Empowering Women to Protect and Improve Their Own Health
Working for a world where women are safe, healthy and heard.
It is a space—a room safe from rain and stress. It is five fingers of emergency—a quick chant of self-defense tactics. It is a life-changing device that offers three months of contraception. It is an abuela in Guatemala who counsels young mothers.
The resources may differ, but they share a common goal: Empower women to protect and improve their own health. Following are stories of Bloomberg School researchers working in Baltimore, Malawi and beyond to help women reach the future they want.
A ROOM OF ONE'S OWN
SPARC Center hopes to be a haven for Baltimore's female sex workers.
Valentine’s Day was cloudy and damp in Baltimore this year, but a warmth pulsed from a converted church in the southwest part of the city. Inside, a group of women sipped hot chocolate, snacked on popcorn and crafted Valentine’s cards as a movie played. It was one of the first events hosted by the newly opened SPARC Center. The goal was for women to feel relaxed and taken care of—to create a place where, at the very least, they could get out of the rain.
That’s the ethos at the heart of SPARC, which opened earlier this year to serve female sex workers in Southwest Baltimore. For some, “getting out of the rain” means addiction management, mental health counseling or treatment for an STI. For others, it’s a nap on a couch, or perhaps a reprieve from the stresses of unstable housing.
“We want women to be able to take a deep breath here,” says Susan Sherman, PhD ’00, MPH, who started the center as the central component of a women’s health study that aims to reduce HIV risk among sex workers in Baltimore. “We want this to be a place they can take their shoes off, have a cup of coffee, watch TV, connect with other women and then hopefully take advantage of our services.”
SPARC—which stands for Sex workers Promoting Action, Risk reduction, and Community mobilization—is one of the first targeted, full-service programs of its kind in the U.S., says Emily Clouse, MScPH, the SPARC Center director. Funded by NIDA, the Center will formally celebrate its grand opening in June. A high-ceilinged reception area outfitted with lockers opens up to a living space furnished with couches and a computer station. Upstairs are a shower and laundry room. The building is outfitted with rooms for counseling, legal counseling and health services. The services are provided at no cost and are designed to be easily accessible for any woman who may need them, sex worker or not.
“We are grounded in a harm reduction philosophy, meeting people wherever they are in their lives and drug use,” says Clouse.
Besides providing care, the Center hopes to encourage stronger bonds among these women. Previous studies show that female sex workers in Baltimore largely operate in isolation and distrust their peers. When asked in one survey if they could rely on a fellow sex worker to borrow money or even a condom, most women said no.
“We’re trying to see whether women can begin to mobilize and empower each other with the help of a place like this,” says Clouse.
To help build that sort of trust, the Center has hired women with lived experiences in sex work and drug use to lead SPARC’s outreach. These peer outreach workers possess unique empathy and insight to better reach the Center’s clients, but they also model the confidence and stability the SPARC team hopes to help their clients achieve.
The program targets women in South and Southwest Baltimore, but the hope is that its impact will ripple out to other parts of the city, resulting in lower overall rates of STIs and HIV. Researchers will look to see if the center promotes “community-level change”—where women who never even step across SPARC’s threshold still see improved health outcomes and more job and housing opportunities.
SPARC has set funding for three and half more years, but the goal is to partner with other organizations and pursue further funding in order to make SPARC a “long-term, sustainable project,” Clouse says.
“We want to be a fixture in the community for the foreseeable future.”
Building the Family
A woman wants to get pregnant, but either she or her partner has HIV. What kind of conversation should she have with her health care provider?
For women facing this situation in South Africa, where 18.9 percent of adults are HIV-positive, there’s often no conversation. Despite the fact that there are proven safer-conception strategies for HIV-affected couples, many providers in sub-Saharan Africa still lack the knowledge or resources to share options.
The safer-conception clinic, implemented by Johannesburg’s Witkoppen Health and Welfare Centre, is called Sakh’umndeni, which means “building the family.” It helps women and their partners form conception strategies that will minimize HIV transmission risk between themselves and the baby, including antiretroviral therapy for HIV-positive partners and pre-exposure prophylaxis for HIV-negative partners.
Schwartz’s research also focuses on women who are especially vulnerable to HIV transmission, such as female sex workers and adolescent women. As these women gain more tools to prevent HIV, they can also become powerful health advocates, says Schwartz. If a male partner avoids coming to the clinic to learn his HIV status—as is often the case—the woman can give him an HIV self-test kit and, if need be, link him to a male-friendly clinic.
“We want these women to be setting the goals and their agendas,” Schwartz says. “We want them to feel like they can take control of their own health.”
Reflexes of Resilience
The continuing impact of group therapy for sexual violence survivors in the Congo.
For one Congolese woman, the violent memories returned in a continuous loop, replaying in her mind over and over again.
“Each time that I thought [of] them, they would envelop me and I became very ill,” the woman, a survivor of sexual violence, told Bloomberg School mental health researchers last summer.
Another survivor reported that a single flashback could physically incapacitate her. “Once, I thought of that which had happened to me,” she said. “The whole evening I felt very ill.”
Such stories of debilitating posttraumatic stress and flashbacks are common among women in the Democratic Republic of the Congo, where officials estimate 40 percent of women have been victims of sexual violence amid ongoing partisan conflict.
Their stories, however, didn’t end with anguish. Instead, the women described the coping techniques they relied on to feel better. “To calm myself, I’d reflect on the techniques [I] learned, and in reflecting I was relieved,” the first woman said. “I reached composure in spite of the pain.”
Department of Mental Health faculty had established in 2012 the power of the cognitive processing therapy, or CPT, treatment model, in which participants recognize and challenge negative thoughts that stem from their trauma. They found that CPT was effective, reproducible and widely accepted. Female survivors who participated in group CPT during that trial showed dramatic improvements. Six months after the trial, just 9 percent of these women continued to show elevated symptoms of depression and anxiety. Most reported that they were able to overcome crippling flashbacks, nightmares and social shame.
Five years later, the researchers were astounded to find the same women were still regularly using the CPT skills to cope with the effects of both old and new trauma.
“We think of talk therapy as something that’s used in the moment to reduce the symptoms, but this shows that there are interventions that give people new skill sets,” says Judith K. Bass, PhD ’04, MPH, MIA, the lead author of the original and follow-up studies. “This model wasn’t just a treatment intervention. It gave these women tools and empowered them in lasting ways.”
When the research team returned to the same villages in 2017, they interviewed 103 women—
66 percent of the women who received CPT in the original trial. Conditions for these women, who live throughout the conflict-ridden South Kivu province, have changed little since 2012; they remain as vulnerable, if not more so, to gender-based violence, says Bass. Many women from the trial had witnessed or been victims of trauma since the first intervention: 16.8 percent said they had personally experienced sexual violence in the last six months.
Yet as the team interviewed these women, they found that their rates of high anxiety and depression symptoms—27 to 28 percent—remained significantly lower than their pre-2012 intervention levels of 64 to 87 percent. What’s more, the therapy groups the women joined five years earlier had evolved into long-term support groups. The field-based data collected by Sarah McIvor Murray, PhD ’15, MSPH ’11, and current PhD candidate Daniel Lakin, MA, found that 90 percent of the women interviewed still meet regularly with these groups, with more than half of the groups gathering at least once a week.
The hope of the research team is that these follow-up results will further convince funders, such as USAID, which funded this research, that these therapy models can have impacts beyond just reducing symptoms in the short term.
“In mental health, the basis of empowerment is building strength,” Bass says.
The life-changing device is small enough to fit in the palm of a woman’s hand. In Senegal, women tuck it in their armoires. In Uganda, they stow it in their handbags and call it the “all-in-one.”
This revolutionary family planning method, subcutaneous depot medroxyprogesterone acetate, or DMPA-SC, contains everything necessary for three months of reliable birth control: a short needle attached to a small plastic ampule prefilled with injectable contraceptive that can be inserted into the skin. The user-friendly design, the first of its kind, makes it easy for any trained person—including the woman herself—to administer the injection. It is also designed so that she can obtain additional doses to take with her for future use.
“The method is powerful because it provides real autonomy,” says Beth Fredrick, executive director of Advance Family Planning, a multicountry advocacy initiative of the Bill & Melinda Gates Institute for Population and Reproductive Health that is working with policymakers to expand women’s access to quality contraceptives. “It’s something women can use on their own to protect their own health, make their own choices and take charge of their lives.”
In Africa, more than four in every 10 women of reproductive age want to avoid pregnancy, Fredrick says, but many have limited or no reliable options. DMPA-SC, available in at least 20 countries, is an especially desirable option for women in communities where contraception, including longer-acting contraceptives like IUDs, can be tough to obtain, she explains.
When a woman can plan her pregnancies, Fredrick says, she’s better able to ensure her own and her whole family’s well-being.
“That’s what the promise of family planning is,” she says. “It’s health, it’s well-being, it’s empowerment, it’s rights, it’s economic and social development. There’s no health intervention I know of that has so many benefits.”
SPEAKING UP AND SPEAKING OUT
Self-defense training for girls in Malawi.
The schoolgirls stand together in the classroom, their arms in the air, their palms pressing outward. They speak loudly in unison.
“Five fingers of emergency!” their voices echo. “Think! Yell! Run! Fight! Tell!”
The girls take turns at the front of the room with instructors, hurling punches against boxing pads, striking an imaginary assailant with their knees and elbows. They shout “no” and “stop.” “Don’t touch me!” the girls say together. “Get back! I am worth defending!”
The girls are among thousands who have taken part in empowerment training sessions held in primary and secondary schools throughout Malawi, a country where one in five girls is sexually assaulted before age 15. The classes, part of the No Means No Worldwide curriculum, are implemented by an NGO called Ujamaa Pamodzi-Africa as part of an effort to reduce gender-based violence.
“These girls are learning to speak up and speak out in spaces where people are not used to hearing young women—and where social norms expect them to endure harassment and abuse in silence,” says Michele Decker, ScD, MPH, an associate professor in Population, Family and Reproductive Health who has studied and evaluated Ujamaa Pamodzi’s effectiveness as part of her work in PFRH and the Johns Hopkins Center for Public Health and Human Rights.
The Malawi program is modeled on a successful initiative from Kenya. In IMPower, girls learn verbal skills, assertiveness and, as a last resort, physical defense skills. Companion programming for boys, Your Moment of Truth, addresses negative gender stereotypes and consent issues and teaches intervention skills for situations of potential violence.
Decker’s evaluation of the IMPower program in Malawi shows it has a significant impact. Within one year, the prevalence of forced sex reported by students who took the classes fell from 15 percent to 9 percent, while the prevalence of forced sex in the control group increased. A key factor in this shift, says Decker, is the group context for training. Abuse or mistreatment that might have been endured by a young woman feeling isolated and powerless becomes intolerable and actionable with the power of the group.
“The social cohesion piece is central,” Decker says. “It also speaks to what we are seeing with the #MeToo movement. The ability to name what’s happening is a powerful starting point in an effective response.”
As Decker studies gender-based violence across cultural contexts, such support systems take different forms. In one intervention in Kenya, for example, Decker is evaluating ways women in abusive relationships can find support and reduce harm, even if they aren’t able to leave their partners. In Baltimore, where Decker has studied the social and structural barriers women face in reporting violence to police, empowerment may look like expanding options for restorative justice, and advocacy to make the police reporting process more accessible and comfortable for women.
“In our global work, we look at the facilitators and barriers to women enacting self-determination in violence prevention and response, and in overall health,” says Decker. “What are the ways that women can be constrained in autonomy, and how does that shape risk for violence and poor health? Working in disparate settings helps us see these points of contrast and helps us tune in to actionable solutions.”
The current cultural conversations around the #MeToo and Time’s Up movements make it an exciting time to be working and teaching in the field, says Decker, adding that the gender-based violence class she teaches at the Bloomberg School has recently doubled in size.
“There’s a palpable feeling of change in the air,” she says. “People are motivated to create change, and the tools of public health are uniquely valuable.”
Meet the powerful new health promoters in the Western Highlands of Guatemala. They are energized change agents and social influencers with clout. And they are grandmothers.
Abuelas traditionally wield great decision-making power in Guatemalan households. Yet health and hygiene interventions in the region have long been geared toward young mothers, which can create rifts in the home.
“These young mothers live in a setting where somebody else makes the decisions for them,” explains Patricia Poppe, who directed the Health Communication Capacity Collaborative (HC3) program in Guatemala. “If you don’t build bridges within this context, it will be very difficult for a young mother to practice those new behaviors even though she understands and knows the importance of them.”
HC3 developed an initiative that trains abuelas in ensuring a clean environment at home, promoting exclusive breastfeeding, managing a budget for a nutritious diet during the first two years of life and building healthy communication. They did so within the framework of their own ancestral knowledge and life experience.
The abuelas became important reference sources not only in their families but in their communities. “Everything that I have learned, I have passed on to them,” one grandmother in the town of Acul told HC3 staff, “so that my grandson may be good and healthy, clean and well-fed.”
Poppe hopes such models can be applied in other contexts in development work. Understanding and creating programs responsive to family dynamics has been a key philosophy for HC3, which is operated under the Johns Hopkins Center for Communication Programs and funded by USAID.
“Instead of dismissing the wisdom these women have gained, we want to capitalize on it,” Poppe says.