Intro:Recent social movements to empower women and promote civil rightshave once again pushed issues of gender inequality to the forefront ofdiscourse around the globe. Gender inequality refers to the systematicdiscriminatory treatment of a group based on gender through the unequaldistribution of resources and power. Disparities in education, healthcareaccess, social and economic power all play important roles in producingnegative health outcomes. By addressing the lack of resources and power givento marginalized groups through interventions or programs, studies have foundthat health outcomes improve significantly (Hendrickson, et al., 2002, Plough& Olafson, 1994).

The relationship between health outcomes and genderinequality has also previously been established in research (Sen & Ostlin,2008).  As a result, gender inequality has been recognized as a majorissue affecting public health (Wallerstein, 2006). A study examining maternaland child health care in multiple African countries revealed that women thathad high household decision making power or that repudiated wife beating hadhigher BMI’s and were more inclined to use child healthcare services (Singh, etal.

, 2015). Another study explored the relationship between a woman’s sense ofpersonal justice, sense of control, and mental health by using a theory basedpath model to illustrate their link to sexist events (Fischer & Holz,2010). The model, which was found to accurately describe the relationshipbetween the three variables among an ethnically diverse group of women, positedthat sexist events decrease a woman’s personal belief in a just world which inturn decreases her sense of control over her life and mental health (Fischer& Holz, 2010). These empirical findings indicate that power, and morespecifically the unequal distribution of power between genders, has significantimplications on the mental and physical health of the individuals with theleast amount of power. Gaining a better understanding of gender relationswithin the wider society may reveal its influence on the power dynamics betweenmen and women within intimate relationships and how these differing powerdynamics affect women’s health. In this paper, power dynamics and attitudestoward gender equality among Haitian men and women participating in an intimaterelationship are examined in order to determine if these factors effect anindividual’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 insupporting the family and raising children. Despite having relative autonomywithin the community and household, women have limited power within Haitiansociety and are subject to gender discrimination. They are underrepresented inthe government and hold less professional leadership positions (World BankGroup, 2017)). Additionally, an estimated one in three Haitian women haveexperienced intimate partner violence with in their lifetime (Ramer, et al.,2016). In 2012, the Haiti Mortality, Morbidity, and Service Utilization Survey wasutilized to provide information on living conditions, maternal and child care, genderquality, and family relations.

An analysis of the data, revealed that a woman’sdecision-making power within her household varies depending on the situation ortype of decision being made. Overall, in 73% of the cases, women were eitherthe sole decision makers or involved in the decision-making process with theirspouse (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 theirpersonal healthcare (Cayemittes et al., 2012). Furthermore, this type ofdecision was made solely by the spouse in 25% of cases (Cayemittes et al.,2012). Although these findings indicate that a majority of women believe thatthey lack complete control over their healthcare, there is little researchexamining what factors may contribute to this issue. The purpose of this studyis to determine if a relationship exists between attitudes toward genderequitability, power dynamics within an intimate partner relationship, and anindividual’s health locus of control. Illuminating these relationships maycontribute to better understanding how attitudes toward gender norms affecthealth and healthy behaviors by examining one’s sense of control anddecision-making capabilities.

Method:Participants and ProceduresA secondary analysis was completed on data from a health involving68 parents, 29 men and 39 women, of newborn males recruited from the GHESKIOCommunity Clinic in Port-au-Prince, Haiti. A recruiter described the study toall 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 werenot approached to participate in the study.

Those that were approached and expressedinterest in the study were asked to provide their contact information and basicdemographic information. Newborn parents that showed interest were subsequentlycontacted and given a time and location to meet with an interviewer to completea questionnaire. The questionnaires were completed orally with a trainedinterviewer in Haitian Creole who recorded the participants response. Everyparticipant received a phone card, refreshments, and US $2.50 to covertransportation costs.QuestionnaireThe structured questionnaire contained 139 closed and open-ended questions.Twenty-two questions were used to collect the participants’ socio-demographicinformation, immunization history, religious activity, and mode oftransportation.

The remaining questions assessed the participants’ attitudestowards certain child healthcare practices, intimate partner relationship,gender norms, and health locus of control.MeasuresThe measures analyzed in this secondary analysis include:HealthLocus of Control Scale (HLOC)The HLOC scale is used to determine if an individual has anexternal or internal health locus of control (Wallston et al.,1976). Thesemeasures are often used to predict health-related behavior. In this study, the11 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 healthlocus of control items reverse scored. The minimum score is 11 and the maximumscore is 44.

Higher scores indicate an internal health locus of control, whilelower scores are indicative of an external health locus of control.GenderEquitable 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 attitudestowards 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 scoresindicating greater support for gender equitable norms.SexualRelationship Power Scale (SRP)TheSRP scale is a 25-item scale with two subscales: the Relationship controlsubscale (14 items) which is only completed by women and the Decision-makingdominance subscale (11 items) which is completed by both men and women. Thescale is used to measure power within sexual relationships (Pulerwitz et al.,2000).

The Relationship control subscale was scoredon 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 partnersexual relationship control. The Decision-making dominance subscale was scoredon a 3-point scale with, 1 =  Partner decides, 2 = Both decideequally, 3 = I decide.  Score ranges of23 – 33 indicate that the respondent has decision making power, ranges of 17 –22 indicate equal partner decision making dominance, and ranges of 11-16indicate that the partner has decision making dominance. It must be noted thatone item was removed from the original Relationship control subscale, whilethree 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 threescales described were completed to describe the general characteristic andattitudes of the participants.

Pearson correlation tests were used to examinethe relationship between the GEM, HLOC, and SRP scale. A bivariate chi-squareanalysis was done to determine the relationship between HLOC and educationlevel.Results:The average age of participants was approximately 31 years with anage range of 18 to 56 years. Forty three percent of the participants are maleand fifty eight percent of the participants are female. Approximately 45.6% ofthe parents reported being common-law married.

The majority of participantsattended primary school, 45.6%, and were unemployed, 67.7%. About 52% ofparticipants reported earning up to 1000 Haitian gourdes annually.

Results indicated a relatively high internal locus of controlamong the participants (28.91, SD 2.34). However, 30.

9% of the participantsreported a higher external locus of control. Therefore, most participants feltthat their health outcomes were within their control, while those with a higherexternal locus of control feel that powerful others are in control of theirhealth. Most participants (22.

53, SD 3.01) also reported equal decision-makingdominance within their relationship. The relationship subscale of the SRP scalecompleted only by female participants had a mean of 34.53, SD 4.23, indicatingequal partner control. Additionally, according to the Gender Equitable Menscale, participants had relatively high support for gender equitable norms(48.

76, SD 9.99).Pearson correlation tests revealed a significant positivecorrelation between the GEM scale and the HLOC scale (r=0.507, p=0.00).

Thisfinding shows that participants who had a higher support for gender equitablenorms also had a higher internal health locus of control. A significantpositive correlation was also found to exist between the GEM scale andRelationship control subscale (r=0.435, p=0.01) which shows that participantswith higher support for gender equitable norms also felt that they had equal partnerdominance in their intimate relationship. No significant correlations werefound between the Decision-making dominance subscale and the GEM scale or theHLOC scale. Additionally, a Chi-square test revealed a significant positivecorrelation between the HLOC scale and level of education (Chi ?2 = 34.46, df22, p = 0.

044). As the level of education increased, participants were found tohave a higher internal health locus of control or they felt more in control oftheir health.Discussion:In the present study, participant attitudes toward genderequitable norms were generally favorable. Most participants also felt that theyhad equal partner dominance in their intimate relationship in terms of controland decision-making power. These findings support data obtained from theMinistry of Public Health national EMMUS showing that 78% of married Haitianwomen participate in decisions for major household purchases (Cayemittes et al.

,2012). Additionally, 85% participate in decisions about visiting family (Cayemitteset al., 2012).Significant correlations were found to exist between genderequitable attitudes, relationship control, and health locus of control. Highsupport for gender equitable norms correlated with a sense of equal partnerdominance within an intimate relationship. Furthermore, participants with agreater sense of responsibility and control over their personal health also hadhigher support for gender equitable norms and a higher level of education. Thismay be a result of women entering in relationships with men with similar beliefsystems and feeling more in control of their lives and bodies. Haitian womenwith higher levels of education may feel more knowledgeable about taking care oftheir health and that they are better able to make decisions about their healthcare.

Research suggests that individuals with a higher internal health locus ofcontrol engage in healthier behaviors. A study completed in Germany found that collegestudents with a higher internal health locus of control were more likely tohave healthier eating habits, less likely to use drugs, and were morephysically active (Helmer et al., 2012). Therefore, Haitian women with greatersupport for gender equitable norms in their intimate partner relationship mayalso be engaging in healthier habits. Empowering women financially is one way that some organizationshave attempted to increase gender equitability and improve health outcomes inthe Haiti.

Economic factors often contribute to unequal relationship controlbetween partners and lower support for gender equitable norms.  Adrien and Cayemittes revealed that Haitianwomen dependent on men for financial support have little to no decision-makingpower regarding sexual practices due to fear of retaliation (Adrien , 1991). The women believed that the man should be given the choiceof whether or not to wear a condom, otherwise they could lose his financialsupport (Adrien & Cayemittes, 1991). Another study focusing on women in rural Haiti showed that 25% of thewomen surveyed and in relationships where they were financially dependent onthe 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 riskfactors for STD’s were economic variables (Fawzi et al., 2003).

They alsodetermined that providing women with better economic opportunities to empowerthemselves may decrease their risk of being infected with an STD (Fawzi et al.,2003). Rosenberg et al.

, found that giving Haitian women access to amicrofinancing program, not only decreased their HIV risk behavior, but alsoincreased indicators for relationship power when the program was used for along period of time (Rosenberg et al, 2010). These studies highlight the needto empower individuals by giving them the education and tools they need tobecome financially independent and in turn increase their sense of control. Educational programs are often utilized to promote genderequitability and improve health outcomes. The Johns Hopkins Center forCommunication Programs (CCP) is one of many programs that have implemented thepromotion of gender equitability into their public health programs. This studyhas shown that education and health locus of control are positively correlated.Thus, encouraging gender equitable attitudes in educational programs that wishto improve health outcomes may enhance the efficacy of the program.

In summary, these findings indicate that both level of educationand equitable gender attitudes are associated with a greater internalHLOC.  This suggests that educationalprograms promoting gender equitable attitudes may contribute to greaterperceptions of self-control over personal healthcare. This highlights theimportance of encouraging gender equitable attitudes not only in Haiti, butacross the globe. 

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