title: Women’s health behavior in unequal gender power relations: The example of carrying heavy loads in Nepal
Creators: name: Tomberge, Vica Marie Jelena
Publisher: name: Universität Bern
Year: 2023
Subjects: subject: 150 Psychology
subject: 610 Medicine &amp; health

description: Unequal gender power relations are a major reason for women’s high health-related vulnerabilities in low-resource populations. The sociological theory of gender and power proposes a gender division of labor restricting women to lower-paid and unpaid labor, a gender division of power granting women limited decision-making autonomy, and a division of cathexis including affective attachments and norms. All these challenge women’s engagement in healthy behaviors. Health psychology research can describe, explain, and promote women’s health behavior but seldom integrates gendered norms, roles, and differentials in power relations. Even so, established health behavior models address certain promising factors that might be of relevance for women’s health behavior in unequal gender power relations, such as self-efficacy and social resources.
One example of women’s health behavior in unequal gender power relations is the frequent carrying of heavy loads in low- and middle-income countries. Many households lack improved water and energy access and thus need to carry heavy loads of water and firewood from sources off-premises. A traditional gender division of labor makes this physically demanding task women’s responsibility, and it can pose a severe risk of pelvic organ disorders. Behavioral adaptations that protect the pelvic floor when carrying loads can diminish this risk. However, no studies have investigated pelvic-floor-protective carrying behaviors from a health psychology perspective such as identifying the psychosocial determinants that are essential for developing theory-based health behavior interventions promoting such behaviors.
This thesis aims to understand and address women’s health behavior in unequal gender power relations with the example of carrying heavy loads in Nepal. To do so, the present research first seeks to understand women’s health behavior in gender power relations by gaining knowledge on the behavior of carrying loads and its relevance for women’s everyday lives and by identifying the psychosocial determinants of protective carrying behaviors. Second, it aims to identify the role of influential social partners’ cognitions in women’s protective carrying behaviors, specifically women’s mother-in-law. Third, it aims to investigate whether interventions that promote self-efficacy and social support can enable women’s protective carrying behaviors in unequal gender power relations.
Two studies in rural villages of Nepal were conducted that provided surveys and interviews to address several research questions. The first study included three investigations, all using different designs and subsamples: A first large-scale survey (N = 1001) described the physical burden of carrying loads and its correlation with women’s psychosocial well-being. Second, a mixed-methods study comprising a quantitative survey (N = 921) and qualitative interviews with women and their family members (N = 21) was conducted to understand the psychosocial determinants of pelvic-floor-protective carrying behaviors. Third, a dyadic survey with N = 476 daughters- and mothers-in-law nested in 238 dyads investigated the interrelatedness of daughters- and mothers-in-law’s cognitions and behavior related to pelvic-floor-protective carrying. The findings of these investigations informed the development of a pilot intervention study. This pilot intervention study applied a 3-arm parallel nonrandomized, controlled trial with N = 300 women and their N = 300 social partners to assess whether self-efficacy and social support promotion can enable women’s pelvic-floor-protective carrying behaviors.
The large-scale survey and the mixed-methods study identified the carrying of heavy loads as a highly prevalent everyday working task for women in rural Nepal, even during vulnerable periods of pregnancy. The large-scale survey further described the physical burden of this behavior and its relation with women’s impaired well-being. The mixed-methods and the dyadic study identified self-efficacy, injunctive norm, and social support as the most important determinants of women’s health behavior and emphasized the powerful influence of family members’ cognitions and a shift in decision-making power towards them. The results of the intervention study found that promoting self-efficacy and social support can enable women’s pelvic-floor-protective carrying behavior more effectively than providing only information. The intervention effects were partly explained by social support received from a social partner. In addition, women in all conditions indicated improved women’s pelvic floor health and well-being over time.
Using health psychology theory and methods allowed to identify the behavioral risk factors of carrying heavy loads and the psychosocial determinants of women’s protective carrying behaviors. The information obtained was useful in enabling women’s protective carrying behaviors. Established health behavior models thus proved useful to understanding and changing women’s health behavior in unequal gender power relations, particularly by emphasizing the role of self-efficacy and social relationships. The results of this thesis further indicate that qualitative and dyadic methodological approaches and particular theoretical adaptations may be promising in better accounting for women’s limited decision-making power and a more gendered lens on social norm and structural barriers. Considering unequal gender and power relations when investigating women’s health behavior in low-resource populations may contribute to overcoming gender inequalities to health and can support the development of socially-inclusive perspectives in health behavior research.