Security lies in obedience - Voices of young women of a slum in Pakistan

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Security lies in obedience - Voices of young women of a slum in Pakistan
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  RESEARCH ARTICLE Open Access Security lies in obedience - Voices of youngwomen of a slum in Pakistan Saima Hamid 1,2* , Eva Johansson 1,3 , Birgitta Rubenson 1 Abstract Background:  Existing literature shows that young people, especially women, have poor knowledge about sexualityand reproductive health. Many of the difficulties young women experience are related to beliefs and expectationsin society making them more vulnerable to reproductive ill health. The objective of this study was to explore howyoung women living in a slum in Islamabad are prepared for marriage and how they understand and perceivetheir transition to marriage and the start of sexual and childbearing activity. Methods:  Twenty qualitative interviews and three focus group discussions were conducted with young womenresiding in a slum of Islamabad. Content analysis was used to explore how the participants represented andexplained their situation and how decisions about their marriage were made. Results:  The main theme identified was  security lies in obedience . The two sub-themes contributing to the maintheme were  socialization into submissiveness  and  transition into adulthood in silence . The theme and the sub-themesillustrate the situation of young women in a poor setting in Pakistan. Conclusion:  The study demonstrates how, in a culture of silence around sexuality, young women ’ s socializationinto submissiveness lays the foundation for the lack of control over the future reproductive health that theyexperience. Background Although teenage marriages are on the decline in Pakistan,one out of six women aged 15-19 years is married [1].Strong societal, cultural and religious expectations areattached to the sexual innocence and ignorance of womenas a sign of purity and virginity, with marriage markingthe beginning of sexual relations and childbearing [2].There is great societal pressure on parents to arrange mar-riages for their daughters [2], with marriages traditionally arranged by families with minimal involvement of thecouple [3]. In the 2002 Adolescent and Youth Survey of Pakistan, 80% of women and 85% of men reported beingmarried to relatives [4]. Marriage initiates new livingarrangements and many new relationships, including thehusband and his family, and most women find mother-hood the main focus of their new life at the expense of personal or relationship development in other areas [3].Existing literature shows that young people, especially women, have poor knowledge about sexuality andreproductive health [5-10]. A community-based study by  Sajan & Fikree (2002) in the squatter settlements of Karachi found a high prevalence of gynaecological morbid-ity among young married women. Women who begansexual activity in their teens, as compared to women whostarted after 25 years of age, reported a greater burden of reproductive ill-health. This affirms the risks associatedwith early marriage and the need to improve and broadenreproductive health services and education [11]. In an ear-lier study the authors interviewed newly married youngwomen in the same slum area about their experiences of marriage. A narrative analysis of the interviews revealedthe submissive nature of the respondents [12]. The sub-mission described by participants was instilled in the young women through the impact of diverse levels of thefamily, community and society on their lives: their parentsdeciding about their marriage, often without their consent,the extensive demands placed on them by their parents-in-law and the pervasive societal expectations for them tobe obedient in all spheres of life. Many of the difficulties young women experience are related to societal beliefs * Correspondence: saima_hamid@yahoo.com 1 Global Health, Department of Public Health Sciences, Karolinska Institute,Stockholm, Sweden Hamid  et al  .  BMC Public Health  2010,  10 :164http://www.biomedcentral.com/1471-2458/10/164 © 2010 Hamid et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the srcinal work is properly cited.  and expectations that make them more vulnerable toreproductive ill health [11,13,14]. To further investigate the situation of young women liv-ing in the slum area in Islamabad this study explores how they are prepared for marriage and perceive their transitionto marriage and start of sexual and childbearing activity. Methods A qualitative approach using latent content analysis[15] was used to explore the situation of poor youngurban women at the time of their marriage and tostudy their knowledge of and expectations for marriedlife. In qualitative research human behaviour is under-stood from the perspective of those being studied; theirperceptions, attitudes and experiences are the focus[16]. For this purpose the Principal Investigator (PI)approached the respondents through a community worker and met them multiple times to establish rap-port with them. Multiple meetings helped the partici-pants to open up to the PI and discuss sensitive issuesregarding sexuality and growing up with reference totheir marriage and other related topics of their choice.In this respect unstructured interviews helped elaborateon the topics of participants ’  choice and probe furthertheir concerns something which could not have beenachieved through participatory observations. In usingin-depth interviews and focus group discussions(FGDs) information was sought to increase the under-standing of young women ’ s interpretations of theirsituation [16]. The FGDs were conducted following thein-depth interviews using a field guide based on theinterviews with the respondents to further explore young women ’ s preparedness for marriage, theirknowledge about sexuality, sources of information andtheir experience of growing up. Research Team The research team comprised a Pakistani medical doc-tor specialized in public health (PI), a Pakistani com-munity worker and two Swedish public healthscientists. As a Pakistani woman and public healthdoctor the PI had both social and cultural knowledge,spoke the language and could move in the community without arousing curiosity. The community workerwas a resident of the community who met regularly with the women ’ s groups and played a key role in giv-ing the insider ’ s perspective to the study and facilitat-ing the entry of the PI to the community. The insider ’ s view of the Pakistani researcher was broadened by theoutsider ’ s view of the Swedish researchers, whoseexperiences living and working in low-income coun-tries enriched the understanding of the data and con-tributed to the analysis. Setting The study was conducted in a slum community in theoutskirts of Islamabad city. There are 900 houses inthe community with almost 400 having more than onefamily living in the house. The residents are mainly daily labourers and the majority are illiterate. Few women have attended school beyond the primary leveland many have never even started. The young womenhave limited opportunities for employment and aremostly married shortly after puberty. Their marriage is viewed as a social and religious duty for the parents. If the marriage is delayed it is usually rather because of economic reasons than for lack of finding a suitablepartner. The family has to save or generate resourcesto bear the expenditure of dowry and weddingcelebrations. Participants and Data Collection With the help of the community worker, young womenaged 15-24 years and engaged to be married withinthree months were identified. Twenty women whoagreed to participate were included in the study. Paren-tal consent was taken as well. Interviewing was done tillsaturation was reached. Altogether twelve15-19 year oldand eight 20-24 year old women were interviewed. ThePI interviewed all of the participants. Given the sensitiveissues under discussion the authors counter checkedwhether the age of the PI could be an obstacle in open-ing up of the respondents to the PI and candidly sharingconcerns about growing up. A younger interviewercould have been more aware of the world of the youngwomen; using familiar language and raising issues withthem she could facilitate their communication and dis-cussion with her. For this five of the respondents werealso interviewed by a young data collector. Since theinformation gathered by the data collector and the PIwas the same, it was decided that the interviews carriedout by the PI were valid. The participants were inter- viewed in their homes on three occasions with a few days in between to overcome the barrier of talkingabout sensitive issues with the researcher. This series of conversational interviews gave the women an opportu-nity to expand on a range of issues that they wanted todiscuss [16]. Their knowledge about sexual activity,child bearing and sources of sexual and reproductivehealth information were explored. Following the inter- views, three focus group discussions (FGDs) were heldwith 14 additional 15-19 year old women. Four or five young women participated in each FGD, which wereconducted in the home of one of the participants attheir choice. The FGDs were conducted to explore par-ticipants ’  views about adulthood with a focus onwomanhood. The young women were asked to base Hamid  et al  .  BMC Public Health  2010,  10 :164http://www.biomedcentral.com/1471-2458/10/164Page 2 of 7  their answers on community perceptions and not onpersonal feelings [17]. Data Management and Analysis Most of the interviews and FGDs were conducted in thelocal language by the principal investigator (PI) whoalso transcribed and translated them into English. Thetranscripts were read several times to gain an in-depthunderstanding of participants ’  life experiences and their views on their preparation for and knowledge about sex-ual and childbearing activity. The data were analyzed by the research team using latent content analysis, with afocus on the description and interpretation of messagemeanings and concepts. Latent content analysis entails aconstant comparison of different parts with a constantattention to the overall individual- and group-level datain a search to achieve an accurate understanding of theunderlying meaning [15]. It is only through this carefulexamination of the women ’ s perspectives that authorswere able to understand the situation of the youngwomen in the study. In the interviews and FGDs mean-ing-units were identified, condensed and then coded.The codes were grouped into categories and abstractedinto sub-themes and a main theme, always maintainingthe practice of constant comparison during the codingprocess. Trustworthiness Various assurances were integrated into this study inorder to ensure trustworthiness of the data during datacollection and analysis. During data collection, informa-tion was collected using both in-depth interviews andfocus group discussions. The women that participated inthe interviews were visited several times to increaseinterviewer-participant rapport, to provide participantswith the opportunity to recapitulate their story, and toprovide the interviewer to confirm what had been toldand understood. Two interviews and the FGDs werecoded by other qualitative researchers who were notinvolved in the study and compared to the coding doneby the research team. Any differences in coding werediscussed and a consensus was reached about the finalset of codes. The codes generated from the interviewsand FGDs were similar, which added to the credibility of the data. The findings were brought back to the com-munity worker for verification. Ethical Considerations Ethical clearance for the study was granted by thePakistan Medical Research Council and the KarolinskaInstitute. Verbal consent was taken from the decisionmaker in the house and the respondent. In most casesthe decision maker was the mother who gave consent inthe absence of the father. The consent statement, whichexplained the study objectives and the expectations of the study participants, was read aloud to facilitate theirunderstanding. Study participants were assured of confidentiality. Results The two sub-themes illustrate the ideals,  submissiveness and  silence , that the Pakistani women are socialised intofrom childhood. These were combined into the themeof the study,  security lies in obedience , thus illuminatingthe situation of young women in a poor setting inPakistan. The data are presented starting with the sub-themes and their relation to the categories of analysisand concludes with how they contribute to the maintheme (Table 1). Socialization into submissiveness The first sub-theme refers to the experiences of the young women who described how they were socialisedfrom childhood into submissiveness and obedience.These ideas represent the expected ideals in the socialenvironment of the local society, which underlie thecustoms guiding the socialisation of girls. The psycho-logy of participants ’  parents became apparent in the varying degree of freedom and opportunity that differentparents allowed their daughters. This socialization intosubmissiveness was achieved by: Living up to family expectations The young women described the behaviours, duties andresponsibilities they were brought up to fulfil. They understood their primary role to be tending to theirhousehold and listed the typical duties such as cooking Table 1 Analysis Process for moving from Categories to Themes Category 1 Category II Category III Category 1 Category IILiving up to family expectations Finding security in learningobedienceLevel of freedom defined byfamilyBecoming a woman insilenceFindingcracks in the wall of silence Sub-theme I Socialization into submissiveness Sub-theme II Adulthood transition in and into silence Main Theme Security lies in obedienceHamid  et al  .  BMC Public Health  2010,  10 :164http://www.biomedcentral.com/1471-2458/10/164Page 3 of 7  and cleaning as the main things that gave them personal value. They had agreed not to attend school, instead stay-ing at home out of a sense of duty and thus enabling theirsiblings (especially brothers) to go to school. They pre-ferred to work at home, looking after everyone else ’ s needsand literally serving as substitutes for their mothers. To beselfless, loyal and possess empathy for the family wereimportant characteristics valued in their upbringing. “    My mother is away visiting relatives for the past 5 days. She told me to be a good daughter and look after the family. I have been looking after my younger brothers and sisters and my father and have donerather well. My younger brothers and sisters arehappy and not missing Ami (mother) .... ”    (15 yearsold) Finding security in learning obedience The young women were expected to be obedient andfaithful, to defer to their parents for decision-makingand to oblige their future in-laws in the same manner.All decisions regarding their marriage were entrusted tothe family and the family  ’ s (not the women ’ s) opinionswere what mattered most. “   There is a girl, who married by her own choiceagainst her parents will. ...the husband does not work and beats her.... she used to be so pretty and now sheis in such a pathetic state. I think she should havemarried the person her parents wanted her tomarry. ”    (15 years old)When asked to express their aspirations for the futurethey were unable to enlist any wishes and showed reser- vations to elaborate. Disobedience by participants resultedin displeasure on the part of their parents, especially mothers, who stressed that their behaviour reflected theirupbringing and thus disobedience reflected badly on theparents. They learnt that the sole path to being lookedafter and feeling secure was to abide by the rules. The young women said that they had to learn to control theirtongue and exercise  sabar   (patience), the main compe-tencies for a successful future married life. “    My mother tells me to show sabar (patience) and not to answer back. My behaviour is a reflection of  my parental upbringing. ”    (19 years old)Young female participants illustrated the subservientrole of women in society by referring to television seri-als. A young woman in a FGD referred to a serial thatshowed how all decision-making lay in the hands of thehusband and then concluded that the woman had nocontrol over her life. This perspective was echoed by other participants, who voiced the importance of obeying their future husbands to avoid the consequencesof divorce and being left for another wife. They under-stood the fragility of marriage and the ease of remar-riage for a man in society. Level of freedom defined by family  The young women stated that their mobility both insideand outside the home was closely monitored by theelders in the family. They feared that these restrictionswould continue after marriage. “    My fiancé is shakki (does not trust). In the villagewhen we visit them, he does not like it if I talk to our other relatives. I am afraid of what will happen after my marriage. ”    (19 years old) Adulthood transition in and into silence In the FGDs the young women discussed the challengesof menstruation and body changes, which caused dis-comfort and raised questions to which they were givenfew answers. They saw the onset of menstruation as thefirst sign of growing up and the end of childhood andfreedom. They also considered this physiological changeas marking the beginning of an era of confinement. Becoming a woman in silence Not prepared for their first menstruation, participantswere shocked by the experience. When they approachedtheir mothers they were told not to talk about it andonly shown how to handle the bleeding. Throughfriends, aunts or their mothers they learnt that they were not to offer prayers during menstruation and totake a cleansing bath once the bleeding stopped. Youngwomen felt severely inhibited in their ability to askquestions about physical and related changes and they understood that keeping silent on women ’ s health issueswas part of being a grown-up woman. “    I stopped going to school as I was afraid of having todeal with menstruation in school. No one at homeasked me why I stopped and nobody at home told me to go to school either. ”    (17 years old)Silence around sexuality was expected and curiosity,although evoked at the time of marriage, was notaddressed. Instead they learned that talking about sexu-ality and having questions about married life was a signof having no shame. “    I am looking forward to my marriage and I want toask questions but I do not talk about this with my mother.... she doesn ’   t even know I menstruate. Howcan we talk about these things?  ”    (19 year old)The young women either lacked or had deficientknowledge about sexuality, contraception and Hamid  et al  .  BMC Public Health  2010,  10 :164http://www.biomedcentral.com/1471-2458/10/164Page 4 of 7  pregnancy. They knew marriage included some kind of physical contact with the husband but could neitherexplain nor understand the actual sexual encounter.When asked how a woman conceived a child they responded that it happened after marriage and at God ’ swill. “    My sister is happy. Her husband is a plumber. My elder sister used to say that she has had enough chil-dren but then she had another son... now she saysthe same thing. It  ’    s your fate as to how many chil-dren you will have and God  ’    s Will!  ”    (22 years old) Finding cracks in the wall of silence The young women interviewed knew about contracep-tives through television (TV) advertisements, but they lacked full understanding of how to use and accessthem. The mothers approved of their daughters havingcontact with older cousins, sisters and aunts as asource of information about sexuality and childbearingnear the time of their marriage. The information how-ever was vague and not fully understood by the youngwomen. There were a limited number of young womenwho sought out or accepted  “ pockets to think, ”  whichwe define as space and time approved by their mothersto talk with their fiancés prior to marriage. Those young women communicated with their fiancés briefly about general issues using mobile phones. These con- versations sparked the women ’ s own thinking aboutplanning for their married life and the number of chil-dren they want to have, although this thinking was notshared with others. This small sub-group was keen tolearn about child spacing and accessibility tocontraceptives. Security lies in obedience The main theme identified from the perspectives womenshared in the interviews and FGDs as the underlyingmeaning of their lives well illustrates the feelings andexperiences of the young women regarding their upcom-ing marriage: security lies in obedience. They claimed tolove and trust their parents, listening to their opinionsand feeling secure in following their rules as they wereolder and more knowledgeable. A  “ good daughter ”  wasdefined as one who abided by the rules. The youngwomen trusted that continued family support wouldensure security in future life. “    I love my mother. If she is happy so am I. I knowthat my parents know what is best for me as they areolder and wiser. If they think I should marry this per- son then I am fine. ”   (17 years old)Participants expressed fear of the consequences of notfollowing the rules. “    If one decides oneself on whom to marry, then onedoes not have the support of the parents. You arebound to like the husband chosen for you by your  parents. If one decides oneself and does not like thehusband later then parents say it was your choiceand you lose ..... you are alone......have no one to turnto and no support from the family and no security anywhere. ”    (FGD 1) Discussion In the traditional Pakistani society, marriage is seen as afamily, communal and societal affair more than a jointenterprise of the couple. Girls are socialised from child-hood into the role of a wife who should fulfil the expec-tations of the mother-in-law and husband and who theparents were proud of handing over to the new family [18,19]. This was brought out also in the earlier study  by the authors, which interviewed married youngwomen. It showed how the women were raised by par-ents, family and broader society to practice obedience insilence and to not question the decisions of elders, firstin their parents ’  homes and then in their new homesafter marriage [12]. The unmarried participants in thecurrent study affirm the perspectives of the marriedwomen in the earlier study, sharing in detail how thefoundation for the ideals of submissiveness, obedienceand silence is laid. Socialized towards family Participants were brought up in a social environment inwhich adolescent girls were neither expected norallowed to move on their own outside the home or tomeet young men. Instead they were busy in the homelearning household chores and helping their mothers,who underscored the need to learn  sabar   (patience) andto trust the decisions of the elders, including about theirown health and fertility. The message of   sabar   that wasforcefully reiterated from childhood prepared them forthe coming challenges of a minimal voice in the deci-sions around marriage. These findings are in accordancewith the Pakistani tradition where collective welfare out-weighs individual well-being. Only after considering allother family members needs are women allowed tothink about their own [20]. Participants learned that “ being acceptable ”  in society  ’ s eyes meant becoming self-less. This limited self-concept is also described by Kagit-cibasi, who illustrated how children in collectivistsocieties in Turkey lack an understanding of self, as aconcept of a person with her or his own desires, prefer-ences, attributes and abilities [21]. In our study the young women defined their self-identity in relation tothe community and family, especially the parents, whichis consistent with other findings from South Asia [22]. Hamid  et al  .  BMC Public Health  2010,  10 :164http://www.biomedcentral.com/1471-2458/10/164Page 5 of 7
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