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C. Relation. Other. Ex-girlfriends. Wives of. Migrant. Girlfriend. Wives. Migrant ... her visit back to village my ex-lover insisted with me to have sexual relation.
International Journal of Research in Economics and Social Sciences (IJRESS) Available online at: http://euroasiapub.org Vol. 7 Issue 12, December- 2017 ISSN(o): 2249-7382 | Impact Factor: 6.939 | Sexual behavior of left behind wife and potential migrant in India Dr. Anjum Shaheen 1, Senior Program Manager Monitoring, Evaluation & Research Division, MAMTA Health Institute for Mother & Child, New Delhi, India. Dr. Sunil Mehra 1, Monitoring, Evaluation & Research Division, MAMTA Health Institute for Mother & Child, New Delhi, India. Vandana Nair 1, MAMTA Health Institute for Mother & Child, New Delhi, India Rajesh Ranjan Singh1, MAMTA Health Institute for Mother & Child, New Delhi, India Dr. Suchismita Roy1 MAMTA Health Institute for Mother & Child, New Delhi, India

Abstract Background: The paper explores sexual behavior across migrant and left behind populations along with the use of condom in different relationships. Methodology: A mixed method cross-sectional study captured wives of migrants (891), potential migrants (881), and migrant husbands (40). Information on socio-demographic characteristics (age, education, and employment status), knowledge of HIV (transmission and prevention) and sexual behavior (number of partners and condom use) was gathered. Descriptive statistics and bivariate analyses had been used for the quantitative findings, whereas content analysis was done for the qualitative data. Result: It was observed that degree of sexual network was highest in case of migrant husbands and potential migrants. Knowledge about condoms’ downplaying HIV/STI risk was lowest among wives of migrants (6%), followed by migrants (10%) and adolescent boys (37%). Results indicate low condom use with primary partner and increase with the rise in number of relationships. An unmet need to promote the condom as triple protection measure has been felt during the study.

Conclusion: The paper stipulates an urgent necessity for further evidence-based study on promoting safe sexual practices amongst wives, who are left behind along with their partners. Keywords: Migrant, Sexual network, Condom, Wives of migrants, Sexual behavior.

Corresponding author: Dr. Anjum Shaheen, Senior Program Manager

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International Journal of Research in Economics and Social Sciences (IJRESS) Vol. 7 Issue 12, December- 2017, ISSN(o): 2249-7382 | Impact Factor: 6.939

Background Worldwide throughout the history of HIV, women have been considered as a passive and men as an active factor especially when it involves migrant men. However, being a migrant alone is not sufficient to act as a potential vector for HIV rather the structure changes brought along with migration process accentuates the propensity to engage in risky behavior. They act as a bridge, connecting unconnected components of population forming new partnerships [i]; facilitating shift of HIV virus from high to low prevalence areas [ii,iii]. In India migrant men usually travel without their spouses. Staying away from family and community for a long period often frees them from social and sexual control. Probability of multiple relationship increases as formation of new social network takes place [iv]. The route of HIV transmission has been associated to social networks; depending on the degree of network [v] as personal relation has substantial importance in STI/HIV transmission [vi]. Pathways linking migration to risk behavior involves individual, dyadic, and network characteristics. Presence of sexual relationship in a defined group shows the evidence of sexual network [vii]. Number of people in a network and their “links” each has determines spread of HIV/STDs and called as network degree. It often overlaps with social network [viii]. The process of migration links distinct sub-populations of place of destination and origin. The sexual network structure of sending migrants to another community increases their risk behavior. In Tanzania, the separation of couples increased the risk behavior of the stay-at-home spouses [ix]. Out-migration may lead to broadening of network structure by creating a sex ratio imbalance [x]. Empirical studies in India on sexual network have viewed one – side of the story, addressing migrant population and leaving behind non-migrant population. Sexual behavior survey (2006) reported that 10-20 % of the HIV infection was introduced by female partners [xi]. Similarly, National Family Health Survey III showed 39 % HIV infected women who had uninfected husbands. There are number of factors which compels stayed behind spouse to indulge in risky sexual behavior. Henceforth, wives of migrants are not only vulnerable to HIV infection by their spouse’s risky behavior rather their own behavior too is involved in it. Condom use is an important measure of protection against HIV and other sexually transmitted infections (STIs), especially among people with multiple sexual partners [xii-xiii]. It’s constant used assess progress towards preventing exposure to HIV through reducing unprotected sex with non-regular partners, in addition to the extent to which condoms are used by people who are likely to have risky sex and have multiple concurrent partners [xiv]. During the intervention Meri Life Meri Choice, supported by Elton John AIDS Foundation, implemented by MAMTA Health Institute for Mother and Child on reducing vulnerability of rural girls to HIV in four districts of Madhya Pradesh (Rewa & Satna) and Uttar Pradesh (Allahabad & Banda); has a long distance migration history and those tested positive were amongst these families. Henceforth in final phase of implementation focus was realigned to reach out to women with migrant husbands, potential migrant (adolescent boys having at least one family member as

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International Journal of Research in Economics and Social Sciences (IJRESS) Vol. 7 Issue 12, December- 2017, ISSN(o): 2249-7382 | Impact Factor: 6.939

migrant) and migrant husbands themselves. Contemplating literature and project’s experience, a baseline was conducted firstly with an objective of exploring the degree of nodes in sexual network through egocentric approach (individual focal node) and secondly use of condom in different relationships. Material and Methods Survey Design A cross sectional baseline study captured wives of migrants (891), potential migrants (881) through quantitative method and migrant husband (40) through qualitative method. Of the four districts three of them were “A” category (HIV prevalence over 1% in general population and more than 5% amongst the high risk groups). July and August, 2015 was the time when survey for final phase of implementation of Meri Life Meri Choice was conducted. Multi stage stratified sampling was carried out to select the Primary Sampling Unit and the target population as suggested by State AIDS Control Society in the concerned states. Villages in the selected blocks were stratified based on their Scheduled caste and scheduled tribes (SC/ST) status (assuming that women in this ethnic group belong to underprivileged community). Altogether, 56 villages were selected across two states UP and MP. Complete house listing was done in the selected villages to identify migrant households. Further households with wives of migrants (15 - 35 year), potential migrants (15 – 19 years) and migrant husbands (19 – 35 years) were selected using systematic random sampling procedure. The questionnaire was validated and translated into Hindi (local language) and revised after insight obtained during pre-testing. Ten field investigators and three supervisors in each district were trained for baseline quantitative data collection. The qualitative data was collected through a trained team of four members. Ethical compliance for the study was obtained from MAMTA’s Ethics and Review Board. Consent of the respondents was taken before the interviews were conducted, after which they were explaining the purpose of the study in detail. Investigators were trained on the ethical protocol beforehand. A unique identity code was provided to each respondent in-order to maintain the confidentiality and anonymity Data Analysis The survey tool collected information on socio-demographic characteristics (age, education, employment status), HIV/AIDS knowledge (transmission and prevention) and sexual behavior (number of partner and condom use). The subjects were asked to recall their life time and recent sexual partners. Information on condom association with HIV infection was also collected. Descriptive statistics (i.e. mean and standard deviation) and bivariate analysis has been carried out to describe the type of sexual network and its association with the use of condom. Data entry and analysis was carried out by using SPSS.

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On the other hand qualitative data was manually coded reviewed before analyzing it under different themes that we had formulated through a structured process. Results Socio-Demographic Profile Nearly half of the women respondents were educated up to secondary level. Two fifth of them never received any form of education. More than 80% of the wives stay with in-laws, 12.5% alone and rest with their parents. A large number of them had freedom to go out of home on their own wish (53%) rather than spending money according to their wish (32%). Out of the total, 80.58 % had some source of income. In majority of the cases money was sent to in-laws by their husbands and it was in-laws who catered to their economic needs. Potential migrant boys were between 15-19 years. Majority of them were either in high school or college students. Out of total, 2.2 % never attended school. Nearly half of them had experience of paid occupation i.e. agricultural laborer, farmer, mechanic, construction worker, shopkeeper, sewing/ embroidery worker. The mean age of migrant husbands was 24.6 (+ 4.8) years whereas for wives of migrant it was 25.4 (+4.1) years. Migrant husbands were mostly high school drop-outs and usually migrated to Maharashtra, Gujarat and Delhi in search of livelihood. People from UP migrated to places at a greater distance from home than those in MP. At place of destination these migrants mostly worked as laborers in the factories, brick-kilns, railway tracks, and construction sites. The skilled occupations they pursued were mostly of a driver, guard, electrician, Zari/embroidery and painter.

Sexual Behavior Around 8% wives of migrants reported physical relationships with men other than their husbands. Compared to men, women had lesser number of partners. The highest node reported was that of three alters. Network degree for 93% wives of migrants was 66.7% having three nodes of connection. Figure 1 (A) shows that in most of the cases it was a family member (77%) like brother of husband, close relative or neighborhood guy. Pre-marital relationships (11%) were reported with class-mates, brother-in-law and friends. A migrant husband, 36 years of Kamasin block revealed that: “My friend used to help her (my wife) whenever I went back to Haryana for work. Then slowlyslowly he became attached with my wife and one day, asked her to have physical relation with her.” Women having economic problem had higher percentage of having non-spousal sexual relationship than those who had emotional or loneliness problem. None of these problems were significantly associated with non-spousal sexual relations. Potential Migrants too showed a lot of variations in sexual network design. Nearly half of them had multiple sexual partners; of which 72% of them had 66.7 % of network degree with three nodes, 8% of them had 40% network degree with five nodes. In all more than two third had physical

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relationship with girl friends and one tenth with the other women (figure 1 (C)). Paid sex was common among the adolescent boys (47%). B A

C

Relation

Other Ex-girlfriends

Wives of Migrant Girlfriend

Wives

Migrant

of

Migran

Sex

t

Workers

Potenti

Sex Workers

Wives of Other Potenti

Wives

of

coworker

Migrant

Figure 1. Egocentric design reported by different egos. A: representing nodes for wives of migrants (ego); B: representing nodes for migrant husbands (ego); C: representing nodes for potential migrants (ego). Among migrant husbands, in total, twelve egocentric networks having fifty alters were reported; of which the largest had eight alters and smallest had two alters. As represented in network design (figure 1 (B)) non-spousal relations i.e. multiple sexual relationships were observed. Exposure to sex workers and having paid relation was found commonly among those who had pre-migration exposure to sexual relationship. Relationship with co-migrant wives was also reported at the place of destination. Condom Use Concurrent relationship was observed among migrant husbands; associated with low use of condom and often considered as scariest part of a relationship. In total, only five of them used condom with their wives. “I had physical relationship with three partners before marriage. One relation among these lasted over eight years. We could not get married due to caste problem. After marriage during her visit back to village my ex-lover insisted with me to have sexual relation. After that, whenever we both visited village and met, every time we had physical relation. Including my wife and sex workers, I had physical relationship with almost 5/6 women. I never used condom. I gave her pills (26 year migrant husband, Banda).” Results showed low usage of condom among couples and steady sexual partners outside marriage. Use of condom in a marital relationship in India leaves a person under a doubt of being engaged in multiple relationships. "I had physical relationship with two girls in my village; didn’t use condom with anyone of them. Neither had they asked me about my other relationship nor I asked them. If you love someone, and think them as your own then why would you get scared? Why use a condom?” (28 years migrant

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husband, Rewa) Had relation with three women and used to do it with condom but with wife I never used a condom.

You do not need it in this relationship (34 years migrant husband, Allahabad). I trust my wife then why use a condom. (26year, migrant husband, Rewa) Out of 896 women, only 18 % used condoms during sexual intercourse; of which 67% used it with their husbands and remaining 33 % with partners other than their husbands. Use of condom in monogamous relationship was not common. Due to inaccessibility of condom including barriers posed by husbands and in-laws, unavailability at village health centers, its use was less.

Condom use and number of relationships has presented a direct relationship in this study. Physical relations other than husbands were significant with use of condom (Chi-sq 0.002). Marital status of women decided the condom use. While having relationship with married women as compared to unmarried girls, with whom its use was low. Some participants reported that they wanted to use condom but their partners refused. A migrant husband said: “She does not like using it. When I asked her why, she said it reduces the pleasure.” (21 years migrant husband, Banda) Buying of condom is perceived as a matter of embarrassment in India. One of the migrant husbands explained his hesitation as: “I had relationship with a girl before marriage and continued after marriage. I asked her about her other relations and she said all truth about it. I didn’t use condom with her. I trusted her and it’s embarrassing to buy a condom.” (25 years migrant husband, Rewa) Condom in India has only been considered as a birth control measure and less as a safety measure to prevent from HIV and STIs. The respondents stated that: “Never felt the need. Condom is used to do birth control.” (23 years migrant husband, Satna) “I give her pills then why to use condom.” (30 years migrant husband, Allahabad) Condom downplays the risk of HIV/STI infection which was known by only 37.7% of adolescent boys, 6% of wives of migrants and 10% of migrant husbands. Risk is optimized due to inadequate knowledge about HIV among all the three groups. INSERT TABLE 1.

Discussion This mixed method study highlights prevalence of concurrent partnerships in four rural Indian settings through sexual network. As the data was collected from the same geographical settings and villages, it has possibilities of overlapping to form a broader sexual network within and beyond the village due to involvement of migrants even in an egocentric network. Migration status of the husbands not only often puts them at risk for HIV infection, but also increases risk of infection to their partners. Concurrency alone can fuel an epidemic even if the average number of partners is relatively low [ xv and migration acts as a catalyst [ xvi , xvii . Serial monogamous relationships (series of relation one after another) were found in most of the cases among

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potential migrants along with a seprational relationship among migrants’ wives and migrant husbands. Recent studies suggest that migrants have risky non spousal sexual relation at place of origin. It was reported that migrants had their sexual debut before migrating as most of them got married during their late teens or had girlfriends prior to migration. Half of the migrants in the study who had nonspousal relation at the place of destination had similar history. Placing their partners and themselves at risk to STI and HIV both knowingly and unknowing was high. Low use of condom both in nonspousal and spousal relations was due to its association as a barrier to sexual pleasure and trust. Analysis reveals that the use of condom with regular partners was fairly low in all the three cases allowing body fluid exchange and increasing the chances of vulnerability to HIV and STI of nodes (individuals) connected through the network [xviii . Migrants exposed to brothel based sex work revealed higher use of condom and had better knowledge about HIV than others [xix .

Short-term migration and frequent visits resulted in less involvement of both migrant and their wives in extramarital relationships. Geographical distance from home may alter risk [ xx and increases women’s dependency over her in-laws and other relatives on most occasions make her vulnerable to have intimate relationship. In this study women’s extramarital affair was significantly associated with duration of husband’s stay at destination. Among migrant husbands, frequency of visit to native place lessens due to geographical distance. Separational relationship was evidently marked during the absence of individual’s partner with low use of condom both with the former and new partner [18 . Migrant Married Girl Friends

Wives of Migrant Sex Workers

Non-migrant male

Potential Migrant

Unmarried Girl Friends

Figure 2. Web of relationship and use of condom The study demonstrates prior social connection between the women and her sexual partner. Physical initiation by devar (husband’s younger brother or husband’s friend) was most common among wives of migrants’ divulged relationship. When asked about condom use with husbands, most of them narrated its low use as they meet each other after a long time. Limitation of the study: The study left out an important group of unmarried girls and men having sex with men, as its main focus was on wives of migrants, along with adolescent boys and their knowledge about HIV. Data from them could have helped understanding the dynamics of sexual

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network more clearly. To get names or specify her/his sexual partners was difficult, but as we collected three sets of data (migrant husband, wives of migrants and adolescent boys) from same villages, it was a strong possibility to have overlapping groups and relationships. Due to sensitive nature of the research questions the responses might have been given socially desirable answers and the responses might have been underreported and methodological problem of identifying boundary along with its nodes of network. Lastly, there are changes of recall bias when asked about their life time sexual partners. Conclusion Application of network analysis has been made to explain the structure and nature of egocentric sexual relation within the population surveyed. We can conclude that both the partners, the one migrating as well the one staying back showed sexual risk behaviour and high risk of being exposed to infectious diseases (STI/HIV). The study clearly represents the lack of condom use especially with the primary partner and their lack of awareness about its consequences. It has become the need of the hour to highlight the triple protection of condom amongst the population and not just as a preventive measure against unwanted pregnancy. The paper stipulates an urgent need to gather more evidence in this regard and to intervene, and promote safe sexual practices amongst wives who are left behind along with their partners. Further research on wives of migrants their sexual network in connection to mobile population can also provide information about how network can bring change in relevance to health at the national level. Since, this study has further reiterated the risk groups this study will be useful for programmers in designing more targeted interventions to reduce the risk behaviour, to avoid severe health consequences such as STI/HIV and unwanted pregnancies. Acknowledgement The research was funded by the Elton John AIDS Foundation. The authors extend thank all the team members involved in Meri Life Meri Choice project for their important contribution. Competing Interests: No authors have any competing interests. Source of funding: There is no funding support for this publication. Statement of Informed consent: The paper did not require as such any required consent.

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International Journal of Research in Economics and Social Sciences (IJRESS) Vol. 7 Issue 12, December- 2017, ISSN(o): 2249-7382

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Impact Factor: 6.939

Table 1 : Sexual Behavior and use of condom among the Target Groups Variables

Wives of Migrants

Potential

Total (n=896)

Migrant Total

Migrant Husband Total (n=40)

(n=881) Use of Condom Yes

18.1 (162)

7.7 (68)

25 (10)

No

80.9 (734)

92.3 (813)

75.5 (30)

92 (824)

17.9 (150)

75 (30)

7.4 (66)

14.6 (123)

18 (7)

0.6 (5)

4.3 (38)

7 (3)

Life time Sexual Relationship Single Relation Two - Three Relations More than three Relations Never had Relation

-

63.1 (556)

-

Use of Condom when in Sexual relation Single Relation Two - Three Relations More than three Relations

19 (137)

12.7 (20)

16 (5)

41 (20)

13.2 (17)

20 (3)

90 (5)

40.9 (16)

50 (2)

6 (54)

37.7 (332)

10 (4)

94 (842)

62.3 (549)

90 (36)

Condom prevents risk to STI/HIV Yes No

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