Breaking New Ground in Vietnam
Gender norms affect the behavior and life choices of both men and women. In Vietnam, these norms sometimes drive people into situations where they are at increased risk of violence, STI acquisition, and/or incarceration. This case study (one of nine in a series) examines CARE International's STEP program, which seeks to ensure that both men and women have equal access to services to prevent STIs, safeguard their health, avoid gender-based violence, and participate in income-generating activities.
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Breaking New Ground
By Kai Spratt and Quach Thi Thu Trang
Integrating Gender into CARE’s STEP Program in Vietnam
Giang was recently brought to the Social Education Labor Center for people who inject drugs (PWID) near Can Tho. It was her second arrest. During her first detention, Giang received education on avoiding drug use and received a mandatory HIV test. On her release, she was told that she was living with HIV and was thrust back into the community with no plan, no information on where to receive HIV services, no marketable skills, and no one to turn to for help. Her family refused to let her into the house, and her husband—who also injects drugs—abused her. She was soon back to injecting drugs and was subsequently arrested.
This time, Giang’s experience at the treatment center was very different. Before her release, she received individual counseling on general health and prevention of HIV, other sexually transmitted infections (STIs), and hepatitis. Center staff also met with her to talk over her return home. In the confidential counseling room, Giang brought her fears into the open. She was afraid that the family would reject her again, and that the violence she endured at home would continue. And she had questions: How could she earn money to help support the family? And most importantly, where could she find services to help her protect her health and stay away from drugs? Counselors discussed her fears and told Giang that when she returned to the community this time, she could count on help from a post-release support center (PRSC) in her home town. PRSC staff could provide counseling on problems she experienced, refer her to health services, or visit her at home to help work through family conflicts.
The PRSC in Can Tho is one of two centers set up as part of the Striving for Transformation through Empowered People (STEP) program in Vietnam’s southwestern province—one of the first projects in the country to address gender and its effects on the behavior and life choices of both men and women. The program, a collaboration between CARE International in Vietnam (CVN) and the provincial Department of Labor, Invalids and Social Affairs (DOLISA) government staff, provides support and health information both before and after rehabilitation to enhance the social reintegration of PWID and sex workers (SWs). In particular, STEP seeks to ensure that both men and women have equal access to services to prevent STIs, safeguard their health, avoid gender-based violence (GBV), and participate in income-generating activities.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
HIV in Vietnam
HIV prevalence in Vietnam is not high relative to other countries, but it is highly concentrated within most-at-risk populations (MARPs). Prevalence among the general adult population (15 to 49 years of age) is expected to reach 0.31 percent by 2012, stabilize at 30 percent among PWID, and increase to 9.7 percent among SWs, remaining highest in urban centers, including Can Tho, Ho Chi Minh City, and Hai Phong (Ministry of Health—Viet Nam Administration of HIV/AIDS Control 2009). Preliminary results of the second round Integrated Biological and Behavioral Surveillance in 2009, which was conducted in 10 provinces for SWs and PWID, and four provinces for men who have sex with men (MSM), showed an average HIV prevalence of 3.2 percent among SWs, 18.4 percent among men who inject drugs, and 16.7 percent among MSM (The Socialist Republic of Viet Nam 2010).
An estimated 200,000 PWID (82 percent of which are men and 18 percent of which are women) account for about 65 percent of all people living with HIV in Vietnam (Needle and Zhao 2010). PWID risk HIV infection by sharing injection equipment and buying and selling sex. Many men who inject drugs are married or in long-term partnerships with women, who are increasingly becoming infected by their male partners (Joint U.N. Programme on HIV/AIDS [UNAIDS] 2009); hence, the proportion of people living with HIV who are women is expected to increase.
The national response to the HIV epidemic in Vietnam has been substantial, with prevention efforts appropriately focused on MARPs and rapid scale-up of treatment and care for people living with HIV. The 2006 Law on HIV/AIDS Prevention and Control endorses harm reduction programs for PWID and stresses a behavior change approach at the strategic planning and programmatic levels. However, this approach does not take into account that HIV risk behaviors are embedded in and reinforced by the risk-taking norms of social networks of SWs and PWID (Lam 2008). HIVrelated policies and programs also pay little attention to the effects of gender-related norms and the way in which social and gender-related inequalities influence behavior, risk prevention, and access and adherence to health services and treatment.
Gender Norms in Vietnam
Vietnam’s transformation in 1986 from a centrally planned economy to a socialist-leaning market economy (referred to as doi moi, or “renovation,” of the economic and political system) resulted in rapid economic and social change. This transformation created new economic opportunities outside of traditional agricultural work, including jobs for women, especially urban women and those in the Kinh, the dominant ethnic group (Packard 2005). However, women mainly work in low-paying and lower status jobs. Men have the primary role of providers, and their ability to support their families is an important indicator of masculinity (Vu et al. 1999). Society still supports the concept of men as primary providers, while women take a subsidiary economic role. In practice, the female to male labor force participation is 0.92, indicating considerable economic participation by women, especially in the agricultural sector. In the non-agricultural paid labor sector, women make up 40 percent of the labor force. However, women earn significantly less than men for the same work (World Economic Forum 2010).
Furthermore, Vietnamese society is heavily influenced by Confucian philosophy characterized by male dominance and privilege, son preference, and hierarchical relationships that support gender inequality (United Nations Viet Nam 2010). After marriage, women move to the home of their in-laws and are expected to strive for the ideal of the “happy family” that emphasizes women’s roles as mothers, wives, and self-sacrificing caregivers. Women are expected to be obedient and innocent in sexual matters, while it is acceptable for men to seek extramarital sex. Social norms discourage discussion about sex or sexuality, which constrains opportunities for safe sex, reproductive heath choices, HIV testing, and other preventive actions. Violence against women is a fairly common and accepted practice in Vietnam, though it is not well documented (Gardsbane et al. 2010). While in many ways MARPs transgress societal norms, traditional gender roles influence their goals and aspirations—marriage, family, gender-specific productive and reproductive roles—in the same way they affect the general population.
The Policy Environment
The Constitution of Vietnam provides for equal rights for all in political, economic, cultural, and social realms, including the family. Several laws have been passed in the last 20 years to strengthen individual rights and responsibilities of men and women. A 1986 law promotes equal responsibility of husband and wife for household chores and child care, and equal treatment for sons and daughters in property, inheritance, and education. A 2000 law allows land use rights for both husband and wives. Laws passed in 2007 promote gender equality and define and prohibit domestic violence (the term “gender-based violence” was not accepted by policymakers; U.N. Population Fund [UNFPA] Viet Nam 2007). While these laws demonstrate efforts to address gender inequality, most do not yet have guidelines that instruct organizations, the judiciary, law enforcement, or government ministries on how to implement or monitor them.
Current laws and policies frame sex work, drug use, and homosexuality as “deviant” behavioral choices (Ngo et al. 2009) and “social evils” that degrade cultural and familial traditions. Sex work and drug use are both illegal (whereas homosexuality is not), and communities shun and police harass and arrest both groups; the threat of harassment and arrest heightens these groups’ vulnerability by driving them to operate underground (Lam 2008). After arrest, SWs and PWID may be confined to Social Education Labor Centers (“05 centers” for SWs, “06 centers” for PWID) for periods of up to five years for repeat offenders. In 2007, there were approximately 50,000 residents held in an estimated 83 06 centers (International Harm Reduction Development 2008).(1) These centers face numerous problems. For example, all centers lack basic medicine and adequately trained health personnel, and have little capacity for peer education and outreach programs. The government has begun to embrace the idea of drug-dependence treatment in the 06 centers, but opiate substitution therapy is still in the pilot stage and is not provided in 06 centers. Vocational training to prepare SWs and PWID for productive work is limited to gendered notions that sewing and weaving classes are the best job options for women, which few female center residents take up. Consequently, rates of recidivism are high for former inmates of both 05 and 06 centers.
CARE International in Vietnam and the STEP Project
The STEP project is part of CARE’s effort to mainstream gender concerns in all its projects worldwide by 2012. In 2008, CVN developed a country strategy that includes gender equity as a key issue. Because gender integration was a new concept, CVN developed a gender strategy with the objective of increasing understanding of, and ability to promote, gender equity among staff and partners; improve organizational mechanisms for supporting gender equity in programming; and broaden the evidence and advocacy base for promoting gender equity in policy and practice. CVN put together a gender task force and established a requirement that all country programs and proposals include gender activities. Staff receive ongoing training on gender equity as well as indicators to measure progress toward gender equity goals, both within the organization and within developing community-based programs.
CVN launched the four-year STEP project in 2008, with approximately U.S.$795,000 from the Australian Agency for International Development and five core staff positions.(2) The project, a collaboration with the provincial DOLISA and the Department of Social Evils Prevention (DSEP), is underway in two cities, Can Tho and An Giang, in southwestern Vietnam (see Box 1). It is the first CARE program in Vietnam to address gender equity, and the two project cities will serve as learning sites on gender mainstreaming for CARE globally.
BOX 1. INTEGRATING GENDER SENSITIVITY WITHIN STEP
While developing the STEP workplan, CVN analyzed each activity with government partners to address gender-related needs within every project component. The project set up community integration counseling rooms in both 05 and 06 centers, and provided group counseling for PWID on the harm of drug abuse. Counseling was tailored to gender-related needs in several ways:
- Easy access to appropriate counseling spaces: Counseling for women took place in “safe” places that ensured confidentiality, usually within residents’ living areas; men were less concerned about the location of the counseling room.
- Counseling according to gender preference: Women had access to the female counselors; men showed no preference for male or female counselors.
- Appropriate training for counselors: Counselors were trained to address gender-related concerns and psychological needs when working with center residents and returnees.
STEP seeks to reduce recidivism in the 05 and 06 centers by improving the readiness of SWs and PWID (“returnees”) to re-enter their community when released from the centers. STEP activities introduce a new paradigm by 1) focusing on relapse 2 CVN received a one-year extension in early 2010. prevention, infectious disease prevention, coping skills, and social support; and 2) recognizing that gender inequality increases the risk and vulnerability of drug users and SWs, both inside the centers and outside in the community. The project seeks to build the capacity of its government partners, communities, and families to address the gender-specific needs of men and women during their detention, and to consider gender-related challenges within their communities and how these challenges contribute to continued drug use and sex work. The overall goal of the STEP project is to improve the experience of reintegration for residents and returnees from the An Giang and Can Tho 05 and 06 centers so that men and women benefit equitably in terms of health, safety, and livelihood security. The project’s main objectives are the following:
- Reduce the risk of STIs, HIV, and hepatitis among center residents through gender-sensitive behavior change interventions, both within the centers and in community settings
- Increase access to gender-sensitive harm reduction and addiction support services for men and women who inject drugs, both within and outside the center setting
- Increase the capacity of SWs and PWID to prevent and avoid GBV
- Increase inclusion of returnees and their families in social and economic activities within targeted districts.
STEP addresses two complementary strategies to prepare residents for release and support them upon release:
1. A pre-release support program (PRSP) is based in the 05/06 centers near Can Tho and An Giang. The staff at these centers are trained to provide supportive counseling and basic health services to center residents, in addition to the traditional sessions on the harms of drug use and sex work and optional courses in industrial knitting or sewing. When they leave the center, returnees receive a “release package” that includes a t-shirt with the slogan “Determination and Victory,” condoms, a post-release support services (PRSS) brochure, and a list of services available in their home community.
2. PRSS drop-in centers are located in Binh Thuy district and Can Tho City, Can Tho province, and in Long Xuyen City, An Giang province. PRSS staff visit residents at the 05 and 06 centers to introduce themselves and let the residents know about the services that will be available when they return home. The PRSS serve returnees who want counseling or referrals; social workers based at the sites conduct home visits to provide support and counseling to returnees who are having family problems or difficulties with reintegration. They also provide communication sessions with families and in the community to reduce stigma and discrimination against SWs, PWID, and returnees at the family level.
The five-member CVN staff carry out training, technical support, and monitoring in collaboration with provincial DSEP and DOLISA staff. Local government staff implement all activities at the 05 and 06 centers, and retired or current district-level employees staff the PRSS centers.
Former PWID and SWs, including former center residents, were recruited to serve as PRSS staff members and peer educators to augment existing staff. STEP has trained hundreds of returnees in the community to act as peer outreach volunteers, who try to identify new returnees and encourage or accompany them to the PRSS for counseling and support. However, retaining returnees has proved challenging, as many have difficulty staying in routine jobs; some returnees moved to other communities, while others returned to drug use or sex work, or were arrested again and detained in the centers.
Figure 1 describes the conceptual framework for the STEP approach.
Figure 1. Components and Outputs of the Vietnam STEP Program
PEPFAR Gender Strategies
The STEP program addresses three of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) gender strategies by its approach:
- Increasing gender equity and access to HIV programs and services: As part of its commitment to enhancing gender equity, CVN requires that every program objective and activity be designed to increase gender equity and access to services for men and women. 05/06 center staff receive training in different counseling needs of men and women as well as establish separate counseling spaces for men and women in order to improve privacy and increase the uptake of services. CVN uses indicators such as “number of female trainers” and “number of women using services” to track gender equity and access to services and assess progress toward gender equity goals.
- Addressing gender norms and behaviors: STEP’s primary challenge has been building the capacity of its government partners to understand gender differences among PWID and develop appropriate services. Though the government directs its agencies to address gender issues, awareness and understanding of gender norms and their effects on individuals and communities is still developing.
Interviews showed that STEP staff and partners understood that gender influences vulnerability and the risk of using drugs, engaging in sex work, and relapse, though the degree of understanding varied. Most center staff identified stigma against women who inject drugs and SWs as a major obstacle to their reintegration into the community. Stigma against all PWID and SWs is substantial, but women who use drugs or work in the sex trade are seen as violators of norms that require men to focus on the family and to be discreet and self-sacrificing, and are therefore more likely to be rejected by their families.
- Increasing access to income and productive resources: To address the low education levels and very limited employment opportunities for center returnees, STEP is working with DOLISA to implement a microfinance program. Returnees submit applications to DOLISA, which then selects the grantee and supervises the loan. So far, 75 returnees have received small loans of up to 3,000,000 dong each (approximately U.S.$154) to setup small trading kiosks or raise domestic livestock such as chickens. Staff members say that the majority of awardees have been women who have generally asked for smaller loans and are also more likely to repay money they have borrowed.
In late 2010, STEP conducted a survey to analyze the job market in Can Tho and An Giang. The survey serves to inform the project and its partners of current work opportunities, which will help match available jobs to the needs of residents who are receiving training in the 05/06 centers, and also of returnees looking for employment.
BOX 2. SELECTED RESPONSES ON GBV FROM STEP EMPLOYEES
Do you give [women] any strategies to deal with GBV?
We give them advice. Women should know how to compromise with the husband. We always ask women to be silent so that she doesn’t do anything to upset the husband.
Did you report to police?
We reported it to the Women’s Union (WU). Most women do not report to WU because if they report they will lose the reputation of their family. Some couples live with their parents-inlaw and the in-laws may not allow them to report to police.
–Post-Release Support Club staff
The Challenge of Violence
STEP included GBV as an objective in its workplan, but activities related to this objective are still in the formative stage. A major issue, both in treatment centers and in the community, is that GBV is generally denied or minimized (see Box 2). It is considered a private issue within the family and generally not discussed by non-family members. When asked about what is being done in the community to address GBV, respondents often said, “I don’t know of any such cases.”
Within the community, Reconciliation Committees, consisting of volunteers from the various Communist Party “mass organizations” such as the Farmer’s Union and the Women’s Union, that are organized from the national to community level, respond to a wide range of issues, and offer to mediate conflicts between community members. The Reconciliation Committee or local police, who have not received any significant training in conflict resolution, may be called on to intervene in a case of GBV. According to STEP and PRSS staff, however, this rarely happens. More often, the Reconciliation Committee discuss the matter and try to persuade the husband not to abuse his wife or partner. When asked what could be done to address GBV, most people said that women were responsible for managing their husbands and themselves; only a few responded that the husband had any responsibility for his behavior or could be at fault. When asked, “What would you do to respond to GBV in your community” a common response is, “Nothing, it’s a family matter.”
Nor is there a significant government response to GBV. There are no GBV services in either An Giang or Can Tho provinces: no public health facilities provide specialized medical care, and police have no procedures for documenting cases of GBV. Police may detain perpetrators who have inflicted significant physical harm to the victim, but generally release them within hours or days. There are no safe places or shelters for women and their children who experience GBV.
What Worked Well
Integrating gender considerations within activities: CVN has a well-defined gender mainstreaming strategy championed at all levels of the organization and integrated throughout the STEP workplan. STEP’s training and technical support enabled government partners, for the first time, to reflect on and understand the different realities and needs of men and women who spend time in the 05/06 centers.
Initiating changes in traditional beliefs about gender roles: STEP successfully introduced the concept of gender sensitivity and encouraged government staff in the 05/06 centers with which they collaborate to examine and change their own attitudes about gender and gender roles. For some, this was a significant personal outcome of working with STEP. For example, a senior manager of one of the rehabilitation centers said that he tries to model the way he wants his staff to behave toward women who inject drugs, and strives to increase awareness of why women become injecting drug users.
Initiating efforts to address domestic violence: CVN has demonstrated leadership in seeking to meet an explicit objective related to GBV. Such an objective is very rare in programs that work with SWs and PWID, both in Vietnam and globally.
Addressing the need for economic opportunities: STEP recognizes that economic opportunities for returnees must reflect their aptitude, education level, interest, and skills—and that the resulting skills or businesses must fit in with the needs of the local economy. Even though this is a small component of STEP, this activity responds to both market needs and the barriers and constraints that PWID and SWs face in reclaiming their lives and supporting their families.
STEP is halfway through its implementation period and planned to conduct a midterm assessment in May 2011. During the field work for this case study, the project manager and STEP staff were very open about the challenges they face, with a small staff (five full-time workers) covering a relatively large geographic area over two provinces.
Hiring returnees, or engaging them as peer educators, has proved difficult: No STEP staff, and few PRSS staff, are former PWID or SWs. The majority of service providers are government employees. The absence of peers with whom returnees feel they can safely discuss their problems may limit returnees’ willingness to seek information or support at the PRSC. STEP has made it clear that it is open to hiring former PWID and SWs if they have the right background and education. It could be helpful for STEP to look for peer educators and outreach workers trained by CVN and other implementing organizations in Can Tho and An Giang, and recognize that competency interacting with peers may be a more important criterion than education level and work experience.
Understanding of gender issues remains limited: To address specific gender-related issues effectively, STEP’s partners need to further understand and “unpack” information on the gender norms that influence behavior. Gender is still mainly viewed as an issue for women. STEP partners recognized the existence of gender norms—for example, that “real men” work hard, make a lot of money, drink and smoke, and may lose their temper—but struggled to grasp the idea that existing norms could hurt both men and women. At the community level, stigma and discrimination against women who inject drugs remains higher than discrimination against men who inject drugs.
Limited potential of STEP’s GBV component: While some staff members may know about GBV, they did not clearly understand that gender norms (men’s privilege and women’s lower status) perpetuate violence. Most staff felt that GBV could be addressed if women try to not upset their husbands. Interviewees reported that the local context includes widespread but unacknowledged incidence of GBV, coupled with the absence of prevention programs, supportive services, or any referral processes. Given this situation, STEP’s goal to increase participants’ ability to prevent GBV may be difficult to achieve.
The quality of counseling provided by center and PRSS staff is not systematically assessed: STEP plans an annual refresher training and performance assessment, but there still needs to be a formal assessment of the quality of the counseling provided in PRSP and PRSS centers to ascertain whether and to what extent staff provide accurate information on STIs, hepatitis, and other health issues, and whether interactions with residents and returnees meet their gender-related needs and to what extent efforts are being made in each center to achieve equitable provision of services.
Tailor the GBV component to the level of community understanding: GBV in this setting, and in Vietnam in general, is common (UNFPA Viet Nam 2007) but unacknowledged. Lapinski and Rimal (2005) shows that the degree of discussion— interpersonal communication—about a given behavior is correlated to the degree of perception, or misperception, of its prevalence. Hence, as no one discusses GBV, the common perception is that it never happens. It is unlikely that GBV services will be established in the near future in either Can Tho or An Giang. In the two years remaining in the project, STEP might focus its GBV activities on examining or changing community norms that allow GBV while blaming and shaming the women who experience it. For example, the project could develop community dialogues(3) and training on GBV for staff at 05 and 06 centers, Reconciliation Committee members, and community-level organizations, and provide training in skills, strategies, and actions for discussing, responding to, and preventing GBV in the community. Progress could be tracked through a baseline and end-of-project randomized cluster survey sampling approach.
Focus training on strengthening critical thinking about gender norms and their effects: Because gender sensitivity is new in this setting, STEP staff and partners need guidance to help them consider more deeply the effect of gender on vulnerability to HIV and sex work. Future training, mentoring, and supervision activities should introduce STEP staff and partners to exercises that help them think more critically about gender norms for both women and men, and how these norms influence not only stigma but also decision making on a wide range of issues, including reproductive health, STI prevention, treatment seeking, and livelihood opportunities.
Support equitable business and job opportunities: Job training can be useful, but in this setting, jobs are strongly gendered (men in mechanics, electronics, and construction; women in hairdressing and sewing), with men’s work typically higher paid than women’s jobs. Men and women should be encouraged to look at job opportunities based on their attitudes and interests, not their gender roles. The career survey revealed interests of residents and returnees and should be used as evidence to influence the 05/06 centers to incorporate more practical approaches and interestdriven occupations within the job training program.
Consider providing basic education: Several government staff noted that PWID and SWs “weren’t interested” in vocational training. However, given the low education levels of PWID and SWs, basic education may be needed before they are ready for vocational training. A step-wise approach, which offers basic literacy and financial education and then access to vocational training or a microfinance program, might be more appropriate.
Increase the level of loan support for women: Reconsider the rationale for loaning women—who are more likely than men to repay loans—only half the funding that men receive. Giving women smaller loans reinforces the stereotype that women cannot do “big businesses”; providing loans appropriate for larger enterprises, provided the women can repay them, gives women better opportunities in the business they prefer.
Strengthen monitoring and evaluation: The current indicators are predominantly output indicators making it difficult to ascertain the extent to which program activities have an effect on the intended outcomes. Improving the collection of outcome data (and potential impact data if the program is funded for additional years) would greatly improve the program’s capacity to understand how and to what extent their gender strategies are contributing to program outcomes and to what extent the programs are providing equal access to services for male and female residents and returnees.
Scaling up HIV services or programs without analyzing the effect of gender norms, GBV, or gender-specific needs on program outcomes can limit the success of HIV programs. Given the absence of gender integration in other national or bilateral donor-supported programs in Vietnam, STEP is making an important contribution to increasing gender equity within the country’s HIV programs. The personal and programmatic changes required to successfully address—and begin to alter— cultural norms about gender represent a long-term commitment. Donors should commit to refunding STEP to enable CVN and its government partners to incorporate lessons on gender and adapt promising gender strategies. CVN hopes that with continued support STEP could become a national technical resource on integrating gender perspectives within HIV and other programs in Vietnam.
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AIDSTAR-One would like to thank the CARE Vietnam team, especially Huynh Ngoc Minh, STEP Project Director, for their hospitality and willingness to participate in this case study; the Center for Creative Initiatives in Health and Population (CCIHP) for their technical expertise and logistical and technical support; Ms. Nguyen Ngoc Suong, Director of Health of the Department of Labor, Invalids and Social Affairs (DOLISA) and Ms. Pham Ngoc Phuong, Chief of Department for Social Evil Prevention, both of Can Tho City; and the President’s Emergency Plan for AIDS Relief (PEPFAR) team in Hanoi for their support in conducting this case study, as well as the PEPFAR Gender Technical Working Group for their support and careful review.
Spratt, Kai, and Quach Thi Thu Trang. 2011. Breaking New Ground: Integrating Gender into CARE’s STEP Program in Vietnam. Case Study Series. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAROne, Task Order 1.