Public Health  
 
Asking the Right Questions
The SHAWL study attempts to draw parallels among the social factors that affect women's sexual health, including HIV risk.
 By Rebecca Rakoczy

    
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  Through the SHAWL study, Gina Wingood and a team of interviewers are surveying 1,500 women to understand how social issues may have a bearing on their sexual health. Her team includes Christina Camp, Eve Rose, Deja Hunger, Tamu Daniel, and Nikia Braxton. Ralph DiClemente frequently collaborates with Wingood.    
 
   
       

Sometimes, it’s just about asking the right questions. For Gina Wingood, it’s about posing the most appropriate questions to 1,000 African American and 500 white women to assess how they confront specific issues in their lives that affect their sexual health, and ultimately, their vulnerability to HIV/AIDS.
     As principal investigator in a five-year study called SHAWL, an acronym for the Social Health of African American and White Women’s Lives, she has applied Robert Connell’s theory of gender and power to her questionnaire. That theory assesses areas such as gender and racial discrimination, stigma about sexual issues, gender norms, and economic hardship. All may have some bearing on sexual health.
     “This survey focuses on personal or cognitive factors, attitudes and actions, and how different women handle the social health issues in their lives,” says Wingood, director of the doctoral program in behavioral sciences and health education at the RSPH. “It’s likely that HIV transmission depends in important ways on gender, stigma, discrimination, or socioeconomic status. We’re looking at those variables and other factors that might place women at risk for HIV beyond typical personal factors.
     “For example, we’re looking at women’s personal experience of violence, which we know is very strongly associated with HIV risk. But in this survey, we’re also asking women about violence in their communities to get at the impact of the broader environment.”
     Funded by the National Institute of Child Health and Human Development, SHAWL is now in its third year. A small companion questionnaire, funded by Merck & Co. Inc., asks young women as well as older women with daughters about their feelings toward the HPV (human papillomavirus) vaccine to thwart the sexually transmitted virus that can cause cervical cancer.
     Women participating in the study are from urban, suburban, and rural communities across the United States, between 20 to 44 years old, and unmarried. The nationally representative sample was identified through random-digit dialing, and all women are being compensated for their participation. If an interviewer suspects that a woman is being abused based on her answers to the questionnaire, she is referred to local social services.
     Wingood and her team have just begun analyzing the first round of data from the survey. They will administer a follow-up questionnaire to a subset of women in two years to assess how women’s lives change over time and what factors drive those changes. The researchers are particularly interested in how gender and racial discrimination, economic hardship, and community and interpersonal violence may affect over time the decisions that women make about sexual behavior.
     “We’ll ask the same battery of questions and reassess their answers. The changes might affect their HIV risk,” Wingood says.
     The companion study on acceptance of the HPV vaccine fits well into this survey, she adds. “It will be interesting to see if mothers in this group would be willing to have their daughters obtain the HPV vaccine.”

    
         
   
   
    Gina Wingood believes the SHAWL study will lead to an intervention program to empower women to take charge of the social health issues in their lives. Her team is examining how gender and racial discrimination, economic hardship, and community and interpersonal violence may affect the decisions women make about their sexual behavior over time.    
   
   
         
   
   
    "We're looking at women's personal experience of violence, which we know is strongly associated with HIV risk. But in this survey, we're also asking women about violence in their communities to get at the impact of the broader environment."    
   
- Gina Wingood
    
   
   
         
    A national perspective
While Wingood is a well-established voice in developing intervention programs for HIV prevention among African American women and teen girls, SHAWL is her first national survey.
     She often collaborates with Ralph DiClemente, Charles Howard Candler Professor of Public Health and co-director of the RSPH doctoral program in behavioral sciences and health education, in developing face-to-face intervention programs. Their successful interventions include SISTA (Sisters Informing Sisters about Topics on AIDS) and SihLE (Sistas Informing, Healing, Living and Empowering.) These programs aim to reduce sexual risk among African American females from ages 14 to 29.
     SHAWL is the first study Wingood has conducted that was not designed as an intervention. Compared with intervention programs, “Conducting a telephone survey is an easier way to get women to express themselves and what they’ve experienced,” she says.
     According to the theory of gender and power, three major social structures characterize the gender relationships between men and women: the sexual division of labor, the sexual division of power, and the structure of cathexis—the way women form emotional ties with others.
     Wingood has explored the relationship between women’s health and the gender and power theory before. More than seven years ago, she and DiClemente co-wrote an article for the quarterly Society for Public Health Education publication Health Education & Behavior. In that article, the authors used the theory of power and gender to examine the effectiveness of intervention programs aimed at reducing women’s HIV risk. Wingood is eager to see what the final results of SHAWL may show and where they may lead.
     “I’ve done a lot of studies for intervention programs, trying to reduce women’s risk of acquiring HIV. I know that information alone doesn’t really change things, but if we create programs with the support and knowledge of these studies, they are much more likely to do good by empowering women,” she says. “I have no doubt that SHAWL will lead to an intervention program. This project is motivating me to do more, to be more curious, and to do different things.”		    
         
         
     
 

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