Women's Health and Rights in Underserved Communities

Review by Chelsea Wan, Juhi Meta, Zoe Staggs, Rakhi Banerjee, Krutika Joshi, Talia Rajasekar, Susanna Givan, Reem Bardan

Poverty, social and economic inequality, conflict, lack of education, and environmental fragility continue to undermine the struggle for gender equality in developing countries. Countries like Mexico have sought to dismantle the patriarchal values still deeply rooted in the social, economic, and political climate. Gender-based discrimination and violence are most pervasive in womens’ education, reproductive rights, healthcare, and the workplace, inhibiting women from attaining the very resources needed to dismantle these constraints. Mexico’s social trends reflect a far more pandemic issue; millions of girls and women globally continue to lack access to basic sexual and reproductive health services. Unwanted pregnancy, reproductive cancer, maternal morbidity, and unsafe abortion pose risks to women’s physical and mental well-being throughout the life-course. To illustrate, every two minutes a woman dies from preventable complications from pregnancy, devastating countless families and communities (Lozano, 2011). A further 200 million adolescent girls lack access to safe and effective contraceptives, a fundamental component of family planning (Lozano, 2011). The stigma and deep-rooted inequalities associated with female reproductive health prevent women from controlling an integral part of their lives. 

 

Education & Schooling

Women’s education has long been a topic of contention in traditionally patriarchal societies, and the effects of lack of education can be detrimental. Not only is education essential to creating opportunities for independence, but it also plays a role in health and well-being.

 

Women’s education is necessary for producing new opportunities, some of which are economic advancement and reducing levels of poverty. Throughout Mexico, it has been found that increased access to education for women results in increased women’s economic participation (e.g. labor participation) and eventually economic growth and reduction of poverty (Garduño-Rivera, 2013). In rural Mexico specifically, higher education level is one of the factors that is associated with higher women’s participation in the non-farm sector, in which many studies have shown that employment outside of the farm sector is related to mitigated levels of poverty (Martínez-Domínguez, 2019). Increased finances, alongside potentially steady sources of income, mean that women are able to become more financially independent, and ultimately gain greater autonomy overall.

 

Women’s education is also one of the factors that shapes health, not only by facilitating attainment of higher income (meaning increased resources for disease or injury treatment and prevention options), but also by promoting learning and critical thinking skills that can be directed towards one’s health and well-being. For Mexican women, education may also be more strongly linked to health due to Mexico’s patriarchal gender norms. Even though educational levels are similar across genders in Mexico, women are still subject to other disadvantages in a system built on patriarchal principles, such as the wage disparity between men and women (Gorman et al., 2019). Another vital aspect of women’s education and its relationship to health is reproductive health. As seen in rural regions of Latin America, lack of sexual and reproductive education means low rates of contraceptive use, leading to high maternal death rates, teenage pregnancies, and dangerous abortions, all of which are exacerbated by the lack of health resources in such areas. As demonstrated by a study conducted on two especially vulnerable groups of Mexican women (indigenous women and adolescents from Huasteca), the implementation of a sex education program resulted in a significant drop in lack of contraception use across participants and overall increased reproductive health knowledge (Sanjuan-Meza et al., 2018).

 

Reproductive Justice

Women in Mexico face numerous barriers to achieving gender based equality. This is largely in part due to limited access to menstrual hygiene products, and women living in poverty are disproportionately affected. According to data collected from UNICEF, 43% of adolescent girls in Mexico choose not to attend school while menstruating (Bello, 2021). For these young children, a lack of access to menstrual hygiene products serves as a barrier to accessing their education, which contributes to gender inequality. Lacking access to these products also poses a health hazard, leaving women more prone to infection and related reproductive issues. While previously, products such as sanitary napkins, tampons, and menstrual cups were taxed at an astounding 16% as value added tax (VAT), a 2021 senate decision broke barriers by eliminating this tax (van der Gracht, 2021). The Mexican government has also recently taken progressive strides regarding abortion rights. In 2021, a historic decision by the Supreme Court of Mexico found abortion to be noncriminal, and criminalizing abortion to be unconstitutional (Kitroeff & Lopez, 2021). As the Supreme Court did not specify how far into pregnancy an abortion is still deemed legal, state level legistalation must be passed. 

 

Health and Wellness 

 

Abortion rights, cultural stigma, & health ramifications

Throughout history, gender-based discrimination has permeated Mexican society in innumerable ways. Women’s sexual and reproductive health are not exempt from these pervasive social inequalities, with abortion estimated as the third or fourth leading cause of death in Mexico (Chambers, 1993). Like many Latin American countries, Mexico outlawed abortion for most of the 20th century, upholding hostile attitudes around abortion. Despite social progress and budding democracy throughout the country, abortion remains a prevalent and nuanced topic of contention. Each of Mexico’s 32 states has autonomy when it comes to abortion laws, giving rise to inconsistrent legislation across the country. While states like Oaxaca have legalized abortion in the first 12 weeks after conception, at least 17 states have adopted constitutional amendments that protect life from the time of conception. Despite the legal ramifications of abortions, many Mexican women continue to terminate unwanted pregnancies in unsafe conditions. In 2006, a reported 149,700 women were hospitalized from complications following abortion procedures (Becker & Olavarrieta, 2013). Many of these are conducted without proper medical professionals, resources, and procedures, with an estimated 95% of abortions across Latin America and the Caribbean deemed as unsafe (Becker & Olavarrieta, 2013). 

 

Abortion laws also disproportionately affect those living in poverty, primarily indigenous women that already bear the brunt of racial, social, and economic injustice in Mexico. Low-income women, which made up 41.9% of the population in 2018, must rely on free government-run clinics in order to undergo safe abortions (World Bank Group, 2020). Given the dearth of womens’ clinics in rural areas and conservative Mexican states, women are likely to seek out risky and unauthorized methods of ending pregnancies. Restrictive abortion laws also prevent women from seeking public health services altogether. A 2010 New York Times exposé investigated women in the conservative state of Guanajuato who had suffered from miscarriages and pregnancy complications, such as severe bleeding and amniotic fluid embolism. Many hesitated to seek emergency medical services in fear of being wrongfully prosecuted for attempting to terminate their pregnancy. Moreover, many indigenous women lack access to public healthcare altogether, contributing an even greater number of maternal deaths to Mexico’s health statistics. In the state of Chiapas, 27.2% of the total population identifies as indigenous, one of the highest concentrations in the country (National Institute of Statistics and Geography, 2011). Chiapas reported a maternal mortality ratio (MMR) of 59.8 per 100,000 live births in 2012, a figure nearly 40% above the national average (Women’s Mortality Observatory of Mexico, 2013). Overall, poverty, gender inequalities ethnic discrimination, and geographic inaccessibility, compounded by restrictive abortion laws and stigma, put the most vulnerable groups in peril, backpedaling on rudimentary human rights. Future efforts by FISH 

 

2000’s reform to COVID-19 pandemic: impact on maternal health

In 2007, Mexico DF’s government legalized elective abortion in the ILE reform, immediately allowing for women over the age of 18 to request an abortion up to 12 weeks into their pregnancy, without restriction and free of charge. Additionally, sexual education was improved in schools following this law and post-abortion contraceptives were made available (Clarke 2021). While some steps have been taken, with a decline in maternal mortality from 88 to 33 per 100,000 live births from 1990 to 2017, a great deal of work still needs to be completed. 

 

One recent study looked into the effects of the COVID-19 pandemic on maternal health, specifically in how it served to aggravate health care access disparities for pregnant women (Mendez-Dominguez, et al., 2021) The retrospective study found that maternal mortality increased by 56.8%, of which the mother contracting COVID-19 was only the cause of 22.93% of cases. Included within Mexico’s response to the pandemic was the “protection” of pregnant women, limiting their exposure to the virus by reducing prenatal and postpartum visits, as well as reducing the number of staff focused on their care, redirecting resources to patients suffering from the virus. Despite these recent numbers, even prior to the pandemic in the 2019 calendar year, the maternal mortality rate remained high, at 31.2 per 100,000 births, though a decrease from the year before. While steps are being made towards addressing this issue, the need for pregnant women to have increased access to healthcare remains clear. While access varies largely between different states, factors such as education, residence in rural areas, and indigenous ethnicity remain key in determining access to health resources and infrastructure. 

 

Gender-Based Violence

Gender based violence refers to acts of violence based on gender. It is largely a product of gender inequality and harmful social norms under which women predominantly suffer. Gender based violence is prevalent everywhere. However, poverty, lack of education, and political systems entrenched in patriarchal traditions enable domestic violence at a higher rate. Moreover, since gender based violence can be rooted in cultural gender roles, many women tolerate the abuse they are subjected to, or even think it is justified. A study surveying rural women in Nicaragua showed 32% of those women surveyed believed it acceptable for a husband to beat his wife if he thinks she is cheating on him (Hughes, 2011). Finally, many women who endure acts of violence do not report it because of a fear that they will be ostracized, abused more, or neglected. A study on domestic violence against women revealed that 29% of women who reported the abuse did not recieve medical care and only 5% consulted a health worker (Chandrasekaran, Krupp, & George, 2007).

Violence against women has long been a problem in Mexico. It occurs in places of worship, parks, markets, and public transportation. Recently, multiple studies have examined gender-based violence in public transportation. A study conducted in 2020 found that seven of ten women in Mexico City felt unsafe on public transportation centers, six of ten reported experiencing a form of assault, and one of ten reported being followed by a potential threat (Méndez, 2020). In Saltillo, Mexico, 59.74% of surveyed women reported feeling unsafe on public transport, and 95.9% expressed being afraid of catcalling, groping, and unwanted sexual behavior (Infante-Vargas & Boyer, 2022). While many scholars have recommended that cities provide women-only transportation, most also conceded that ultimately, these acts of violence are deeply rooted in inequalities that undermine women and frame them as responsible for all that they endure. Lack of safety on public transport is hardly a new issue, and it is significant of the dangers women face in everyday life, in general. They live with the constant possibility of violence in most public spaces, and governmental authorities have failed to make any protective changes, or even acknowledge the problem. 

 

Workforce Equality

When confining their definition to a strictly academic context, the foundations of workforce equality can sometimes be misunderstood as exclusively elaborating upon the demands of women’s rights. However, while it is crucial to acknowledge that general injustices outlined by advocates of women’s equality still permeate the workplace, there has been an observable discrepancy in wages not between single women and men but between men and women with children. In fact, a study by the National Bureau of Economic Research assessing the earnings of various parties in the workforce in Denmark concluded that bearing children was responsible for as much as 80% of the wage gap, with evidence indicating that women with at least one child under their care earned half as much as women without children (Kleven et al., 1993). This discrepancy has particularly devastating consequences for women in Mexican communities looking to enter the labor market, given that an overwhelming proportion of these women are constituents of single female-headed family models (Mills & Hazarika, 2003).

Not only does such large a wage gap deter mothers from entering the workforce and discourage women who are considering becoming mothers from temporarily leaving the workforce for fear of lower wages when they return, but this fear can prevent current mothers from taking maternity leave either because they are not compensated for these temporary furloughs or because their employers will not meet their earlier wages. Given this blatant lack of social and economic support, the health of women—especially new mothers—suffers dramatically, causing mental exhaustion and diagnoses of mental health disorders in addition to the various physical responsibilities with which women are charged in the home (Bourke-Taylor & Law, 2011).

 

Women’s Right to Protest and Seek Justice 

Historically, it has been high-status women who mobilized for better access to funding and education for the betterment of women and created outlets for their mobilization such as publications, pamphlets, and in today’s society, social technology. Since 1916, they were granted permission to hold the first female congress and the right to run for political office (Wright, 2002). However, the legality of their demonstrations and justice seeking movements comes with strong backlash when actually implemented. Government leaders call the demonstrations being done by the antifemicide movement, violent, and blame the women for inciting strikes and unrest. Their motives are questioned as provocation for seeking a more violent response from the state intended to create more attention and condemnation by the public; government leaders point to their opposition as orchestrating the demonstrations for political purposes. (Wright 2002). This undermines the legitimacy of women as the key leaders of the strike and increases the likelihood of repudiation from both public and private parties. A report by Amnesty International found multiple human rights violations by police at five feminist protests in 2020, including the use of excessive force, arbitrary detention, and sexual violence. Police officiers arrested more than a dozen women without properly identifying themselves, held them incommunicado for long periods of time, transferred them using unusual routes without telling them where they were taking them, sometimes without even bringing them to the relevant authorities. They were also spoken to in violent and sexualized language and threatened with sexual violence.  Police officers would intentionally use excessive violence to “teach them a lesson” for daring to protest in public. The mistreatment from government officials comes with the political and economic elites pushing forward the narrative that women who protest publicly on the street are hysterical and suspicious. This all culminates into an hostile environment for women’s right to peaceful assembly that discredits their activisim (Gamero, 2021). However, many high-profile cases of femicide still serve as the catalysts for major demonstrations, in spite of the difficulties. On January 9th, 2016, Ingrid Escamilla was killed and skinned by her alleged partner; just a few days later, 7-year-old Fatima Aldrighetti was kidnapped, tortured and murdered. A national demonstration on March 8 in honor of International Women’s Day drew thousands of protesters. The next day, tens of thousands of women took part in a nationwide walkout, disappearing for 24 hours from their schools and jobs. The largely leaderless movement, known as #UnDiaSinNosotras(“a day without us”), was a statement challenging the government’s perceived indifference to the growing issue of femicides in the country (Villegas 2020). The outcry from these deaths grew into powerful political mobilization, including alliances with the private sector and state institutions that sponsored and participated in nation-wide marches held on August 13, 2016. By some estimates, as many as half a million people took to the streets in support. As women make up 40% of the workforce, their absence cost an estimated $1.37 billion loss in productivity (Boesten, 2018). The true safety of women practicing their right to assembly, protest and seek justice is unknown; it was extremely difficult finding sources, as many fear doing so may cause them to be targeted. Social media serves as a powerful tool for debate and mobilization, as a way to share testimonies that nonsympathetic members of society might identify with and provides women a powerful pressure mechanism that keeps those that might disagree at a safe distance. 

 

Annual Women’s Rally 

Thousands of women march in the streets annually on International Women’s Day in Mexico. They march peacefully for the eradication of violence against women. The women protest against femicide, which describes the killing of women because of their gender. They march against the political system which has been accused of not doing enough to stem the rise in femicide in the past years. The risk to their health or autonomy is significant however, as police have retrieved Molotov Cocktails, bats, hammers, and explosive devices such as fireworks and homemade small bombs from people attending the marches to disrupt them. 


 

Applications to the Fellowship of International Service and Health (FISH)


 

Education and Schooling

While women’s education in underserved communities is beyond the scope of FISH, nor is it our place to implement change in this area, it is important for FISH to be aware and culturally-sensitive of what challenges different populations within the community face—especially those that affect community health. Thus, while FISH may not be impact women’s education in Maclovio Rojas directly, FISH can work to educate its own members about how the challenges surrounding women’s education in the community affect women’s health, and/or possibly find resources to direct women in the community of Maclovio Rojas to (e.g. sex education programs or reproductive health resources).

 

Reproductive Justice

Health and Wellness (Abortion rights, cultural stigma, & health ramifications)

Although providing safe maternal healthcare falls well beyond FISH’s scope of authority, the organization can continue to provide culturally-appropriate education on abortion rights and safe healthcare practices. Members of FISH should be familiar with reputable and safe womens’ clinics near the Maclovio Rojas community so that they can refer women with healthcare concerns. Moreover, it is important for FISH to seek out non-violent spaces to have open conversations regarding reproductive health, abortion rights, and unsafe practices in order to destigmatize womens’ healthcare.

 

Women’s Right to Protest and Seek Justice

 Source of authority, government, police and other seats of power, have not been protectful  of women’s rights to seek justice for violent crimes and to protest them. They have been harmed for daring to speak up, seek justice and protest. This generates distrust between the women of Maclovio Rojas and any potential sources of power. FISH can work to build this trust, to show the women of Maclovio Rojas that we believe their stories and support them. Although we cannot resolve the complicated policy and societal issues related to femicide and lack of ability for women to speak up in a safe manner outside of FISH, we can hear them when they speak to us about it. We can educate our own members as well about the injustices occurring that obstruct women’s right to protest and seek fair justice and how the women of Maclovio’s might have difficulty opening up about this topic or trusting us to be safe people to speak with about this. 


 

Annual Women’s Rally 

The thousands of women within Mexico march to demand justice, security, and protection against violence every year on International Women's Day. Although FISH as an organization cannot work to resolve political issues, FISH can participate in spreading awareness about the conditions that women face in addition to uplifting the women who participate within these protests. FISH can educate their members about the violence that occurs within Mexico through having open conversations.In addition, FISH can work to develop close relationships with the women and provide a safe haven where they can speak openly about their experiences to individuals who would support them. FISH can direct women to organizations which would support their fight for justice and safety and aid them in spreading their message.

 
 

Cultural Competency, Imperialism, White Saviorism, and Global Health Ethics:

Improving FISH’s Associate Training and Operational Ethics

 

Review by: Tessa Fier, Presentation by: Shivangi Goswami, Erika Gonzalez

History of Maclovio Rojas 

  • Why is this important: To be more culturally aware of the origins and current realities of the community we enter to  serve 

 

Understanding Imperialism

  • Conceptual definition: “ the process whereby the dominant politico-economic interests of one nation expropriate for their own enrichment the land, labor, raw materials, and markets of another people” - Michael Parenti

  • Modern Imperialism - The US and Mexico

    • Maquiladoras as engines of modern imperialism 

    • Recent attempts by the United States Department of State and associated corporate interests to force the Mexican government to reopen maquiladoras despite the coronavirus pandemic

 

Global Ethics and FISH

  • FISH has integrated global health ethics  training and resources

  • Effort to include the rationale of this training 

  • Examples:

    • Documentaries created for international clinical programs

    • Case study scenarios used to train medical students abroad

  • Despite being more clinically oriented, lessons and perspectives are applicable to FISH

 

On FISH’s To-Do List...

  • Broadening its curriculum with information on history, imperialism, and global health ethics

  • Create a curriculum for associates that is adapted to the realities of the pandemic

  • Make available a list of vetted and reliable resources relating to these topics for associates in search of more information

 

Discussion Questions

  • Have to remember the group is the unit of analysis! (not the individuals)

  • Ascertain whether something was a view of one member or a theme for the group

  • Note whether a specific discussion emerged as a result of moderator prompting or spontaneously from the group

  • More text/discussion does not necessarily mean the topic is more important

Health Education Efficacy

Overview

  • Questions Faced:

    • What makes people act on the health education they receive?

    • What are common reasons why people do not act on health information they receive? 

    • What is the best way to disseminate information so that the message sticks?

Art

  • Main Idea: Health education is more effective if visual and artistic elements are implemented into the dissemination of the curriculum. 

  • Applications:

    • Use animated videos to explain a certain topic or scenario

    • Use a music and pictures to engage the audience

    • Explain a concept visually through pictographs and flowcharts

Culture

  • Main Idea: People motivated to change behavior if that change fits within their perceived identity

  • Applications:

    • Use correct language

    • Include characters & representation that matches target population

    • Include appropriate cultural symbols

Science

  • Main Idea: Health education based on science will be more memorable if messaging is simple, concrete, credible, and relatable. 

  • Applications:

    • Create messages that have influences such as community culture/norms, art, family & friends, etc

    • Keep complex scientific ideas simple and easy to understand

    • Focus on “how” individuals can improve in addition to  “why” person engages in behavior and “what” needs to be targeted to intervene

Conclusion/Discussion

  • Possible Questions:

  • What are some specific ways that FISH can implement art, culture, and science to increase the effectiveness of its health education?

    • For the cultural component of the SEM, how does one from outside the community use this tactic without appropriating the community’s culture or sounding insensitive?

    • What are some challenges that could arise when trying to implement science and use statistics and evidence-based tactics to explain concepts? 

Citation https://www.mdpi.com/1660-4601/16/5/872/htm

Transtheoretical model of Behavioral Change

By Daniel Zoleikhaeian

 

Background: SCT + SEM

  • Social Cognitive Theory (SCT): self-efficacy

    • Achievable goals, track progress, self-reward

  • Social Ecological Model (SEM): 

    • Good environment = good behavior

 

5 Stages of Behavioral Change

  • 1. Pre-contemplation

    • Individual thinks change is not important or necessary

  • 2. Contemplation​

    • ​Individual realizes the problem but does not implement change

  • 3. Preparation

    • ​Individual makes formal plan for implementing the change

  • 4. Action

    • ​Individual executes their plan for change

  • 5. Maintenance

    • ​Individual has successfully executed plan. Goal is to now maintain the healthy behavior

 

The Progression towards Maintenance

  • Pre-contemplation

    • Consciousness Raising

    • Environmental Re-evaluation

  • Preparation

    • Self-liberation

    • Counterconditioning

    • Stimulus control

  • Contemplation

    • ​Self-evaluation

  • Action

    • ​Contingency Management

What FISH Can Do: Motivational Interviews

  • Discussion Questions

    • What additional training may be needed to implement motivational interviews during consultations?

    • How would we implement motivational interviewing in our health fairs?

Bibliography

  • Cassidy, C. A. (1999). Using the Transtheoretical Model to Facilitate Behavior Change in Patients with Chronic Illness. Journal of the American Academy of Nurse Practitioners, 11(7), 281–287. doi: 10.1111/j.1745-7599.1999.tb00578.x

  • Franklin, B. A. (1978). Motivating and Educating Adults to Exercise. Journal of Physical Education and Recreation, 49(6), 13-17. doi:10.1080/00971170.1978.10617817

  • Kennedy, A. B., & Blair, S. N. (2014). Motivating People to Exercise. American Journal of Lifestyle Medicine, 8(5), 324–329. https://doi.org/10.1177/1559827614524135

  • Resnick, B., Vogel, A., & Luisi, D. (2006). Motivating minority older adults to exercise. Cultural Diversity and Ethnic Minority Psychology, 12(1), 17-29. doi:10.1037/1099-9809.12.1.17