically participate in the
activities, but their underlying concern appears to be replication in the field. They
are preoccupied with their own lack of knowledge and with preparing the materials
they will take back with them. The coordinators are concerned that they will not
have adequate resources when presenting the course to the madres in the regions.
In the module activities, they bring up the major problems in their regions
of adolescent pregnancy, high fertility, and age of marriage. They are able to
recognize these issues and request ways to confront these through the intervention.
They provide good definitions of rights and citizenship and appear knowledgeable
on all of the topics. They discuss condom use in their own relationships and
express their personal problems in communicating with their partners. They are
concerned about how to express this with the madres cuidadoras, bringing up
machismo, which is dominant in the regions and does not allow for open
communication with their partners. They also discuss the problems with the lack of
adequate health care, resulting in misconceptions and lack of information in the
community. They mention the problem of unwanted procedures completed on the
women in the community after birth, such as involuntary tying of the fallopian
tubes. The coordinators also have many questions about HIV/AIDS and
transmission. They seem to have a lot of misinformation and myths about AIDS.
These are discussed in detail by the trainers. The themes of this module assume that
182
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women have the power of negotiation in their lives and in their relationships. This
module serves as a good opportunity to focus on empowerment on the cognitive,
psychological, and political realm in order to provide women a voice in the social
and cultural gender discrimination. However, the module falls short of addressing
these issues and providing avenues for empowerment for the women.
Day Four—Family Violence
The last day of the workshop consists of the module on family violence.
The main activities are family violence in Peru; causes and consequences,
identification, prevention strategies, and incorporation.
Lilian is again the workshop leader. They discuss the various types of
family violence and sexual abuse. She explains that sex with a person under age 14
is abuse, between age 14-18 with permission is seduction and without permission is
violation. She says this includes within a marriage as well, “Sex is a right not a
requirement. Nothing is going to die, break or atrophy if you do not have sex.”
Several of the coordinators laugh and throw out lines, “My testicles will explode!
My semen will back up!” “These are all lies,” they exclaim. They discuss the
cases and consequences of family violence for the rest of the morning. The
coordinators come up with list of their own responsibilities when it comes to cases
of family violence:
1) Educate the individuals, families and community about rights.
2) Coordinate training with other local institutions.
3) Train the madres cuidadoras on these issues so they can identify cases.
183
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
4) Report cases of violence to the authorities.
5) Orient the madres cuidadoras and padres usuarios on their rights and
responsibilities as members of a family.
Nancy agrees to these and other ideas and reminds them not to get involved
past these issues, as it is not their responsibility to end the problem within a family.
There is no opportunity for behavioral empowerment by addressing negotiation and
communication about the gender roles that render women vulnerable to family
violence. The day ends here and the coordinators complete their final course
evaluations.
Summary
This final day of the workshop is cut short as the second half will be spent
in the focus groups and on final preparation of materials. The women discuss the
myths in their community around sexual issues. They go through the problems with
family violence in their communities and recognize this as a major problem. They
are able to express their roles and responsibilities in dealing with cases of family
violence. The use of role-playing and case scenarios helps to illustrate these
problems. Family violence is a major issue in the lack of power women have in
their relationships and lack of control they have over their bodies. There is a need
to incorporate empowerment strategies in this workshop to address communication
and negotiation and to express their political voice.
184
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
As the workshops come to a close, the coordinators will now provide their
feedback to the trainers in order to revamp the modules prior to the implementation
in the regions.
Feedback from the Coordinators
On the final day of the workshop, the coordinators and I visited several
Wawa Wasi homes in Lima. They then returned to the hotel for a focus group to
allow their feedback on the modules. The researcher from Calandria led this
evaluation and I was allowed to observe and ask questions. Six of the regional
coordinators participated in the focus group on each module. They were very
excited about the last day of training and brought gifts for all of the leaders. The
atmosphere was festive as they played games, danced, and joked with each other.
The researcher from Calandria asked questions about the module on
sexuality and asked for their input and evaluation. After discussing their feelings on
the course, several topics emerged, such as their prior sex education, ability to
communicate, and fears about bringing these issues up with the madres cuidadoras.
They all felt it was very helpful for them personally to gain a new understanding of
issues of which they did not have prior knowledge. One coordinator feels that it
helped a lot, especially the difference between sex and sexuality and about AIDS.
She also felt it helps to know the correct names of the parts of the body and helped
her to think about her relationship with her husband and if she needed to use
protection. Another stated that it helped to know about the different diseases:
before she was too shy to go to the doctor and find out about these things. Another
185
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
stated that she was always able to talk to her mother, but her father scared her about
sexual issues so she did not communicate with him. The workshop content really
helped to understand issues about sexual health she did not know about before like
contraceptives.
Many stated that they had not received education on these issues before and
that it was very hard to talk about these issues. Most felt they had few options or
opportunities to talk about sexual issues:
I grew up with my grandparents, like all grandparents they did not
talk to much about these issues.
It is very hard topic for me. I had a much stricter education, there
were a lot of things I did not know, plus the way to ask a
gynecologist these things. The course helped a lot.
It’s a very difficult topic to talk about with my husband. He is very
machista and I am not sure how to bring up the topic with him, but I
will. I am really worried about AIDS especially, the consequences,
he is very machista.
These comments point to the issue that there are few outlets for the
coordinators to discuss sexual issues. In addition, little education had occurred on
sexual health. For most this was the first time they had an open environment to
discuss their concerns and to get feedback from others. Access to skills, education,
and information is one of the basic preconditions for empowerment according to
the Cairo agenda. The course appeared to provide the coordinators with an avenue
for this discussion. However, this environment was temporary and as they returned
to their regions it remained to be seen whether they could continue to communicate
and whether they would have support to do so.
186
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The coordinators expressed concern regarding how to discuss these issues
with the madres cuidadoras and if they would be prepared. Many felt it would be
better to bring a nurse to discuss the diseases and health related issues. Others felt
that it was enough to bring up the topic with the madres and they could go and get
more information from there.
I feel I need more time to discuss STDS, I need to know more. If
they have questions about things I may not be able to answer.
They [madres cuidadoras] are going to have many questions about
STDS that I can’t answer, it is going to be a very superficial
discussion.
The content is very relative to everything [in our lives], its natural,
and all the women need to know about prevention, especially AIDS
and STDS. I didn’t know all the other things about contraceptives. I
understand it now and think I can present it in this way.
I have always been afraid to talk to the madres about their partners, I
only asked about the kids. Now that I know about the practice and
theory, I can approach these themes, but little by little.
It’s [sexual health] an important topic, but very sensitive. How do I
talk to them about contraceptive methods and values?
As we get to know the madres we can introduce things little by
little, but this theme is different especially with those more
experienced and older than me.
The coordinators expressed justifiable concern about their own ability to
relay this information to the madres cuidadoras. The four-day workshop provided
only a brief overview for them, especially on some of the more difficult concepts.
They now had to go and reproduce this information in the field. As most had
expressed little prior education or information on sexual health issues, their
concerns appear justified. In addition, these comments express the limits of their
relationships with the madres cuidadoras. Many had superficial relationships,
discussing only issues surrounding the Wawa Wasi. They now would have to
187
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
embark on new territory that is especially difficult for those who are younger, less
experienced, or unmarried. They expressed their fears that the madres may not trust
them or listen to them, as they did not have experience in relationships. The
coordinators were not provided with the necessary skills through the workshop to
empower them to communicate or express these issues in an open dialogue with the
madres.
Another topic of interest was about the self-esteem of the madres and how
to discuss machismo:
We did not have enough time to discuss certain themes, like self
esteem and how to talk about machismo.
When we talk about sex we are going to face a lot of machismo. I
am preoccupied that we may start another problem which is
violence.
Well, they are going to have sex regardless, so someone needs to
talk to them about taking care of themselves. I have talked to some
of the more extraverted madres before, others don’t want to talk .
When the madres start talking to them and changing they are going
to ask who they have been talking to about these things. Luckily, I
am able to talk to their husbands, and some of them trust me so I can
talk with them, carefully about each topic.
Machismo becomes one of the main topics with both the coordinators and
later with the madres cuidadoras in the field. The issues around men and violence
within relationships are major issues that regularly came up in the discussions. The
coordinators had serious concerns that the women would face major problems with
their partners if demanding their rights or even learning more about sexual health.
This becomes an extremely sensitive issue and points to the basic recommendations
that men must be included in sexual health and AIDS interventions in order for
progress to occur. However, with the level of violence and lack of power women
188
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have, the best intervention would educate men separately, then provide joint
avenues for communication. Ability to negotiate safer sex is a major factor in
elimination of risk of AIDS. With the level of machismo that the women expressed
in all of the regions, it is unclear how deeply effective the intervention could be
without taking the men into consideration. The coordinators need to be able to deal
with and understand power issues in relationships, both their own and those of the
madres. Both structural empowerment, including economic dependence, and
behavioral empowerment, the ability to communicate and negotiate, need to be
brought into the training and discussion. Structural empowerment would require an
intensive and collective approach that allows women, and men, to recognize and
address the systematic forces that create this oppression. An open dialogue between
women and men should be included in the intervention in order to transform and
address these conditions.
When discussing how to communicate these themes, the coordinators were
unsure if the madres cuidadoras would in the end be able to share this information
with the madres usuarias. They felt the madres cuidadoras do not have sufficient
direct contact with the madres usuarias, and perhaps, it was more the coordinator’s
responsibility. It also may be the coordinator’s responsibility to get the information
out to the community through handouts and posters. This directly relates to the
underlying goals of the program for informal learning options. If the coordinators’
perceptions of the relationships between the madres cuidadoras and usuarias were
correct, then few ongoing effects would occur. The women would need to be in
189
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
empowering roles in order to handle gender sensitive issues and messages and to
deal with the social constraints creating these issues.
Summary
Through the focus groups, the coordinators brought up appropriate issues
and concerns they would now face in the implementation of the modules. The
coordinators themselves did appear to receive some benefits from their
participation in the workshops. They increased their own knowledge and awareness
of the issues, yet they still felt they needed more time and information to be fully
knowledgeable and to be able to successfully reproduce the materials. Issues of
trust, communication, and gender inequality become major issues they will face
when trying to educate the madres cuidadoras. The coordinators did express strong
feelings for the need for this type of education in their communities, so the topics
appear appropriate. However, the long-term goals may not be effective due to the
limited time frame and lack of sustainability, which will be discussed later in this
chapter.
The major concerns that emerge from the focus groups are the lack of
resources and support provided to the coordinators, lack of adequate health care,
issues of machismo, and sociocultural constraints. First, there is both a perceived
and a real lack of information about sexual health and educational resources in all
areas. This is seen through the misconceptions and myths surrounding all aspects of
women’s sexual health including HIV/AIDS. Most women do not have adequate
health education provided to them and there are few outlets to access such
190
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
information. If the coordinators, who represent high educational levels, have little
information or education on these issues, then it is clear that those with fewer
opportunities will have less information. This relates to the incredible inadequacies
in health care for women as expressed by the coordinators. This renders women
even more susceptible to HIV infections and contributes to the gender inequality
facing women, especially in marginal areas.
Machismo becomes a major barrier to the ability to negotiate safe sex and to
achieve any sense of power in relationships. Women have been rendered powerless
in their relationships by the social practices that allow men to seek relationships
outside of the home and to deny women the ability to demand fair treatment in their
own homes. The fear of violence is a real factor for both the coordinators and the
women in their communities. This places a major roadblock in the ability of the
coordinators to communicate and empower women (and themselves) in their roles
as women and in their sexual relationships. In addition, there is little access to
condoms and no perceived ability to negotiate condom use.
These sociocultural constraints contribute to the gender messages that
women receive on a daily basis. Rights to health care, education, income, and
equality in relationships can not be achieved without empowering women to
demand these rights. Through the course, the coordinators are not provided with
the resources necessary to address these issues and to develop a sense of
responsibility or power in their roles as educators and facilitators. This results in
hindering their ability to safely and effectively communicate these messages to the
191
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women in the community. The intervention was not sufficient in dealing with self
esteem issues and providing steps to creating empowering environments.
Course Implementation for the Madres Cuidadoras
After having trained the coordinators, the modules could be implemented in
the three regions. The workshops in Lima took place in mid July, in Huancavelica
at the beginning of August, and in Huanuco in mid-August. I was invited to attend
the three workshops and to travel with the groups from UNFPA and PROMUDEH
to the regions. The training schedule was that each coordinator would give the
workshops in their respective region. Groups of 18 madres cuidadoras would
attend each session, with the same ones receiving two of the four modules each.
Each workshop was from 3 p.m.-6 p.m. with a focus group interview of one hour
on the day following completion of each course.
Lima-Callao
In Lima, the workshops were held in the neighborhoods of Barranco, Lince,
Callao, and Independencia on two afternoons each. As the workshops overlapped
in the different locations, I was able to attend the workshops on sexuality in Lince
and family violence in Independencia. These groups of madres cuidadoras became
those whom I would follow in my research for the next year.
Day I—Sexuality Part I
The first afternoon, I met Maria, the area coordinator in the main
auditorium for the Municipality of Lince. After about a half-hour searching for the
location, the doors were finally opened to the room and I helped Maria set up the
192
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
workshop. Fourteen madres cuidadoras, the evaluator from Calandria, and two
representatives from UNFPA were in attendance. The room was damp and cold
with sparse furnishing. There were several chairs that we lined in a semi-circle for
the madres. As they arrived, I noticed women ranging in age from 25-65 years old
dressed in a variety of styles. Some were dressed very professionally, in skirts,
blouses and high heels, while others had come more casually in jeans.
At 4:15 p.m. the workshop finally got underway. Celia, from Calandria,
opens up the workshop with a description of the sexuality module and evaluation.
Maria then begins the workshop on sexuality with each woman introducing herself
and describing her sexual fantasies. When the women begin to giggle nervously,
she tells them “ We are all just women here, so do not worry, no one will know... is
it Tom Cruise? Mine is to be on a deserted island with Tom Cruise.” They each
stand and tell their fantasies ranging from getting married to traveling to Europe.
As each one shares, they become more enthusiastic, now laughing and yelling out
different fantasies. The next activity is a game in which one person is blindfolded
and the rest stand around her in a circle. As she grabs them they must yell out their
first thought about sexuality. “Hugs! Love! Wishes! Pleasure! Intimacy! All of my
body! Education! Protection!” And, the list continues. This activity begins to break
down the inhibitions surrounding sex and allows for initial communication between
the women.
Several of the madres cuidadoras are laughing now and telling jokes, a few
others remain quiet and appear a bit shy or uncomfortable. They move back to
193
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
their chairs and Maria asks them if sex and sexuality are the same. Several respond
with a loud, “No!” As Maria begins this section of the workshop, she asks several
questions about sexuality. Some of the women respond with yes or no, but a few
still remain quiet. Most appear attentive and listen to her descriptions. The next
task requires them to tape a sign under the appropriate title on the board for
sexuality: physical, psychological, or biological. The madres watch as each person
walks up and places her sign. Several women laugh and yell out comments or
advice to the others, “Penis!” “Masturbation!” are some of the recommendations.
When they are finished, they discuss why some are incorrect. “Reproduction
should be biological,” is one comment as it is misplaced under social. Another
asks, “What about machismo? Is it psychological or social?” “It’s both,” is the
answer. “And violence?” “It’s also both.” Maria then asks them which is the most
important and one madre answers, “Between the couple, communication and
education.” The process is mostly informational and does necessarily incorporate
the information into their lives.
Maria has some trouble throughout the workshop explaining some of the
activities and themes. She looks at times to Celia or me and asks us for advice on
how to move along or represent certain ideas. She is preoccupied with a section
that she missed or an explanation she forgot to give. Celia ensures her that she can
give the information and workshop however she wants. The madres seem confused
at times because they do not understand the activity or what they should do to
participate. As they play the next game, the madres are happy and laughing, but I
194
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
notice one stands off to the side and does not participate. They then break up into
groups to create drawings. The groups work well together, but some work more
than others. The woman who stood separately before is still slightly apart from her
group, looking around the room at other things.
When the groups present their drawings, they have each created a picture of
the internal and external male and female sexual organs. The drawings are accurate
and show that they have a good understanding of the biological aspects. They
begin to discuss the pictures and joke about penis size and the number of sperm a
man has. One jokes, “Tonight she is going home to count them!” Maria continues
to lead them through the discussion, some pay attention, others appear bored and
look around the room. The madres have a few questions, “Why would a man’s
parts get inflamed?” Maria is unsure and looks to Nancy (who arrived a few
minutes ago). She tells them it is common for older men to get inflamed after
sitting for awhile. The same madre asks why it would happen in a younger man
and Nancy gives her several medical reasons. The questions continue:
Why is the scrotum outside of a man? Is there no room for it inside?
I think it’s because it needs air or something.
Maria tells them it is for the temperature and that the sperm could not live
inside; they need a lower temperature to reproduce and she gives them homework
for that night to measure the temperature. The madres laugh with approval. As
they move on, the madres seem knowledgeable about many of the biological parts.
I notice the same people continue to answer the questions and others remain very
195
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
quiet. One madre cuidadora answers the majority of questions as they move on to
the birthing process and female body parts. This section allows them to recognize
and understand their bodies, the first step toward being able to control their bodies.
At 6:15 p.m. they finally take a break. The madres appear a bit relieved as
they eat snacks and use the restroom. Maria realizes that she is far behind schedule
and decides to skip the importance of sexuality and moves onto the final section.
When they return from break the atmosphere appears lighter and the madres are
more relaxed, laughing and talking. I notice the same woman remains a bit outside
of the group and alone. The women break into groups to draw a poster of the
importance of sexuality. The first group draws a picture of a man and women
entitled “La Sexualidad” (the sexuality) that states “different sexes, but equal in
society.” The second group also draws and man and women, but the title is
“Getting to know my body”. The groups complete their work at this time. The
gender messages presented here are important and a gender-sensitive discussion
should surround this part of the training to consider these messages.
The workshop did cover some of the major themes of sexuality and its
components and the functions and recognition of sexual organs. However, the
coordinator was unable to cover some of the concepts such as the importance of
sexuality in their lives. It did not appear that the women were able to grasp the
concepts, as many of them appeared to have prior knowledge of the issues
especially on those of the sexual body parts. Most of the women appeared at ease
with the conversation as they participated in each activity. Some, however, did
196
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
seem bored or uninterested at times, which may indicate they did not fully
comprehend some of the information. The coordinator often appeared flustered and
unsure of the activities and themes, which also created a level of frustration for the
participants. There appear to be no real opportunities for empowerment as the
training is largely informational which did touch on cognitive empowerment,
allowing for understanding of the conditions of inequality in their lives.
Day II—Sexuality Part II
The following day, the group meets again in the Calandria office in Jesus
Maria for part II of the sexuality module. This includes sexual development,
contraceptive methods, AIDS and STDS, and self-esteem. Most of the same
madres cuidadoras are there, although there are some new participants and a few
from yesterday do not return. The same observers from Calandria and UNFPA are
in attendance. The group starts very late again and several of the madres appear
bored and irritated. The woman who remained outside of the group yesterday asks
for the time, it is already 4:30 before the workshop begins. This time issue is
important as mentioned earlier current research recommends that successful
programs must recognize time and other constraints for women when inviting them
to participate in an intervention.
Maria asks the madres why sexuality is important in their lives. “Because I
can know my body and learn how to take care of it.” “Because it keeps me young
and vital.” They begin to talk about their relationships. One woman says she is
separated from her husband, and they have children so she would like to work out
197
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
their problems. Everyone gives her feedback on the importance of communication.
Before they can continue, Maria begins a new activity. They begin to discuss their
own pregnancies. Several talk about the fact that they had Caesarian sections. To
my surprise, the woman who has stayed quiet begins to talk about her own
pregnancy and that she also had a Caesarian section. She was so happy to have a
baby, and her other two children were normal deliveries. The first woman begins
to talk again and begins to cry, “It wasn’t in my plan to have the baby, but it was in
my heart.” The others tell jokes to try and cheer up the woman. The oldest woman
in the group then tells her story. Her children are young and many people ask her if
she is the grandmother or the mother; she also becomes emotional. Maria quickly
moves to a new game and they begin to laugh and play again. The stories are
forgotten for the moment. This activity is supposed to lead into the discussion of
contraceptives and when it is recommended to have children. The discussion did
become emotional as the women related their own experiences. However, they did
not seem to fully get the link to prenatal care and reproductive rights.
Although she is still quiet, the woman who has remained alone appears
more interested now and involved in the topics. They talk about rights and
pregnancy, then move on to contraceptives. One comments, “I don’t use anything,
just the natural method. You know abstinence or the rhythm method.” Maria says
the only one that is one hundred percent sure is abstinence. “You need to talk to
your partner if you are not sure if he is safe.” This message assumes that women
have the power of negotiation in their relationships. The quiet woman responds,
198
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
“Well, that’s if he respects it, many men do not have respect.” The madres have
never heard of the female condom and discuss this next. She tells them with a
condom, it is just an excuse if the man says he can not feel anything, they can. This
is an important time to discuss the power roles in relationships and touch on
recognizing the gender inequalities. Nancy has also joined the group and goes over
many misconceptions that they have about contraceptives, such as that the IUD can
wrap around the baby’s neck if they were to get pregnant.
The final topic is AIDS. Many have misconceptions; others have questions.
One believes there is a cure for it now. The madres understand that you do not die
from AIDS, but from other diseases you contract when you have AIDS. They
understand you can live for a long time with AIDS. They discuss how AIDS is
contracted, from blood, mother to child, sexual contact, and from needles. Nancy
describes the situation to them, “It is not just those who are homosexual or
promiscuous. A married woman who does not protect herself because she believes
her husband is not with other women can get AIDS. A woman can only guarantee
that she has not been with another person. Nobody can guarantee that his or her
partner has not been with another person. If the partner from outside is infected, he
comes home and infects her.” There is small discussion and the course comes to an
end, leaving out the final topic of self-esteem and partner negotiation. There is no
chance to provide methods of empowerment for the women in negotiating. They
receive no general skills to go along with the information they have discussed.
199
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The madres seem to have a basic understanding of contraceptives and of
STDS and AIDS. Although most report no prior education on these themes, they
are aware of the way AIDS and STDS are contracted. Many had misconceptions
about AIDS and how it spreads, but appear to have recognized the myths
surrounding AIDS. Self-esteem and negotiation, two of the most important topics
were not discussed in this workshop. As discussed in the literature, the ability to
negotiate safe sex is one of the most important ways of protection from contracting
AIDS. The women were given adequate information and gained knowledge on the
issue, but were not provided the tools to safely and effectively exercise safe and
responsible sex, one of the indicators for the workshop. This assumes that women
have control and power to negotiate and communicate their needs in their
relationships. They do not touch on social or cultural constraints that place women
in subordinate roles.
Day III—Family Violence
The third workshop was conducted at a church in Independencia, on the
topic of family violence. This is now a new group of madres cuidadoras from this
region. The location is in a pueblo joven and the houses are poorly constructed
along the mountainside. There are sixteen madres cuidadoras, one madre with her
baby. The coordinator, Gabby, has two assistants with her, and the evaluators from
Calandria and UNFPA are also in attendance.
Celia again begins this meeting with a description of the programs and the
evaluation. Gabby starts the workshop at 3:45 with the typical game. The women
200
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
laugh, but appear a bit shy at the start. They break into groups and appear to work
intently on their projects to define family violence. This group runs a lot smoother,
in that Gabby has the two assistants who are able to do the majority of the set-up
work while she is able to interact with the madres. When they present the results,
the others applaud. Most seem interested, but a few look around the room and
appear bored. They define family violence and discuss the different forms of
violence: physical, psychological, emotional, and sexual are the main forms they
find.
They continue to the next game and some participate, laughing and having
fun. Others appear bored and do not actively participate. One woman, in fact, is
asleep in her chair; two others ask me about the time. Those still participating give
examples of family violence and infant maltreatment. The next activity includes
the causes and consequences of family violence. The women place cards on a
poster of a tree, with the causes near the roots of the tree and the consequences in
the leaves. The causes include lack of dialogue, economic, lack of work, machismo,
and drinking. Consequences consist of social, emotional, future, abandonment,
mistreatment, fighting, low self-esteem, and children rebelling. This leads into a
short discussion of some of the personal cases they have witnessed of family
violence. There is an awareness of the problem and an understanding of the reasons
for violence.
They break into groups again and try to solve case situations of family
violence. When they return to their group to read their results, no one is listening;
201
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
they talk amongst themselves. Unfortunately, the workshop ends at this point,
because the church is located in a dangerous zone and it is already getting dark
outside. They did not get to the final two sections of family violence, which
include the prevention strategies and the way these issues should be dealt with in
their communities. These two issues are the main goals of the workshop because
they enable the madres to be able to recognize the symptoms and support the
prevention of family violence. It seems they already had knowledge and awareness
of the violence that occurs in their families and community, but still lack the
method to be able to successfully confront this violence. The awareness and
understanding does not translate to increased ability to deal with the issues and to
create a political voice against family violence.
Summary
The workshops in Lima covered the modules of sexuality and family
violence. As the women met and discussed the topics and activities several themes
began to emerge through the training. First, the workshop environment appeared to
provide an opportunity for group dialogue about issues of sex and sexuality that
most of the women had never had. One of the recommendations from the literature
is that this type of safe group dialogue be provided for effective programming. In
addition, there was no outside stigma associated with their attendance in the
workshop as they often meet to discuss issues surrounding the children, and this
workshop did not appear any different to outsiders. Therefore, the women felt free
to attend and participate.
202
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The teaching methodology, including role-playing and case scenarios,
allowed the women to interact and express their issues freely. The themes of
sexuality and AIDS were new to the women and most reported they had never
discussed these prior to this training. They were more knowledgeable about the
sexual organs and contraceptive methods, although they did not know about the
female condom (Reality female condom) and most saw an IUD for the first time.
The women were most familiar with the natural or rhythm method, reporting this as
their method of choice. This does not allow for adequate protection from AIDS or
STDS, which was discussed through their concerns about communication with their
husbands. The women had many questions about sexual health, especially about
men’s issues and prior education seemed to be lacking in this area. There were also
concerns about adequate health care for themselves and problems with pregnancy.
The women were also able to discuss cases of family violence and related causes to
lack of communication, alcohol, and machismo, which became a major part of later
discussions in the focus groups.
A major problem with the workshop was that they did not get to complete
the full module due to time constraints. Unfortunately, the parts not covered were
those that allowed the women to incorporate action into their lives as a result of the
new information. The coordinators also did not have the full preparation they
needed to provide adequate training. One was frustrated and confused at times with
the process and had to improvise as she went along. The time issue is important, as
the training has to accommodate the madres’ schedules. Starting late does not
203
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
consider their time limitations. In addition, the safety situation in the pueblos
jovenes has to be addressed in regards to making the workshop safe for the
participants.
The workshop did not touch fully on gender relations and the lack of power
women have in their relationships. It assumes that women have control over their
bodies and does not provide avenues for empowerment. Change would also require
that men be included in the discussion in order to create open dialogue and the
beginning of cognitive empowerment.
Huancavelica—Day I—Sexuality Part I
The workshops in Huancavelica take place in the office of the municipality
in the plaza de armas. The location consists of two small meeting rooms separated
by an entryway covered with a curtain. The room is decorated red and white for
the upcoming birthday celebration of the city. There are two large photos on the
wall, one of Christ and the other of President Fujimori. There are two tables in the
main room and chairs are in four rows. Jessica is the coordinator leading the
session; one evaluator from Calandria and one from UNFPA are in attendance. In
the second room the set-up is the same. Eighteen madres cuidadoras are in each
room to participate in two different modules simultaneously.
As the workshops are again held simultaneously, I am able to observe the
module on sexuality. There is a great mix of tradition and age in the group of
madres. There are five women in the traditional dress of the region, with full
skirts, colorful blouses, scarves, and the black bolo hat. The other madres are a
204
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
mix of young women in their early 20s in modem clothing of jeans, and older
women in more modem dress. Several of the Indian women do not speak Spanish
and the younger women translate for them to Quechua. A group of young children
play in the back of the room and on the outside patio. Two young girls care for the
younger infants outside.
As Jessica defines the three aspects of sexuality, the women giggle and
laugh in groups but appear comfortable with their activities. One woman does not
participate as she has a young baby asleep on her lap. Once they complete the
definitions of biological, psychological, and social aspects of sexuality, Jessica asks
if there is machismo in Huancavelica. The madres responses are “Yes” and “A lot”.
Jessica asks if men are faithful here and the response is, “No.” They do, however,
comment that the women are also unfaithful. Most of the women are taking notes
and appear very attentive. They respond that they could not talk to their parents
about sex, it was too embarrassing. Several mention that they are different and can
talk to their children about sex. The women state they can learn about sexuality
and sex in this type of workshop and can share the information with their own
children and families. The women mention the problem with machismo standing in
the way of educating their children if their husbands to not allow discussion about
sexual health issues. As they move on in the activities, a few women remain to the
side and do not participate. The main discussion allows for opportunities for
understanding their conditions, a first step in cognitive empowerment.
205
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The atmosphere is extremely loud and active as children run in and out and
several are crying. The women are asked to fill out an attendance sheet. One of the
traditionally dressed women approaches Celia and states that she can not write and
asks for help filling out the sheet. The younger women help several of the older
women who are not able to fill out the form. The lack of language and literacy
prevents a barrier for these women to fully understand the training. The next
activity is to define why sexuality is important in their lives. The three groups
develop their answers, “It’s important to know the parts of our body, it’s important
because through sexuality we can promote the attitudes and behavior in society,
through sexual knowledge exists human reproduction, for men and women to share,
think, and feel and live good between each other, to have good communication and
mutual respect, and without sex there are no children.” The messages presented
here should be gender sensitive and discuss the socially prescribed gender roles.
They then break into four groups to draw their renditions of the male and
female body parts. The groups work together intently on their drawings. When
they finish the results are posted on the wall. The drawings accurately represent
both male and female sex organs and the women seem to be familiar with this. As
Jessica asks questions, most women are responsive and yell out answers. I notice
that the younger women do not share as much information. They appear
embarrassed to comment as they glance at each other before giving any responses.
Several of the participants give the slang terms for the male and female body parts
and laugh out loud; however, the younger women giggle and hide their faces. As
206
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Jessica moves on with the definitions, some of the women draw and take notes, but
two of the Quechua speakers doze off, as it appears they do not understand. The
initial understanding of their bodies and how they function can lead to
understanding their rights and control of their bodies.
Jessica talks about the hymen, how it can break prior to sex and that too
much importance is placed on this and that the myths surrounding this are often
incorrect. At 5:20, the lights to the room turn off unexpectedly and the course is
cut short. The women visit for awhile, eating snacks and soon head home.
Although the course did cover many of the main themes, the women were not able
to get to the main parts of the workshop. In addition, many of the Quechua
speakers did not appear to understand much of the information. The major themes
of the sexuality module are contraceptives, AIDS and STDS, and self-esteem and
negotiation. These were not included in this part of the workshop, so the women
only touched on the key issues. There was no perceived opportunity for
empowering the women in this situation, or to address power and gender relations.
Day II—Sexual Health and Reproductive Rights
On Friday, we meet again with the same group of women for the module on
sexual health and reproductive rights. Jessica leads the group. The representatives
from Calandria and UNFPA rearrange the chairs into a semi-circle to make the
environment more open to discussion. Sixteen women are in attendance as Jessica
begins at 3 p.m. discussing sexuality. As they move on to rights, she asks them to
write on cards the reasons for being a citizen. Three of the women, who can not
207
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
write, ask others for assistance with their cards. The responses include, “having
rights, to live in the country, to vote, the right to get married, to identify us, and for
liberty”.
Jessica talks about sexuality and asks for the proper names of the female
body parts. The women give their comments; many giggle and whisper their
responses. When asked if they are satisfied being women, most agree, but several
of the younger women shake their heads and state they would prefer to be men.
One states the reason being that men have more rights. This is one of several
occasions when the younger women have different answers than the older women.
Jessica does not appear to understand the meaning of the comment as she mentions
transexuality instead of touching on the issue of women’s rights. It seems that she
thinks the women really want to be men. They soon move on to a discussion on
AIDS. Most of the women are listening; a few talk amongst themselves. Most state
that they know there is no cure for AIDS. She asks if they know what
contraceptives are. One of the older women responds, “Before I had to protect
myself, now I don’t.” Laughter emerges from around the room. Jessica mentions
the different methods of contraceptives, the younger girls appear very interested
and ask about the rhythm method. In groups, they write lists of their sexual and
reproductive rights:
The right to decide when and how many children I want to have;
The right to use contraceptive methods;
The right to sexual education;
The right for parents to protect their children;
The right to not be abused;
The right to have [sexual] relations when I want;
208
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The right to have respect as a woman;
The right to respect my body; and
The right to talk about sexuality with my partner and others.
One group explains that their rights include telling the doctor which
contraceptive methods they want to use, not just the one they tell women to use.
Another mentions they can talk with their partners, but many laugh and joke about
this answer as they are not sure this can occur. As Jessica places their lists into
three themes, contraceptives, rights of a woman, and family planning, the women
shake their heads in agreement and listen intently to the discussion.
The next exercise is about self-esteem and each woman has to walk up to
the mirror and look at herself. The goal is to gain knowledge of their bodies and
their sexual rights. The first woman approaches like a model and prances in front of
the mirror; the next turns bright red and can hardly look; several approach and fix
their hair, one removes her traditional hat and fixes her wrap and skirt; two of the
younger women run up quickly and run back; and the final woman spends a long
time looking over her whole body. They applaud each other in the end and move
on to the next activity. This initially addresses gender messages and basic rights
and can lead to expression of control over their bodies. This type of activity allows
for equal participation for all of the participants. Even though the younger women
are embarrassed, they do participate. In addition, the Quechua speakers are able to
participate in the interaction due to the active nature. In earlier activities, language
barriers at times limited their activity.
209
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Next they must talk about the things that they want and like, for example, “I
like to be kissed on.. and “I like to kiss on...” Everyone is laughing and joking
about the activity. As they write down their fantasies, the younger women help the
older women to write. One woman laughs out loud as she translates the fantasy of
one of the older woman. One yells out “With Fujimori!” The room breaks into
laughter. The fantasies range from Enrique Iglesias to getting married to being
stranded on an island. The women laugh and applaud in approval. The goal of this
activity also to understand their sexual and reproductive rights. However, a clear
description and explanation of the activity’s objectives are not made and they move
directly to the next section.
The afternoon has moved to early evening and the woman are tired, but they
continue to take notes and participate. Jessica talks about their rights as she writes
them on the board. “The right to exercise sexuality independently of reproduction,
the right to freely decide on our maternity, the right to access of quality sexual and
reproductive health services, especially over knowledge of family planning
methods”. She points them out, but does not read them out loud, although many of
the women can not read. She comments, “The State is responsible for our rights. It
has promises it must keep for us.” However, there is no connection to the
expression of and demand for equal rights. There does not appear to be clear
understanding or opportunities to communicate these demands. The group ends a
few minutes later. This is the last module in Huancavelica and the focus groups,
which are discussed later in detail, are held the following days.
210
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The workshop ended abruptly without clear connection to the main goals.
This particular workshop has possibilities for mobilization efforts with the women.
Some of the indicators include the ability to demand quality health care, to
negotiate with their partners, and to be able to transmit these ideas in their
immediate environment. The women did appear to gain knowledge on citizenship
and rights, but did not seem to get the connection to the responsibilities of the
government.
Summary
In Huancavelica, the modules focused on part one of sexuality and on
sexual health and reproductive rights. Some of the themes in the training were
similar to those in Lima and some new themes materialize. As in Lima, the
environment appears to be safe and comfortable for the women. No one in the
community is aware they are coming to discuss anything other than their regular
meetings for the Wawa Wasi, so it is safe to attend without outside social stigma.
They are also provided open group dialogue about sensitive issues, which the
majority state they have never had.
One of the major new issues that emerges is that of language and literacy. In
this case, the women who are Quechua speakers do not fully understand the
information and can not complete the written materials. In addition, most of them
can not read the Spanish signs and posters presented in the workshop. The trainers
have to be more sensitive about meeting the needs of these women. Options as
211
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
simple as reading out loud the information instead of just placing it on a poster
would help.
In addition, other physical issues were the need for childcare and the time
issue. Older siblings and the madres watched the children, which was distracting to
the group. The workshop also entered into the night, and most women were
concerned about getting home to prepare dinner. In addition, there was not
adequate preparation of the facility as the lights went out early.
A topic that emerged in the course and later in the focus groups, was that of
the difference in age groups. The age range in Lima and Huanuco was not as
distinctive as that in Huancavelica. Here, the younger women felt constrained to
fully share and respond to the course activities. The younger single women reported
later that they were uncomfortable discussing sexual issues with the married
women as they may judge them unfairly or report back to their parents. This
resulted in their hiding their responses and not speaking freely. This was a major
barrier to learning and participation, and should be considered in future training and
boundaries and confidentiality should be discussed.
In regards to information, the madres responded with good definitions for
sexuality, sexual organs, citizenship, and their rights. They saw their rights in three
main themes of contraceptives, family planning, and as women. The problems with
machismo and communication with men were discussed, and the women reported
high levels of machismo in the community. This results in increased risk to the
212
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women as they are not able to effectively communicate their needs and rights in
their sexual relationships.
Huanuco—Day I—Sexuality part II
The workshops in Huanuco take place the following week. The modules
are again given at the same time, so I am able to attend the module on sexuality.
This workshop takes place in an elementary school. It is very hot and there are no
fans. There are seventeen women in attendance; some dressed casually in
PROMUDEH t-shirts, others are dressed in skirts and blouses. There are two
coordinators leading the session, with representatives from UNFPA and Calandria
observing. The other workshop is held upstairs in the same building. The women
are seated in a large half-circle, facing the board in the front of the room. There are
four long tables in the back and a teacher’s desk in the front. Several children play
outside in the courtyard as they wait for their mothers in the workshop.
They begin with a game and everyone claps and dances in a circle. The goal
is to understand sexual development as they place their definitions under the titles
of “infancy, adolescence, and adulthood” in order to describe the developmental
stages. In the next activity, they are asked to remember their own pregnancies, but
several of the women are very young and seem unsure of what to do, as they may
not have children yet. One woman describes her pregnancy,
I was married three years and wanted a baby, I lost the first one. I
finally had a baby, my oldest, but I was very sick the whole
pregnancy. I could not even drink water; I wanted to eat but
couldn’t. It was a very difficult pregnancy. But, when the baby
came, I remember the worst pain, but it is nothing compared to
213
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
when you get to see the baby, how beautiful. I suffered a lot the
second pregnancy as well, but thank God I have two children now.
They talk about the health centers and how expensive it is to have a nurse or
to have the baby in the clinic. Several report how lucky they are to have healthy
children now. The theme of lack of access to safe health care comes up repeatedly
in the focus groups. As outlined in the goals of the course modules (Attachment
III), this session has a goal of recognizing their rights for health care, the women
seemed to have gained some knowledge of these needs. They have recognized their
rights to health care, but have not necessarily been placed in empowering roles to
express these rights.
When discussing contraceptives, the women are familiar with several types.
Lydia talks about how some of the methods are not very safe. The women mention
vasectomies and having their tubes tied as safe options. Lydia tells them that
condoms can protect them from STDS, but not all of the diseases. She asks them to
pick the method that is best for them when they go to the health center. She
mentions Norplant, a birth control method that is placed in your arm, but that the
Ministry of Health is no longer providing this free service. Several of the women
are interested in this method and ask about it as an option. One woman asks about
the natural method of contraception. Lydia responds, “Yes, this is a good method, if
you have communication with your partner. But, there exists a lot of machismo, for
example if he comes home drunk. Only if your partner understands this method,
but no method is bad.” This touches on gender relations and power but should be
dealt with on a more open level. One woman comments that she has not found a
214
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
method that makes her comfortable. Lydia recommends combining methods like
the natural method with a condom, in that it protects you more. The discussion
now surrounds the natural method and most of the women state this is the method
they use. The women have many questions about the different methods and the
conversation is extensive on issues of safety and availability.
After a break, they continue to discuss health and pregnancy. Lydia
mentions the importance of prenatal care and most of the women appear to be
paying attention and show interest in the topics. They move on to discuss AIDS,
the number of cases in Peru and the risks. Lydia states that the husband can be
with someone else and if that woman has AIDS it will come into their home. She
dispels the myths about getting AIDS from kissing or hugging and about the real
ways of contracting AIDS. She also mentions other STDS and how they are
contracted. “You do not have to have it, but it can be in your husband. You need to
protect yourself in your home, as you can not be sure of your partner. Sometimes
you are in your house and your husband can be with another woman, not all of the
men, but some.” Lydia states, “I want to be clear, so you understand, these
diseases are transmitted sexually, from mouth to penis or mouth to vagina as well.”
One woman questions whether some STDS can get transferred through clothes, but
Lydia responds that this can not happen. The woman says this is what happened in
her home, Lydia tells her this is not true. These seem to be typical of the myths
about AIDS that the women describe in each of the three regions. The methodology
also assumes women have control over their bodies and access to condoms.
215
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Lydia moves on to discuss Hepatitis A and B. She explains that A is
contracted through food and water and that B is sexual. One woman asks if HIV
and ADDS can be passed on to a baby. She explains how HIV can be passed on to
the unborn child. At the end of this section, Lydia puts up a sign and asks the
women to yell out how you can protect yourself from AIDS.
Have sexual relations with only one partner!
Use a condom!
Appropriate medical care!
Keep your hygiene clean!
One of the women gives an example of a friend who went to the health
center and found out that she had contracted AIDS. She was only with one partner
but he had it and now their baby does too. The women are aware of several cases
of AIDS in their community. They seem knowledgeable on the issues of AIDS and
have gained some good information. As the coordinator quizzes the women at the
end of the section on AIDS, they respond appropriately. The women have
knowledge of AIDS but this does not necessarily connect to empowerment and
ability to negotiate and control their bodies.
All of the women state they have been to a gynecologist at some point.
They discuss mammograms and breast cancer and the importance of getting regular
checkups. As they move onto the next theme, Lydia mentions the importance to
talk about these issues little by little with friends and family. “We worry about
everything, our family, our children, our Wawa Wasi, but we never worry about
ourselves.” She moves into the topic of self-esteem. The women role-play
relationships and the way couples communicate. One role-play is of the husband
216
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
coming home and wanting sex, but the wife does not want to. The wife asks him to
use a condom but he does not want to use one, as it does not feel the same. The
wife says that she will get pregnant and she does not want to have another child.
Finally, the husband relents and says he will use a condom for her even though it is
not the same. This begins to address gender roles and communication, but should
delve deeper into skills for negotiation. The women then discuss the importance of
communication with their partners about sex and condoms. They state that in order
to communicate with their partners they should “think with anticipation about the
situation, think how they can talk, look for an adequate time, and be flexible.”
Again, negotiation and communication are not fully addressed in order to empower
women to demand safe sex.
In the final section, Lydia asks the madres cuidadoras to draw a picture or
pamphlet about what they learned in the class today. Both groups present drawings
about AIDS. The first explains what AIDS is and how to prevent it, with the final
statement, “AIDS, It Kills, Protect Yourself.” The second group has the slogan,
“Fight together against AIDS. We want to live healthy and strong. Use a condom.”
They identify how to test for AIDS and how to talk about AIDS. It is interesting to
note that through the entire workshop, both groups chose to create a poster on
AIDS. This indicates that the topic of AIDS had the most impact on them and that
this information may be what they take with them as they leave the workshop. This
is an initial glimpse at the information gained and what they may share with those
outside of the workshop.
217
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The course ends today with Lydia expressing the importance of sharing the
information they have learned with the community and the madres usuarias. At the
end of the workshop, Nancy leads the participants in a breast exam, explaining how
and why this should be done on a regular basis. Focus group evaluations will take
place on the following day.
Summary
The workshop in Huanuco focused on the module for the second part of
sexuality. Again, in a safe environment the women were able to openly discuss
issues that most had not talked about prior to this intervention. The issues
surrounding pregnancy were very emotional for the women as they were in Lima.
This brought up the discussion about lack of adequate health care for women. The
women were knowledgeable about contraceptives, most stating they used the
natural method although the injection was also very popular in this area. The
women wanted more information about the safety of both of these methods. The
women had basic knowledge of AIDS, but the workshop dispelled many of the
myths they had and they gained adequate information about the disease and
transmission. They were able to personalize the risk in their own relationships
through examples from their own community. They understand, but they still lack
the skills for successful negotiation with their partners.
The role-playing in this workshop was very useful for improving
communication with their partners. The women got involved in the process and
presentation and actively presented true to life cases in their personal lives and
218
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community. This seemed to be a good way to get at the issues of machismo and
lack of communication with their partners. Role-playing like this is recommended
from the literature discussed in previous chapters and have proven most effective in
intervention efforts.
In the conclusion of the workshop, the women were asked to create posters
with the knowledge they gained during the day. As the groups all focused on AIDS
prevention in their posters, it seems that this was the most relevant theme for them
during workshop. They found this to be most important for themselves and for
getting the information out in their community.
219
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Section Two
Analysis of Intervention Outcomes
In analyzing the focus groups, interviews and surveys, and drawing my
original research questions, several themes began to emerge. Knowledge, behavior,
and attitudes are the underlying topics, and through these condom use, sociocultural
issues including gender roles and “machismo”, access to information and health
care, and self-esteem emerge as themes. Extremely important then, with the goals
of the program, are the ability to communicate the messages to families, partners,
madres usuarias, and the general community. Also, important to consider is
whether these factors varied by region. Further information was gleaned through
the six in-depth observations with the women in Lima. The following sections will
provide further analysis of the intervention and of the impact it had on the
participants.
Knowledge of Sexual Health and Reproductive Rights
In the area of knowledge, it was important to understand what the women
knew about sexual health prior to the intervention and if their knowledge increased
as a result of the intervention. Questions were asked about participation in prior
workshops and about their general knowledge of health, sexual rights, STDS, and
AIDS. Also, immediately following the course the participants were asked about
what they learned and what was most important to them.
Many of the madres cuidadoras stated that they had received some sort of
class or program on women’s health prior to this workshop; however for many this
220
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
was the first time they had heard about these specific topics. Those who had prior
intervention mentioned that the information was never as intensive or as clear as in
this course. The madres receive training on a monthly basis from the Wawa Wasi
program. Training topics they mentioned included; infant mistreatment, self
esteem, gender, childhood diseases, health, family planning, vaccinations, nutrition,
female diseases, and hygiene. Other than the training listed, they felt they had little
prior intervention or information on sexual health and reproductive rights, and that
they had many misconceptions. The majority had difficulty talking about these
themes prior to this training. All of the madres stated that the intervention helped
them to gain an understanding of sexual health and their reproductive rights.
When asked about their knowledge of sexual health prior to the training the
women responded:
I knew for example that there were sexually transmitted diseases,
but I wanted to know more.
There are many lies, like if you are breastfeeding you can not get
pregnant.
Before, neither our moms nor an older sister ever talked to us about
this. Up until our menstruation they never even told us at what age
we were going to menstruate. The first time I menstruated I was so
scared, I cried. I thought that I had conceived, because I heard in
school that this blood was because you had relations with a man.
Because I was bleeding, I cried day and night, because no one told
me anything.
I feel chills, embarrassed, I feel like I am talking bad.
It’s worse when a mother talks to her daughter, if the mother was
educated differently you can not talk.
Some mothers to do not talk, but my mom talked to me, my mom
and dad talked, but my mom’s mom did not talk to her, she was
embarrassed, she could not ask her, she was afraid.
221
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
These comments mirror those of the coordinators’ in that the women had
few instances of prior education either in a formal setting or at home. There is little
communication with family and the women report very little knowledge except
what they learned by their own means. This placed them in situations where they
were poorly informed and even fearful of changes in their bodies and on issues of
sexual health. This indicates low access to adequate medical information and
education.
Most women stated that they had little prior knowledge and few
opportunities to talk to friends and family about issues of sexual health. However,
they felt that this type of training was becoming more common and that they were
looking for this type of education.
But here, almost 30 years old, I have never heard a talk like this,
never, because I mostly lived in the jungle, and the people are not
socialized, when I came to Huanuco I got myself in every type of
program to learn more and I like it.
Now there are many talks, for the case of family planning there
always are, there are students from the university and they come to
the comedores, and to the mother’s clubs, and to the moms they are
always talking about family planning.
This indicates that access to education and information may be improving
and that those who take the incentive can find the information they need.
After the course, the participants discussed in the focus group the
information they had gained in the course and what they felt were the most
important issues for them. As mentioned, the majority of women responded
positively to the training, although several mentioned that they hoped the training
222
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
would be longer and give more detail on the issues. In addition, they discussed
increased knowledge of their rights as women and their rights to access to adequate
information. They felt it was the responsibility of the government to provide this
information and they had the right to access additional resources.
We want the State to give us a special talk about health that informs
us correctly.
We learned that we have rights to a sexual education, principal
sexual and reproductive rights, rights against mistreatment and
abuse, and the right to exercise our sexuality with autonomy.
We learned about our rights to go to a health center and the medics
have to explain things to us.
When we see the nurse she needs to explain to us clearly what the
doctor said.
We learned to defend ourselves, to demand our rights and not stay
quiet. To demand what is ours, and they can not take it away.
We have a right to decide how many children we want. They can’t
obligate us, no one can force us.
The women also stated that the course provided a safe and comfortable avenue for
them to openly discuss sexual issues, something most had limited access to prior to
this course. They appreciated the new information about sexuality and their ability
to express their needs and desires with out being embarrassed.
I was very relaxed in the course, like we were in the house talking
about any other thing.
It took away our embarrassment to talk about sex.
The theme was very interesting, but what impacted me the most was
that we are able to understand our sexuality, express it liberally, to
have normal sexual relations, without having fear or simple using it
to reproduce. We can also use it to enjoy ourselves.
A major problem that emerged was the lack of time to completely cover the
topics in each module. Due to time constraints as well as the preparedness issues
with the trainers, many of the themes were not touched upon. In addition, the
223
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
workshops were only three hours long for 2-3 days, which resulted in the women
wanting more time to discuss the topics.
We would like to know more about the diseases. That a person
sometimes has had relations with their partner, how to prevent them.
The class was too short, we ran out of time. Each thing they
explained was very brief. It needs to be amplified and specific.
Two other major barriers to effective intervention were the issues of age and
ethnicity. These two issues particularly emerged with the courses in Huancavelica.
In the first case, the mix of the younger and older women in the classes did not
allow for complete participation for the younger group. As the majority of the
younger women were single, they were not comfortable in sharing sexual
experiences and knowledge. They felt constrained by the older women possibly
judging them or sharing information with their families. The younger women
stated in the focus groups that they would be much more comfortable sharing
amongst each other and would hope the trainers would consider this issue in further
courses. This is a serious problem that should be considered in additional
programming, especially on sensitive issues.
In addition, the problem of language and literacy also arose for the women
in Huancavelica. Several of the older women did not speak or write in the Spanish
language. As a result they could not fully participate without translation. They
could not read or understand the written material that was presented throughout the
courses. This is a major barrier to effectively reaching this ethnic population.
Future programs need to include translated materials and all materials should be
224
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
read out loud, not just presented in written form to allow for full comprehension.
Translators should also be available whenever possible.
As stated, the women felt that they gained information about their bodies
and their rights in the workshop. Many still felt they needed more information and
had a desire to learn about these topics. They felt they had a right to this type of
education and would demand it in the future.
Sociocultural Messages: Gender Roles and Machismo
In discussing the sociocultural issues with the madres cuidadoras in each of
the three regions, the themes repeatedly mentioned were those of societal pre
determined gender roles and issues of machismo. These two issues appeared to
stand in the way of effective communication and ability to express their rights and
even to make their own decisions. This theme did not appear to vary by region.
The issue of machismo came up in each of the discussions as a very serious issue
that affected the participants and the women in their community in profound ways.
The women spoke of violence, abuse and lack of basic rights in their relationships
with men.
For me this theme is very important, because sometimes like the
women say, the husbands tell them what to do and they do it. To me
it has happened, sometimes no, he says don’t go to this place and
there it is, I don’t go.
That is very machista.
It is important to learn about respect, because if there exists respect
in the couple, the woman also has to respect herself, because
women, with machista men, they do not respect her.
I think to have relations both have to be in agreement. But
sometimes it is not like this. Here still, in Huancavelica, machismo
225
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
continues; here in Huancavelica we go on with this, that the men can
do what they want; and this is what we need to do with the madres
cuidadoras that we train, we can try to change this.
We have women who I know until today who say, “I serve my
husband in bed and he continues to hit me”. This can not be.
As mentioned, these issues did not appear to vary by region. The concerns
about violence and issues of machismo were a major part of each discussion in
each region. These issues have precluded the women from talking to their partners
about basic health, let alone AIDS or using a condom. These themes were revisited
and supported in the long-term observations of the madres cuidadoras in Lima.
This has serious programmatic effects on the workshop intervention. It directly
relates to the ability to negotiate safe sex, to demand reproductive and sexual health
rights, and to create reproductive choices.
The gender role issues have left the men out of the discussion of sexual
health and reproductive rights. Many of the women felt it was important that the
men also attend training in order to gain an understanding of the information. They
stated that the men are always left out of this type of workshop and that for them it
may be most important to learn. They felt that the issues of reproductive rights
could not change unless the men participate.
I am not only referring to the women; it’s also for the men.
Yes, the men as much as the women.
It is also not good that, for example, the training about sexual
education is always given only for women.
They need to find a way to also involve the men.
Sure, for the men too, give them the training, they also don’t know,
they don’t know and with their machismo, their egos, they are going
to say I am not going to go to these things, what am I going to say.
226
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
For a change, my husband, he likes to go to these talks. He says,
don’t they have one for me? And I ask him if he wants to go and he
says let’s go. But he says I am not going to go and be the only man
in the middle of all the women.
My husband is this way and I say thanks to God that I have this
husband, because he is like this, he washes, irons, he does
everything and we have been married 20 years and it’s like we were
just recently married.
These comments from the participants coincide with the recommendations
for effective sexual health and AIDS intervention programs, that men must also be
included in the education and discussion of these issues. The madres cuidadoras
felt strongly that the men must be part of the process and also be educated in order
to create effective change. These concerns are especially important due to the
limits that society and machismo has placed upon them. However, with the strong
sociocultural forces men may be very resistant to change and education on these
issues. Men would have to be willing to participate and open to the changing roles
of women and gender and power issues. Intervention programs will have to create
innovative methods to motivate the men to participate in such efforts.
The participants also talked about the gender roles that they face in their
communities. Many of the women describe the situations in their homes or in the
community where there are strict socially prescribed gender roles. These roles
forced them into situations where they have limited rights.
. . . sometimes in reality it’s different. I told my husband that I think
that the male and female sexes have the same rights and he said,
yeah right, you are not going to read too much about this.
227
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
My dad, when my mom is not there, he does not do anything not
even if he is thirsty he can’t eat, he waits for my mom to come and
serve him. But now we have boys who cook and serve themselves.
My husband helps a lot, if he has to he can stay with the children,
when I go to the store, he cooks, washes, watches the children, while
he does not work.
Because he is a man, he thinks he is the man of the house, everyone
has to obey him, but it is not like this.
In my case, when I wanted to demand, demand but no, this didn’t
happen with my husband. I said we have to do this, my opinion
didn’t have value, but his opinion did, it was good while it was bad
and it was always like this for me. I wanted something and he didn’t
want it. Sometimes I doubted myself, maybe what I am saying is
bad, maybe its better that I do what he says, and I accepted it, but
sometimes this made me feel bad. But not now, what I know is, I
can say this is my right, not only what he thinks. Now I can begin to
do this.
Although each woman has a different personal experience, they are faced
with these issues on a daily basis within their communities. These issues limit their
options for work, at home, and in daily negotiation with their partners. These roles
also limit their rights in their homes and in their communities. The women
described several instances in which their rights were limited by their role as
women, wives, and mothers. Several women mentioned they never knew prior to
the workshop that they had rights as women and that they could express these
rights. However, after the workshop, many also mentioned that they realized they
could change these rights and demand equal treatment.
For example, you can say to your husband, I have the right to this,
thinking about sexual relations, because he can’t, when you don’t
want to, he can’t force you.
Yes we can demand now.
With conversation we can demand.
228
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
I can say that I also have rights, equal to you, I also have this right.
Before he hit me, now I will not let him.
Now I have rights.
The madres cuidadoras expressed a desire to make a difference and demand
their rights as women and equal members in society. These rights often dealt with
their roles in the home and with their partners but also included issues of health
care and equal treatment by the government. These are the rights they mentioned,
but from this intervention they were not offered a method for expressing these
rights or for determining change in their communities. The sociocultural issues
place large restrictions on these women and their ability to voice their rights. It is
unclear whether over time the women had access to ways to discuss the information
they gained and the rights they hoped to demand.
Condom Use and Behavioral Change
When educating women on sexual health and issues of AIDS and STDS, a
recommended outcome would be increased condom use and ability to negotiate
safe sex practice with their partners. Both of these issues require behavioral change
on the part of the participant as well as their partner. The participants would also
need a general understanding of AIDS and STDS and their transmission. The
women also described their understanding of AIDS and HIV prior to the training
and the knowledge that they gained:
AIDS is not just for homosexuals, it’s for all people. You can get
sick if you go to la posta or a hospital. They can inject you with a
needle that is contaminated and there you can get AIDS.
AIDS is not just for women who go with any man, I am in the street
and I am the woman of the house, but you do not only hear of this,
229
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
you can be in your house, but imagine if your husband can give it to
you.
On the contrary, I though that when you kissed a person or if you ate
with the same spoon, I though you could catch AIDS, but yesterday
I heard this is not so.
We knew only a little about AIDS.
I think we all knew a little, but yesterday was more extensive, what
we learned.
These comments indicate increased knowledge of AIDS and that many
myths were dispelled. These comments support the findings that knowledge about
AIDS did increase with the intervention and that the women could describe this
information adequately.
Many of the women expressed concern about the use of needles. In Peru,
needles can be purchased in a pharmacy over the counter. These needles are often
washed and reused for drawing blood or giving injections, not only for drug use.
The participants had heard of cases of people becoming infected in this manner and
were concerned about the use of needles.
But now with the needle, I think you have to be very careful.
You can only use the needle once.
You have to buy them.
They wash them.
But you have to be sure they disinfect them.
Although the women expressed that they did have adequate knowledge
about AIDS and STDS, they were still concerned about their ability to protect
themselves. They expressed little ability to negotiate or even discuss the issues of
sex and sexual health with their partners. They expressed the importance of
communication with their partners, yet many were unable to do so.
230
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
No, we do not protect ourselves.
We are with our normal partner, no more.
With our partner, but we do not know about our husbands, this is the
problem, right, we are not sure.
We can communicate and counsel our husband, about what we just
studied.
More than anything you need to know your husband, because we
sometimes have cynical men who are with others and they seem
faithful.
More than anything is communication, if the man you live with,
from the start you have good communication together, he will
always tell you, if he did something in the street or if he didn’t, but
more than anything, he won’t do it. He cares about you and he won’t
come and transmit it in the house, more than anything you have to
think about the children.
We have men who ignore AIDS, thinking they are not going to get
it, they are with any woman, but we have men who know.
But we do not have a lot of confidence in them, because some are
not clear.. .they say they are only with you, but you have to see.
The example of my cousin, they both cared, but my cousin’s
husband had another girl, my cousin thought he went to work, but he
lied and won.
The women have increased knowledge but have not increased their ability
to negotiate safe sex or make their own decisions about sex with their partners.
The pure increase in knowledge then does not appear sufficient for creating
opportunities to change behavior and increase condom use. This supports the fact
that effective intervention programs must empower women through a myriad of
factors as discussed through the Cairo Program and other recommendations in
chapter two, rather than just providing knowledge.
Many of the participants discussed cases of infidelity and that it was very
common for men to have another sexual partner outside of the home. They felt that
231
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
communication was important, but that it often was not enough. These issues were
further validated in my in-depth observations with the madres cuidadoras in Lima.
They described similar problems with their partners and the inability to negotiate
condom use. One woman stated that if she asked her husband to use condoms, he
would assume she was the one being unfaithful. However, the women desired
respect and the ability for their opinion to be valued in sexual relations.
The part about diseases was very important. It’s that we believe that
our sexuality is autonomous, it belongs to each person, and that we
are obligated, we can not be obligated. I think that we can
emphasize this and we can say no, when its no, when we don’t want
to, that we can not be obligated. That we can be valued. This is from
where comes the mistreatment, the violations, because we do not
know how to defend ourselves. My body is my body, I know my
body in order to respect and want something you have to know it,
therefore I know my body and I am not going to want or respect
anyone who does not respect it. Therefore, these have to be the most
important points.
These are two of the most important points, knowledge and respect for their
bodies. But, the ability to voice this and to create change may not coincide with this
knowledge.
Access to Health Care and Information
Another theme that emerged in each of the three regions, was the issue of
adequate medical care and access to appropriate medical information. The Cairo
Program of Action shows the ability to access services and information as one of
the key mediating factors in empowering women in order to achieve the
reproductive health goals. Health care access became a very serious and life-
threatening issue in many of the cases discussed. Even when the women were able
232
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to access the local clinics or hospitals, the information and advice they received
was very limited. They felt they were severely mistreated by staff, nurses and
doctors. Many of the stories were extensive and often dealt with childbirth. Many
of the madres cuidadoras preferred to have their children naturally at home due to
stories of mistreatment in the hospital. They also discussed the high costs of having
a child in the clinic or hospital and that midwives at home were preferred. There
were also numerous misconceptions about childbirth, the recuperation period,
breastfeeding, and contraception.
The doctors don’t explain anything.
Its true, it also happened to me, when I just had my baby they forced
me to put in an IUD, and I did not want it. I told them I would go to
Huancayo to have it put in, because here they do not put it in right.
They don’t respect our rights; they need to be trained more than we
do.
We do not have rights in front of them.
Including also when I put in the IUD, I went to consult with the
obstetrician but she said you are fine you are fine, you are fine, and
sure enough I was getting an infection. In these cases they need to
learn to converse, to ask. Our rights are that we can do this.
We do not have access to information. Because a person goes to la
posta and they see you and use a needle [birth control injection],
they give the shot and you are ready, they don’t explain how many
months it is good. If your menstruation comes or not and you get
scared. They say it is normal and do not explain anything.
It’s like a demand, no, to put better personnel, because there are
nurses who are good, well trained, but to be professional I think you
have to have contact with the community. In la posta where I live
they do not have contact with the community, they reject the people,
they work to make money, to work and not to help the people. Not
like you helped us, what did it cost you to help us, good like this, not
like you are better than we are. With them, they are nurses and they
start by looking at your ID and if you are well dressed then
sometimes they back down. They have to have contact with the
233
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
community if not it is not very professional. Nothing that I say has
value.
They do not apply it, the nurses are taught about human rights, but
they do not apply it, not in relations to people.
But other people who go without money, they do not have many
finances, they go away with their children in their arms. One with
money can go and say attend to me.
They accept this and the poor humble people wait and they don’t
know, they get tired and they go home.
The madres cuidadoras described both a lack of adequate health services and
discriminatory practices with the current services. This workshop intervention
placed a focus on the basic rights of access to sexual and reproductive health care
and the women did recognize this as a major problem. However, as mentioned in
the module descriptions, the trainers discussed how to demand these services. As a
result the madres may lack the skills they need to negotiate with the community or
the government for equal and adequate care. The result is continued risk for their
health and safety.
I will tell you a story about what happened to us in the same
hospital. We went with a madre cuidadora who was very sick and
we took her to that same hospital. At this time we had 10 soles, we
were saving it for her medicine, she was at the beginning of a
miscarriage. The doctor said to pay the cashier, pay at the entrance. I
thought that in emergency you just went in and I said we do not
have any money now. We can’t pay. So a doctor came out and said
if you do not pay, then she can die outside. In the end we paid 5
soles, but it just wasn’t right.
And it was one of our friends, very poor, she had no money.
Because of the lack of many you are not going to die.
This is a typical example of the treatment that the madres described from
the health care professionals. However, many stated that they would now be able to
demand change and fair treatment in the hospitals and clinics.
234
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
We know that we have rights that before we did not have, we have
value and know that now, no one is going to pass by us. For
example in the hospital, you go and they say they are open from 8 in
the morning, and at 8 they need to talk care of us. Because
sometimes we go at 5 or 6 in the morning to wait in line and they
start taking care of us at 9 in the morning. Now we have the right to
demand that they attend to us at 8 exactly.
I want to say that one of the principal rights that we all have is
access to services for sexual and reproductive health. That’s the
information they gave us; that it is a right that we have. Because if
the state has put this in the health centers and hospitals, the places
where they talk about sexual education, then they can not come and
tell us only to take the pills, take your pills. They come the next
week and tell you, look take all the pills and next week if you want
take more. Just count seven days and take them. That’s how they
talk to us. Therefore, these people need more training and they are
people who don’t want to be there.
It can change.
We have rights now to say you can not obligate me.
We can decide, they cannot impose on us, this is good.
We need a social worker in the clinic, because the social worker is
from the country, this is what we are missing in la posta, because
she understands the people.
Now we are going to go to la posta or a health center and demand
that they explain how we use the medicine.
We are going to say they cannot treat us just any way.
It is clear the madres are now aware of their rights and have gained
knowledge regarding the type of treatment and health care they deserve. However,
the access and ability to make these changes are still very limited. The “how” of
creating change is not yet clear from the workshop or from the madres themselves.
These comments were also discussed in the observations with the women in
Lima especially in relation to the children. The madres cuidadoras described
serious medical issues with the children under their care in the Wawa Wasis and the
inability of their parents to get adequate medical care for the children. Most
235
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
reported that access to the health post for the children in their care was provided
through the Wawa Wasi program, however few reported adequate medical care for
themselves. Most women reported that they did not have a regular doctor or
medical insurance. Although most stated they had gynecological examinations,
they have normally self-treated illnesses in the pharmacy or visited the local health
center in an emergency. As mentioned, many did not even venture to the clinics for
childbirth, opting for in-home care rather than face the mistreatment in the clinics
and hospitals.
The Government’s Responsibility
The discussion of access to medical care led to issues of the State in
respects to women’s health care rights. These also included rights to education and
political involvement. Most women commented that they had little prior
knowledge of their rights as women in this arena. They felt that the State had not
effectively advocated or informed them of these rights. Now, many felt they could
demand these rights be met and required the government to take an active role in
ensuring these rights. First, the women described their understanding of their rights
and concerns about discrimination:
I don’t like how they always picture us like this (in the workbook).
Why is it always the woman from the mountains, the women from
the small town is the woman who has to be living like this, why? It
is all of us, we are equal.
This is giving a discrimination here of everyone. It’s penning us in,
marking us.
It has been on television, now you see that there are women leaders
and they say that sometimes there can be equality with men. They
236
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
were not explaining it to us, not like yesterday, and now I know how
it can happen, with my right foot forward.
There are people who do not understand, if you use protection [birth
control] they fault the husband, if you take care they say you are
winning you do not want children. There are husbands who want to
have the children they want, but do not accept what she wants.
You see this more in the families that are illiterate, this is not to
discriminate against them, it is just that you see it more there. They
do not know, they haven’t studied. But they have 8 or 9 children and
they become poorer. They are poorer and want more children and
they believe the government will help them.
This discrimination and lack of support for their basic rights are some of the
issues the women attribute to the family planning problems as well as birth rates.
They also attribute this to the socially constructed gender roles that often result in
increased issues of machismo. The participants want the State to get involved and
feel they can demand this involvement.
The State also needs to understand, not to say the State, but to
understand politically. It looks like they are dedicating more to us
women, but before we had no value.
I think now they are including us in the laws.
Or saying that we are equal, men and women have to be equal.
Equality is what it is, when both have to do things, to value us as
much as the man, the woman as much, not only one. Before the
men only wanted to mandate us the women, but not now, between
both communicating, both can do this.
I want to say what is missing; the State doses give good talks, but
need to do so about human rights because we need more of this.
Because in reality they need to treat the violence between children,
between parents, and sometimes there is abuse between uncles and
children. We can’t just cover our eyes about these things. Therefore
it is important that the State also worries about the well being of the
women like the men, because we are all human, we don’t have
differences, in color in nothing. What we need to have is
communication, for the family it is so important, first so we can
continue forward.
237
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Recognition of their rights as women and citizens as well as the
responsibilities of the government are the first steps in informing and educating
women on these rights. Now they need the means for demanding these rights and
creating true change in order to reduce their health risks and improve the quality of
care.
Social Interaction: Communicating the Message
One of the major goals of the workshop was for increased communication
regarding sexual health and reproductive rights. The training was designed so the
madres cuidadoras who participated would be able to share their knowledge with
the madres usuarias, and as an underlying effect with families and friends. In the
focus groups, the madres cuidadoras were asked if they could share this
information and with whom. Their responses to the question on ability to
communicate the information were in four categories: families, partners, madres
usuarias, and the community. Most of the madres cuidadoras felt that they could
and would share the information, although prior to the training they had reported
embarrassment and lack of opportunities to discuss these issues. When discussing
communicating with their families, many had already shared the information and
many planned to do so.
What I liked most was how they explained to me, that if I want to
have a baby and my partner is in agreement, and if I don’t want to
have one it is not an obligation. What impacted me most was also
that they gave us the idea that we can explain to our children about
sex. Because they think that a bird brings the baby, but this is not
true. I like most that we can teach our children. When we can teach
our children we win, we can’t be fearful. Because before if the
parents talked about sex it was horrible. I had my mom and until
238
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
now she is alive and I tell you she did not explain anything. For me
it was my father who explained about sex, not my mom. My mom I
see as very rare, for her it would be a thing of horror.
I really like the workbook because there are lots of thing here that
we can learn more about. There are distinct things and what I like is
that my husband and my daughter began to read it. Between the two,
and I watched, and how they explained the things in the book. This
is what I like, that my daughter asked my husband what does this
mean and he explained it to her. I like that I brought the workbook
to my house and my daughter and husband took it and saw many
things in it.
I also took it[the workbook] to my house and my little sister, 12
years old, also read it, she read it all in one night, she finished it.
Many of the women with children expressed the greatest concern for
sharing the information with their children, indicating a lack of this kind of
information in the schools. Also, that they had so little information before that they
did not want their children to have similar experiences. Some of the women
discussed sharing the information with their cousins, siblings, or sisters-in-law, but
most felt it was a topic they would share with their families. This indicates that as
their knowledge in these areas increased, they had the ability to communicate the
messages.
When asked about sharing the information with their partners, the women
felt that it would be much more difficult to share the information. They seemed to
express the most embarrassment with their husbands and partners in
communication on sex and sexual health issues. Few described ever talking about
these issues and although they felt it was important to discuss these issues, found it
unlikely that they would do so.
239
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
With your partner, it is most important with your partner, because
yesterday I spoke with my husband about sexuality and just
yesterday, do you remember we talked about the parts of a man. I
explained everything to him. He asked me what is it they are
teaching you? I told him it is something natural.
If you are confident in him, with your partner, you can talk about
this, about sexuality.
If with you are with a guy, but after years, one or two years. But if it
is at the beginning, one or two months, and no.
Sincerely, we do not talk together; I was embarrassed, up until now
when we just had this training.
Focus group question: Do you talk to your friends? No. We are
embarrassed.
Focus group question: Your partners? Worse. I don’t even tell my
husband when I am menstruating. We laugh about it sometimes. But
if they hit us we are afraid to advise anyone.
Focus group question: How do you feel inside? Destroyed.
Humiliated.
Although some of the women did mention they would and had discussed
this with their partners, most still found it difficult. As discussed previously, the
social roles and issues of machismo often stand in the way of successful
communication for these women. Again, increased knowledge does not necessarily
provide the ability to negotiate or initiate behavioral change. These must happen in
union in order to create avenues for change.
The main goal of the workshop was that the madres cuidadoras would
share this information with the madres usuarias. Most women stated they were
comfortable expressing this information with the madres usuarias. Most reported
good relationships with the madres usuarias, and although it was a sensitive
subject, they could find ways to bring up the topic. Many expressed concerns that
this was an that area the madres usuarias were lacking information.
240
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
I think we can help with a lecture in the Wawa Wasi program. I am
not sure about these children, but the parents have older children.
Therefore they are related to this talk, it is a talk for all of the family,
therefore I want us to help them too. In my home, a girl came
yesterday and said that her dad hit her mom. The children see this
and they also hit each other. This is how the chain from the parents
begins. So, I say we should also help them, give the talk to the
parents we have, the eight parents. We have the program and they
can, these eight, advise their Mends that they had this talk and that
they are gong to try and change. So they have a motivation to
change.
I think because we are closer to the moms, we can be a nexus to
allow them to learn and give this training to them. I see that they
[the trainers] know that the majority of the moms are single, and for
this they have different knowledge. Like the woman [the trainer]
said, when we came we did not know and now we can diffuse this
information with the mothers of the children.
This helped educate us a lot. It helped support us a lot because we
are working with single mothers and they need to support us to talk
to them and give them information. I at least, talk to them a lot. I
tell them to go to training, but they do not go.
I am going to casually go and make copies for the madres of this
and hand out pamphlets.
But some of the language is too technical. Some is hard to
understand.
We need more common and commercial language, with examples
and illustrations.
The madres cuidadoras felt that the madres usuarias need the information
most in their lives and that they would be able to communicate such information.
However, they felt there was a need to change some of the language in the
workbooks and training in order to make the information clear to the madres
usuarias. They also felt they needed additional support in the form of handouts and
materials that could provide further information for them and the madres. In fact,
during my subsequent visits to the homes in Lima, several of the madres had
241
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
created their own form of brochures they provided to the madres usuarias. One
madre cuidadora even held an informal lecture in her home regarding STDS and
AIDS.
In addition to families, partners and madres usuarias, the madres
cuidadoras mentioned that they would also be able to communicate the information
with the general community. This was also an underlying goal of the workshop
intervention that the information would be passed on in this method from the
madres to the community. The participants mentioned that they would share this
information with the community, and many felt it was their responsibility.
I think also that it serves us, in some cases for ourselves and in other
cases for the moms that we see in our community. Because for
example, I do not have problems in my family, but I have seen cases
of people who are hit by their husbands, they have forceful
relationships with them, if they do not want them, they hit them.
Therefore the women do what they tell them, because they do not
know their rights. Then we can convince them it is like this. We can
tell them, “no, no, no don’t accept this.” I think it is a fault of
communication and information.
There is a lot of abuse. And sometimes there are men who abuse a
woman and the women are obligated to do something they do not
want to. This is how they become abused, the children and
everything. Therefore it is beautiful to learn many things and to
teach them like you taught us, we can teach others.
It’s right what she said, that many resist this information. But look,
we can give this information not only to the moms, but to our own
friends, if I tell them to go to this reunion, this talk, it can help them
too.
The women expressed a desire and need to talk to the community. Although
this is a very difficult theme for the madres cuidadoras to discuss, most stated they
could and would share this information with the community. They expressed
242
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
concerns about many of the problems in the community and how this type of
training would be beneficial. This type of communication did occur as was found in
the homes observed in Lima. The handouts and informal training that took place in
the Wawa Wasis serve as a method of communication with the community. As
many of the madres cuidadoras serve as a resource center for their neighborhoods,
this information becomes a new theme for them to share.
Nonformal Learning vis-a-vis Informal Education
An additional goal of the workshop was that the madres cuidadoras would
take the informal training they had received and provide a nonformal learning
atmosphere for the madres usuarias. The Wawa Wasi program seemed to be a
strong atmosphere for this type of education as the relationships between the
madres were open to this type of discussion. The madres cuidadoras often
reported that the madres usuarias had no one else to talk to and trusted them with
many of their personal issues. The madres usuarias regularly stayed to converse in
the Wawa Wasi home, on issues from their children’s health to problems with their
families and partners. The madres cuidadoras reported that this type of nonformal
learning could happen and that they planned to educate the madres usuarias on
sexual health issues.
We can talk to the neighbors.
We can invite them to our Wawa Wasis and explain the theme. It is
very important for them to know their rights.
We can give the talk ourselves.
Right, like a conversation with the parents.
243
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
It is very important that they give us pamphlets to help explain to
them. A lot of them, because it helps validate what you are saying. It
helps to amplify it.
Through my observations, I saw that in cases this learning process did
occur. As mentioned in one of the Wawa Wasis in Lima, Irma invited other
madres cuidadoras and the madres usuarias to her home for a talk on STDS and
AIDS. She had invited a nurse from the local hospital to show a video and discuss
sexual health issues. In another home, Roxana created a number of pamphlets on
sexual health and AIDS that she handed out to the madres usuarias, beginning a
discussion on these themes. Many of the other madres reported in-depth
conversations with the madres usuarias about their partners, which often resulted
in counseling and advice from the madre cuidadoras.
Multiplier Effect
An underlying goal of the workshop was that the information from the
informal and nonformal education would be spread into the community creating a
“multiplier effect” of the issues. As described above, the madres cuidadoras did
express a desire to share this information with the community. They did see that
the dissemination of the information would help the community as a whole. As one
woman described, they would become a “radio” to transmit the information:
For example, us now we can teach my eight moms, call my eight
parents and talk, explain to them, and move forward for our
children. I know that they will then tell their friends and then it
starts to transmit like a radio and we hope with this they understand
and become aware, it can be like this.
I think we are like a pillar of protection, because through us we are
going to protect our children, from our children to their friends. And
244
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
we are forming the children in our Wawa Wasi, we are forming
them and the mothers will also learn to defend them. Therefore it’s
more extensive into the community. It’s a way of getting it there, to
more people, to educate more people.
Their comments do indeed express that this multiplier effect could happen.
However, the long-term effects of this have not yet been seen. Although the
madres cuidadoras I observed did share the information with the madres usuarias,
it is not clear at what level and how much information was shared. The madres
cuidadoras also expressed that they needed more support in order to share the
information effectively, through further training and availability of workbooks or
pamphlets. In addition, the strong sociocultural issues along with the severe
economic needs of the madres usuarias could hamper the ability to create the
pathway for this type of effect.
Socioeconomic Situation
As each of the conditions of successful interventions is examined in the
PROMUDEH program context, the women’s socioeconomic situation must be
considered as a “precondition” for empowerment. These preconditions from the
Cairo Agenda include access to employment and income and poverty reduction as
essential socioeconomic factors. If women are “empowered by gender equitable
social and economic development they are more likely to genuinely affect their
reproductive choices: they are more likely to want fewer children, access services,
and practice sexual behavior that is risk free of disease and unwanted pregnancy”
(Malhotra and Mehra, 1999, p. 1).
245
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
As the women spoke of the gender roles they often discussed the financial
situation of the family and how many women in the community are dependent on
men for their daily economic survival. The madres cuidadoras felt that their ability
to provide for themselves economically through the Wawa Wasi helped them to
create a level of freedom from their partners and within their families. Although
the job with the Wawa Wasi program provided limited funds, they felt a sense of
accomplishment. They often described the situation of the madres usuarias, whom
had limited options for financial stability and the situations this created in their
personal lives. Having income allowed the madres cuidadoras to make at least
some decisions in their lives.
It is more than anything, because he brings the money, for this you
have to listen to him say no, but now in our cases we have work, and
the more education that women are receiving, so we can move
forward also.
The job that we have is very good, because sometimes we are
buying life, we can die and the children are going to suffer ahead,
for this I also work, I don’t go for necessity, but for my own
children so they will value themselves. With my illness we are not
very well, and this is my only way out, that I work.
In my case, I feel good because the money I make I share with my
children, my husband and my family. I can buy something I wish
for; this is when you work.
If you do not work, there are machista men; not all homes are the
same.
My husband makes money and I want something and ask and he
denies me, you don’t work, you don’t do anything, this is the
moment when it hurts me the most. I looked for my job, washing,
selling make-up, and selling everything. People have parties, so I
made my own business, little by little, my friends and I made the
business, selling food for the parties.
246
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
When you are working and you are not receiving anything from the
man; you are also autonomous in your decisions.
In these cases, the women did feel “empowered” by their ability to provide
for themselves financially and to have employment. They recognized the limited
situations of the madres usuarias and the strain this places on their daily ability to
demand fair treatment. Their socioeconomic situations, although in most cases still
bleak, allowed them to have some voice in their home and in their families. It
helped to create some sense of power and self-worth in their lives.
The pre-survey asked the madres cuidadoras about their economic
status and whether they felt they could provide financially for their families.
Of the participants, 30 (66%) agreed that they could provide economically,
9 (20%) disagreed and 6 (13%) were unsure. This indicates that many of the
women feel some sense of economic security, while others have limited
financial resources. The position in the Wawa Wasi program does make
some economic difference, but remains very limiting.
Evaluation Results from Calandria
During the training, Calandria conducted simultaneous observations and
focus groups to this dissertation. Through analysis of the focus groups and training,
the Calandria evaluators (Aldana et al., 2000) made several recommendations for
improvements in the modules and training. These observations coincide with and
support the findings of this dissertation. Calandria recommended changes in the
themes, methodology, and modules and made overall observations about the impact
of the course on the participants. The objectives should be revised and the themes
247
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
presented in a sequence for the women to fully grasp the consequences. The
absence of men was clearly noted by women in dealing with equal rights, the value
of paternity, and in the general methods of including men in the discussion. Both
the coordinators and madre cuidadoras worried about confrontation when dealing
with gender issues. They want to talk about these issues without confrontation from
men and their partners, but regardless will drop the dialogue to avoid confrontation
and not say anything about what they are thinking. The women need a vehicle to
manage conflicts along with skills for negotiation that does not diminish them as
women. The workshops should succeed to motivate the women in their roles as
negotiators for change.
In the evaluation, Calandria noted that it is important understand that there
has been a lifetime of education that supports machismo and gender inequity when
developing this type of educational program. Media communications support these
messages in all areas. The participants did not find opportunity to change these
messages from the course and should be involved in further classes to provide them
with new information and to become part of a new education system that changes
these messages. The madres cuidadoras do not yet recognize stereotypical gender
messages. Although the madres do now recognize that jobs typically held by men
such as taxi driver or taking money on the combis can be done by a woman, they
still see positions such as a congresswoman being held by a different level or class
of woman. Women can enter the public jobs such as working in the comedores, but
it is very difficult to enter a private company such as a banker. The course did not
248
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
provide support for the madres cuidadoras to improve their self-esteem in the area
of gender messages and inequality.
The madres cuidadoras themselves support these gender stereotypical
messages with their children and the children in the Wawa Wasi. As a result of the
course, the madres now recognize that they have supported these issues and are
committed to changing these messages. However, the madres are preoccupied with
the issue of sexuality and how to develop sexual identity with the children. They
are worried if they change the typical gender messages it will perpetuate
homosexuality.
In addition, many of the madres cuidadoras feel like victims and do not
value themselves as women, especially those who do not have children, as
motherhood is often linked to womanhood. The course needs to incorporate support
in the area of the value of being women. For many of the madres cuidadoras, the
topic of family violence was very personal as they have been victims or have seen
violence in their neighborhoods. Family violence has a direct impact on many of
the children in their care. Many of the madres cuidadoras state they have been
victims and remain with their husbands for the sake of their children. They
contribute violence to a problem with alcoholism. They constantly justify family
violence to alcohol and remain victims of the violence. The coordinators need
further training on how to respond to issues of domestic violence with the madres
cuidadoras. In addition, the madres cuidadoras need further training on their rights
as women, as they do not have a clear understanding of these basic rights. As a
249
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
result of the training the madres do recognize violence as a problem in their
communities. As they gained knowledge on family violence, they began to
recognize problems within their families, and now recognize they need to create
change in their own homes prior to educating the community and the madres
usuarias. The madres cuidadoras also need more information about sexual abuse.
Although the course touched on the theme, it was not sufficient in providing
enough background and prevention strategies.
Sexuality is an important theme, but also has strong taboo and is a sensitive
topic. Some of the madres cuidadoras state that they sometimes talk about
sexuality with their husbands, but most said they prefer to keep sexual issues to
themselves. The madres also had numerous questions about sexuality, for example
why men want sex more than women do or why they do not feel anything when
they are with their husbands. The madres want more information about sexuality,
but they are nervous to discuss the theme and do not feel comfortable sharing
personal issues. Calandria recommends that the courses become less technical and
instead relate more to the personal issues of the women. This is one of the most
important topics that will help the madres with their husbands and families.
Regarding STDS and HIV, Calandria finds that this is one of the most
important themes of the course. Knowledge on this issue can have the greatest
impact on the madres and the ability to communicate the information throughout
the community. The participants need much more information as they continue to
believe in the myths surrounding AIDS, such as transmission from sharing a spoon
250
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
or from kissing. The madres have a general understanding about AIDS, but do not
comprehend how it is contracted and the difference between HIV and AIDS. The
other most important topic is that of contraceptives. The madres need much more
precise and detailed information about contraceptives, as they did not fully grasp
the information from the course. The participants did not receive sufficient
information about the male and female sexual organs; the course should be much
more explicit. In addition, the courses should include more profound details on
pregnancy and about healthy prenatal care.
Sexual and reproductive health rights is a totally new theme for both the
coordinators and the madres cuidadoras. The majority state that they were not
familiar with women’s rights, but now understand the basics of their rights. They
still need further information and details about these rights to grasp the full
concept. These rights include liberal election of the number of children they want to
have. Family planning information has been available for many years, but
especially in the rural zones, women lack the ability to make family planning
decisions, as their husbands often relate more children to masculinity. Also, women
are embarrassed to go to the medical centers, as they do not want the male doctors
treat them. The taboos surrounding sexuality remain and the madres and
coordinators express inability to talk to their husbands or sons about sexual issues.
Calandria also found that the training workshops were too long and should
instead be broken into increased sessions. They suggest that in order to make the
concepts clearer they should work with cases through analyzing the cases,
251
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
comparing them to their own lives, and understanding causes and consequences. In
addition, the workshops should be based not only on writing and lecture, but should
also include illustrations to enhance understanding. There was high participation
but poor dialogue and almost no debate on the issues. In addition, the coordinators
were not prepared enough prior to implementation in the regions. The materials
should include a glossary of terms and focus on adapting these terms to the
respective regions. The modules should also picture women from diverse
backgrounds and age groups. The madres should be able to utilize the workbooks
in the training, to clarify ideas, and to share with others.
In the gender module, there should be more concrete activities to clearly
grasp the concepts. This module should focus on how to communicate with
partners and issues of equality. Objectives should be redesigned to include
recognizing the situations of inequality affecting women, recognizing how the
situation is reproduced through education, methods to revert this situation, and
should involve both men and women. Family violence should focus on two issues
of child violence that directly effects the Wawa Wasi and domestic violence that
directly effects the women. It is clear they recognize violence, but prevention
methods are not presented effectively. Inclusion of videos or dramas would help
this process.
Regarding sexuality, the discussion of sexual organs should be combined
with STDS and contraceptive methods to increase understanding. The women also
expressed a need to discuss all aspects of abortion. The coordinators need more
252
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
preparation on these issues. Groups should be separated by age so that younger
women are more comfortable expressing their ideas. The sexual health and
reproductive rights module should have clearly focused objective. Understanding
their sexual needs is a process much more complex than knowing what their rights.
There should be much more work on negotiation and understanding of the legal
framework. Again it is necessary to incorporate men into the dialogue and
formulation of rights (Aldana et al., 2000).
These recommendations from Calandria support the findings of this
research and observations of the implementation of the modules and focus
groups. The current intervention did not successfully address gender
relations and did not provide the women with adequate skills for negotiating
with their partners and understanding the gender discrimination in their
society. The women need to be further motivated and provided the
resources to confront gender inequalities and to voice their rights as women.
253
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Section Three
Life Realities
In each of the regions I visited, I was able to spend time with some of the
madres cuidadoras to get a glimpse into their lives as they function on a daily
basis. Although the trainers had specific goals and objectives, I was curious how
these ideas really meshed with the realities the women face each day. Each of the
women volunteered for these observations and interviews and eagerly invited me
into their homes. They became key agents in creating a clearer understanding of
the problems and successes they face in their daily lives. We discussed the themes
from the workshop along with issues about their own sexual health and
reproduction as well as with their families. Accessibility to the site enabled me to
spend the majority of the time with the women in Lima. During each of the three
time periods I was in Lima, I was able to see how things had changed and what
may have developed in their lives. They opened up their homes and lives to me,
and these are their stories.
Lima-Callao
As mentioned, access to the location allowed the in-depth interviews to take
place in Lima throughout the three time frames of the study. Six madres
cuidadoras participated in the long-term study. The participants were chosen on
recommendation from the coordinators, their willingness to participate, and access
by the researcher. These participants resided in six distinct districts in Lima and
Callao. They ranged in age from 28 years to 46 years. One was single, three were
254
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
separated and two were married. Two of the participants had no children, one had
one child, two had three children and one had four children. Their education
ranged from three who had completed secondary education to three who had
completed university. In most cases, I spent extended time with their children and
families during the interview process in order to glean a full glimpse of their lives
and relationships.
Irma
The Wawa Wasi is located in Lima, just west of downtown. The
neighborhood is low-income. People line the narrow streets, talking, walking, or
just hanging out in doorways. Just two blocks down from the central plaza and
school, Irma’s house is easy to spot with the Wawa Wasi sign displayed
prominently on the wall. On my first visit, a metal can was burning with high
flames on the street in front of the home. Entering through a screen door of thick
metal bars, I found myself in a small hallway. On the left were two makeshift
rooms, recently constructed from plywood. In between the rooms, furniture was
stacked nearly to the ceiling, beds, chairs and a dining table could all be seen. The
hallway led to a large open patio area providing home to the kitchen. From this
patio was an upstairs apartment, where Irma’s parents live. Around the kitchen, a
separate doorway led to two bedrooms and the bathroom. Irma’s daughters and six
of the children from the Wawa Wasi were sitting on the bed in this back room
watching television and having lunch.
255
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Irma lives here, in her father’s home, with her three children; girls age 19
and 18 and a boy 16 years old. Irma, 45 years of age, is a tall, very attractive, black
woman. She always dresses professionally, in business skirts with a blouse and
heeled shoes. Irma is separated from her husband, although I later found that the
family also shares a house with him. She stays in the Wawa Wasi during the week
and in the other house in Pueblo Libre, a nearby district in Lima, on the weekends.
Her children go back and forth from the two residences. With a post high school
education, Irma was a secretary in a company until 1980; from there she worked in
different restaurants and made pizza in a pizzeria at night. She had heard about the
Wawa Wasi program when in first came into being and decided to try it. She has
run the Wawa Wasi for six years.
Irma is very connected to the families and the children in the Wawa Wasi.
With very little pay, if any, the madres cuidadoras often become the main
caretakers for the children. They also can become extremely enmeshed in these
families’ lives. This hints to the possibilities for communication and sharing of the
information Irma received in the workshop. With close connections to the family it
is more likely that avenues for communicating these types of sensitive messages
will be available. Irma becomes very involved with the families and is
knowledgeable about all aspects of their lives, including their relationships. It
seems an opportune way that sensitive issues can come to discussion with the
madres usuarias.
256
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
After the PROMUDEH course, I talked to Irma about her thoughts on the
class and what she learned. She had training like this before, but mostly on
pediatrics and child development not about contraception.
We talked about AIDS and HIV, it helped a lot. I didn’t know they
were different. It was very interesting and important for everyone.
These are things we are close to, for example how are AIDS and
HIV different. What is the quantity of sperm in ejaculation. In la
posta I had heard about the topic of sex and AIDS, but this training
was much more informative. We were able to talk more, yet we are
still missing some. We are missing family planning.
Irma felt that she learned a lot in the class and that she would be able to
share this information with others. She could talk to the madres usuarias and would
plan to share the information with her own children as well. She also talked about
the reunions they have once a month with the other madres cuidadoras from her
area. Here, they talk about problems with the daycare and other problems they
have. They learn about different activities to help the children. Like many of the
other madres cuidadoras I met, Irma appeared to be a center of resources and
information for both other madres cuidadoras and madres usuarias. She said a lot
of the others did not receive the same training and preparation she had. There are
three other Wawa Wasis nearby and they always come to her for advice and with
questions. They help take care of each other’s children and take turns going to get
the food from the comedor. Irma, then, has the ability to become a central
communication media for the neighborhood and Wawa Wasi. As these women trust
her and reach out to her for assistance in other areas, this may transfer to the topics
of sexual health and reproductive rights.
257
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Irma talked very little with me about her husband. She told me that she did
not currently use condoms, as she did not need them. She was not planning on
getting into another relationship. Irma stated she did gain a lot of information in
the workshop on condom use and safe sex. However, the decisions she makes and
her ability to negotiate safe sex cannot be determined until she is in a relationship.
Currently, she is practicing abstinence as a form of safe sex. Research does show
that increase in knowledge does not necessarily equal behavioral change, however
this cannot be fully assessed unless Irma enters into a new sexual relationship.
When I returned to Lima in December, Irma invited me to a reunion in her
house where they would be discussing sexually transmitted diseases. Irma had a
friend who was a nurse at the local hospital. Part of her studies required her to give
several presentations, so Irma offered her house. Five women, a mix of madre
cuidadoras and madre usuarias, attended the meeting. Squeezed into chairs in the
small front entry hall, the nurse explained the different types of STDS and the
problems related to them. She also spoke specifically about AIDS and its
consequences. Cartoon drawings on poster board provided support for the lesson.
A video gave the causes and symptoms for each disease. The video also went over
high-risk behavior and how to protect yourself from contracting AIDS and other
STDS. After the video, the nurse discussed the importance of fidelity, but said in
married couples you do not use condoms any more, but it is still recommended.
She also stressed the need for regular gynecological exams.
258
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The participants in this meeting all seemed very interested in the topic.
They had a lot of questions afterwards about cervical cancer, condoms, and many
about AIDS. It seems that Irma, was indeed sharing the information she had
learned in the course with the others. Although she did not provide the direct
information, she was able to gather resources that enable her to distribute
information to the madres. Irma told me she did have a few opportunities to speak
with some of the madre usuarias about the course. She warned them about AIDS
and told them to only have one partner. This shows that continuing communication
about the topics learned in the workshop did occur in this instance. Irma did share
and communicate information to others. The result is that the informal educational
component did occur; however, the more long-term multiplier effect in the
surrounding community is uncertain.
Four months later, upon my third visit to Peru, the household had
significantly changed. Paola, Irma’s oldest daughter, was pregnant and had a baby
in March, a fact she had hidden from her mother and everyone else. Irma and I
spoke at length about her concerns and feelings about the pregnancy. She informed
me that she was unaware of the pregnancy the last time I was there. She was very
upset with Paola, but loved the new baby very much and was willing to take care of
him. The father was not in the picture and they had some serious concerns about
the baby’s health.
The birth of the new baby partially verifies assumptions that although
communication did occur the behavioral change was not significant. It is unclear
259
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
how much information Irma shared with her daughter. In any case, Paola may very
well have used a condom, as this method is not totally effective in avoiding
pregnancy. The pregnancy does bring up issues of communication and information
sharing and would need further investigation to determine Paola’s level of
information and understanding about safe sex and ability to negotiate.
Things had also changed significantly with the Wawa Wasi program. Irma
only had five children in the home; stating it had become increasingly difficult to
get new referrals. With the recent governmental changes, she had heard that the
Wawa Wasi program might move back to the Ministry of Education. She felt this
might be better in that the ministry had more resources. When they were originally
with the Ministry of Education in 1994, they received more training to help with
the children. She had a lot of new children, the parents worked in the markets or as
vendors on combis (bus) and micros (van). One child stays from the early morning
until seven at night. She felt she still needed further resources with the children,
especially on teaching language and spelling. Irma felt it was necessary to have
social workers for the madres usuarias themselves:
They should come to the house like social workers because it’s only
the moms. They don’t want to give the father’s name. They don’t
receive any money or anything from them or for the baby. When
the baby has the mom’s last name it is like they are sisters. We need
help for them on how to talk to the fathers. Maybe it’s something
they can resolve. The moms have to pay the apartment and the
Wawa Wasi, they can not provide the nutrition that the children
need. They often have bad jobs, they do not get paid but still have to
work. They have no one to talk to, they talk to me a lot. They listen
to me sometimes. Some can’t pay me. They work as maids or
selling on combis or washing clothes, when they get here they just
want to talk.
260
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
She said she shares as much information as possible with the moms. When
she gets materials and resources from the classes she brings them home to share.
One friend is giving talks for family planning as part of her thesis. She has invited
to her to talk to the madres and she will provide the training for them.
In the case of Irma, a direct observable result of the workshop intervention
was found in communication with madres usuarias. By inviting others into her
home for the lecture on sexual health, a true informal education process had
occurred. Through her role as day care provider, Irma does become a knowledge
provider for the madres usuarias and other madres cuidadoras. Although she may
not have had the direct personal skills for passing on this knowledge, she was able
to gather resources to share with the madres. Irma’s relationship with the madres
seems to be one of trust and openness, where this type of sensitive communication
could occur. However, it is unclear if these messages were also translated to her
family. Irma is a central resource for the community, making this a good
atmosphere for a multiplier effect of the learning to occur. In the case of her
behavior and impact of the training, it is uncertain whether behavioral change or
increase in condom use occurred. The environment and context of Irma’s personal
relationship with her husband was not established, so communication and
negotiation can not be fully evaluated. It appears that the main results of the
intervention were knowledge gained and communication of the message.
261
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Claudia
Brena is located south of the center of Lima; the neighborhood is extremely
poor. Even the taxi driver warned me that the neighborhood was very “active” and
that I should be careful. Drug sales and use are rampant and the houses are always
locked with bolted metal gates. Claudia’s house was very small with very sparse
furnishings. Entering the home from the street, I found myself in a small hallway.
To the right was a small living room with two couches. This served as the play area
for the children.
Claudia, age 43, is divorced. She has four children, a boy 19, and three girls
aged 18,17 and 3 years. The father provides the main financial support for the
family. Like Irma, Claudia appears to be a center of information and resources for
the neighborhood. The home constantly had visitors, stopping by to chat or to ask
about programs like the Vaso de Leche. Claudia told me that she meets a lot with
the other madres cuidadoras in the neighborhood and they often share ideas and
problems. They meet with the coordinator once per month. She has also attended
numerous classes including topics of vaccinations, child development, anemia,
family violence, and sexual diseases. Claudia, in fact, represents the Wawa Wasis
from her area at the various training and reunions. She is very proud of the fact
that she met the former Minister of PROMUDEH, Ministra Cuculiza, and former
President Fujimori’s daughter at the events.
This type of interaction with the community and those in the Wawa Wasi
program provide means for communication and information sharing. Claudia is a
262
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
valued member of the community who others come to for assistance. Again, as in
the case of Irma, it appears an effective basis for informal learning to occur.
Claudia’s relationship with the madres is based on trust, which may allow for
discussion of sensitive issues.
Claudia and I talked about the sexual health course and how she felt about
the content. She felt it was extremely helpful and described something about her
past knowledge:
It helps so much; I can help the moms or talk to my daughters. For
example, I thought AIDS and HIV were the same. I asked my
daughter and she told me, “No mommy, they are very different.” I
was very hidden when I was young. I did not know anything [about
sex]. I am learning more little by little. When I came back from the
class, I spoke right away with my daughter and friends about AIDS.
We had two neighbors, gay men, who had AIDS. We used to play
volleyball with them, now one is in the AIDS clinic. They were
very skinny, with white skin and very sick.
I can talk to the madre usuarias about sexual issues, and I do a lot.
Everyone comes to my house to talk. They are all very anxious to
learn as much as they can. The free training is very good for them. I
am only a little embarrassed. One mother talked to me, she was
afraid to have a new relationship, afraid of diseases and doesn’t
want to have a new baby. Another mom had two babies, the first
dad was a drug addict and the second is married. We talk
sometimes for hours and hours.
This class helped me a lot. I was missing a lot of information, but I
learned a lot. I am very shy and these helped me to talk more.
Everything I learned I told the other Wawa Wasis. I talk to them
and go to their houses. They always ask if we can meet in my house
and I always offer it.
Claudia felt she could share the information she had learned and was very
willing to do so. She felt that she had changed so much in that she was beginning to
learn things she had no idea about, nor had ever discussed in the past. Claudia also
263
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
felt that she could protect herself from AIDS but she stated she did not need to use
condoms because she did not want to be in any physical relationships.
The baby’s [her daughter’s] father left, he just disappeared. I do not
want any more problems like that. I have no one now. I am not
going to get in another relationship, it’s closed to me now. I want to
do this for my daughter. It’s not her fault, I need to work for her and
make sure she doesn’t lack anything. My ex-husband told me I am
young and can find someone. But not now, I don’t want it, I am
tranquil now.
When asked about using condoms is she was in a relationships again she
stated, “I have never bought condoms before, but they give them free in the
hospital. They give pills or anything you want.” Claudia is currently using
abstinence as a form of safe sex, and did not plan to get involved in further
relationships. If Claudia does get into a relationship at a some point, then her ability
to internalize the information and negotiate safe sex would have to be determined at
that time.
Claudia’s three oldest children are in school, two in university and one in
high school. Her ex-husband is the only one in the family who works and provides
for the family financially. Her oldest daughter took one year off between high
school and university and helped her with the Wawa Wasi. Claudia appears to
have a very close relationship with her children. She shared the survey she was
provided in the workshop and asked her daughters to read it and try to answer the
questions. She also asked them for information on issues that she did not
understand. The daughters had more information on AIDS issues that they had
obtained in school and were able to provide their mother with correct answers.
264
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Claudia’s son, however, did not appear as involved with the family and was
constantly coming and going to school.
In my family, I talk a lot to my daughters, but not my son. I give
them liberty, I trust them, but I am also afraid. They study these
sexual issues in the university. One book has over 200 pages about
ADDS only. For my part, it is better to talk with my children, to see
things in a different way.
Claudia’s financial situation is similar to that of the majority of madres
cuidadoras. In this case, Claudia is dependent on her ex-husband for financial
support for daily survival. One of the Cairo Agenda preconditions for effective
intervention programs is access to employment and income. However, in this case
it is not enough. Claudia can not be fully financially independent through her
employment with the Wawa Wasi. This places her in an extremely vulnerable
situation that can result in the inability to communicate, negotiate, and express her
desires and rights.
Claudia explained that Wawa Wasi program had changed a bit in the last
few months, due to the changes in government. They opened a new Wawa Wasi
last month, but the coordinator was not invited and this was not the norm. They
had several classes in the previous months. The most recent topic was on rights and
the law. They will also have training for the madres usuarias in the next month,
but she was concerned that few come to these training sessions due to their work
schedules, which is a major deterrent for their participation.
Most of the children come at eight in the morning until seven at
night. Our job ends at 5 p.m., but in these cases, we have moms who
work late and what do we tell them, come at 5? If not they will take
the children to sell candy on the combis, up and down the bus
265
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
selling. They are too tired. So, I tell them to tell the truth and come
when they are finished, no problem. One boy stays overnight often.
His mother works in an office, and in houses at night. He is like one
of my children. I miss him if he is not here. The moms do want
more training. For people who do not know a lot, it helps them a lot.
She was also concerned about the health care provision. They used la posta
in the past and they also came to the home once per month, but she heard that the
contract with the Ministry of Health and PROMUDEH had ended. She was not
sure what was going to happen. She took a child to la posta last week and they told
her they do not accept the Wawa Wasis anymore. Claudia expressed her frustration,
“When we have an epidemic like hepatitis or chicken pox, they help everyone for
free. However, when there is no epidemic, they abandon us.” These issues mirror
those discussed in the focus groups. The madres describe a serious lack of access to
quality health care for the children and themselves. She does recognize this as a
fault of the government, but the ability to take things a step further and demand
health care rights is not realized.
During my final stay in Lima, I again spent time with Claudia. The
apartment looked very good. They had hung up paintings and decorated the play
area for the children. The Wawa Wasi continued, but they had fewer children then.
She was very concerned about the changes with the new government and whether
the Wawa Wasi program would continue to exist. During the past few months they
had only opened community Wawa Wasi sites and planned not to open any more
private homes. She had been told that the government would support only
community sites and that the private homes with more than six children would also
266
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
be considered as possible sites. All of the employees at PROMUDEH above the
coordinator level had changed. Her coordinator might only have a job for a few
more months. As a result, her daughter also lost her job with the Wawa Wasi. This
became a central issue in the sustainability of the reproductive health program,
which is discussed later in this chapter. With the lack of sustainability, Claudia
cannot get the support necessary for her role as knowledge provider for the madres.
She is limited in her role as a cuidadora with the changes in the ministry and the
lack of ongoing support.
Claudia had a few questions about the survey they had taken before the
course. She had a few questions about AIDS. Her daughter was very
knowledgeable on the subject and provided her mom with a lot of the correct
answers. Claudia still was not in a relationship and does not plan to get in one. But,
if she was, she is not sure she would use condoms. She is still timid about the
subject and is not sure she would be able to talk to her partner about this.
Claudia pointedly expresses that she is unsure of her ability to effectively
communicate and negotiate with her partner. She has never purchased condoms and
has not been provided with a method of accessing these if in a new relationship.
Claudia did exhibit an increase in the ability to communicate with her family and
with the madres usuarias. In sharing the survey with her daughters, she provided
both sides with new information and knowledge of AIDS and sexual health.
However, she had very limited communication with her son on these themes. This
is similar to the case of Irma, who was much more involved on an intimate level
267
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
with her daughters than with her son. In this situation, knowledge and
communication did improve following the intervention; she is also practicing safe
sex through abstinence. Her ability to negotiate and communicate on safe sex issues
would have to be assessed if she does get involved in a sexual relationships.
Although Claudia is able to recognize her rights as a woman and a citizen,
especially in the case of health care, her ability to demand these rights remains
limited.
Susana
Susana’s home is located in La Victoria, one of the nicest neighborhoods I
visited. Susana lives in a small complex with two apartments. Her apartment is on
the top level. The Wawa Wasi is separate from her apartment, it is actually a
converted garage which she rents from the apartment manager. The Wawa Wasi is
set up like a typical preschool. There are toys, paints, small tables, lots of photos.
On my first visit, the area was decorated for the 28th of July festivals [Independence
Day] in Peru. There was a large easel outside on the sidewalk with the name and
information about the Wawa Wasi, so that visitors and new parents can easily
locate the home. Susana uses the upstairs apartment to cook for the children. The
downstairs has a bathroom, outdoor patio, and small cots for the children to sleep
on.
Susana, 36 years old, has three children ages 16,13 and 6 years. On most
visits we met downstairs in the Wawa Wasi and her children were rarely present.
Susana is married, but her husband works in the provinces and spends a lot of time
268
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
traveling. Susana has worked in the Wawa Wasi program for five years. After
completing university and her teaching credential, she worked as a special
education teacher for eight years. When she had her last child, she decided to stay
home and the Wawa Wasi program seemed the perfect fit. She often spoke about
returning to teaching or to the university to improve her education and get a better
job.
The Wawa Wasi seemed to be a general center area for the neighborhood.
During each visit, several people stopped by to ask about the program or to talk.
Most people stated they noticed the sign or had heard about her from neighbors and
wanted to see if there was room for more children. Susana stopped several times
during each visit to talk to passersby with questions.
Susana feels she has very little contact in general with the other madres
cuidadoras, only when the coordinator brought them together, but not all of them
participate. Susana feels she has a good relationship with the madres usuarias. If
she asked them to come to a talk or class about health they would come. She feels
the majority of the women are interested in attending these types of programs and
want to come, especially the younger ones. Very few have opportunities to talk
about their husband or partner. Susana became a person they can confide in and
share information. She seems to have developed trust with the madres who are
willing to share sensitive issues with her. She also provides a central resource
mechanism for them that includes referral and direct information on these issues.
The madres usuarias do not know about stuff, for example those
things [condoms] are free in the health center. They live in poor
269
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
areas; some live upstairs in small rooms and do not have help. The
Ministry of Education did not even want to open a Wawa Wasi here,
but it is needed.
When discussing her participation in the sexual health course, Susana felt
that she learned a lot and that it was very beneficial for her:
We did not have this when I was in school. I know about it, but can
not transmit the information to others. When I got married, I did not
know one thing. I found out after my first baby. The doctor gave me
birth control pills without even asking, he just said take this. Now, I
know more, I learned a lot. There was not a lot of information in the
university either, but I think they talk about it more now in school.
This class was clear, I learned a lot. I always wanted to learn, I
always asked the doctor about contraceptives and things. I had
never, for example, seen the IUD and I had one before, so I was able
to see what it was like.
Even though Susana had achieved a university education, her prior
knowledge of sexual health was limited. She felt she gained substantial information
in the workshop. She also describes lack of information and adequate health care
from current health care sources and recognizes these as very limited. When asked
about her prior knowledge of AIDS:
I knew various things, like contamination, or how a person gets
infected. I know I need to protect myself, also that it is only passed
on through sexual contact, needles, blood or from mother to child. I
heard about it in talks at the health center or on posters on walls, and
I also heard about it on the radio. AIDS is the virus that infects all
of your defenses. You need to be very careful and be sure the
couple is protected and be sure with the children also.
I am married and I know that most married women don’t protect
themselves. I trust my husband is not with anyone, but I do worry
because he works in the provinces. I have told him to use a condom
if he is with someone. Then he gets worried with me, so how can I?
I don’t protect myself, I can’t use condoms, he would think I am the
one with someone else.
270
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
This statement touches the main concerns about current AIDS intervention
programming. Knowledge and information are not enough if the participants are
not given adequate skills for negotiation and communication with their partners.
Susana describes a very serious “catch-22” that may be the typical case for many
women. She finds it likely that her husband is with other women and recognizes
the risk this brings to her; however, she is unable to negotiate effectively with her
husband. If she asks him to use a condom, he questions the trust with her so she can
not be successful in this situation. Here the course helped her to recognize her risk
and to increase her knowledge, but did not provide her with appropriate outlets
with her husband. This is a case that is repeated in many relationships, continuing
the high-risk situations in which many women find themselves.
When asked about purchasing condoms and the availability of
condoms and birth control:
I have never purchased condoms. They give them out in the health
center. My husband buys them. I would be too shy to ask for them
in a pharmacy, I prefer for him to buy them. Other people don’t use
anything. I am now using pills, from the health center, they sell them
or give them free there, and I used to buy them.
This situation places increased jeopardy on Susana’s sexual health. She is
using birth control pills to prevent further pregnancy, but does not protect her
against STDS or HIV. The lack of access to condoms is a serious concern
expressed by all of the women in the study. Most know where to purchase
condoms, but lack the basic right to be able to do so.
271
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Susana mentioned she had participated in other training on topics of
nutrition and first aid. She says there are not a lot of opportunities to talk to others.
She has very few friends she can talk to about sex and other personal issues, but she
felt she was able to ask questions and make comments in the class. She also felt it
was very important to talk with her family and children.
You need to educate the men as well to prevent pregnancy. The
women are more careful, but I think it is difficult to talk to them. I
tell my children to stay “pure” until marriage. We are Christian. I
tell them that sex outside of marriage is bad and there are
consequences. My boys are embarrassed to talk with me, but I do
talk to them. I do talk more with my daughter. My son is more
embarrassed with me than she is. It think it is better for him to learn
in school, he can listen and talk. It is also very difficult to talk with
my husband. He never had sex education and is closed to these
issues, so it is very difficult.
Susana describes a similar situation as the other madres cuidadoras. They
are comfortable sharing information with their daughters, but are limited with their
sons. So where are the boys getting information about sexual issues? If they are
learning from their fathers, then it becomes a repeated cycle that cannot stop until
men are educated on sexual health issues. Susana, as discussed in the focus groups,
recommends including the men in education and training on sexual health issues.
Susana describes the most serious problem that many of the women face in
their relationships dealing with their ability to protect themselves. If they are not
given skills to negotiate safe sex and communicate effectively with their partners,
then all the knowledge they have will not help protect them from high-risk
situations. With a university education, Susana still lacked the basic information
she needed about sexual health and reproductive rights. The workshop served to
272
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
increase her knowledge and ability to communicate the information, but did not
provide a method for behavioral change. All of these issues support the research
recommendations that men must be included in educational interventions. Men
must become partners in the learning process in order to access opportunities for
long-term change in gender issues and equal rights that place women in situations
where they lack the ability to protect themselves from AIDS and from the ability to
voice their basic rights as women. This can happen if men and women are part of
separate educational processes that evolve into opportunities for combined
communication and opportunities for dialogue.
Roxana
Roxana lives in San Miguel, an area southwest of the center of Lima that
runs along the ocean side. The neighborhood is low income and the house is very
small. The home is located near an elementary school, so children in school
uniforms are constantly walking down the street. The street is somewhat busy,
with taxis and cars and many people walking. The front door faces the main street.
As I entered I had to step down into a small patio where the children were busy
playing. To the right was a sparsely furnished living room, two couches lined
either wall, both covered with blankets. A dining room table and three chairs were
to the left in front of a bookcase, with a television blaring. There are several
posters of Wawa Wasi information and photos of the family hanging on the walls.
Straight ahead a curtain served as a door leading into the bedroom, with a dirt floor
and two sets of bunk beds. The kitchen area and bathroom are located on the other
273
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
side of the patio. The kitchen had a sink, shelf and oven, all very dark with no
windows. To the back was another bedroom area. On my first visit, Roxana was
there with her daughter, granddaughter, brother, and nephew.
Roxana resides here with her daughter (19 years old) and granddaughter (2
years old) and her adult brother. Roxana is 45 years old and separated; her
estranged husband lives in Miami. She reports having many problems with his
family and has very little contact with him. Roxana was a secretary for twelve
years. When her daughter became a teenager she decided it was better to be close to
home. She began taking care of her niece and opened the Wawa Wasi. She
completed five years of high school and took English classes. Roxana has had
some medical problems and was in the hospital last year. She says it was a
syndrome of stress and her age. She had many tests, but with vitamins she is getting
better now. She states she is happy the way things are and plans to stay single. She
participates in reunions with the family and the Wawa Wasi only and sometimes
with friends, but does not want anything else.
I am not in a couple now; I am very tranquil. I had a gynecological
exam and all is ok. I am 45 years old now, 46 this year. My
husband lives in Miami and we have a lot of problems. For two
years we did not receive anything from him. He has to come here
and sign everything [for the divorce], there are many problems.
There are many problems with his family here in Lima.
Like Claudia, Roxana states she will ever get into a relationship again
although she is estranged from her husband. Roxana is practicing safe sex through
abstinence. Her knowledge and understanding about safe sex did increase as a
result of the program, but as she is not currently in a relationship the ability to
274
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
negotiate safe sex is cannot be assessed. If at some point Roxana decides to enter a
new relationship then behavioral change could be evaluated.
Roxana participates in many reunions with the other Wawa Wasis from San
Miguel. They were in a parade that week and they often meet as a committee. She
does have access to the Vaso de Leche program; she goes every two weeks with
two of the madres usuarias. Many of the other Wawa Wasis do not receive these
services, only in San Miguel as it is a low income area.
When discussing the course, Roxana stated she found it very interesting in
that it “opened our eyes” to things such as contraceptive methods. She has been
involved in many courses before such as health, nutrition, first aid, and
reproduction. The university gave a training, but most are at la posta or in
someone’s house. Regarding AIDS, there was very little training before, mostly at
the health clinics. When Roxana’s daughter became pregnant two years before, she
went to the clinic with her and heard about AIDS. Most of the moms were very
young and they discussed these types of things. Roxana feels the PROMUDEH
course helped a lot and that she would be able to share the information with the
madres usuarias.
This helped a lot. I am very interested in this. I had read magazines
before. But, the madres usuarias don’t know a lot. One thought that
you could get AIDS from a kiss or handshake or something. I can
explain this from the talks about health. I have a collection of
pamphlets from the Health Center. Many of the madres usuarias are
very young, their husbands are risky, I can explain this to them.
Roxana appears to have a good relationship with the madres usuarias.
Many stay to talk and visit in the home. She talks to one about the health of the
275
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
child, the visiting neighbor also gives advice about how to resolve the child’s
health problems. Roxana feels that further talks should happen at the level of the
municipality so that the community and public will attend. At public places open to
the community, such as the Vaso de Leche, everyone has access to go and get new
information. These provide good locations for lectures and information sharing to
take place as is being done with the Flora Tristan SISMU program described
earlier. In addition, the Wawa Wasis appear to be accessible locations for similar
educational opportunities.
Roxana continues to receive assistance from Vaso de Leche and has one
reunion per month with the other madres cuidadoras. There are also talks at
PROMUDEH for the madres usuarias about violence and children’s education.
She states that the madres talk to her a lot about their husbands and the health of
the children. She feels they have a lot of confidence in her. Most are single and
confide in her a lot about their partners as they do not have anyone else with whom
they can talk. She talks to the madres often about everything including the classes,
health and their husbands. She shows me the legal contract she has with the parents
of the one girl ensuring that the father will pay the Wawa Wasi. Roxana describes
closeness in these relationships and she is certainly knowledgeable about their
personal issues and relationships, but it is not clear if the madres usuarias see her
as a close person with whom they could share more sensitive issues. It appears to
be more of a teaching type of relationship that one of shared trust.
276
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Roxana had taken it upon herself to create a collection of pamphlets and
information for the parents. She showed me the information she had collected on
AIDS and condoms and health. She loves attending talks and meetings and gets
most of her information in these informal educational settings. She shares this with
all the madres. She asked me about the female condom, stating they now have it in
Peru. She is not sure how to use it and asked for my advice. We talked about how
it works and how women have the control of this type of contraceptive. She told
me that the madres usuarias have to talk with the husbands and share everything.
She would love for PROMUDEH to have another meeting to get more information.
This is another instance where the workshop encouraged the madre cuidadora to
go out and seek more information. This information was then shared in informal
learning settings with the madres usuarias and the community. Here, a multiplier
effect of the information did seem to take place. Roxana was very interested in
learning as much as possible on the topics and sharing this new knowledge. In this
situation her role as day care provider enhances her ability to share the knowledge
with the madres.
On my final visit, several months later, Roxana had been very sick with
asthma. She stated she was getting better, but that she had to go into the hospital.
There were three children in the home, plus the niece and her mom. Roxana asked
for copies of the survey given prior to the workshop so that she could share it with
the madres usuarias and neighbors. She would like for me to come back and visit
and perhaps have a talk with some of the madres. She would like to discuss the
277
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
questionnaire and talk with them. “Maybe we can discuss it with them and teach
them. Because it helped me a lot and they could understand more about these
topics”. Roxana continues to seek more information and education and addresses
the need for this to occur with the madres usuarias.
The house appeared the same, but there were fewer children. Roxana
appeared very tired and drawn from her illness. She shared with me several fliers
she has created for the madres usuarias. These were copies she has gained from the
different meetings, and imposed the name of her Wawa Wasi on the cover. She
handed these out and shares the information with the madres and padres.
Roxana truly became a resource for disseminating the information and
knowledge gained in the workshop out to the community. This case shows that the
effects of the educational intervention were multiplied through her own resources
and desire to increase her own knowledge and those of the madres and the
neighborhood. Roxana developed her own pamphlets and went to additional
lectures in order to improve her knowledge base. This was one of the main goals of
the workshop intervention. Roxana did gain extensive knowledge on the topics of
sexual health, but still does not appear to have applied these to her own life. She is
abstinent now, but is not in a relationship. The true long-term effects of the
intervention would be best evaluated if she were to enter into a new relationship,
through her ability to communicate and negotiate. In addition, she is able to
recognize some of the major inequities through the lack of adequate medical care,
but has not done anything to demand better treatment. Although she is aware of her
278
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
rights, she has not yet demonstrated the ability to mobilize and create change at this
level.
Carolina
Visiting Callao for the first time, I set off in a taxi. Upon arrival, the taxi
driver was very concerned; asking if I wanted him to wait and telling me this was a
very dangerous neighborhood. He advised me to only walk back the way we came
and not to go any further forward. It was very difficult to find the home, in that it
had no official address only a “plot” number signified by the name of a fruit. I
finally found the house on a small side street, but predominately displaying the
traditional Wawa Wasi sign. The taxi driver waited for me until the door was
opened and I stepped inside.
The house was very small, a cardboard roof covered dirt floors and plywood
walls, with sunshine spilling in the holes barely covered with newspaper. As I
entered the living room, I found a small worn couch and chair, a dining room table
with five chairs, a small table with a television and a pantry. There was electricity
with one light bulb hanging in the center of the room. Wawa Wasi posters and a
clock adorned the walls. To the right was a curtain partitioning off a bedroom with
a bunk bed, one wall brick the other plywood. Straight in from the living room was
a small hallway leading to a bright kitchen with limited ceiling covering. There
was a small table and toys for the children in the living room.
Carolina, age 40, lives in this small house with her husband of fifteen years.
They have no children. Previously, Carolina worked in a comedor in La Molina
279
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and in a higher education institute. She has a high school education. Carolina’s
husband is a fisherman and the family has suffered financially the past years due to
problems with the fishing industry caused by El Nino.
There are two other Wawa Wasis nearby and they often meet together. They
also try to have meetings each month with the madres cuidadoras. These types of
meetings are helpful for her as they provide opportunities to talk and hear
everyone’s opinions. Carolina, like the other madres, describes a supportive
environment provided by PROMUDEH that includes educational opportunities.
Through the interactions with the other madres, they develop their own support
system and increased opportunities for personal communication.
Carolina reports she was very interested in the sexual health and
reproductive rights course and found out many things she did not know prior to the
training. She had been to talks before about nutrition and development, but not
about this. She had participated in reunions and talks about cancer and even
pictures on the wall describing these themes, but not about AIDS.
It was very nice and interesting. I didn’t know for example that sex
and sexuality were not the same. Also about AIDS, here in the
barrio we have people who live a bad life, we hear about those who
have AIDS. I had no information before, this helps me a lot.
I can talk with my husband and he explains some things to me. I
can talk to him about AIDS; he explained everything to me about
AIDS. I can talk to many people in my family, my in-laws and
sisters. But, not my family, they are old-fashioned. I did not learn
anything about this in school, only from talking to my husband,
never with my parents.
280
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In this case, Carolina describes many opportunities to share with family and
friends and open communication with her husband. This is not a situation
commonly described by the other women. She feels she has adequate outlets for
personal relationships as well as an ability to talk about sexual health issues with
her husband.
Carolina feels that now she can explain AIDS to the madres usuarias. She
would explain to them that it “is a disease you contact from HIV and that you get it
from injections or sexual relations”. She stated that she would explain to them that
they need to take care of themselves by using condoms. She is able to share the
information she has gained in the workshop, providing another case of informal
learning with the madres usuarias. Therefore, increased knowledge and ability to
communicate the messages has occurred both in this case and possibly with her
husband.
Carolina states that condoms are available at la posta; they give condoms
and pills to the madres usuarias. She said that she could not buy condoms herself
and feels it would be very difficult to do so in the pharmacy. Her husband would
ask her why she was buying them. “I don’t use anything. My husband is here in the
house, we don’t use anything.” This situation goes back to the one described by
Susana in the negotiation with the husband. In this case, Carolina is practicing safe
sex through what she feels is a monogamous relationship with her husband. But, it
also points to the problems with access to condoms due to the stigma that follows
women who would purchase condoms openly.
281
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
One concern she had was how difficult it is to come to the talks. Saturdays
would be the best day as the majority of the madres cuidadoras work during the
week until 5 or 6 o’clock. One madre works until 10 p.m. every night but she
could come on Saturday. Some of the other parents work on Saturdays because
most of the fathers work in the market, so it is very difficult for them to attend
meetings.
She does talk to the madres usuarias more than the padres. She talks to
them about their children and if they want to have more children or not. She often
suggests getting the “injection” or the IUD in order to not have other children. The
madres have a lot of confidence in her and trust her so they are able to talk about
these sensitive things. She herself would like to have children, but feels that it is
very expensive. The medical check-ups and all parts of having a child are
expensive, so she and her husband have decided to wait awhile longer.
She has attended several other classes in the past few months on family
violence, child development, and stress. They had many reunions with the other
Wawa Wasis in December for the holidays. There were also several classes for the
madres usuarias in the center of Callao about the Wawa Wasi program.
Unfortunately, not many parents attend due to work. This is one of the major
complications surrounding sexual health and AIDS intervention programs, that of
making the program accessible to those in need. Working parents are less likely to
be able to attend this type of workshop if time is not properly taken into
consideration. In the situation described by the madres cuidadoras, most of the
282
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
madres usuarias work extremely long days including weekends, so the issue of
time is very important. In this case, her role as a madre cuidadora may inhibit the
ability to act as a provider of knowledge for the madres usuarias as her role as day
care provider takes precedence over time to communicate these messages.
Carolina talked about not having children. She admits that they do not
necessarily want children now, but that she is not using birth control. She says she
may not be able to have children as she has not used protection for awhile and has
never gotten pregnant. She would not mind having children, but is not sure it will
happen.
Carolina’s case also supports the information gained through the workshop
and the desire to communicate this information on a larger level. She reemphasized
the fragile situation of many of the madres usuarias and the need for this type of
education to continue on a widespread basis. Carolina is in a monogamous
relationship and feels she has developed a level of trust and open communication
with her husband. However, as she describes, even if she wanted to purchase
condoms she would be unable to do so due to social constraints. This is the
situation repeated by the majority of madres in that the sociocultural norms do not
allow them adequate access to protection through use of condoms. This hints to the
level of negotiation that may fail to occur in their relationships and the inability to
demand safe sex.
283
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Karina
Karina lives in Chuquito, a suburb of Callao, just a few blocks from
Carolina’s house, but the neighborhood was a very different environment. The
house was one block from the ocean, in a more beach type atmosphere. On a very
busy street, combis passed constantly on the way to La Punta, a nearby beach town
and naval reserve. The home was brightly painted on the outside. Upon entering
the living room, I found it nicely furnished with two couches and a dining room
table. To the right was a bright and clean kitchen and to the left a small bedroom.
There were two other bedrooms to the back of the house.
Karina, 27 years old, is single with no children. She lives in this home with
her parents, brother, and grandparents. She runs the Wawa Wasi with the help of
her mother while she is completing her thesis for the university. She has completed
her courses in teaching and only lacks the title needed for her thesis. She likes the
Wawa Wasi program but would like to work in primary school or pre-school.
Together she and her mother have had the Wawa Wasi for six years and currently
have eight children.
Karina found the training very interesting, especially themes she had not
discussed before, like contraceptives and AIDS. She felt that the trainers were
really dynamic and helped them to understand a lot. She had prior training on
contraceptives at la posta, but found this course much more interesting. In the
other courses they did not teach the information, they only passed it out.
With AIDS I understand you need to be in a stable couple; don’t go
with different people. You need to use condoms, but be careful. I
284
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
have heard about this before from my brother and my mom. I can
talk to her, she is very modem.
The previous courses included nutrition, development, and gender. She also
worries about the times of the classes as they are often at times the parents are
working, so neither she, nor the parents could attend. This same issue has been
repeated by the madres cuidadoras and is one of the recommendations from the
research regarding effective programs. In order to be successful, these programs
must be accessible. Karina feels she could communicate with the madres usuarias
about themes of sexual health and stated that she and her mother often talk to them
about relationships and pregnancy.
I could talk, it is important for everyone to talk about this, especially
AIDS and contraception. Many of the madres usuarias are single;
they get pregnant and abort the babies because they can not take care
of them. They usually live with their families and just can’t take
care of them. One madre leaves two of her children here, but she
has seven children. She only takes care of two of them; the fathers
have the others. They talk to my mom and to me about things.
Karina had a boyfriend before, but is single now. She admits it was hard to
talk to her boyfriend about these types of themes and was not really able to share
with him. There is a posta clinic nearby her house where they provide pills or
injections. She stated that if you go for a consultation that they would provide
these for free. She could get condoms in the pharmacy, but felt that for a woman it
was very embarrassing and difficult, it is easier to go to the clinic. She said la
posta it is easier to talk and ask questions. They have a psychologist and they have
talks about anything they need even about the children.
285
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The posta has had some courses on AIDS, but they need to be more
dynamic for the people to participate like we did in this class.
Sometimes the people just lecture, but this type of class is better so
they don’t get bored. We did not get information about AIDS in
school, only on TV, from friends, or in the papers. Now I can talk
with the madres usuarias about HIV and AIDS, now I know they
are not the same. I thought the IUD was bigger, I can explain that
and the difference between sex and sexuality and its importance.
You can confuse these two things and they are not the same, there
are different aspects.
Karina has gained knowledge and states she would be comfortable sharing
this information with the madres; however, would not be able to do so in her
relationship. She also discusses the situation that for even the younger women it
would be very difficult to purchase condoms.
During my last visit, I found Karina much the same. She shared photos with
me from the Wawa Wasi and from her school. She was very proud of the pictures.
She and her mother were still with the grandparents, but recently found a place
where they will move and perhaps reopen the Wawa Wasi. She still needed to
complete her thesis and would like to look for a job teaching. Her brother was in
New York and doing well. They still did not have any children in the program, but
will do so at some point. She was not working currently, but going to the
university to study and work on her thesis.
Karina provides a case of a younger single woman, which mirrors many of
the situations described by the other madres cuidadoras. She felt she lacked
information in school and from her family about sexual health. She did know where
to access that information, in the health clinics, but the social stigma attached to
this and to purchasing condoms still was a major barrier. It was difficult for her to
286
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
communicate with her past partners, and did not express that this situation would
change following the workshop. She did gain knowledge in the workshop and felt
she could share this with the madres usuarias. Karina recognizes the lack of
information and the tenuous situations of many of the madres usuarias, and feels
this information would be most helpful in their lives. However, their ability to
attend such programs is a concern. Therefore, the ideals of this workshop to share
the knowledge through forms of informal education seem most appropriate, if it
does occur.
Huancavelica
Following the course modules in Huancavelica, I was able to conduct in-
depth interviews with three of the madres cuidadoras. These interviews are limited
in length and detail due to the short time frame that the program was in each region.
Most of the women were not available prior to or following the course due to time
constraints with work and family. As I was only in each region for the four days of
the course, further interviews could not be conducted. Interviews were not held in
Huanuco due to the lack of access and time constraints. The following contains the
details of the interviews in Huancavelica after the course intervention.
Diana
Diana was 19 years old at the time of the interview. She comes from a
family of four girls and three boys. She left high school to go to work and was in
training to start her own Wawa Wasi. She had her own program for just three days
at the time we met, with seven children in her home. She lives at home with her
287
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
mother and five of her siblings. One of the rooms in the home serves as the Wawa
Wasi. She has a comedor available for the daily food for the children. She feels it
was much better to leave school and work in order to help support herself and her
family. She had previously worked as a secretary and a cook.
Diana reports that she found the module very interesting and stated that it
helped her a lot. This was the first time she had attended training on the theme of
sexual health and reproductive rights. Prior to this she had talked about the topics
in school, with friends, and in the hospital about prevention. Diana is able to talk to
her mom about these issues and feels she has friends with whom she could talk.
She stated that one friend has a baby and her partner hits her. Diana talks with her a
lot about her relationship and about sex and pregnancy. She counsels her on being
careful and brings her milk and things, as her friend is very poor. She has three
other friends who are single mothers, so she talks with them about protection and
prevention. But, she feels it is still very difficult to talk about these themes. It is
even worse with men because she can not discuss these issues at all. Even in the
workshop, she found it uncomfortable to talk openly about sexual issues. In this
situation, Diana appears to be a person whom others trust and who is in a position
to provide resources and information to her friends.
Regarding AIDS, there was a newspaper that had articles about AIDS and a
famous artist who died of the disease. In school, there was some work about AIDS.
She knew that people contract AIDS from sexual contact and from blood. She
knows “you get very skinny if you contract AIDS.” Diana was not sure if a
288
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
condom could really protect a person from AIDS as it could break, so was not
totally safe. She had never purchased condoms and felt she would not be able to do
so. She stated that in Huancavelica it is not common for women to buy condoms. “I
can’t buy condoms. Here the men buy them, not the women. I don’t know if my
friends have bought them, maybe in the pharmacy. I don’t know how to use one, I
have never even seen one.” She also had heard about sexually transmitted diseases
in high school, but did not remember too much about them as it was a long time
ago. If she had sexual relations she would ask her partner to use a condom. Even if
the partner tried she would not allow him to proceed without a condom.
Diana felt it was important to invite more young people to this type of
training. It was difficult for her to participate jointly with the older madres
cuidadoras and to express her thoughts in front of them. She stated she was
embarrassed they would think she was behaved badly or would share the
information with her mother. She would prefer the training to be held with younger
people. She says the young people are interested and would come if invited. She
has many friends who are machistas, but if she invited them they would come. She
feels they need to hear things like in the training module. These friends speak in a
bad way, but if they are confronted on the issues they can change. Her brothers, on
the other hand, are not machistas. One studied in Lima and does not talk bad about
anything.
Diana also provides a case of a young single woman who faces a different
situation than that of some of the older madres who are married and already have
289
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
families. She discusses the issues of machismo in the community and the impact
this has on women and their relationships. Having four friends who are single
mothers shows a very high pregnancy rate among her peer group. This could
indicate that condoms are not being used in these relationships, placing these
women at risk. She also expresses the fact that women do not really have access to
purchase of condoms, although her male friends do have them. Diana had some
prior information on sexual health and AIDS, but felt the workshop provided good
information. She states she could exert her rights and needs in a sexual relationship,
but since she is not in a relationship currently, this is difficult to gage. When she
does become involved in a relationship it may depend on the outside support she
has at that time whether she will be able to negotiate with her partner and express
her needs. Many of the women in Huancavelica described severe problems with
the machismo and the problem they encounter within relationships and in the
community. Diana will have to deal with this situation as she finds herself with a
future partner in order to discuss these sensitive issues of sexual health and AIDS.
Rosa
Rosa is 23 years old and lives at home with her mother and eight siblings.
Her father works away from the town in the mines. Rosa has been training with
another madre cuidadora for two months and has recently started her own Wawa
Wasi. Her Wawa Wasi is located in her family home, where she currently provides
care for eight children. She is studying at the university, where she is working on
290
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
her thesis. She plans to finish in one year and hopes to become a primary school
teacher.
Rosa reports that she has gone to previous training on family violence and
sexuality. In the university she also learned about parent education and early
childhood education. This prior training involved family planning methods,
pregnancy, and abortion, but did not directly discuss sexuality. She did not know
about the concepts of sex and sexuality, but now feels she has a clear
understanding. She learned that sex is natural and that it should not be
embarrassing. In the past, she was able to talk about sex with her sisters, but not her
brothers. However, after the training she felt she would also talk with them. On the
other hand, her mother is very traditional and she was never able to talk to her
about sexual issues. She also felt that many of the older madres cuidadoras were
more traditional and did not feel comfortable sharing with them. With close friends
she could talk about these issues but learned most from books. Again, the need for
separate courses based on age may help the younger women to participate fully.
Rosa expresses the lack of information and education that many of the women had
prior to the workshop, with very limited options for discussing sexual health issues.
She also expresses the difficulty in women and men communicating about these
topics, even amongst her brothers.
Rosa had read about AIDS before and knew that it was a virus contracted
from HIV. She had seen posters and handouts about AIDS and STDS in la posta
and health clinics. Rosa said she would have sex with a condom. She also stated
291
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
she would have sex with only one partner to protect herself from diseases. “I would
have sex with only one partner, not many because you do not know who they were
with.” However, she felt she had limited access to the ability to purchase condoms.
“It’s not for a woman to buy, for men, yes they can buy them. I could ask him to
use a condom. If he didn’t want to then we wouldn’t have sex.” She was aware of
ways to protect herself from contracting AIDS. However, she felt that many people
did not use protection as they felt that there were not many cases of AIDS. Rosa
expresses that she could communicate, negotiate, and demand her rights in a sexual
relationship. However, as she is currently not involved and will have to determine
the actual opportunities for communication at that time.
She also discussed the importance of educating young people in the
community about AIDS. She felt the best methods were in schools and the
university. She said the youth do not go to the plazas for talks, it is much better to
go where the youth hang out like schools.
Rosa, like Diana, expressed a great need for education on sexual health
issues and AIDS with youth in the community. They both feel there is a lack of
information in the current educational system, both formal and nonformal as the
youth do not participate in these events. They are concerned that their peers do not
have the knowledge or ability to negotiate and protect themselves. This often
relates back to the issues of machismo that resonate in the community. Women do.
not have access to information or condoms, let alone to communication with their
partners about AIDS. Both women state they would be able to demand their rights
292
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
in sexual relationships or they would just not have sex. However, it is unclear
whether this behavior will actually occur and whether they will really be able to
demand and negotiate safe sex until they are again faced with the situation.
Daniela
Daniela is 19 years old and lives at home with her parents and four brothers.
She provides care for 8 children in the Wawa Wasi located in her family home. Her
mother helps her with the children. She also has only been with the Wawa Wasi for
three days. She reports that she is very happy with her job and loves being with the
children. Daniela completed high school and studied technical resources and
economics in an institute, but left prior to completion.
She has been involved in prior training on family violence, sexuality of
women, and children’s rights. She felt that this module was very helpful and easy
for her to understand. She learned a lot and was able to ask questions. She had also
talked about these issues with friends and wanted to know more. She talked about
sex with her dad. He explained that boys lie about sex and taught her about the
body parts. Daniela’s mother talked to her about menstruation because she had
never been taught properly so she felt it was important to teach her children. She is
very close to her mother as she does not have sisters. Her parents have set aside
every Sunday as time to talk with their children. “They talk with us about drugs
and different things.” Daniela’s family situation and the ability to communicate
about sensitive issues are different than what has been described by many of the
293
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
other madres cuidadoras. Her family seems to have a fairly open relationship and
she had somewhat more information than some of her peers.
She had heard about AIDS in training before in school and with talks she
had attended. They saw videos of diseases in school and showed drawings and
brochures. She heard that people in Huancavelica had been infected with AIDS.
“Three people here have it we heard, but in the cold it is difficult to catch. The
people from Lima come here and go with girls, but they have AIDS. With AIDS
one person has it and its like cholera, everyone gets it.” She states that AIDS in
contracted through having relations with several partners and not protecting
yourself. She described a lecture she attended where they used a “plastic penis” to
show how a condom is used correctly. She is also aware of syphilis, gonorrhea, and
herpes and that any sexually active person can get these. She knows that condoms
are necessary for protection and that pills will only protect you from pregnancy.
She knows that nothing is fully effective. Daniela had a lot of information about
STDS and AIDS prior to the workshop. She had been to lectures and training where
this information was discussed and was knowledgeable about these issues.
On condom use, Daniela felt that she could buy and use condoms. But, that
she would need to be older to go to a pharmacy to buy them. “I am young so they
would talk [if I bought condoms.] They guys, they all have a condom in their
wallet. They have three in their pocket.” She knows that her male friends do use
condoms and that they have heard about diseases in neighborhood talks. She felt
confident she could ask her partner to use condoms if she had sexual relations. “If it
294
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
was the first time for him, I would not use condoms. But, if he was with others, first
I would protect myself. They lie, and I don’t want to know.” She has a boyfriend
now and they talk about AIDS, women, and condoms. They both agree that
condoms are the best way to protect themselves from diseases. He has talked to her
about sex, but she is not ready to be sexually active. “But, I am not prepared [for
sex], if he doesn’t understand that, then goodbye to him.” Daniela expresses a
strong stand on the issues of condoms and safe sex. She does not feel she could
purchase condoms, but states that most of her male peers have them. She is
practicing abstinence and says she has been able to demand this with her partner up
until now.
She talks with her friends a lot about being responsible about sex. But, with
the machismo in the community she feels it is often very difficult. She describes the
case of her neighbor who is machista and hits his wife. It would be difficult to get
him to go to a talk about sex, someone would need to go to his house and talk to
him or bring information to him. “We have the same rights as men, we are equal in
everything including sex and physical things. Machistas don’t even let their boys
play with dolls in the Wawa Wasi. They would yell. We have to go and insist, little
by little that they change.” She talked about the machismo in Huancavelica, but
that her father and uncles had changed and even cooked and washed clothes now.
It has been passed on to her brothers, who prepare dinner and let her mother rest.
Daniela provides an example of a young strong woman in her community.
She appears able and willing to demand her rights and express her choices with her
295
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
family, friends, and partners. She has been able to negotiate safe sex with her
partner in the form of abstinence and states if he was not willing, she would be able
to leave the relationship. She discusses the problem of machismo with her peers
and in her community but recognizes options for changing this situation with her
father, her boyfriend, and friends. She has a strong yet hopeful outlook on the
issues of machismo and on sexual health issues. She also states that she is able to
communicate and does so intimately with her boyfriend.
Conclusion
The previous section provides a glimpse into the daily lives of the madres
cuidadoras and the role they play as knowledge providers for the madres usuarias,
their families, their partners, and the community. This was meant to develop a
clearer understanding of the situations they face in relation to their families,
partners, the madres usuarias, and in their communities as a whole. This helps to
evaluate whether this type of workshop intervention did or could have an impact on
their lives enough to create possibilities for behavioral change and increased voice
on their rights as women and citizens in their society. This leads to an
understanding of their role as knowledge providers through analysis of their ability
to communicate the messages they have gained in the training. As evaluation and
discussion of their stories took place, several themes began to emerge which will be
discussed.
Following the course, the madres cuidadoras were expected to become
knowledge providers for information about sexual health and reproductive rights,
296
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
including AIDS information to the madres usuarias. However, in their role as day
care providers for the Wawa Wasi program at times absorbs their role as
knowledge providers. As their focus is on the children and the financial or health
status of the family, communication of the course messages becomes lost. In
addition, the role the madres cuidadoras play in their personal lives has an effect
on their ability to share knowledge with the madres. When the cuidadoras express
inability to negotiate or communicate adequately with their own partners, it places
them in a difficult situation to effectively share information with others.
An important issue was that of each of the madres cuidadoras’ relationships
with men. In these cases, two of the women were married, four were young single
women, and three were in less-definable situations. Of the two married women,
Susana and Carolina, both reported long-term and stable relationships with their
husbands. However, both men worked away from the home, Susana’s husband in
the regions and Carolina’s in the fishing docks. Susana felt that it was likely her
husband was with other women while away from home; whereas, Carolina was
more confident that her relationship was monogamous. In both cases, economic
need required the husbands to work in demanding jobs away from their homes. As
described in the research in chapter two, this type of migratory work often
supported the AIDS cycles in these countries.
With the younger, single women, only one was currently in a relationship
although the other three had been in prior relationships. Only one described open
communication with her partner or past partners. They each stated they would be
297
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
able to negotiate and communicate in future relationships, but this has not been
tested. Each of these women is educated and self-supported with their jobs and
their families. They each recognize the severe problems with machismo, especially
in Huancavelica, and almost describe their male friends in almost a comical form
walking around with their condoms in their pockets. Each is practicing safe sex in
the form of abstinence, but what they will be able to negotiate in future
relationships will need to be determined at that time.
The other three women seem to be in more tenuous situations with their
relationships. Each of these appears to be based on the socioeconomic situations
that they face. Roxana’s estranged husband lives in Miami, but they are not yet
divorced and she still needs him to complete paperwork and finalize their situation.
Irma is married, but lives the majority of the week with her parents in a separate
residence and city. She rarely spoke of her husband and appeared to have little
contact with him. However, he continued to reside in “their” home, which included
most of her belongings. It appears he may have provided additional financial
support for the children and family. Claudia is divorced and her husband
remarried. She had another relationship which ended resulting in a new baby. Her
ex-husband acts as the father for this baby as well as his children. He is remarried
with children of his own. The two maintain a close relationship and he continues to
provide the majority of the financial support for the family.
These three women have been placed in situations, whether totally
economic or on a basis of personal or social need, where they are dependent on
298
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
V
these men for support. These appear to be risky situations for these women in
respects to negotiation and their rights. However, all of the women are in high-risk
situations for their sexual health and AIDS in regards to their relationships.
The economic situations of the women are very limited even with their
employment through the Wawa Wasi. In the cases in Lima, they are fully
dependent on the ability of the madres usuarias to provide financial support. As
they described, this support is usually lacking. In the regions they receive
additional support from the government, but in both cases this support barely
covers the food for the children. The younger women are also supported by their
families as they reside at home with their parents, so in these cases may be a bit
more financially stable. What was noted from each of the madres cuidadoras,
however, was the self-value instilled from the access to employment. The women
expressed gratitude for the fact that they were working and the financial stability it
did provide, although limited.
Another common theme among the madres was the sense of personal
strength, which allowed them to act as information hubs and resource centers for
their communities. Most of the women were leaders among the Wawa Wasi
program and the community. They participate actively in training and have
represented the Wawa Wasi program in special events and in top level government
activities. They sought out information and education that would improve their
skills and knowledge and attended most programs available. They then shared this
information with their friends, families, and the madres usuarias. As these madres
299
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
cuidadoras were a small representative group of the Wawa Wasi program, they
may have been chosen for the research project as they are leaders. So, it can not be
said that all madres cuidadoras are this active. However, this leadership role places
them in an excellent position to become community mobilizers and to speak out
actively on equal rights. They would need to be given the tools and support to seek
this role, which does not seem to have been developed adequately through the
workshop.
All of the madres cuidadoras interviewed seemed to have good solid
relationships with the madres usuarias. They shared information vital to the health
and well-being of the children. They were very knowledgeable about the madres
personal lives and relationships, indicating that they had developed a level of trust
that allowed the madres usuarias to share personal information. This sets up a
communication line that allows the madres cuidadoras to become educators and
play support roles for the madres usuarias. In most cases, they stated they would
and had communicated information on the sexual health and reproductive rights
modules. It did seem that the madres cuidadoras at times were more in a
supervisory role with the madres usuarias, expressing what the problems were with
the children and berating them for not taking proper care of the children. In these
situations, the personal relationship was not as clear and may have caused the
madres usuarias to hide information or to lose trust with the madres cuidadoras.
The relationships, though, seem to be an effective way to communicate the
information such as that provided in the sexual health workshops.
300
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Another common theme with the madres cuidadoras was that of lack of
access to adequate health care. They mostly complained about the poor health care
services for the children in the Wawa Wasi. Although the children did have access
to la posta, which even came to the day care homes once per month, they did not
find this to be sufficient. Many of the children had special medical needs that were
not being met and often the madres cuidadoras spent extensive effort seeking out
proper care. In regards to adequate care for themselves, the madres cuidadoras
expressed distrust and frustration with the health care system. Most did not have a
regular doctor and went to the health clinic if they needed something. They did
have the knowledge to seek out proper resources, but in cases of health and sexual
and reproductive health the resources were often not available.
One way that this lack of resources was observed was in the perceived
access to condoms. Condom access is one of the essential requirements for
negotiation and behavioral change. Although most of the women knew where to get
condoms, due to social stigma they were not allowed to do so. Regardless of age,
marital status, or regional area the madres stated that purchasing condoms was not
socially acceptable for women. In addition, communicating the desire to use
condoms with their partners was often not an option. This sociocultural situation
places increased risk on the women of AIDS, STDS, and for their basic sexual
rights.
301
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Interviews with the Madres and Padres Usuarios
During the long-term observations of the madres cuidadoras in Lima, I had
the opportunity to interview several of the madres and padres usuarios. In these
interviews, I wanted to explore their experiences with the Wawa Wasi and get a
clearer understanding of their relationships with the madres cuidadoras and their
level of trust. This would help to ascertain the extent of communication shared
from the madres and padres usuarios’ point of view. As the goal of the program
modules was to have an underlying multiplier effect, extending the program to the
madres and padres usuarios, these interviews helped to determine whether such
learning occurred or had the opportunity to occur. It also helped to have a fuller
concept of the lives of the madres and padres usuarios and how such intervention
would or could effect their life realities.
Sandra
I met Sandra in the Wawa Wasi home of Roxana in San Miguel, Lima.
Sandra is 30 years old with a 2-year-old boy, Javier. She lives with the boy’s
father. She has completed her bachelor’s degree and works in an office. Initially,
her son was in day care, but she felt they were not caring for him well. When she
changed jobs there was a Wawa Wasi in the new location, so he started there. She
brought her son to Roxana’s home four months ago. She is very confident about the
care Javier receives in the Wawa Wasi. Sandra states that she trusts Roxana with
the care of her son.
302
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Sandra has participated in reunions with other parents in the Wawa Wasi
program. The themes discussed in these meetings centered on treatment of children
and couple’s counseling. She stated that the baby’s father had more contact with
the madres cuidadoras in the Wawa Wasis as he was the one to bring the child and
pick him up. The father talked a lot with the madres cuidadoras and relayed
messages to her. But, when it came to calling or talking to the madres cuidadoras
he always asked her to make contact, as he was embarrassed.
Sandra stated she has never participated in meetings about AIDS or HIV.
She has heard about these diseases through reading or on television. She is aware
of classes in the clinics on these issues, but has never attended any program. She
believes there is a problem with AIDS in Peru but only hears about these things
from friends. She is aware that HIV is transmitted through sexual relations, from
blood, and through pregnancy, but not in all cases. Also, that people can protect
themselves by using condoms or by not having sexual relations. Sandra has never
purchased condoms, but believes they can be easily purchased. She is only able to
talk about these issues with friends from high school or work, but not about very
intimate things. She is easily embarrassed and does not talk with her partner about
sensitive issues. She states that she never goes to the doctor for herself, only to the
pharmacy.
Sandra expresses limited outlets for communication among friends and
family. She has participated in training through the Wawa Wasi and had adequate
knowledge about HIV/AIDS. She mirrors most of the madres cuidadoras in that
303
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
she does not communicate with her partner about sexual issues and has limited
access to medical care and condoms. She does not have much contact with the
madres cuidadora and it does not appear they have discussed the sexual health
issues from the workshop. There does seem to be a level of trust, which could open
to opportunities for communication of sexual health issues. But, due to the short
amount of time her son has been in the Wawa Wasi a close relationship with the
madre cuidadora has not been formed.
Raul
In certain homes, I was able to talk with the padres cuidadoras as well.
Raul has his children in day care in the Wawa Wasi home of Roxana. Raul is fifty
years of age and has five children, three grown adults and twins five years of age.
He is currently separated from his wife who is living in Miami due to health
reasons. She has been living there for six months with his sister. His oldest three
children are studying in the Universidad Catolica de Lima. The first will complete
his engineering degree at the end of the year.
The twins have been in the Wawa Wasi program for four years. They are
new to Roxana’s home where they transferred from another Wawa Wasi as the
madre cuidadora closed her home. The family has had good experiences with the
Wawa Wasi program and the madres cuidadoras. Raul feels the madres take good
care of his children, like their own grandchildren. He does have other family and
his adult children who could help with the younger ones, but feels the Wawa Wasi
program is sufficient.
304
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Raul has been invited to reunions with the Wawa Wasi program on several
occasions. He usually attends the meetings. He reports that the topics are about the
care of the children, which he finds easy as he has already raised three children.
This time raising his children has been different as they do not have a live-in
nanny, so he is learning new things. The courses have been helpful and he usually
finds some benefits. The children also benefit from the insurance provided through
the posta clinics for emergencies. His children have their own insurance, but this
helps in case he is not available.
When discussing AIDS/HIV, Raul states that he is aware it is a non-curable
disease. He has read about it, seen it on television, and also received information in
lectures. He feels he has enough basic information and is aware it is transferred
through blood. His grown children receive information in the university, but
information is also available through any institute. Raul states he always talks to
his older children about sexual issues, especially the boys. The five year old is the
only girl, so it has been easy to deal with the older boys.
Raul does not present the typical case seen in the Wawa Wasi program. As
a single father, raising his children, he has become very involved in the Wawa Wasi
and with the madre cuidadora. The madre was very knowledgeable about his
home situation, informing me that the children were from a different woman, but
that his wife had been raising them until she left for Miami. They were planning to
send the daughter to live with the wife in Miami, but the boy was going to remain
in Lima with his biological mother. Roxana was concerned about the effect this
305
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
was going to have on the boy and felt that he was having some emotional problems
as a result. Raul had been to Wawa Wasi training and was interested in being
involved and gaining more information on the care of his children. It appears Raul
has a good relationship with the madre cuidadora, but this does not necessarily
relate to the ability to communicate about sexual health issues. As discussed in
detail, there is a lot of social stigma attached to the ability of men and women to
communicate about sexual health issues. When approaching the issues of HIV and
AIDS, he became somewhat quiet and withdrawn and looked away from my eyes.
Therefore, our discussion on sexual health issues was limited. This would probably
be the case with the madre as well, unless they were able to break through these
socially prescribed boundaries.
Andrea
Andrea also has her child in the care of Roxana’s Wawa Wasi. She is
twenty-five years old and works as an employee in a private home. She is single
and reports she has very little family available and little social or financial support.
She moved to Lima from a small province by herself. Her son Ivan is three years
old and has been in the Wawa Wasi program for one year. In the past, her
neighbors helped to take care of her son. The Wawa Wasi program has been very
helpful to her as her family is in the province and she has no other support. She
feels it has been a very good experience, that Ivan learns a lot and each day has a
new thing to share with her.
306
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Andrea talks with Roxana about Ivan and how he is progressing. She has
been invited to several meetings with the Wawa Wasi but has been unable to attend
as she works late. Regarding AIDS, she feels she knows hardly anything. She
knows it is an incurable disease but is not sure how it is contracted. She has heard
about AIDS in the news, on television, and sometimes in soap operas. They also
have lectures in the Posta about AIDS, but she has never attended. Andrea does
not have friends or family in Lima with whom she can talk about these issues. She
has one neighbor with whom she can talk, but not about private issues. She is not
currently in a relationship, but before was never able to talk with her partners. She
feels it was the fault of both sides. She does not know much about condoms but
thinks there are condoms for women too. She feels she could protect herself if she
was in a new relationship.
Andrea presents more of the typical situation of the madres usuarias. She is
a single mother with few resources and outlets for emotional support. She has
limited knowledge on sexual health and AIDS and does not have the opportunity to
seek out information on these issues. She has never talked to her partners about
sexual issues. In addition, she has not been able to participate in educational
programs at la posta or through the Wawa Wasi due to her work schedule. These
programs have not provided sufficient access for her needs. She has developed a
good relationship with the madre cuidadora, but does not describe her as one of the
people with whom she could share private information. Roxana did provide her
307
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
with the brochures she had created, but Andrea did not bring these up as sources of
information.
Vicky
Vicky is the grandmother of a seven month old baby, Delia, who is cared
for in the Wawa Wasi home of Claudia. The baby’s mother is a secretary and the
father is a salesperson. Delia’s mother works from seven in the morning until
seven at night, so the Wawa Wasi program helps Vicky in providing adequate care
for Delia. She is very confident the baby is well cared for in the home. Vicky has
the most contact with Claudia as she brings and picks up the baby each day. They
often discuss the baby’s health and how she is progressing. She has heard about
the meetings in the Wawa Wasi program, but has never attended. The parents have
never attended as they work late hours.
Vicky feels these classes are very important for the parents. She feels the
parents need a lot of help in how to provide proper nutrition for the children. She
sees many mistreated children and feels that parents in general need better
preparation and parenting courses. When discussing AIDS, Vicky feels it is
contracted by infidelity in the couple. She says couples need incentives to use
condoms. She has never purchased condoms nor does she know where to do so.
She feels that it is important to teach about virginity in that the earlier
people start having sex, the more partners they have and the more opportunities
they have to get AIDS. She sees this as a problem that is passed down from parent
to child—“a chain that never ends.” Vicky feels AIDS is a problem in her
308
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
neighborhood, especially among homosexuals. She says that many neighbors who
are homosexual have contracted AIDS and died. She speaks to her children about
these issues. Her oldest son says he will never have relationships outside of his
marriage and so she is sure that he will not get AIDS. She believes that religion is
important in tackling this problem and that people should follow what the bible
says about marriage and sexual relations.
Vicky expressed very strong opinions about the social problems associated
with AIDS and with the lack of education among the youth in her community. She
advocated monogamy and abstinence based on her religious background as the best
methods of AIDS prevention. It is interesting to note that among all of the
interviews and observations, this was the one of the few times that religion was
mentioned as an issue in the AIDS discussion. Vicky did have some knowledge of
AIDS and its transmission. She, like most women, did not have access to condoms.
Vicky was very outspoken about the responsibilities of the government to provide
adequate education for the youth especially about parenting. She did have a close
relationship with the madre cuidadora and it appeared they had communicated
about these issues.
Carla and Jaime
In Irma’s Wawa Wasi home, I was able to meet with three madres and
padres usuarios. Carla and Jaime are the parents of Raphael, who is two years old.
He has been in the Wawa Wasi program for six months. The parents wanted to wait
until he was old enough to talk before placing him in day care, so that he could
309
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
express any problems. They are comfortable and trust Irma with their son. Carla is
employed in an office and Jaime takes care of their ranch. They are currently
having problems with the police over ownership of the ranch, so most of his time is
focused on their legal issues. The couple has been married for 14 years, with one
child. Rafael has some medical problems with his ability to walk. He wears
orthopedic boots to straighten out his feet. They have insurance for the family, but
often have to ask Irma to help with medical appointments and health care.
Carla and Jaime both state that they talk a lot with Irma. They mostly
discuss the development and progress of their son, but they do communicate about
other topics. They have been to training through the Wawa Wasi. One was in the
hospital that discussed medical care for children. Others included nutrition, prenatal
care, and general childcare.
Carla and Jaime have been active participants in the Wawa Wasi program.
They both have attended meetings and both have open communication with the
madre cuidadora. Irma provides additional support for the family with the medical
needs of the child, so it appears that a level of trust has been established. This
family does have access to adequate employment and health care. They feel they
have sufficient resources for their son, only lacking the time for his proper medical
care. They do communicate with Irma about their son, but it is not clear that they
discuss more intimate issues. They discuss their legal and financial problems
openly, but this does not necessarily relate to sexual health issues.
310
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Viviana
Viviana is the third parent I met with in Inna’s Wawa Wasi. She has a 4-
year-old son, Miguel who has been in the Wawa Wasi for six months. They found
out about the program as they live in the neighborhood and saw the signs and
children coming to the house. She had good references as others in the
neighborhood recommended the Wawa Wasi. Miguel has special needs as he is
developmentally delayed. She feels her son is learning a lot in the Wawa Wasi. He
is talking a lot more than he used to and has progressed in all developmental areas.
They have special medical insurance through their school and take Miguel mostly
to the children’s hospital. Viviana has been living with Miguel’s father for five
years. His father works in a local factory.
Viviana also has a very limited support system, both financially and
emotionally. She has access to medical care for her son, but has few other resources
for her family. She has not participated in Wawa Wasi training due to conflicts
with her work schedule. Irma provides a support mechanism for the care and
education of her son, and often helps with medical appointments. They have
developed a close relationship during the six months they have participated in the
Wawa Wasi program, but this has been a somewhat limited relationship. Viviana
appears to have developed a level of trust with Irma, but this has not included
issues of sexual health.
311
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Summary
The interviews with the madres and padres usuarios bring a better
understanding of the relationships with the madres cuidadoras and to the real life
situations of the usuarios. These families present a broad range of educational,
financial, and familial backgrounds. Most of the families have limited economic
resources and work long hours. Those who have not participated in educational
meetings with the Wawa Wasi have not done so due to problems of access. All of
the parents have developed a level of trust with the caretakers, but in most cases it
is not clear this transfers to intimate levels of communication. This may be partly
due to the fact that most of the parents interviewed had been involved the Wawa
Wasi home for less than six months. The single working mothers each present a
case with little financial, educational, emotional, or health care support. They
depend on the madres cuidadoras for much of this additional support; they have
few other resources. Most report little communication with their partners about
sexual health issues and few other outlets for this type of communication. Although
some had information about AIDS and its transmission, most of that information
was limited and they expressed few other avenues for gaining information. It is not
clear from these interviews if the relationships with the madres could become close
enough to create opportunities for communicating sensitive messages. It does
appear that as the madres become more enmeshed in the families’ lives the more
likely this communication can occur.
312
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Section Four
Sustainability of the Sexual Health and Reproductive Rights Course
While analyzing the effectiveness of the program for the madres cuidadoras
and the madres and padres usuarias, a successful intervention would have a long
term impact on their knowledge and behavior. One of the major issues with the
PROMUDEH sexual health and reproductive rights program has been that of lack
of sustainability. As mentioned, following the pilot study and evaluation of the
modules the goal of the program was to train 12,500 madres cuidadoras on the
modules. In turn, the madres would provide an informal learning environment for
90,000 madres usuarias who utilize the Wawa Wasi services (UNFPA, 1998, p.
10). After the pilot study Calandria completed the evaluation and revalidation of
the modules. The recommendations and revisions were presented to PROMUDEH
and UNFPA in September 2000. The next training phase of the program and the
final revisions to the modules never took place due to changes in government,
which resulted in the closing of the program.
A major issue effecting the sustainability of the program was that the
program was solely externally funded. With the granting agency (UNFPA)
providing the funding, the government did not have personal commitment with the
program. This made it easy for the government to leave the contract, as they had
no intrinsic financial obligation. As the government folded, the sustainability of the
program was doubly vulnerable due to its lack of commitment on a financial and
participatory level.
313
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Government Changes
As a result of the governmental changes that occurred in 2000-2001, the
major players in PROMUDEH left office and the program did not see full
implementation. In November 2000, former President Alberto Fujimori left office,
followed by the two vice-presidents. As a result, Valentin Paniagua was sworn in as
president until a new election could take place. In April 2001, Alejandro Toledo
was elected as the new Peruvian president, taking office in July 2001.
When I returned to Lima in December 2000,1 found that all of the leaders
in PROMUDEH had left office following the leave of Fujimori. PROMUDEH now
had a new minister, vice-minister, and on down to the program directors. The
UNFPA consultants, several of the Wawa Wasi supervisors, and all of the field
coordinators were still working. I was able to meet and discuss the situation with
many of them during this visit. They all expressed serious concern whether they
would still have their jobs after the full governmental transition occurred. In
addition, the continuance of employment depended on the next election.
The UNFPA and Calandria researchers described a stagnant period as they
had lost most of the major administrators in PROMUDEH who supported the
program. They had completed the revisions and evaluations, but were not sure
what would be the commitment of the new government.
In May 2001, during the final phase of my research, the second set of new
government administrators were being chosen and placed by July. At this time, the
majority of supervisors also left their positions and only a few of the field
314
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
coordinators were still in place. The madres cuidadoras became my main source of
information. They had serious concerns about the continuance of the Wawa Wasi
program itself, let alone the sexual health and reproductive rights program.
However, several mentioned that they had been to or heard of additional sexual
health training taking place. Whether this training was based on the revised
modules has not been assessed.
The researchers at Calandria and UNFPA reported that they had not yet
made new connections with PROMUDEH and were still unable to evaluate
commitment and continuance of the program. They were still committed to full
implementation of the modules, but felt it would take time before sustainability
could be completely assessed.
Current Situation
It does not appear that the program will be implemented on a large-scale
basis. The Wawa Wasi program is still undergoing major changes and the madres
cuidadoras report that they no longer receive major support from PROMUDEH as
they make the transition to more community Wawa Wasi homes. Many of the
private homes have been closed during the past year. Most of the remaining field
coordinators have also lost their jobs. Although the module revisions and
evaluations are complete, the program is not sustainable and has been cancelled.
315
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER SIX
SUMMARY AND RECOMMENDATIONS
Overview
This research is a case study evaluation of a sexual health and reproductive
rights education course for women. This particular study focuses on the HIV/AIDS
program and identifies opportunities for behavioral change and increase in safe sex
practices as a result of the educational intervention. The goal of the research is to
determine whether current HIV/AIDS intervention program recommendations are
adequate and effective enough for women in developing countries. The specific
focus on women in Peru allows a glimpse into the socioeconomic and sociocultural
issues that define the roles and rights of women in the Peruvian society which has a
determining effect on their ability to voice their opinions in the community, with
the government, and in their relationships.
Summary of the Research Questions
After evaluating the impact of the program intervention, a return to the
initial research questions is imperative.
1. Does the program provide a context for empowerment in the framework of the
research recommendations (Cairo Agenda)?
• Does it educate and inform on social relations, sexuality, negotiation, and
bargaining practices? Does it educate on sexual knowledge and rights?
316
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The program touches on each of these issues through the four topics
addressed in the modules. The themes of sexual and reproductive rights, sexuality,
gender relations, and family violence focus on the themes recommended in the
research and through the Cairo Agenda. However, negotiation and bargaining
practices were not discussed in all of the workshops. Whether due to time or the
lack of adequate training for the trainers, the workshops did not have an effective
focus on these issues. The women did increase knowledge on sexual health and
especially HIV/AIDS. They expressed concern and understood the importance of
addressing high-risk situations, but they also did not have the proper tools
necessary to adequately negotiate or bargain with their partners.
• Does it provide skills for negotiating male-based contraceptives and the ability
to demand? Does it provide communication skills?
The modules did cover activities related to negotiation and communication,
however condoms were not provided as part of the course. The women practiced
role-playing and discussed case scenarios addressing communicating effectively
with their partners. But it does not appear this was sufficient for implementing
these skills into their home environments. First, not all of the women participated in
this part of the workshop as it was not given in all of the regions. Second, the
coordinators focused more on the informational parts of the modules than the
behavioral based activities. Communication did increase with families, neighbors,
and the madres usuarias, but did not seem to increase with partners or for
negotiation. Much of this is due to the sociocultural issues that define their ability
317
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
to address their rights in sexual relationships. Most women stated they were unable
to successfully negotiate condom use with their partners. This indicates the
importance of men being included in intervention efforts to increase
communication and negotiation. As discussed, this participation should at first be
separate in order to allow for a true empowering environment for women, but
should then allow for opportunities for communication amongst both groups of
participants.
• Are women provided access to employment and income?
The research suggests that in order for intervention programs to be
successful with women, they should be attached to existing microenterprise
programs or other economic development programs. In this case, the madres
cuidadoras are all employed through the Wawa Wasi daycare program. They
received the intervention based on their participation in the Wawa Wasi. However,
as discussed, the income provided is very limited and most of the women are
dependent on their partners to supplement their financial support. The fact that
they are working and providing care for children and families in need does give
them a sense of accomplishment and most expressed satisfaction with their work.
However, in this case the combination of programs did not help to resolve issues of
socioeconomic dependence on male partners. This is due to the fact that the women
still have extremely limited resources even with the current employment.
318
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
• Do women have access to medical care and prevention?
Medical care is one aspect that was extremely lacking in all areas. One of
the biggest concerns of the madres cuidadoras was the lack of adequate medical
care for the children and for themselves. They described, in detail, stories of abuse
and mistreatment by the medical personnel in both the health clinics and the
hospitals. There are appropriate resources available for contraceptives through the
health clinics, but the information provided with the materials is weak and
dismissive of their sexual health rights. In addition, the women report that they
would rather seek midwives at home than have their children in the hospitals, due
to high costs and mistreatment by hospital staff. In regards to prevention, access to
condoms is highly limited due to social stigma attached to purchase of condoms by
women and the lack of access to female-controlled barrier methods.
• Is social support provided?
The madres cuidadoras do receive social support through the Wawa Wasi
program in the form of the coordinators, other madres cuidadoras, and the regular
reunions. The coordinators visit the madres on at least a monthly basis to provide
an outlet for support and resources for their daycare programs. This can serve as an
opportunity for social support with their personal situations. In addition, the madres
cuidadoras from each region meet together on a monthly basis to discuss the
children and other issues. The madres often work in teams to help each other with
the childcare and the nutritional program. The madres in turn end up serving as a
support mechanism for the madres usuarias and the general community in the form
319
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
of information and resources. This general social support does not necessarily
include support for sexual health and reproductive rights issues presented in the
workshops. If they are to have effective support in this area, the madres would have
to actively seek out this support and be willing to address confidential issues
• Are women provided an opportunity for increased political voice?
The modules addressing gender and sexual rights each have a focus on the
rights and responsibilities of the government and how to access these rights. The
sexual rights module starts with defining citizenship and rights, as well as finalizes
with rights to quality attention for sexual and reproductive health services. This
module also discusses the ability to demand proper care from providers of health
care services through a process of recognizing those responsible for these services.
Each of the four modules delves into the ability of the women to express and
demand their rights with their partners in their environment. Again, not all of the
women participated in all of the module workshops, so they did not receive a full-
scale view of the program intervention. The process and procedures of the
workshop and modules appear to address these urgent issues; but the full support
and resources are not provided to the participants. Women are not provided with
the skills required for empowering them to express their political voice.
• Does the program seek to eliminate violence against women?
The program module on “Saying No to Family Violence” focuses on the
knowledge and recognition of family violence incidents in Peru. The women were
able to discuss in detail the situations in their immediate community. In most cases,
320
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
the women related family violence to the predominance of “machismo” in their
communities. They expressed that women have few rights or avenues to express
their rights. They reported emotional, psychological, and physical violence in their
own relationships, as well as with those of the community and the madres usuarias.
In the family violence workshop, they did not get to the final activities, which
provided them opportunities to address and confront these issues. However, they
were able to define their responsibilities when confronting family violence in the
Wawa Wasi program. The main goal was to recognize and report incidents without
becoming directly involved to avoid increased personal risk. They are in a position
to provide counseling and advice to the madres usuarias in this situation. All of the
madres cuidadoras exhibited the ability and desire to openly discuss issues of
family violence with the madres usuarias. But, this did not relate to the increased
voice against family violence on a more political level.
2. Did the women increase their knowledge of sexual health and reproductive
rights as a result of the program intervention?
• What did they learn?
As found in the focus groups, observations, and interviews, there was
increased knowledge of sexual health, reproductive rights, AIDS, and STDS. The
madres were able to recognize and address methods of transmission, effective
forms of protection, and high-risk behavior. Through the workshops they increased
understanding of gender roles, family violence, sexuality, sexual rights, sexual
organs, sexual development, contraceptive methods, AIDS, and STDS. The
321
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
workshops were effective in increasing knowledge and information about sexual
health issues.
• Did this have an effect on their attitudes, beliefs, and practices?
This intervention did seem to have an effect on the attitudes and beliefs of
the women but not necessarily the practices. Evidence is seen through the madres
cuidadoras’ ability to express their concerns about the madres usuarias, the lack of
adequate health care, and issues of machismo. They did recognize and voice their
opinions about personal issues and those of the community and expressed the
responsibilities of the government, the health care system, and the community.
They recognized risky sexual behavior and believed that this needed to change.
However, they did not express personal behavioral change or practices as a result of
the intervention. This indicates that the women were not empowered through the
program in an effort to create behavioral change. Women remain powerless in their
relationships in regards to expressing their needs and negotiating safe sex.
• Did any increased knowledge remain over a period of time?
As the study took place over a one-year period of time following the
intervention, increase in knowledge could be evaluated. In all cases, the madres
knowledge base remained the same through the final meetings one year later. They
continued to discuss issues of sexual health and were still creating fliers and
communicating with the madres usuarias. They were able to define and describe
the causes and effects of HIV/AIDS and STDS and recognize high-risk behavior.
322
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
3. Was the sexual and reproductive behavior effected by the program intervention?
• Did condom use increase?
Condom use is one of the behaviors that appears least effected by the
program intervention. The program did not provide condoms to the women and
there was no increase in access to existing condom resources. Issues of machismo,
sociocultural practices, and lack of access to adequate health care and information
had a stronger impact on the women than any increase in knowledge or change in
attitudes and beliefs. The women do not have access to condoms. This may be
because of the social stigma or an actual physical problem. There was very little
knowledge of availability of the female condom, which is viewed by best practice
research as a viable gender equitable alternative to the traditional male condom.
The female condom would allow women the increased ability to negotiate safe sex.
This lack of access signifies that condom use can not increase until these societal
variables are addressed and changed. This is further evidence that, men must be
included as separate and then joint partners in the intervention process to create
avenues for changing these social and cultural barriers. Women must be given the
resources to express power in their relationships and to negotiate safe sex.
• Was there any behavioral change in regards to sexual practices?
Although the women were able to recognize high-risk sexual practices and
behavior, they were unable or unwilling to change their sexual practices. Some of
this is related to the socioeconomic conditions, because many of the women are
dependent on their partners. In other cases, it is related to the lack of
323
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
communication and negotiation skills. One woman best described the problem, by
saying that if she asks her husband to use a condom, he would assume she is
cheating. This change in sexual practice cannot fully occur until men become
partners in the equitable discussion and attention to sexual health and reproductive
rights. Women must feel empowered to demand equal rights in their relationships
and the skills to negotiate safe sex, otherwise the power roles will remain the same.
4. Are the participants able to communicate the information to others?
• With whom do they communicate (children, spouses, friends, madres/padres
usuarios)?
Communication is one of the variables that was affected most positively
from the program intervention. The madres cuidadoras were able to and did
communicate the messages learned in the workshops to their children (mostly
female children), friends, community members, and madres usuarias. This was
presented in the form of direct communication, provision of brochures, and
facilitating lectures in their own homes. The madres cuidadoras appeared
committed to the importance of the information and wanted to “multiply” this
through forms of informal education processes, even if lacking proper resources.
Communication did not increase however with male children or partners. The
madres did not gain the skills or tools to effectively approach these issues with
their partners. The workbooks and training did provide some avenues for
discussion immediately following the intervention as the partners questioned them
and viewed the workbooks that they brought home. In some situations, this led to
324
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
discussion, in others the partners became angry or “blew o ff’ the program as
frivolous or unimportant. However, this limited communication did not continue on
a long-term basis.
• What are they able to communicate?
The madres cuidadoras were able to communicate most of the main
informational messages from the training. Their major focus was usually on AIDS
and STDS and contraceptives. They also discussed family violence and access to
health care. The women are able to communicate ideas about sexuality and its
components, sexual organs, contraceptive methods, and AIDS and STDS from the
sexuality module. They also discussed rights as a citizen, sexual rights, and
reproductive health care from the reproductive rights module. From the gender
module, they communicated gender roles and socialization, including issues of
machismo. And, from family violence, they discussed personal case situations and
identification. Communication was less likely to occur about demand for equal
sexual and reproductive health rights, for self-esteem, and strategies for promotion
of sexuality, equitable relationships, or prevention of family violence. These are the
areas that are most necessary for creating behavioral change along with change in
beliefs and attitudes.
• How does that communication take place? In what context?
The communication took place on several levels: individually, communally,
and through informal training and dissemination of information. In all cases, the
madres cuidadoras shared the information on individual and personal levels with
325
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
the madres usuarias, family, and friends. This was through informal discussions,
usually during visits to the Wawa Wasi home. Communication occurred during,
and immediately following, the workshop with their families and partners when
describing their day and their participation in the training. Some of this
communication was stimulated from the workbooks they brought home.
Additional communication occurred, when some of the madres shared the survey
with their friends and family throughout the following year. In addition, the
information was shared through informal gatherings in the Wawa Wasi related to
lectures on sexual health and AIDS and through brochures and pamphlets the
madres created and disseminated.
5. Is the project sustainable? Over what period of time? And, with what level of
commitment from key agencies?
As discussed, this project was not a sustainable program and has not
received appropriate commitment from the government. The program was doubly
vulnerable due to the fact that the program was totally externally funded, needing
little commitment from the government. The change of government twice within
one year created further turmoil in the continuance of the program. The
commitment to the program could not be fully assessed as the main players in the
PROMUDEH organization changed three times during the evaluation of the
project. The outside partners, UNFPA and Calandria, completed their part of the
evaluation, but were unable to establish renewed commitment from each new
326
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
government. The project is currently on hold, due to this lack of commitment from
PROMUDEH.
Summary
One finding from this research, in accordance with existing literature, is that
increased knowledge about sexual health, HIV, and AIDS does not necessarily
translate to behavioral change. If the knowledge does not accompany the skills and
training necessary for successful negotiation, then women remain powerless in their
relationships. Empowerment is a key element in working with women in order to
allow them the ability and the process for effective negotiation. In this case, strong
sociocultural norms, stigma attached to condom use and purchase, and machismo
denied the women the opportunity to demand their rights for safe sex and health
rights. Empowerment was not a central issue in the course and the women left the
course without the support and skills necessary for creating or maintaining
behavioral change.
The course was a short-term one-time intervention with a goal of
widespread distribution of the information through the participants. This method of
intervention was not sufficient to creating ongoing behavioral change for the
women. The participants never fully grasped the full meaning of the intervention
nor the expectations of their role as knowledge providers. This type of “quick-fix”
intervention did not prove effective in processing and retaining the information.
There was no ongoing or long-term support for the women in their communities to
continue building their knowledge base and gain additional resources. This type of
327
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
“Band-Aid” approach was not effective in creating a long-term or efficient cure for
the women or in the community.
One of the goals of the sexual health and reproductive rights program was
to have a multiplier effect in the community. However, the participants were never
fully informed of the expectations and goals. Although many of the women made
attempts to share the information with the madres usuarias they did not have the
necessary means for reaching these goals. The program placed large expectations
on their ability to process the information and to share knowledge through their
roles as day care providers. However, their job in the Wawa Wasi oftentimes
absorbed their role as knowledge providers through the focus on the children and
families. The madres cuidadoras often had only moments with the madres usuarias
and the core of their discussions were based on the children, this did not leave
space for touching upon more challenging issues. In this situation, the peer
educator format was not necessarily effective as a double role for the madres
cuidadoras, when they were focused on the central role of their job as day care
providers.
A further issue was that men were not included in this intervention
inhibiting the ability of the women to successfully communicate and change
situations without men becoming part of the learning process. The women were not
able to effectively negotiate with their partners as a result of the course. Including
men in the courses directly with women can be counterproductive to creating an
empowering environment for women. Therefore, separate courses for men and
328
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
women along with joint opportunities for discussion is an effective way to address
sexual health issues.
Lack of access to adequate health care and to condoms places women in
high-risk situations for protection against STDS and HIV. Condoms were not
provided through this course and are a necessary part of effective interventions.
The women were clear that they did not have adequate health care resources and
that condoms were inaccessible. This lack of resources greatly hindered their ability
to practice what they had learned in the intervention and their ability to seek
additional support.
Finally, the lack of sustainability of the intervention did not allow for
continued support necessary for creating avenues for behavioral change. The
Peruvian government did not have a financial or participatory commitment as the
program was totally externally funded. The initial goal of the program was to train
12,500 madres cuidadoras who would in turn reach 90,000 madres usuarias. The
lack of sustainability and ongoing support for the participants made this goal
extremely far-reaching.
Recommendations
Further interventions and research on sexual health and HIV/AIDS in Peru
and with Peruvian women should focus on the long-term commitment by the
government and agencies involved in these issues. With the instability of the
government during the past several years, perhaps the intervention focus should be
on the more stable NGOs or feminist agencies working in the field. This will allow
329
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
for continued support and long-term efforts. The government’s commitment to
sexual health and reproductive rights of women should be fully evaluated for
further education and intervention. This type of short-term intervention without
sustainable support is mostly ineffective. Therefore, future programs should
consider long-term holistic interventions that provide ongoing and sustainable
support for the participants.
The sociocultural practices, including machismo, must be addressed at all
levels in order to provide opportunities for women to be safe in their environments
and to address issues of power in their relationships. Men need to be included in
these efforts in order to confront the social norms and socially prescribed gender
roles. However, including men with women may not lead to empowerment for the
women when dealing with the stringent cultural norms. Further programming
should consider separate and joint interventions for both men and women and
include adolescents in order to affect these issues. Domestic violence and its
repercussions are urgent problems that need to be addressed within the
sociocultural realm of further interventions.
Language and diversity should also be part of the evaluation of future
interventions. In this case, Quechua speakers did not receive full benefits from the
program due to the lack of support for their language and illiteracy in the Spanish
language. In addition, the combining of courses for young single women and older
women in the community placed barriers for the younger women to speak freely
330
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
and openly about their sexual lives and practices. Here, the cultural norms did not
allow opportunities for communication or support for younger women.
Access to adequate health care and contraceptives, especially condoms, is a
serious problem in all three regions of the study. This issue should be addressed at
the governmental level as well as with the local community based organizations
and with the community members themselves. Women must be empowered to
demand their rights to appropriate care and resources in order to exercise their
rights in their relationships. Without this support, little change can take place and
women will continue be powerless over their own bodies and with their partners.
Finally, socioeconomic situations place the women at increased risk of
serious sexual health problems including contracting HIV/AIDS. Research and
further interventions should address the opportunities for financial independence
and stability for women in Peru. This support will further allow them to become
empowered and to seek appropriate power in their roles as women and with their
partners.
One questioned gleaned from the study is that as the intervention was
developed as a subprogram of an existing government program, and was terminal at
best, can this type of weak intervention really have an impact? Can prevention
really be achieved through small and weak efforts? Perhaps this program is the
best available at this time, as exemplified by research on other existing programs in
Peru, but it is still a very limited effort at prevention, resulting in limited success.
331
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Further research should consider this type of short-term and incomplete program to
determine the possibilities of impact at this level.
As current research suggests and this study supports, in order to address
sexual health and reproductive rights issues, including protection from transmission
of HIV/AIDS, women must become empowered to voice their opinions and express
their rights as women. This empowerment can happen through overarching support
for health care, access to education and services, access to financial independence,
increased political voice, and elimination of violence. With this support in
sociocultural and socioeconomic conditions, women will be able to effectively
negotiate safer sex and demand their reproductive rights. This is the method and
the means to improving conditions of health for women and for eliminating
transmission of the HIV/AIDS virus not only for women in Peru, but for all
women.
332
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
References
Adams, Rebecca, Morris, Gayle, Martin, Patricia, and Baldwin, Hannah.
(1998). Gender analvsisof USAID/Haiti’s strategic objectives. Washington, D.C.:
WIDTech.
Aldana, Celia, Sandoval, Lourdes, Alvarado, Carmen, and Ravines, Tomy.
(2000). Informe de validacion de los modulos de capicitacion a coordinadoras v
madres cuidadoras. Report presented to the Wawa Wasi program, PROMUDEH
and UNFPA. Lima: Calandria.
Alliance for South Asian AIDS Prevention (ASAP). (2001). South Asian
women Living With HIV/AIDS. Canadian Woman Studies. v.21n.2, pp. 131-3.
Ankrah, E. Maxine, Mhloyi, Marvellous M., Manguyu, Florence & Nduati,
Ruth W. (1994). Women and children and AIDS. In Max Essex, Souleymane
Mboup, Phyllis J. Kanki, & Mbowa R. Kalengayi (Eds.), AIDS in Africa (pp. 533-
546). New York: Raven Press Ltd.
Ankrah, Maxine E. (1996). Let their voices be heard: Empowering women
in the fight against AIDS. AIDScaptions. vlln3. [On-Line]. Available:
http://www.fhi.org/aids/
Ankrah, Maxine E. & Long, Lynellyn D. (1996) Epilogue: What next? A
policy agenda. In Lynellyn D. Long and E. Maxine Ankrah (Eds). Women’s
experiences with HIV/AIDS: An international perspective (pp. 388-396). New
York: Columbia University Press.
Bain, Irene. (1998). South-East Asia. International Migration, v36, pp.
553-581.
Barnett, Tony & Blaikie, Peirs. (1992). AIDS in Africa: Its present and
future impact. New York: The Guilford Press.
Bianco, Mabel. (1997). ETS y VIH/SIDA en Argentina: un problema de
mujeres. In Blanca Rico, Susan Vandale, Betania Allen, & Ana Luisa Liguori
(Eds.), Siutacion de las muieres v el VIH/SIDA en America Latina: una agenda de
investigacion-accion (pp. 39-44).
Cuernavaca, Morelos, Mexico: Instituto Nacional de Salud Publica.
Campbell, Carole A. (1999). Women, families, and HIV/AIDS: a
sociological perspective on the epidemic in America. New York: Cambridge
University Press.
333
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Cash, Kathleen. (1996). Women educating women for HIV/AIDS
prevention. In Lynellyn D. Long and E. Maxine Ankrah (Eds). Women’s
experiences with HTV/ATDS: An international perspective (pp. 311-332). New
York: Columbia University Press.
Chiriboga, Carlos del Rio. (1997). Introduccion. MujerySIDA:
conceptos sobre el tema. In Blanca Rico, Susan Vandale, Betania Allen, & Ana
Luisa Liguori (Eds.), Siutacion de las muieres v el VIH/SIDA en America Latina:
una agenda de investigacion-accion (pp. 15-22). Cuernavaca, Morelos, Mexico:
Instituto Nacional de Salud Publica.
Church Human Services, The Church of the Province of Uganda and World
Learning, Inc. (1995). Church Human Services AIDS Prevention Programme
(CHUSA) Project, Follow-up Evaluation Report, July 1995, p. 7.
Clark, Christine. (1996). Africa for Africans. The Economist, pp. 15-17.
Cohen, Barney &Trussell, James (Eds.). (1996). Preventing and mitigating
AIDS in Sub-Saharan Africa. Washington, DC: National Academy Press.
Confidential Approach to AIDS Prevention (CAAP). (2002). Confidential
approach to AIDS prevention report. UNAIDS Best Practice Digest. [On-Line].
Available: http://www.unaids.org/bestpractice/digest/files.
Coyle, Susan L., Boruch, Robert F., and Turner, Charles F. (Eds.). (1991).
Evaluating AIDS Prevention Programs. Washington, D.C.; National Academy
Press.
Dadian, Margaret, J. (1997). Women’s Forum: Inclusive Prevention Efforts
Stigma in Rural India. AIDScaptions. vIV.nl. [On-Line]. Available:
http://www.fhi.org/en/aids/aidscap.html.
Dikotter, Frank. (1997). A history of sexually transmitted diseases in
China. In Milton Lewis, Scott Bamber, and Michael Waugh (Eds.), Sex, disease,
and society: a comparative history of sexually transmitted diseases and HIV/AIDS
in Asia and the Pacific (pp/ 67-84). Connecticut: Greenwood Press.
Ehrhardt, Anke A. (1996). Sexual behavior among heterosexuals. In
Jonathon M. Mann & Daniel Tarantola (Eds.), AIDS in the world II: The global
ATDS nolicv coalition (pp. 259-263). Oxford: Oxford University Press.
Elias, Christopher J., Heise, Lori L. & Gollub, Erica. (1996). Women-
controlled HIV prevention methods. In Jonathon M. Mann & Daniel Tarantola
(Eds.), AIDS in the world II: The global AIDS policy coalition (pp. 196-201).
Oxford: Oxford University Press.
334
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Family Health International. (2002). Korea: New Look at the Fertility
Transition and Its Impact on Women. [On-Line]. Available:
http://www.fhi.org/en/wsp.wsfinal/fctshts/wsfctl9.html.
Fernandes, Ruben Cesar. (1985). Non-Govemmental Organizations
(NGOs). A new institutional reality in Latin America. Rome: FAO.
Fernandez, Isabel M. (1995). Latinas and AIDS: Challenges to HIV
prevention efforts. In Ann O’Leary & Loretta Sweet Jemmott (Eds.), Women at
risk: Issues in the primary prevention of AIDS (pp. 159-174). New York: Plenum
Press.
Flora Tristan. (1999). Salud: Lo avanzado, los retos. el contexto en el
campo de los derechos sexuales v reoroductivos. Lima: Flora Tristan.
Freire, Paulo. (1997). Pedagogy of the oppressed, 20th anniversary edition.
New York: Continuum.
Frontera, Luis. (1995). Argentina: Pais HIV. Primera encuesta nacional
sobre sexualidad v prevencion del SIDA. Buenos Aires: Editorial Galema.
Gillies, Pamela. (1996). The contribution of social and behavioral science
to HIV/AIDS prevention.. In Jonathon M. Mann & Daniel Tarantola (Eds.), AIDS
in the world II: The global AIDS policy coalition (pp. 131-158). Oxford: Oxford
University Press.
Gollub, Erica. (1995). Women-centered prevention techniques and
technologies. In Ann O’Leary & Loretta Sweet Jemmott (Eds.), Women at risk:
Issues in the primary prevention of AIDS (pp. 43-84). New York: Plenum Press.
Gupta, Geeta Rao. (2000). Gender, sexuality, and HIV/ATDS: The what,
the why, and the how. Plenary Address Xlllth International AIDS conference.
Washington, D.C.: International Center for Research on Women.
Gupta, Geeta Rao, Weiss, Ellen & Whelan, Daniel. (1996). HIV/AIDS
among women. In Jonathon M. Mann & Daniel Tarantola (Eds.), AIDS in the
world II: The global AIDS policy coalition (pp. 215-228). Oxford: Oxford
University Press.
Harrison, Kelsey A. (1997). The importance of the educated healthy
women in Africa. Lancet. v349n9052. pp. 644-647.
Hope, Kempe Ronald Sr. (1995). The socioeconomic context of AIDS in
Africa. Journal of Asian and African Studies, v30nl-2, pp. 80-89.
335
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Institute Nacional de Estadisticas y Informacion (INEI). (2001). Peru en
Cifras. [On-Line]. Available: http://www.inei.gob.pe.
Institute Nacional de Estadisticas y Informacion (INEI). (1997). Estado de
poblacion Peruana: 1997. Salud Reproductiva. INEI-FNUAP: Alan Guttmacher
Institute.
Jimenez-David, Rina and Tadiar, Florence M. (2002). Case Study of the
Women’s Health Care Foundation. Quezon City. Philippines. [On-Line]. Available:
http://www.fhi.org/en/wsp/wspubs/philippine.html.
Kendall, Carl. (1996). The ethics of social and behavioral research on
Women and AIDS. In Lynellyn D. Long and E. Maxine Ankrah (Eds). Women’s
experiences with HIV/AIDS: An international perspective (pp. 370-387). New
York: Columbia University Press.
Kiragu, Jane. (1996). Policy Profile, HIV prevention and women’s rights:
Working for one means working for both. AIDScaptions. v II n3. May 1996. [On
line]. Available: http://www.fhi.org/aids/
Klein-Alonso, Luiza. (1996). Women’s social representation of sex,
sexuality and AIDS in Brazil. In Lynellyn D. Long and E. Maxine Ankrah (Eds).
Women’s experiences with HIV/AIDS: An international perspective (pp. ISO-
159). New York: Columbia University Press.
Kvale, Steinar. (1996). Interviews: an introduction to qualitative research
interviewing. Thousand Oaks: SAGE Publications.
LaBelle, Thomas J. (1986). Nonformal Education in Latin American and
Caribbean: Stability, reform, or revolution? New York: Praeger.
Lamptey, Peter R. & Coates, Thomas J. (1994). Community-based AIDS
interventions in Africa. In Max Essex, Souleymane Mboup, Phyllis J. Kanki, &
Mbowa R. Kalengayi (Eds.), AIDS in Africa (pp. 513-531). New York: Raven
Press Ltd.
Lather, Patti. (1986). Research as praxis. Harvard Educational Review,
v56no3. p p . 257-277).
Law, Lisa. (1998). Local autonomy, national policy and global imperatives:
Sex work and HIV/AIDS in Cebu City, Philippines. Asia Pacific Viewpoint. v39
nl, pp. 53-71.
336
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
LeCompte, Margaret D. & Goetz, Judith Preissle. (1982). Problems of
reliability and validity in ethnographic research. Review of Educational Research,
v52nol, pp. 31-60.
Maguire, Patricia. (1984) Women in development: an alternative analysis.
Amherst: Center for International Education, University of Massachusetts.
Maldanado, Miguelina. (1991). Latinas and HIV/AIDS: Implications for
the 90s. SIECUS Report, v.19 n2, Jan 91, pp. 11-15.’
Malhotra, Anju & Mehra, Rekha. (1999). Fulfilling the Cairo commitment:
Enhancing women’s economic and social options for better reproductive health.
Washington, DC: International Center for Research on Women.
Mann, Jonathon M. & Tarantola, Daniel (1996), AIDS in the world II: The
global AIDS policy coalition. Oxford: Oxford University Press.
Manrriquez, Irma Palma. (1997). Mujeres, relaciones de genero y SIDA en
Chile. In Blanca Rico, Susan Vandale, Betania Allen, & Ana Luisa Liguori (Eds.),
Siutacion de las muieres v el VIH/SIDA en America Latina: una agenda de
investigacion-accion (pp. 75-84). Cuernavaca, Morelos, Mexico: Instituto
Nacional de Salud Publica.
Manuela Ramos. (2002). Oue es Manuela Ramos. [On-Line]. Available:
http://www.manuela.org.pe/.
Manuela Ramos. (1998). Reprosalud: Estrategia de intervencion del
Provecto. Lima; Manuela Ramos.
Marshall, Catherine & Rossman, Gretchen B. (1995). Designing
Qualitative Research. Second Edition. Thousand Oaks: SAGE Publications.
McDaniels, Andrea. (1998). Brazil turns to women to stop dramatic rise in
AIDS cases. Sao Paulo pushes female condom to protect married women from
husbands. But cost of device are high. Christian Science Monitor, January 9,
1998. pp. 7, 8.
Medel-Anonuevo, Carolyn (Ed.). (2002). Addressing gender relations in
HIV preventive education. Hamburg: UNESCO Institute for Education.
Medecins Sans Frontieres (MSF). (2001). Peru: Curative program targets
painful parasitic disease. [On-Line]. Available:
http://www.doctorswithoutborders.org/publications/ar/i2001/peru.shtml.
337
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Medecins Sans Frontieres (MSF). (2000). Peru: AIDS prevention and
reproductive health. [On-Line]. Available:
http://www.msf.org.au/activity2000.peru.stm.
Mendez, Magdalena K. (1996). ETS-SIDA: discursos v conductas
sexuales de las chilenas v los chilenos. Argentina: EDUK.
Ministerio de Promocion de la Mujer y del Desarrollo Humano. (2001).
Cobertura del Programa Nacional de Wawa Wasi. 2001. [On-Line] Available:
www.promudeh.gob.pe.
Ministerio de Promocion de la Mujer y del Desarrollo Humano. (1999).
Conocimientos sobre salud sexual and reproductiva. Lima: PROMUDEH.
Ministerio de Promocion de la Mujer y del Desarrollo Humano—El Wawa
Wasi. (1999). Programa Nacional Wawa Wasi: el program de apovo al desarrollo
de la familia. Lima: PROMUDEH.
Ministerio de Promocion de la Mujer y del Desarrollo Humano. (1996).
INEI Encuesta Demografica v de Salud Familiar (ENDES), Peru: Conocimiento de
Enfermedades de Transmision Sexual. [On-Line]. Available:
http://www.promudeh.gob.pe/Boletines
Ministerio de Salud del Peru, Programa de Control de Enfermedades de
Transmision Sexual y SIDA. (2000). Casos de SID A. Estadisticas. [On-Line].
Available: http://www.minsa.gob.pe/procetss.
Monitoring the AIDS Pandemic Network (MAP). (2000). The status and
trends of the HIV/AIDS enidemis in the world. Provisional report. TOn-Linel.
Available: www.unaids.org.
Monitoring the AIDS Pandemic Network (MAP). (1998). The status and
trends of the HIV/AIDS epidemics in the world. Geneva, Switzerland. [On-Line]
Available: www.unaids.org/highband/document/epidmimio/map.pdf
Mwakisha, Jemimah. (1996). Women’s forum female condom study
explores role of peer support in sustaining use. AIDScaptions. vllln2. [On-Line].
Available: http://www.fhi.org/aids/
National AIDS Control Organisation (NACO). (1998). Country Scenario
1997-1998. New Delhi: Rakmo Press.
Netter, Thomas W. (1992). AIDS in the world: The global AIDS policy
coalition. Cambridge: Harvard University Press.
338
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Newton, Nancy. (2000). Applying best practices to youth reproductive
health. New York: USAID.
O’Leary, Ann & Jemmott, Loretta Sweet. (1995). General Issues in the
prevention of AIDS in Women. In Ann O’Leary & Loretta Sweet Jemmott (Eds.),
Women at risk: Issues in the primary prevention of AIDS (pp. 1-12). New York:
Plenum Press.
Onyango, Christine. (1997). Sub-Saharan Africa women benefit from new
programs. Forum for Applied Research and Public Policy, Summer, pp. 51-57).
Petherbridge-Hemandez, Patricia. (1990). Reconceptualizing liberating
non-formal education: A Catalan case study. Compare, v 20 n 1, pp. 41-51.
Raffaelli, Marcela, and Pranke, Pranke. (1995). Women and AIDS in
developing countries. In Ann O’Leary & Loretta Sweet Jemmott (Eds.), Women at
risk: Issues in the primary prevention of AIDS (pp. 220-231). New York: Plenum
Press.
Renaud, Michelle Lewis. (1997). Women at the crossroads: A prostitute
community’s response to AIDS in urban Senegal. Netherlands: Gordon and
Breach Publishers.
Rojas, Mary Hill & Lopez, Maria de la Paz. (1997). Including gender in the
work of USAID/Mexico: Lessons learned. Washington, D.C.: WIDTech.
Rosenberg, Steven A., Heilman, Samuel, and DeVita, Vincent T. (1997).
AIDS etiology, diagnosis, treatment, and prevention. Philadelphia: Lippincott-
Raven.
Ruteikara, Sam L. (1996). CHUSA: Church Human Services AIDS
Prevention Program in Uganda. In Schenker, Inon, Sabar-Friedman, Galia, and Sy,
Francisco S. (Eds.). AIDS education: Interventions in multi-cultural societies, pp.
231-238. New York: Plenum Press.
Schneider, Beth E. and Stoller, Nancy E. (1995). Women resisting AIDS:
feminist strategies of empowerment. Philadelphia: Temple University Press.
Schuler, ST, Hashemi, SM, Cullum, A, and Hasssan, M. (1996). The
advent of family planning as a social norm in Bangladesh: Women’s experiences.
Reproductive Health Matters. Vol 7, pp. 66-78.
339
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Schoepf, Brooke Grundfest. (1995). Action-research and empowerment in
Africa. In Beth E. Schneider & Nancy Stoller (Eds.), Women resisting AIDS:
Feminist strategies of empowerment, pp. 246-269. Philadelphia: Temple
University Press.
Smith, William A. & Debus, Mary. (1992). The role of qualitative research
in AIDS prevention. In Jaime Sepulveda, Harvey Fineberg & Jonathan Mann
(Eds.), ATDS prevention through education: A world view. New York: Oxford
University Press.
Sobo, Elisa Janine. (1995). Choosing unsafe sex: AIDS-risk denial among
disadvantaged women. Philadelphia: University of Pennsylvania Press.
Stein, Theodore J. (1998). The social welfare of women and children with
HIV and AIDS. Legal protections, policy, and programs. New York: Oxford
University Press.
Stem, Richard. (2001). In Lima, people living with HIV/AIDS demand
treatment access. [On-Line] Available: http://cptech.org/ip/health/aids/peru.html.
Stromquist, Nelly P. (1994). Education for the empowerment of women:
Two Latin American experiences. In Vincent D’Oyley, Adrian Blunt & Ray
Bamhardt (Eds.), Education and development. Lessons from the Third World.
Calgary: Detselig Enterprises Ltd.
Stromquist, Nelly P. (1996). Mapping gendered spaces in Third World
educational interventions. In Rolland G. Paulston (Ed.), Social Cartography:
Mapping wavs of seeing social and educational change (pp. 223-248). New York:
Garland Publishing, Inc.
Taylor & Bogden. (1984). Introduction to qualitative research methods.
The search for meanings. New York: Wiley.
Tiemey, William G. (1991). Utilizing ethnographic interviews to enhance
academic decision making. New Directions for Institutional Research. 1991. 72.
pp. 7-22.
Tsetsgee, P. (2000). Mongolia takes on HIV/AIDS awareness by train.
Regional Programme HIV and Development Asian and the Pacific. v4 nl.
TvT Associates. (2002). HIV/AIDS in Peru. [On-Line].
Available:www.syergyaids.com.
340
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
United Nations Development Programme. (2002). Mision del PNUD en el
Pais. [On-Line] Available: http://onu.org.pe.
United Nations—Executive Board of the United Nations Development
Programme and of the United Nations Population Fund. (2000). United Nations
Population Fund Proposed Projects and Programmes: Recommendation by the
Executive Director Assistance to the Government of Peru. First regular session,
2001. Item 8 of the provisional agenda. [On-Line]. Available: www.unfpa.org.
United Nations—Joint United Nations Programme on HIV/AIDS. (2002).
What UNAIDS does. [On-Line]. Available: http://unaids.org/about.asp.
United Nations—Joint United Nations Programme on HIV/AIDS and
World Health Organization. (2001). AIDS epidemic update: December 2001. [On-
Line] Available: http://www.unaids.org.
United Nations—Joint United Nations Programme on HIV/AIDS and
World Health Organization. (2000). Epidemiological fact sheets on HIV/AIDS and
sexually transmitted diseases: Peru. [On-Linel Available: www.unaids.org.
United Nations—Joint United Nations Programme on HIV/AIDS. (1997).
United Nations [On-Linel. Available: http://www.unaids.org
United Nations—Joint United Nations Programme on HIV/AIDS. (1998).
Report on the global HIV/AIDS epidemic. [On-Line]. Available:
http://www.unaids.org
United Nations. (1999). Acting early to prevent AIDS: The case of
Senegal. Geneva: UNAIDS. [On-Line]. Available: http://www/unaids.org
United Nations Population Fund. (2000). Preventing infection, promoting
reproductive health: UNFPA’s response to HIV/AIDS. [On-Linel. Available:
www.unfpa.org.
United Nations Population Fund. (1998). Acuerdo de provecto entre el
gobiemo del Peru v el Fondo de Poblacion de las Naciones Unidas. Lima: UNFPA.
UNESCO, UNICEF, WHO and World Bank. (2000). Focusing Resources
on Effective School Health: a FRESH start to enhancing the quality and equity of
education, www.unesco.org.www.unicef.org.www.who.ch/hpr,
www.worldbank.org.
Vandale, Susan, Liguiri, Luisa, and Rico, Blanca. (1997). Una agenda
latinoamericana de investigacion-accion sobre mujeres y SIDA. In Blanca Rico,
341
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Susan Vandale, Betania Allen, & Ana Luisa Liguori (Eds.), Situtacion de las
muieres v el VIH/SIDA en America Latina: una agenda de investigacion-accion
(pp. 29-38). Cuernavaca, Morelos, Mexico: Instituto Nacional de Salud Publica.
Webb, Douglas. (1997). HIV and AIDS in Africa. London: Pluto Press.
Weniger, Bruce G. & Berkley, Seth. (1996). The evolving HIV/AIDS
pandemic. In Jonathon M. Mann & Daniel Tarantola (Eds.), AIDS in the world II:
The global AIDS policy coalition (pp. 57-70). Oxford: Oxford University Press.
Whelan, Daniel. (1996). Relationship between women’s status and HIV
risk. In Jonathon M. Mann & Daniel Tarantola (Eds.), AIDS in the world II: The
global AIDS policy coalition (p. 222). Oxford: Oxford University Press.
Wolcott, Harry F. (1990). On seeking-and rejecting-validity in qualitative
research. In E.W. Eisner & A. Peshkin (Eds), Qualitative inquiry in education: the
continuing debate, pp.121-152. New York: Teacher’s College Press
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ATTACHMENT I
Organization of PROMUDEH
Vice-Minister
Wawa Wasi
Literacy
Program
PROMUDEH
Minister
Promotion
of Women
Children
and
Adolescents
Human
Development
Office of
International
Cooperation
Technical Secretary
of Indigenous Topics
INABIF
PRONAA
PAR
COOPOP
343
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ATTACHMENT II
Organizational Chart
UNFPA/PROMUDEH
CHILDREN AND PROMOTION
ADOLESCENTS OF WOMEN
WAWA WASI LITERACY
Calandria
1
Director
I
Consultant
Coordinators
Madres Cuidadoras
Madres/Padres Usuarios Families, Children, Friends
344
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ATTACHMENT III
Reproductive Health Course Modules
TITLE OBJECTIVES THEMES INDICATORS
KNOWING AND
PROTECTING
OUR SEXUAL
AND
REPRODUCTIVE
RIGHTS
1) Recognize
sexuality as a
way of
exercising of
rights.
2) Assume
naturally and
with
conviction
the
necessities
and
requirements
to exercise
their sexual
and
reproductive
rights.
3) Develop
actions for
the promotion
and
permanence
of then-
sexual and
reproductive
rights.
1) Concept of rights.
2) Minimal
conditions for
exercising these
rights. The
citizen.
3) Sexuality and the
rights that it
implies.
4) Development of
sexual and
reproductive
rights.
5) The commitment
of the Peruvian
State for the
sexual and
reproductive
rights of women
and population
control.
6) Principal sexual
and reproductive
rights.
1) Define the concepts of
rights, citizen, sexual
and reproductive rights.
2) Recognize their
necessities and
demands to adequately
exercise their sexual
and reproductive rights.
3) Identify the rights,
obligations and
responsibilities of the
people and other
agencies involved in
achieving these
necessities and the
exercising of a
complete sexuality.
4) Recognize the sexual
and reproductive rights,
the forms and
mechanisms to exercise
fully.
5) Demand and/or
negotiate with their
partner to achieve a
satisfactory sexual life
for both.
6) Demand from the
providers of health
services, quality
attention for care of
sexual and reproductive
health.
7) Transmit to their
immediate environment
attitudes and values that
promote the full
exercise of the sexual
and reproductive rights,
with quality attention
for sexual and
reproductive health
services.
345
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TALKING
ABOUT OUR
SEXUALITY
1) Recognize
sexuality as
an important
dimension in
the lives of
all people and
identify their
biological,
psychological
and social
components.
2) Value
positively
sexuality and
assume their
expressions
naturally.
3) Promote an
integral
vision of
sexuality and
exercise it
responsibly
and
pleasantly.
1) Concept and
importance of
sexuality.
2) Components of
sexuality.
3) Sexual organs
internal and
external, and
masculine and
feminine.
4) Functions of the
sexual organs.
5) Sexual
development.
6) Sexual and
reproductive
health:
contraceptive
methods, AIDS
and STDs.
7) Sexuality and
self-esteem.
8) Strategies for
positive
promotion and
diffusion of
sexuality.
1) Recognize sexuality as
an important dimension
in life.
2) Identify the components
of sexuality.
3) Identify the parts and
functions of the sexual
organs internal and
external, masculine and
feminine.
4) Indicate the conditions
to exercise safe and
responsible sexuality.
5) Have positive
appreciation for the
exercise of sexuality
independent of
reproduction.
6) Accept naturally their
own bodies and assume
a communicative and
assertive attitude about
the exercise of their
sexuality.
7) Choose the channels
and strategies most
adequate to disseminate
workshop contents.
IMPROVING
GENDER
RELATIONS
1) Recognize
the social
construction
of gender
roles,
identifying
the
stereotypes
that create
and maintain
them.
2) Assume a
critical
attitude
toward
gender
stereotypes
and equal
values for
men and
women.
1) Sexual identity.
2) Gender roles.
3) Socialization,
social agents, and
gender
stereotypes.
4) Equality in human
relations.
5) Strategies to
promote equitable
relationships.
1) Define sex for its
fundamental differences
between men and
women.
2) Differentiate the
physiological functions
and those assigned by
culture for men and
women.
3) Identify messages
relative to roles and
stereotypes in: social
norms, institutional
norms, and methods of
social communication.
4) Recognize the agents
that intervene in
socialization.
5) Identify and value the
problems resulting in
the lack of equality in
social perception and
the adult relations with
346
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
3) Promote
equal gender
relations in
immediate
environment
and
communities.
girls and boys and
women and men.
6) Support with the
children in their care,
activities that promote
generation and gender
equity.
7) Elect more appropriate
messages, channels and
opportunities to
disperse information
that promote generation
and gender equality.
SAYING NO TO
FAMILY
VIOLENCE
1) Recognize
sexuality as
an important
dimension in
the lives of
all people and
identify the
biological,
psychological
, and social
components.
2) Assume a
critical
attitude about
the actions of
family
violence and
the social and
cultural
conceptions
that they
sustain.
3) Develop
actions that
prevent
family
violence and
disseminate
the norms for
protection
and existing
social
services.
1) Family violence
in our country.
2) Causes and
consequences of
the violence.
3) How to identify
situations of
family violence.
4) Strategies for
prevention and
attention for cases
of family
violence.
1) Know the levels of
incidence of family
violence in our country.
2) Recognize situations of
violence in their
environment.
3) Explain the causes and
indicate the
consequences of family
violence.
4) Support actions for
prevention of family
violence.
5) Orient the families in
the community for
attention to these cases.
6) Incorporate in their
practice actions that
question the
conceptions and ideas
that sustain the
violence.
7) Incorporate in their
practice actions of good
treatment on their
relations with children
and adults.
PROMUDEH, March 2000
347
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
Bilingual education in California: A policy debate
PDF
Community learning in environmental NGO projects in Vietnam: A comparative study
PDF
Gender, learning, and trafficking: Helping vulnerable Thai women through NGO and government non -formal education programs
PDF
Internationalization of higher education: A case study of a private United States research university
PDF
Catholic schools and civic engagement: A case study of community service -learning and its impact on critical consciousness and social capital
PDF
Educational development aid and the role of language: A case study of AIT -Danida and the Royal University of Agriculture in Cambodia
PDF
Can Reproductive Health Education Empower Women? A Brazilian Qualitative Study
PDF
AIDS knowledge and education for South Korean-born college students attending Korean colleges and United States-born Korean American and South Korean-born students attending United States college...
PDF
A contemporary urban ethnography of Pakistani middle school students in Oslo, Norway
PDF
Adult urban community college student success: Identifying the factors that predict course completion and goal attainment for students aged 25 years and older
PDF
An examination of the contract education program in a multi-college community college district in Southern California: A descriptive and qualitative case study investigation
PDF
Intra-familial child sexual abuse: The experience and effects on non-offending mothers
PDF
Education for change in a changing Nigerian Igbo society: Impacts of traditional African and western education on the upbringing of Igbo children
PDF
Counter -matching in nested case -control studies: Design and analytic issues
PDF
Dealing with the United States' educational crisis: Studying baccalaureate programs
PDF
Empowering urban street children: Freirean and feminist perspectives on nonformal education in Mexico
PDF
Chinese immigrants united for self -empowerment: Case study of a weekend Chinese school
PDF
Getting to know the poor: Early Victorian fiction and social investigation
PDF
Comparison of variance estimators in case -cohort studies
PDF
Data -driven strategies to improve student achievement: A cross-case study of four California schools
Asset Metadata
Creator
Vega, Jennifer Blythe
(author)
Core Title
Educating women on sexual health and reproductive rights: A case study of a prevention program in Peru
School
Graduate School
Degree
Doctor of Philosophy
Degree Program
Education
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
Education, administration,education, adult and continuing,education, health,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Stromquist, Nelly (
committee chair
), Rideout, William M. (
committee member
), Schor, Hilary (
committee member
)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c16-263241
Unique identifier
UC11339388
Identifier
3093926.pdf (filename),usctheses-c16-263241 (legacy record id)
Legacy Identifier
3093926.pdf
Dmrecord
263241
Document Type
Dissertation
Rights
Vega, Jennifer Blythe
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
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
education, adult and continuing
education, health