The Psychosocial Context of Young Adult Sexual Behavior in Nicaragua: Looking Through the Gender Lens
Understanding the nature and magnitude of gender differences in sexual norms among young adults in Nicaragua, and how these differences affect sexual behavior, is important for the design of reproductive health programs.
A representative cross-sectional survey was conducted in six departments in the Pacific region of Nicaragua in 1998. A total of 552 never-married women and 289 never-married men aged 15-24 were interviewed about their perceptions of social pressure to engage in premarital sex; perceived social approval of and attitudes toward premarital sex and premarital pregnancy; perceived sexual activity among peers and siblings; communication with parents on sexuality issues; the psychosocial context of sexual debut; and preferred sources of information on sexuality issues.
Most young men (83%) reported that they had received direct encouragement from at least one person in the last year to engage in premarital sex, and at least half perceived that their father, siblings, other relatives and friends approved of premarital intercourse. A significantly greater proportion of men than of women reported that curiosity or gaining experience motivated their sexual debut (61% vs. 21%). Men perceived themselves to have a higher risk of unplanned and unprotected sex than did women. In contrast, women held more negative attitudes toward premarital sex and were more often discouraged by parents or siblings from engaging in sex.
Reproductive health programs for young Nicaraguans need to address gender-based double standards, which raise the risk of unplanned, unprotected sex and unintended pregnancy.
Many studies have documented significant gender differences in the age at first sex and the prevalence of premarital sex among adolescents in both developing and developed countries.1 A number of theories have been advanced to explain these differences.2 The most common explanation--suggested in studies in Colombia, Kenya, Jamaica, Costa Rica, Peru and Nicaragua--is the existence of dual social norms, whereby society accepts and even encourages men's expression of their sexuality but punishes the same behavior among women.3 However, few representative studies have empirically investigated and quantified the nature, magnitude and source of gender differences in the underlying psychosocial context for adolescent sexual behavior,4 which includes perceived social approval of premarital sex, social pressure to engage in sex, parent-child communication, attitudes about premarital sex and pregnancy, perceived sexual risks, perceived social prejudices and motivations for having premarital sex.
Assessing the magnitude and nature of these gender differences may be crucial for designing effective gender-sensitive programs aimed at reducing unsafe sexual practices among adolescents. Failing to incorporate gender concerns in such programs may lead either to unsuccessful outcomes or to different effects on women and men. For example, a study from Costa Rica showed that sex education courses had a greater effect on reducing the prevalence of premarital relations among females than among males.5 It is important to identify the mechanisms through which society adopts and promotes gender-based double standards toward sexuality, and how these double-standards are transmitted across generations. Programs relying on teachers or health workers to encourage safe sexual practices may fail if the teachers and health workers themselves hold permissive attitudes toward male sexuality and negative attitudes toward female sexuality.
The study described in this article uses data from a comprehensive quantitative survey of Nicaraguan young adults aged 15-24 to investigate gender differences in the magnitude and source of social pressures; perceived social approval and attitudes towards premarital sex and premarital pregnancy; perceived sexual activity among peers and siblings; communication with parents about sexuality; the psychosocial context of sexual debut; and preferred sources of information on sexuality.
The Study Setting
Nicaragua is one of the poorest countries in the western hemisphere, with a per capita annual income of US$410 and 50% of the population living below the national poverty line.6 Young adults--defined here as persons between the ages of 15 and 24--currently make up one-fifth of the country's total population.7 As at least another two-fifths of the population is younger than 15, the proportion of the population in that age-group is likely to grow.
Young adult sexuality presents an important social and health problem in Nicaragua, as elsewhere in the Caribbean and Central America.8 More than half of unmarried males aged 15-19 and 5% of females of the same age are reported to be sexually active,9 and more than half of women aged 20-24 were already mothers by age 20.10 Although sexual activity begins early, contraceptive use among young adults is uncommon.11 Thus, young men and women in Nicaragua are vulnerable to sexually transmitted infections and unwanted pregnancies, and would benefit from health programs targeted to their specific needs.
DATA AND METHODS
The empirical findings presented in this article are based on data from the Nicaragua Young Adults Survey (ENJOVEN'98), which was undertaken by the Comision Nacional de Salud Reproductiva, Nicaragua, and the Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health. The survey was intended to evaluate the national communication campaign "Together We Decide When," which was directed toward reducing early pregnancy and served as a comprehensive source of data on youth sexuality in Nicaragua. The survey was conducted in six major departments* in the country's Pacific region: Chinandega, Leon, Managua, Masaya, Granada and Carazo. Whereas Nicaragua's central, northern and Atlantic regions are predominantly rural, the Pacific region is mainly urban, containing 73% of the country's total urban population.
The fieldwork was carried out between October and December 1998. The sampling plan for the ENJOVEN survey followed the design of the Nicaragua Demographic and Health Survey (ENDESA-98), which had been undertaken earlier that year. In ENDESA-98, 258 clusters were randomly sampled from the six departments, and all households in these clusters were identified and listed. Households and individuals were randomly selected from the above listing for interview.
To collect data from a representative sample of young adults aged 15-24, the ENJOVEN interviewers revisited the same households sampled in the ENDESA-98. One young woman was randomly selected from each household sampled, and one young man was sampled from every third household (following the methodology used to sample men in the ENDESA-98), resulting in a sample of 1,502 young people.
The survey questionnaire was based on communication and behavior change theory,12 and therefore included questions about many social, communication and behavioral aspects of young people's sexual behavior that had not been examined before in sufficient detail. Data were collected on attitudes toward premarital sex and premarital pregnancy, the respondents' perceptions of their risk for unplanned and unprotected sex, family influence and control, interpersonal communication and social support, and perceived sexual activities among peers and siblings. Considering the sensitive nature of the topics discussed during the survey, interviewers were trained and instructed to ensure privacy while eliciting information, and participants were assured that all data would remain confidential and anonymous.
The analyses presented in this article are mainly descriptive in nature. We made no attempt to conduct multivariate analyses to determine the independent relationships of different psychosocial elements with premarital sexual behavior because the bivariate analysis indicated that the underlying gender differences in the psychosocial context would invariably affect responses regarding actual sexual behavior.† Simple cross-tabulations (for categorical variables) or mean values (for continuous variables) are presented by sex. Pearson chi-square tests (for categorical variables) and t-tests (for continuous variables) were used to test the statistical significance of the differences observed by gender. All the estimates were weighted and adjusted for the multistage cluster sample design. Data were analyzed using STATA statistical software.
Because this study deals with the psychosocial context of premarital sex, ever-married respondents were omitted, leaving a sample of 841 never-married young adults--552 women and 289 men. Overall, 73% of the sample were aged 15-19 and 27% were 20-24 (Table 1, page 175); a greater proportion of women than men were in the younger age-group (76% vs. 68%). Seventy-eight percent of respondents lived in an urban area, 62% had a secondary education and 75% were Catholic. Thirty-five percent of respondents (44% of men and 31% of women) were in school at the time of the survey and 74% (56% and 83%, respectively) were working.
Social Pressure for Premarital Sex
A total of 83% of men reported receiving encouragement to have sex from at least one person in the previous year, compared with 26% of women. Men were more likely than women to have received encouragement from persons in any of the 10 categories studied (Table 2). Seventy-four percent of men had been encouraged to have sex by a friend, 30% by a partner, 27% by a sibling and 22% by their father; in contrast, 15% of women had been encouraged by a friend, 29% by a partner, 2% by a sibling and 1% by their father.
On the other hand, a significantly greater proportion of women than of men reported having been discouraged from having sex by their mother (37% vs. 17%), their father (47% vs. 8%) or a sibling (42% vs. 8%). Furthermore, a greater proportion of men than women reported receiving neither encouragement nor discouragement from their partner or their nuclear family. This suggests that society watches women's sexual activity more closely than men's and actively discourages women, while men are either actively encouraged or left alone.
Perceived Social Approval of Premarital Sex
To measure young adults' perceptions about social approval of premarital sex, respondents were asked whether they thought specific persons or categories of people approved or disapproved of premarital sex in general. A significantly greater proportion of young men than of young women reported that each of the 10 categories of people studied approved of premarital sex (Table 3). The most striking differences occurred in male and female perceptions of their father (51% vs. 3%), siblings (54% vs. 9%), other relatives (53% vs. 8%) and friends (82% vs. 30%). In addition, 20% of men believed that their religious leaders approved of premarital sex, whereas only 3% of females had that perception. Furthermore, a greater proportion of women than of men said they did not know the attitude of religious leaders (26% vs. 16%), health workers (34% vs. 20%) and teachers (35% vs. 16%); a greater proportion of men than of women said they did not know the opinion of their mother (16% vs. 3%), father (14% vs. 6%) and siblings (16% vs. 11%).
Perceived Sexual Experience Among Friends and Sibl
Young adults' perceptions of whether their peers are sexually experienced has a strong influence on their own sexual behavior.13 Respondents were therefore asked if all, the majority, some or none of their friends (male and female) and siblings were having premarital sex. They were also asked if any of their male or female friends or siblings had ever been involved in a premarital pregnancy.
A significantly greater proportion of young men than of young women believed that their unmarried friends and siblings were sexually experienced (not shown). For example, half (49%) the men said that all or the majority of their unmarried male friends had had sex, compared with fewer than one-third (30%) of the women. However, only 14% of men and 16% of women said that all or the majority of their unmarried female friends were sexually experienced. Both male and female respondents perceived much lower levels of sexual experience among their siblings than among their friends.
Attitudes Toward Premarital Sex and Early Pregnanc
To investigate young adults' attitudes toward premarital sex and pregnancy, we asked participants to respond to statements reflecting beliefs and values regarding those topics. An 11-point scale was used to measure the degree of agreement for each statement, with zero representing complete disagreement and 10 complete agreement.
Gender differences in social pressure and perceived social approval of premarital sex were reflected in young men's and young women's responses. Overall, men scored higher than women on statements that linked sex with love (Table 4): "The only way to express true love is by having sexual relations" (mean score, 3.2 vs. 1.6) and "If a girl is truly in love with her boyfriend, she should accept the test of love by having sex with him" (4.4 vs. 1.7). In addition, men, on average, agreed more strongly than women with statements that portrayed society as approving of premarital sex: "It is normal for a person like me to have premarital sex" (7.2 vs. 5.2), "If I don't have premarital sex, my friends will make fun of me" (5.4 vs. 2.4), "People my age who have premarital sex show adult behavior and maturity" (5.5 vs. 4.2) and "It is acceptable for boys to have premarital sex" (6.7 vs. 5.3). Women agreed more strongly than men with the statement, "I would feel guilty if I had premarital sex" (5.9 vs. 3.6).
Compared with women, men perceived a significantly higher level of social support if they were to become involved in a premarital pregnancy, but also expressed more negative attitudes toward women who get pregnant before marriage. For example, men had a mean score of 7.4 for the statement "It is certain that my family will support me if I get my partner pregnant," whereas women had a mean score of 5.7 for the statement; however, men agreed more strongly than women with the statements "The single woman who gets pregnant loses all of her value as a woman" (4.3 vs. 3.3) and "If an unmarried girl gets pregnant, she should leave her parents' house" (4.1 vs. 3.4). From these responses, it is evident substantial social bias exists against women who become pregnant outside of marriage. Furthermore, young men tend to feel less responsible for the consequence of their sexual actions: Men had a mean score of 6.3 for the statement "If I get my girlfriend pregnant, it is certain we will break up," whereas women had a mean score of 3.7 for the statement "If I get pregnant by my boyfriend, it is certain we will break up."
Perception of Sexual Health Risks
To assess their perceived personal risk for an unplanned and unprotected sexual encounter, we asked respondents how probable it was that a given situation could happen to them, based on their past experience and usual behavior. We used a five-point Likert-type scale to assess the perceived severity of risk, with one as "definitely not" and five as "definitely yes."
Overall, men perceived themselves as being at much higher risk of unplanned and unprotected sex than women (not shown). For example, 75% said that they probably or definitely would have unplanned sex in the next 12 months, compared with 35% of women. Similarly, a significantly greater proportion of men than of women reported that, in the next year, they probably or definitely would have sex with someone they had just met (55% vs. 21%) or would have sex after drinking (51% vs. 33%).
Parental Communication and Control
All the respondents were asked how often they communicated with their parents about school matters, friends, personal ideas or projects, and doubts or questions about sexuality. A significantly greater proportion of women than of men reported always talking to their parents about school matters (55% vs. 38%), friends (36% vs. 24%) and personal ideas and projects (47% vs. 33). Fifty-six percent of male respondents and 50% of female respondents reported never communicating with their parents about doubts or questions on sex; the difference was not significant.
In addition, women reported a higher level of parental control than did men: Eighty-two percent of women reported that they always had to get their parents' permission to go out, compared with 40% of men. Similarly, 57% of men reported that their parents gave them permission to go out without any conditions, compared with 40% of women.
Psychosocial Context of Sexual Debut
The differences in attitudes toward premarital sex and social pressure seem to directly influence the context of premarital sexual debut among young people. The vast majority of sexually experienced women (83%) reported that their first partner had been a boyfriend, whereas fewer than half of men (47%) had first had sex with a girlfriend (Table 5). Nine percent of men and no women reported that their first partner had been a sex worker or a stranger. The majority of men (59%) and women (86%) first initiated sexual activity in their partner's home or their own home. A significantly greater proportion of men than of women first had sex in a friend's house (17% vs. 6%), in a park (12% vs. 2%) or in a motel (8% vs. 5%).
The motives for engaging in sexual activity differed sharply by gender. A significantly greater proportion of women than of men said they had engaged in sex for the first time to express love (30% vs. 20%), whereas a greater proportion of men than of women had first had sex out of curiosity or to gain experience (61% vs. 21%) or because they wanted to have sex (67% vs. 33%); 7% of young women and fewer than 1% of men reported rape as the reason for their first sexual experience. Respondents were able to give more than one motive for first sex.
Young people's reactions to their first sexual experience also differed strongly by gender. Forty-one percent of men reported feeling fulfillment or personal satisfaction and 39% felt pleasure; 8% reported feeling pain, 8% guilt and 18% shame or embarrassment. In comparison, 9% of women reported experiencing fulfillment or personal satisfaction, and 12% felt pleasure; 39% reported feeling pain, 20% guilt and 38% shame or embarrassment. Respondents were able to give more than one response to how they felt after first sex.
Use of Contraceptives at Sexual Debut
Among respondents who reported having had premarital sex, almost nine in 10 had not used a contraceptive method during first sex (not shown). Forty-five percent of women and 32% of men reported unanticipated sex as their reason for not using a contraceptive. Half of men, but only one-fifth of women, cited not having known that they needed to use a contraceptive method. Other reasons reported for not having practiced contraception during first sex included not having known a method (19% of men and 13% of women), having believed that contraception was not necessary (14% and 19%), having had a desire for a child (1% and 5%) and having had sex during a "safe" period (4% of women).
Intention to Have Premarital Sex in the Future
We asked all the respondents who had not had sex at the time of the survey whether they intended to have sex before marriage and all the sexually experienced respondents whether they intended to continue having premarital sex. Overall, 83% of all men and 36% of all women intended to have sex before marriage or to continue doing so. Among those who had not had sex, 71% of men and 26% of women intended to do so before marriage, whereas among those who were already sexually experienced, 88% of men and 77% of women intended to continue to engage in premarital sex.
Sources of Information on Sexuality Issues
Among young men, peers clearly outranked parents asthe main source of information on sexual matters, with 67% reporting friends and 24% reporting parents as sources (Table 6). In comparison, women were about equally likely to mention parents (40%) and friends (37%). In addition, we noted that a significant gender difference existed in the use of mass media (excluding books and magazines), with 20% of men reporting that they had obtained information on sexuality issues from such sources, compared with 1% of women. Few respondents mentioned teachers (13-15%) or health clinics (3-8%) as sources of sexuality information.
Our findings suggest that Nicaraguan youth have already internalized their society's unequal gender norms by the time they reach adolescence. Double standards regarding the acceptability of male and female premarital sexual behavior are evident both in the attitudes and behavior of the young people in our study and in the explicit and implicit messages they reported receiving from the adults around them. Such double standards may have profound adverse effects on the sexual and social life of young adults.
Young men perceive themselves to be under social pressure to engage in premarital sex. They also perceive that many people approve of sex before marriage, and almost half believe that most or all of their male friends are having premarital sex. Such pressure, favorable attitudes toward premarital sex for males and perceived approval of their sexual behavior could lead young men to engage in risky behavior. For example, 9% of young men reported that their first sexual experience was with a stranger or a sex worker. In contrast, women perceived that their family and friends discouraged them from having premarital sex and disapproved of sex before marriage.
It is unclear whether the parental approval and encouragement to have sex perceived by young men and the disapproval and discouragement perceived by young women are real or merely a result of miscommunication or a lack of communication between parents and children. Some parents may not directly talk to their children about issues of sexuality; instead, they may use indirect means to convey their values, such as restricting or not restricting outside social mobility and social mixing with young people of the opposite sex. Sometimes, such methods miscommunicate the message: For example, if a parent restricts the mobility of a female child while not doing so for a male child, it might convey to them that their parent disapproves of premarital sex for women but not for men when, in fact, the parent may actually disapprove of premarital sexual behavior for both. These issues need to be investigated further using qualitative studies.
Nicaraguan women are likely to find themselves caught between opposing pressures from their boyfriends and from society at large. Although women may feel pressured to have sex to maintain their relationship, the threat of disclosure of their sexual relationship may prevent them from seeking contraceptive and other reproductive health services--increasing their risk of unprotected sex and unwanted pregnancy. A similar scenario exists in Mexico: The majority of ever-pregnant, never-married women reported that they had been persuaded to engage in their first sexual experience through a partner's subtle pressure and promises of a permanent relationship; however, the fear that people might find out about their sexual relationship and that their family would react negatively prevented most women from seeking formal contraceptive or abortion services from providers in the community.14
Though not examined here, another logical consequence of high social pressure on young men to have sex and failure to hold them responsible for the consequences of their sexual activities may be an increased probability of sexual coercion and other forms of sexual abuse of women. This, in turn, may have adverse implications for the social life of young men and women. For example, in many developing Asian and African countries, the perceived threat of sexual abuse, in part, leads parents to unnecessarily restrict their daughters' social mobility and further education once they have reached menarche.15 These issues need to be investigated further in the context of Nicaragua.
However, addressing gender-based double standards may not be simple. Social and cultural constructs that define the sexual norms for men and women have evolved over generations and have been justified and internalized by both men and women. For example, in our study, a greater proportion of women than of men reported having been discouraged from having sex by their mothers, whereas a greater proportion of men than of women reported that their mothers encouraged them to have sex or left them alone. For someone who is born and brought up in such an environment, whether male or female, gender-based double standards may be accepted as the norm, even if they appear blatantly contradictory or unjustified to the outside observer. Hence, an external catalyst may be needed to raise awareness and to address the duality regarding the sexual behavior of women and men.
Overall, peers were identified more frequently than parents, teachers or health care providers as a source of sexuality information. Reliance on peers for information may have serious consequences, as it allows negative attitudes and misperceptions concerning various issues of sexuality to spread easily. Such findings point to the need to work with young adults themselves in the design and implementation of programs such as communication campaigns, youth mobilization and peer education to raise awareness of the risk of unsafe sexual behaviors.
Carefully designed programs that involve all elements of society, including community institutions, can explicitly question differences in sexual norms, raise awareness about their unjust nature and properly educate young people. Several nongovernmental and community-based organizations, such as Puntos de Encuentros, are already active in this arena. However, programs need to recognize the source, magnitude and nature of gender differences if they are to serve as external catalysts for change; our findings may be helpful to organizations and programs in Nicaragua that deal with the double standard in sexual norms.
Findings from our study reveal significant gender differences in social pressures, attitudes and social approval for premarital sex. Acknowledging such gender differences in the designs of youth programs may be a prerequisite for their success. And although Nicaraguan society does not want young women to become pregnant at an early age or before marriage, propagating a sexual double standard that confines women or punishes them for engaging in sex outside of marriage, while encouraging men in similar behavior, is not an effective way to achieve that objective.
*Departments are administrative units in Nicaragua, corresponding to states or districts in other countries.
†The wide gender differences in perceived social approval and attitudes towards premarital sex and pregnancy affect responses even when interviews are conducted in a confidential manner. Because of this, we thought that we might observe a very weak relationship or no relationship at all.
1. Dorius GL, Heaton TB and Steffen P, Adolescent life events and their association with the onset of sexual intercourse, Youth and Society, 1993, 25(1):3-23; Eggleston E, Jackson J and Hardee K, Sexual attitudes and behavior among young adolescents in Jamaica, International Family Planning Perspectives, 1999, 25(2):78-84 & 91; Pino P, Florenzano R and Nudman A, Sexual initiation of school-age adolescents in Santiago, Chile: the implications of gender, religion, and family structure, in: Wijeyaratne P et al., eds., Gender, Health and Sustainable Development: A Latin American Perspective, Ottawa, Canada: International Development Research Centre, 1994, pp. 62-71; Zelaya E et al., Gender and social differences in adolescent sexuality and reproduction in Nicaragua, Journal of Adolescent Health, 1997, 21(1):39-46; and Alexander CS et al., Early sexual activity among adolescents in small towns and rural areas: race and gender patterns, Family Planning Perspectives, 1989, 21(6):261-266.
2. Alexander CS et al., 1989, op. cit. (see reference 1).
3. Eggleston E, Jackson J and Hardee K, 1999, op. cit. (see reference 1); Kiragu K and Zabin LS, The correlates of premarital sexual activity among school-age adolescents in Kenya, International Family Planning Perspectives, 1993, 19(3):92-97 & 109; Gomez VM, Comportamiento sexual en la población y grupos de alto riesgo de los hijos, Technical Report, San Jose, Costa Rica: Caja Costarricense de Seguro Social, Departamento de Medicina Preventiva, Programa Salud Reproductiva, 1993; Uriza GG, Sexualidad y adolescencia, Revista Colombiana de Obstetricia y Ginecología, 1988, 39(4):272-279; and Berglund S et al., The background of adolescent pregnancies in Nicaragua: a qualitative approach, Social Science & Medicine, 1997, 44(1):1-12.
4. Speizer IS, Mullen SA and Amégee K, Gender differences in adult perspectives on adolescent reproductive behaviors: evidence from Lomé, Togo, International Family Planning Perspectives, 2001, 27(4):178-185.
5. Gomez VM, 1993, op. cit. (see reference 3).
6. World Bank, Nicaragua Poverty Assessment: Challenges and Opportunities for Poverty Reduction, No. 20488-NI, Vol. I, Washington, DC: World Bank, 2001.
7. Population Reference Bureau (PRB), The World's Youth 2000, Washington, DC: PRB, 2000.
8. Remez L, Adolescent fertility in Latin America and the Caribbean: examining the problem and the solutions, International Family Planning Perspectives, 1989, 15(4):144-148.
9. Zelaya E et al., 1997, op. cit. (see reference 1); and Instituto Nacional de Estadísticas y Censos and Ministerio de Salud, Encuesta Nicaragüense de Demografía y Salud, 1998, Managua, Nicaragua: Instituto Nacional de Estadísticas y Censos and Ministerio de Salud and Calverton, MD, USA: Macro International, 1999.
10. Instituto Nacional de Estadísticas y Censos and Ministerio de Salud, 1999, op. cit. (see reference 9).
12. Prochaska JO, DiClemente CC and Norcross JC, In search of how people change: applications to addictive behaviors, American Psychologist, 1992, 47(9):1102-1114.
13. Bearman P and Bruckner H, Peer effects on adolescent sexual debut and pregnancy: an analysis of a national survey of adolescent girls, in: Peer Potential: Making the Most of How Teens Influence Each Other, Washington, DC: National Campaign to Prevent Teen Pregnancy, 1999, pp. 7-26; and Kirby D, Antecedents of Adolescent Sexual Risk Taking, Pregnancy, and Childbearing: Implications for Research and Programs, Washington, DC: National Campaign to Prevent Teen Pregnancy, 1999.
14. Ehrenfeld N, Female adolescents at the crossroads: sexuality, contraception, and abortion in Mexico, in: Mundigo A and Indriso C, eds., Abortion in the Developing World: Findings from WHO Case Studies, London: Zed Books, 1999, pp. 368-386.
15. McDougall L, Gender gap in literacy in Uttar Pradesh: questions for decentralized educational planning, Economic and Political Weekly, 2000, 35(19):1649-1658; Subrahmanian R, 'If you build it, will they come?' Educational decision making in the context of economic uncertainty and social risk, IDS Bulletin, 28(3):101-111; and Lloyd C and Mensch B, Implications of formal schooling for girls' transition to adulthood in developing countries, in: Bledsoe C et al., eds., Critical Perspectives on Schooling and Fertility in the Developing World, Washington, DC: National Academy Press, 1999, pp. 81-104.
At the time this article was written, Manju Rani was a consultant, Center for Communication Programs, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA. She is currently director, Social Welfare, Rajasthan, India. Maria Elena Figueroa is chief of research and evaluation and Robert Ainsle is regional director for Latin America, both with the Center for Communication Programs, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.
The research on which this article is based was funded by the U.S. Agency for International Development. The authors gratefully acknowledge Margarita Gurdian, Oscar Ortiz and Luis Blandor for their help in the fieldwork and Manisha Sengupta for comments on an earlier draft.