Recent social movements to empower women and promote civil rights
have once again pushed issues of gender inequality to the forefront of
discourse around the globe. Gender inequality refers to the systematic
discriminatory treatment of a group based on gender through the unequal
distribution of resources and power. Disparities in education, healthcare
access, social and economic power all play important roles in producing
negative health outcomes. By addressing the lack of resources and power given
to marginalized groups through interventions or programs, studies have found
that health outcomes improve significantly (Hendrickson, et al., 2002, Plough
& Olafson, 1994). The relationship between health outcomes and gender
inequality has also previously been established in research (Sen & Ostlin,

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As a result, gender inequality has been recognized as a major
issue affecting public health (Wallerstein, 2006). A study examining maternal
and child health care in multiple African countries revealed that women that
had high household decision making power or that repudiated wife beating had
higher BMI’s and were more inclined to use child healthcare services (Singh, et
al., 2015). Another study explored the relationship between a woman’s sense of
personal justice, sense of control, and mental health by using a theory based
path model to illustrate their link to sexist events (Fischer & Holz,
2010). The model, which was found to accurately describe the relationship
between the three variables among an ethnically diverse group of women, posited
that sexist events decrease a woman’s personal belief in a just world which in
turn decreases her sense of control over her life and mental health (Fischer
& Holz, 2010).

These empirical findings indicate that power, and more
specifically the unequal distribution of power between genders, has significant
implications on the mental and physical health of the individuals with the
least amount of power. Gaining a better understanding of gender relations
within the wider society may reveal its influence on the power dynamics between
men and women within intimate relationships and how these differing power
dynamics affect women’s health. In this paper, power dynamics and attitudes
toward gender equality among Haitian men and women participating in an intimate
relationship are examined in order to determine if these factors effect an
individual’s sense of control over their health.

Haitian women have often been described as the central pillars or
“poto mitan” of Haitian society because of the important role they play in
supporting the family and raising children. Despite having relative autonomy
within the community and household, women have limited power within Haitian
society and are subject to gender discrimination. They are underrepresented in
the government and hold less professional leadership positions (World Bank
Group, 2017)). Additionally, an estimated one in three Haitian women have
experienced intimate partner violence with in their lifetime (Ramer, et al.,
2016). In 2012, the Haiti Mortality, Morbidity, and Service Utilization Survey was
utilized to provide information on living conditions, maternal and child care, gender
quality, and family relations. An analysis of the data, revealed that a woman’s
decision-making power within her household varies depending on the situation or
type of decision being made. Overall, in 73% of the cases, women were either
the sole decision makers or involved in the decision-making process with their
spouse (Cayemittes et al., 2012).  However,
in regards to decisions on their own healthcare, women participated the least.
Only 35% of women reported having sole decision-making power over their
personal healthcare (Cayemittes et al., 2012). Furthermore, this type of
decision was made solely by the spouse in 25% of cases (Cayemittes et al.,
2012). Although these findings indicate that a majority of women believe that
they lack complete control over their healthcare, there is little research
examining what factors may contribute to this issue. The purpose of this study
is to determine if a relationship exists between attitudes toward gender
equitability, power dynamics within an intimate partner relationship, and an
individual’s health locus of control. Illuminating these relationships may
contribute to better understanding how attitudes toward gender norms affect
health and healthy behaviors by examining one’s sense of control and
decision-making capabilities.


Participants and Procedures

A secondary analysis was completed on data from a health involving
68 parents, 29 men and 39 women, of newborn males recruited from the GHESKIO
Community Clinic in Port-au-Prince, Haiti. A recruiter described the study to
all new mothers of male newborns and their partners that came to the clinic.
Men and women under the age of 18 or who could not give informed consent were
not approached to participate in the study. Those that were approached and expressed
interest in the study were asked to provide their contact information and basic
demographic information. Newborn parents that showed interest were subsequently
contacted and given a time and location to meet with an interviewer to complete
a questionnaire. The questionnaires were completed orally with a trained
interviewer in Haitian Creole who recorded the participants response. Every
participant received a phone card, refreshments, and US $2.50 to cover
transportation costs.


The structured questionnaire contained 139 closed and open-ended questions.
Twenty-two questions were used to collect the participants’ socio-demographic
information, immunization history, religious activity, and mode of
transportation. The remaining questions assessed the participants’ attitudes
towards certain child healthcare practices, intimate partner relationship,
gender norms, and health locus of control.


The measures analyzed in this secondary analysis include:

Locus of Control Scale (HLOC)

The HLOC scale is used to determine if an individual has an
external or internal health locus of control (Wallston et al.,1976). These
measures are often used to predict health-related behavior. In this study, the
11 items of the scale were scored on a 4-point scale (1 = Strongly Disagree, 2
= Disagree, 3 = Agree, 4 = Strongly Agree) and summed with the internal health
locus of control items reverse scored. The minimum score is 11 and the maximum
score is 44. Higher scores indicate an internal health locus of control, while
lower scores are indicative of an external health locus of control.

Equitable Men Scale (GEM)

The GEM scale is a 24-item scale often used to predict condom use,
contraceptive use, and partner violence by measuring an individual’s attitudes
towards gender norms in an intimate partner relationship (Pulerwitz and Barker,
2007). The items were scored on a 3-point scale (1= Agree, 2 = Partially Agree,
3 = Disagree) and then summed. The score range is 24-72 with higher scores
indicating greater support for gender equitable norms.

Relationship Power Scale (SRP)

SRP scale is a 25-item scale with two subscales: the Relationship control
subscale (14 items) which is only completed by women and the Decision-making
dominance subscale (11 items) which is completed by both men and women. The
scale is used to measure power within sexual relationships (Pulerwitz et al.,
2000). The Relationship control subscale was scored
on a 4-point Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 =
Agree, 4 = Strongly Agree), with a score range from 14 to 56. Lower scores are indicative of greater partner
sexual relationship control. The Decision-making dominance subscale was scored
on a 3-point scale with, 1 =  Partner decides, 2 = Both decide
equally, 3 = I decide.  Score ranges of
23 – 33 indicate that the respondent has decision making power, ranges of 17 –
22 indicate equal partner decision making dominance, and ranges of 11-16
indicate that the partner has decision making dominance. It must be noted that
one item was removed from the original Relationship control subscale, while
three items were added to the Decision-making dominance subscale.


Data Analysis:

The SPSS statistical software was used to analyze the questionnaire.
Descriptive analyses of the participant demographics and responses to the three
scales described were completed to describe the general characteristic and
attitudes of the participants. Pearson correlation tests were used to examine
the relationship between the GEM, HLOC, and SRP scale. A bivariate chi-square
analysis was done to determine the relationship between HLOC and education


The average age of participants was approximately 31 years with an
age range of 18 to 56 years. Forty three percent of the participants are male
and fifty eight percent of the participants are female. Approximately 45.6% of
the parents reported being common-law married. The majority of participants
attended primary school, 45.6%, and were unemployed, 67.7%. About 52% of
participants reported earning up to 1000 Haitian gourdes annually.

Results indicated a relatively high internal locus of control
among the participants (28.91, SD 2.34). However, 30.9% of the participants
reported a higher external locus of control. Therefore, most participants felt
that their health outcomes were within their control, while those with a higher
external locus of control feel that powerful others are in control of their
health. Most participants (22.53, SD 3.01) also reported equal decision-making
dominance within their relationship. The relationship subscale of the SRP scale
completed only by female participants had a mean of 34.53, SD 4.23, indicating
equal partner control. Additionally, according to the Gender Equitable Men
scale, participants had relatively high support for gender equitable norms
(48.76, SD 9.99).

Pearson correlation tests revealed a significant positive
correlation between the GEM scale and the HLOC scale (r=0.507, p=0.00). This
finding shows that participants who had a higher support for gender equitable
norms also had a higher internal health locus of control. A significant
positive correlation was also found to exist between the GEM scale and
Relationship control subscale (r=0.435, p=0.01) which shows that participants
with higher support for gender equitable norms also felt that they had equal partner
dominance in their intimate relationship. No significant correlations were
found between the Decision-making dominance subscale and the GEM scale or the
HLOC scale. Additionally, a Chi-square test revealed a significant positive
correlation between the HLOC scale and level of education (Chi ?2 = 34.46, df
22, p = 0.044). As the level of education increased, participants were found to
have a higher internal health locus of control or they felt more in control of
their health.


In the present study, participant attitudes toward gender
equitable norms were generally favorable. Most participants also felt that they
had equal partner dominance in their intimate relationship in terms of control
and decision-making power. These findings support data obtained from the
Ministry of Public Health national EMMUS showing that 78% of married Haitian
women participate in decisions for major household purchases (Cayemittes et al.,
2012). Additionally, 85% participate in decisions about visiting family (Cayemittes
et al., 2012).

Significant correlations were found to exist between gender
equitable attitudes, relationship control, and health locus of control. High
support for gender equitable norms correlated with a sense of equal partner
dominance within an intimate relationship. Furthermore, participants with a
greater sense of responsibility and control over their personal health also had
higher support for gender equitable norms and a higher level of education. This
may be a result of women entering in relationships with men with similar belief
systems and feeling more in control of their lives and bodies. Haitian women
with higher levels of education may feel more knowledgeable about taking care of
their health and that they are better able to make decisions about their health
care. Research suggests that individuals with a higher internal health locus of
control engage in healthier behaviors. A study completed in Germany found that college
students with a higher internal health locus of control were more likely to
have healthier eating habits, less likely to use drugs, and were more
physically active (Helmer et al., 2012). Therefore, Haitian women with greater
support for gender equitable norms in their intimate partner relationship may
also be engaging in healthier habits.

Empowering women financially is one way that some organizations
have attempted to increase gender equitability and improve health outcomes in
the Haiti. Economic factors often contribute to unequal relationship control
between partners and lower support for gender equitable norms.  Adrien and Cayemittes revealed that Haitian
women dependent on men for financial support have little to no decision-making
power regarding sexual practices due to fear of retaliation (Adrien &
Cayemittes, 1991). The women believed that the man should be given the choice
of whether or not to wear a condom, otherwise they could lose his financial
support (Adrien & Cayemittes, 1991). 
Another study focusing on women in rural Haiti showed that 25% of the
women surveyed and in relationships where they were financially dependent on
the man found it difficult to convince the man to wear a condom (Fwazi et al.,
2003). In their study, Fawzi et al. revealed that one of the strongest risk
factors for STD’s were economic variables (Fawzi et al., 2003). They also
determined that providing women with better economic opportunities to empower
themselves may decrease their risk of being infected with an STD (Fawzi et al.,
2003). Rosenberg et al., found that giving Haitian women access to a
microfinancing program, not only decreased their HIV risk behavior, but also
increased indicators for relationship power when the program was used for a
long period of time (Rosenberg et al, 2010). These studies highlight the need
to empower individuals by giving them the education and tools they need to
become financially independent and in turn increase their sense of control.

Educational programs are often utilized to promote gender
equitability and improve health outcomes. The Johns Hopkins Center for
Communication Programs (CCP) is one of many programs that have implemented the
promotion of gender equitability into their public health programs. This study
has shown that education and health locus of control are positively correlated.
Thus, encouraging gender equitable attitudes in educational programs that wish
to improve health outcomes may enhance the efficacy of the program.

In summary, these findings indicate that both level of education
and equitable gender attitudes are associated with a greater internal
HLOC.  This suggests that educational
programs promoting gender equitable attitudes may contribute to greater
perceptions of self-control over personal healthcare. This highlights the
importance of encouraging gender equitable attitudes not only in Haiti, but
across the globe.



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