The promises and limitations of gender-transformative health programming with men: critical reflections from the field

Relative power: Explaining the effects of food and cash transfers on allocative behaviour in rural Nepalese households

We estimate the effects of antenatal food and cash transfers with women's groups on household allocative behaviour and explore whether these effects are explained by intergenerational bargaining among women. Interventions were tested in randomised-controlled trial in rural Nepal, in a food-insecure context where pregnant women are allocated the least adequate diets. We show households enrolled in a cash transfer intervention allocated pregnant women with 2-3 pp larger shares of multiple foods (versus their mothers-in-law and male household heads) than households in a control group. Households in a food transfer intervention only increased pregnant women's allocation of staple foods (by 2 pp). Intergenerational bargaining power may partly mediate the effects of the cash transfers but not food transfers, whereas household food budget and nutrition knowledge do not mediate any effects. Our findings highlight the role of intergenerational bargaining in determining the effectiveness of interventions aiming to reach and/or empower junior women.

Trauma Exposure and Intimate Partner Violence Among Young Pregnant Women in Liberia

Intimate partner violence (IPV) is a global threat to women's health and may be elevated among those exposed to traumatic events in post-conflict settings, such as Liberia. The purpose of this study was to examine potential mediators between lifetime exposure to traumatic events (i.e., war-related trauma, community violence) with recent experiences of IPV among 183 young, pregnant women in Monrovia, Liberia. Hypothesized mediators included mental health (depression, posttraumatic stress symptoms), insecure attachment style (anxious and avoidant attachment), and attitudes indicative of norms of violence (attitudes justifying wife beating). We tested a parallel multiple mediation model using the PROCESS method with bias-corrected and accelerated bootstrapping to test confidence intervals (CI). Results show that 45% of the sample had experienced any physical, sexual, or emotional IPV in their lifetime, and 32% in the 2 months prior to the interview. Exposure to traumatic events was positively associated with recent IPV severity (β = .40, p < .01). Taken together, depression, anxious attachment style, and justification of wife beating significantly mediated the relationship between exposure to traumatic events and experience of IPV (β = .15, 95% CI = [0.03, 0.31]). Only anxious attachment style (β = .07, 95% CI = [0.03, 0.16]) and justification of wife beating (β = .05, 95% CI = [0.01, 0.16]) were identified as individual mediators. This study reinforces pregnancy as an important window for both violence and mental health screening and intervention for young Liberian women. Furthermore, it adds to our theoretical understanding of mechanisms in which long-term exposure to traumatic events may lead to elevated rates of IPV in Liberia, and points to the need for trauma-informed counseling and multilevel gender transformative public health approaches to address violence against women.

Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya

While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.

Young People's Experiences With an Empowerment-Based Behavior Change Intervention to Prevent Sexual Violence in Nairobi Informal Settlements: A Qualitative Study

PURPOSE

Young people in sub-Saharan Africa face one of the world's highest burdens of sexual violence. Previous impact evaluations indicated that a 6-week empowerment-based behavioral intervention in Nairobi informal (slum) settlements can reduce sexual assault. This qualitative study investigated girls' and boys' experiences of the intervention to identify potential mechanisms of change.

METHODS

We conducted a qualitative study in Nairobi slums with students (aged 15-21 years) who had participated in 2 parallel school-based curriculums called IMPower (girls) and Your Moment of Truth (boys) at least 1 year ago. Data were collected via 10 focus group discussions (5 for boys, 5 for girls) with 6-11 participants in each and 21 individual in-depth interviews (11 boys, 10 girls) that explored participants' experiences of the intervention and their suggestions for improvement. Findings were analyzed using thematic network analysis guided by empowerment theory.

RESULTS

Girls described how the intervention enabled them to recognize and resist sexual assault via verbal and physical strategies for self-protection, negotiate sexual consent, and exercise agency. Boys described increased ability to avoid risky behaviors and "bad" peer groups and to understand and respect consent. Girls also described how the intervention strengthened their self-confidence, and boys said that it boosted positive life values and gender-equal attitudes. Skilled facilitators and interactive and relevant content were highlighted as key to intervention success. Areas of improvement included expanding the curriculum to contain more content on sexual and reproductive health and rights and involving out-of-school youth, parents, teachers, and communities.

CONCLUSION

Findings indicate that a relatively short, behavioral school-based intervention can empower both girls and boys to prevent various forms of sexual violence in a low-income setting where it is endemic. Incorporating multilevel support structures, such as involving communities and families, could further enhance young people's long-term safety, health, and well-being.

Building community-based helping practices by training peer-father counselors: A novel intervention to reduce drinking and depressive symptoms among fathers through an expanded masculinity lens

BACKGROUND

Problem drinking and co-occurring depression symptoms affect men at high rates and are associated with increased risk of family violence. In low- and middle-income countries, there is a large treatment gap for services due to a lack of human resources. Moreover, masculine norms are a barrier to men seeking treatment for drinking and depression in healthcare settings. We examined an approach for engaging peer-fathers to deliver an intervention to reduce alcohol use, improve depressive symptoms, and increase family involvement among fathers in Kenya with problem drinking. The intervention-LEAD (Learn, Engage, Act, Dedicate)-combines motivational interviewing, behavioral activation, and masculinity discussion strategies.

METHODS

Community and religious leaders nominated fathers with no mental health training to serve as counselors (N=12); clients were recruited through community referrals. Nominated fathers completed a 10-day training beginning with treatment principles followed by manualized content. Three counselors were selected after training based on quantitative and qualitative assessments of communication skills, intervention knowledge, willingness to learn, ability to use feedback, and empathy. Supervision was tiered with local supervisors and clinical psychologist consultation. During LEAD delivery, counselor fidelity, delivery quality, and general and intervention-specific competencies were assessed. To evaluate acceptability, qualitative interviews were conducted with lay-counselors and clients (N=11). Descriptive statistics were calculated for quantitative outcomes; interviews were analyzed using thematic analysis.

RESULTS

Peer-father lay counselors treated nine clients, with eight completing treatment. Counselors reached high rates of fidelity (93.8%) and high to optimal ratings on quality of delivery, clinical competency, and intervention-specific competencies. Qualitative results suggested high acceptability, with counselors expressing satisfaction and empowerment in their roles. Clients likewise described positive experiences with counselors.

CONCLUSIONS

Findings provide initial support for the acceptability and feasibility of recruitment, selection, and training processes for peer-father lay counselors to deliver LEAD through a lens of masculinity that aligned with clients help-acceptance practices.

The Intersection of Inequitable Gender Norm Endorsement and HIV Stigma: Implications for HIV Care Engagement for Men in Ugandan Fishing Communities

Men's engagement in the HIV care continuum may be negatively affected by adherence to inequitable gender norms, which may be exacerbated by HIV stigma. This cross-sectional study with 300 male fisherfolk in Uganda examined the independent and interacting effects of inequitable gender norm endorsement and HIV stigma on men's missed HIV care appointments and missed antiretroviral (ARV) doses. Greater gender inequitable norm endorsement was associated with increased odds of missed HIV clinic visits (adjusted odds ratio [AOR)] 1.44, 95% CI 1.16-1.78) and a statistically significant interaction between internalized HIV stigma and inequitable gender norms on missed ARV doses was identified (AOR 5.32, 95% CI 2.60-10.86). Adherence to traditional gender norms reduces men's HIV appointment attendance, and among men with high internalized stigma, increases the likelihood of poor treatment adherence. These findings point to the need for HIV interventions that reconfigure harmful gender norms with a focus on stigma reduction.

Who’s got the power? Expressions of empowerment among in-school adolescents enrolled in the Girls Achieve Power (GAP Year) trial in three peri-urban settings of South Africa

Background: Empowerment is when a person gains mastery of their life and environment. This paper describes three central elements of empowerment (agency, resources, and institutional structures) expressed by adolescents, discussing implications for strengthening adolescent sexual reproductive health, HIV, and violence prevention programming. Methods: A cross-sectional survey was conducted (April 2017 – May 2018) as part of the GAP Year trial among grade eight learners (12 – 18 years) from 26 lowest quintile public high schools in Khayelitsha, Soweto and Thembisa townships, South Africa. Data were on empowerment experiences using a knowledge, attitudes, and practices survey. Descriptive and chi-square test statistics were employed, assessing the association between sociodemographic and domains of empowerment. Results: A total of 2383 adolescents in 26 schools completed the baseline survey: 63.1% female, mean age 13.7 years, 96.9% Black African. Agency: Males (4.04 vs 3.94, p=0.008) and those 15 – 18 years (4.10 vs 3.95, p=0.027) expressed stronger decision-making capacity. Females (3.18 vs 2.92, p<0.001) indicated a greater sense of collective action. Females (0.77 vs 0.72, p=0.008), those aged 12 -14 years (0.76 vs 0.71, p=0.027) and those with at least one parent/guardian employed (p=0.014) had stronger leadership confidence. Resources: Those 12-14 years expressed higher self-esteem (2.18 vs 2.08, p=0.017). Males (2.24 vs 1.87, p<0.001) and those who had at least one parent/guardian employed (p=0.047) had a higher perception of freedom from gender-based violence. Males showed greater mobility (2.89 vs 2.66, p=<0.001). Institutional structures: Coloured participants showed more positive norms than their Black counterparts (5.38 vs 2.12, p=0.005). Conclusions: Males expressed greater empowerment around decision-making, gender-based violence and mobility; females expressed greater collective action and leadership. Working across the ecological model, interventions addressing sex differences, targeting adolescents of all ages, and parental unemployment may strengthen expressions of empowerment, especially adolescents’ safety, mobility, aspirations, and future hopes.

Engaging fathers to improve complementary feeding is acceptable and feasible in the Lake Zone, Tanzania

In Tanzania, suboptimal complementary feeding practices contribute to high stunting rates. Fathers influence complementary feeding practices, and effective strategies are needed to engage them. The objectives of this research were to examine the acceptability and feasibility of (1) tailored complementary feeding recommendations and (2) engaging fathers in complementary feeding. We conducted trials of improved practices with 50 mothers and 40 fathers with children 6-18 months. At visit 1, mothers reported current feeding practices and fathers participated in focus group discussions. At visit 2, mothers and fathers received individual, tailored counselling and chose new practices to try. After 2 weeks, at visit 3, parents were interviewed individually about their experiences. Interview transcripts were analysed thematically. The most frequent feeding issues at visit 1 were the need to thicken porridge, increase dietary diversity, replace sugary snacks and drinks and feed responsively. After counselling, most mothers agreed to try practices to improve diets and fathers agreed to provide informational and instrumental support for complementary feeding, but few agreed to try feeding the child. At follow-up, mothers reported improved child feeding and confirmed fathers' reports of increased involvement. Most fathers purchased or provided funds for recommended foods; some helped with domestic tasks or fed children. Many participants reported improved spousal communication and cooperation. Families were able to practice recommendations to feed family foods, but high food costs and seasonal unavailability were challenges. It was feasible and acceptable to engage fathers in complementary feeding, but additional strategies are needed to address economic and environmental barriers.

Evaluating Complex Interventions Using Qualitative Longitudinal Research: A Case Study of Understanding Pathways to Violence Prevention

Evaluating social change programs requires methods that account for changes in context, implementation, and participant experience. We present a case study of a school-based partner violence prevention program with young people, where we conducted 33 repeat interviews with nine participants during and after an intervention and analyzed participant trajectories. We show how repeat interviews conducted during and after a social change program were useful in helping us understand how the intervention worked by providing rich contextual information, elucidating gradual shifts among participants, and identifying aspects of the intervention that appear to influence change. Long-term effects of social change interventions are very hard to quantify or measure directly. We argue that a qualitative longitudinal approach provides a way to measure subtle changes that can serve as proxies for longer term impacts.

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups (n = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.

Assessing the Spectrum of Gender Norms Perceptions in Early Adolescence: A Cross-Cultural Analysis of the Global Early Adolescent Study

PURPOSE

There is increasing recognition that gender norms affect adolescent health and well-being. This study explores the consistency of adolescents' gender norm perceptions across different dimensions (roles, traits, relations) and describes how the patterns of these perceptions vary across four culturally different settings.

METHODS

The study includes 8,977 adolescents aged 10-14 years from Kinshasa, Shanghai, Cuenca, and Indonesia. Three gender norm scales were examined: sexual double standard, gender stereotypical traits, and stereotypical roles. We investigated patterns of gender norms across dimensions (roles, traits, and relations) and compared results between sites. We also examined how adolescents' individual responses across the scales compared with average responses in their site, to assess the consistency of their gender views.

RESULTS

Patterns of gender norms varied across sites, reflected in different levels of endorsement of each gender norms scale, from least equal in Kinshasa to most equal in Shanghai, while greater variation of perspectives across gender dimensions was noted in Cuenca and Indonesia. Moving from a societal to an individual perspective, most adolescents in each site (62%-67%) held both more progressive and less progressive views compared with their average peer depending on the gender dimension.

CONCLUSIONS

Our study demonstrates the coexistence of multiple gender worldviews that are assessed and enacted as per adolescents' experiences and social context. Accounting for such complexities is essential for gender-transformative programs, as shifting gender attitudes in one area does not necessarily translate in more gender equitable views across other spheres of life.

Adolescent condom use in Southern Africa: narrative systematic review and conceptual model of multilevel barriers and facilitators

BACKGROUND

Adolescent HIV and pregnancy rates in Southern Africa are amongst the highest in the world. Despite decades of sexual and reproductive health (SRH) programming targeting adolescents, recent trends suggest there is a continued need for interventions targeting condom use for this age group.

METHODS

This review synthesises evidence from qualitative studies that describe the determinants of condom use among adolescents in Southern Africa. We conducted systematic searches in four databases. Data were extracted, appraised for quality and analysed using a 'best-fit' framework synthesis approach.

RESULTS

We coded deductively findings from 23 original studies using an a priori framework and subsequently conducted thematic analysis. Synthesised findings produced six key themes relating to: 1) pervasive unequal gender norms and restrictive masculinities favouring male sexual decision-making and stigmatising condom use in committed relationships; 2) other social norms reflecting negative constructions of adolescent sexuality and non-traditional family planning; 3) economic and political barriers including poverty and a lack of policy support for condom use; 4) service-level barriers including a lack of youth-friendly SRH services and comprehensive sex education in schools; 5) interpersonal barriers and facilitators including unequal power dynamics in sexual partnerships, peer influences and encouraging condoning condom use, and inadequate communication about SRH from parents/caregivers; and 6) negative attitudes and beliefs about condoms and condom use among adolescents. A conceptual model was generated to describe determinants of condom use, illustrating individual-, interpersonal- and structural-level barriers and facilitating factors.

CONCLUSION

SRH programming targeting barriers and facilitators of condom use at multiple levels is recommended in Southern Africa. We present a multilevel integrated model of barriers and facilitators to guide adolescent SRH decision-making, programme planning and evaluation. Given the existence of multilevel barriers and facilitators, interventions should, likewise, take a multilevel approach that incorporates locally relevant understanding of the individual-, interpersonal- and structural-level barriers and facilitators to condom use among adolescents in the region.

Male partner participation in maternity care and social support for childbearing women: a discussion paper

Male partners/fathers are key support persons for many childbearing women and their involvement in pregnancy, childbirth and the postpartum/postnatal period has beneficial effects on a wide range of outcomes related to maternal and child health and family wellbeing. Social support is implicated in the relevant causal pathway, but has received largely tangential attention in the public health literature. This discussion paper aims to reframe men's participation in maternity care as an opportunity to enhance their readiness and ability to provide social support to women, contributing to the debate on the definition and rationale for male partner involvement, and paving the way for further empirical work. I begin by presenting a theory of change illustrating the causal pathway leading from male partner participation, through the key intermediate step of social support, to improved health and wellbeing for women and children. I proceed by arguing that many people desire male partner participation in maternity care; however, in practice, this is often limited owing to cultural, social and institutional barriers. I use examples from the intervention literature to demonstrate how participation in care can boost men's motivation to support women and enhance their ability to do so by increasing their knowledge and skills. Finally, I draw up general implications for further male partner involvement programmes, suggesting that in order to achieve meaningful and sustainable gains, attention to design is crucial in order to avoid reinforcing patriarchal gender norms. Programmes should be implemented alongside other efforts to improve quality and promote woman-centred care. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Study protocol: evaluation of sheds for life (SFL): a community-based men's health initiative designed "for shedders by shedders" in Irish Men's sheds using a hybrid effectiveness-implementation design

Background

Men’s Sheds (“Sheds”) offer a unique opportunity to reach a captive audience of “hard-to-reach” men. However, attempts to engage Sheds in structured health promotion programmes must respect the ethos of Sheds as highly variable, autonomous, non-structured spaces. This paper captures the key methodologies used in “Sheds for Life’ (SFL), a men’s health initiative tailored to the Shed setting.

Methods

A hybrid effectiveness-implementation study design is used to test effectiveness and implementation outcomes across multiple levels (participant, provider, organisational and systems levels). A dynamic, iterative and collaborative process seeks to address barriers and translation into the real world context. Using a community-based participatory research approach and guided by established implementation frameworks, Shed members (‘Shedders’) assume the role of key decision makers throughout the evaluation process to promote the systematic uptake of SFL across Shed settings. The protocols pertaining to the development, design and implementation of SFL and the evaluation of impact on participants’ health and wellbeing outcomes up to 12 months are outlined.

Conclusions

There is a dynamic interplay between the intervention characteristics of SFL and the need to assess and understand the diverse contexts of Sheds and the wider implementation environment. A pragmatic and context-specific design is therefore favoured over a tightly controlled efficacy trial. Documenting the protocols used to evaluate and implement a complex multi-level co-developed intervention such as SFL helps to inform gender-specific, community-based men’s health promotion and translational research more broadly.

Trial registration

This study has been retrospectively registered with the ‘International Standard Randomised Controlled Trial Number’ registry (ISRCTN79921361) as of the 5th of March 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10823-8.

Bystander Program Effectiveness to Reduce Violence and Violence Acceptance Within Sexual Minority Male and Female High School Students Using a Cluster RCT

Bystander interventions have been highlighted as promising strategies to reduce sexual violence and sexual harassment, yet their effectiveness for sexual minority youth remains largely unexamined in high schools' populations. This rigorous cluster randomized control trial addresses this gap by evaluating intervention effectiveness among sexual majority and minority students known be to at increased risk of sexual violence. Kentucky high schools were randomized to intervention or control conditions. In intervention schools, educators provided school-wide Green Dot presentations (phase 1) and intensive bystander training to student popular opinion leaders (phase 2). Each spring from 2010 to 2014, students attending 26 high schools completed anonymous surveys about violence acceptance and violent events. An analytic sample of 74,836 surveys with no missing data over the 5 years was available. Sexual violence acceptance scores declined significantly over time in intervention versus control schools among all but sexual minority males. This intervention was also associated with reductions in both perpetration and victimization of sexual violence, sexual harassment, and physical dating violence among sexual majority yet not sexual minority youth. Both sexual minority and majority youth experienced reductions in stalking victimization and perpetration associated with the intervention. In this large cluster randomized controlled trial, the bystander intervention appears to work best to reduce violence for sexual majority youth. Bystander programs may benefit from explicitly engaging sexual minority youth in intervention efforts or adapting intervention programs to include attitudes that shape the experience of sexual minority high school youth (e.g., homophobic teasing, homonegativity).

Gendered stereotypes and norms: A systematic review of interventions designed to shift attitudes and behaviour

In the face of ongoing attempts to achieve gender equality, there is increasing focus on the need to address outdated and detrimental gendered stereotypes and norms, to support societal and cultural change through individual attitudinal and behaviour change. This article systematically reviews interventions aiming to address gendered stereotypes and norms across several outcomes of gender inequality such as violence against women and sexual and reproductive health, to draw out common theory and practice and identify success factors. Three databases were searched; ProQuest Central, PsycINFO and Web of Science. Articles were included if they used established public health interventions types (direct participation programs, community mobilisation or strengthening, organisational or workforce development, communications, social marketing and social media, advocacy, legislative or policy reform) to shift attitudes and/or behaviour in relation to rigid gender stereotypes and norms. A total of 71 studies were included addressing norms and/or stereotypes across a range of intervention types and gender inequality outcomes, 55 of which reported statistically significant or mixed outcomes. The implicit theory of change in most studies was to change participants' attitudes by increasing their knowledge/awareness of gendered stereotypes or norms. Five additional strategies were identified that appear to strengthen intervention impact; peer engagement, addressing multiple levels of the ecological framework, developing agents of change, modelling/role models and co-design of interventions with participants or target populations. Consideration of cohort sex, length of intervention (multi-session vs single-session) and need for follow up data collection were all identified as factors influencing success. When it comes to engaging men and boys in particular, interventions with greater success include interactive learning, co-design and peer leadership. Several recommendations are made for program design, including that practitioners need to be cognisant of breaking down stereotypes amongst men (not just between genders) and the avoidance of reinforcing outdated stereotypes and norms inadvertently.

A Latent Class Analysis of Gender Attitudes and Their Associations with Intimate Partner Violence and Mental Health in the Democratic Republic of Congo

Gender role attitudes, views held by individuals regarding the roles men and women should play in society, are a powerful social determinant of health. However, work remains in elucidating the associations between gender attitudes and intimate partner violence (IPV) perpetration or victimization and mental health problems. We used latent class analysis to classify patterns of responses on survey items on gender attitudes by male and female adults in households that participated in an economic empowerment intervention and evaluation in rural villages in the Democratic Republic of Congo. Attitudes about IPV and gender equality were two subdomains to emerge from analysis and a 3-class model solution was found to best fit response patterns. Results indicated that, as compared to the least gender equitable class, individuals in the moderately gender equitable and fully gender equitable classes had lower odds of having experienced or perpetrated psychological abuse. Individuals within the moderately gender equitable class were at lower odds of having experienced or perpetrated physical or sexual violence. Further, individuals in the moderately gender equitable and fully gender equitable classes had significantly lower mean scores on symptoms associated with PTSD than individuals in the least gender equitable class. Future research should explore the relationships between gender attitudes, partner violence and mental health to build resilient families.

Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies

BACKGROUND

Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge.

METHODS

We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention.

RESULTS

We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes.

CONCLUSIONS

This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.

Changing men or changing health systems? A scoping review of interventions, services and programmes targeting men's health in sub-Saharan Africa

BACKGROUND

Sex and gender have been shown to influence health literacy, health seeking behaviour, and health outcomes. However, research examining the links between gender and health has mainly focused on women's health, which is a long-standing global health priority. We examine literature focused on the 'missing men' in global health research, in particular empirical studies that document interventions, programmes, and services targeting men's health issues in Sub-Saharan Africa. Within these studies, we identify dominant conceptualisations of men and men's health and how these have influenced the design of men's health interventions and services.

METHODS

This is a scoping review of published and grey literature. Following comprehensive searches, we included 56 studies in the review. We conducted a bibliographic analysis of all studies and used inductive methods to analyse textual excerpts referring to conceptualizations of men and service design. An existing framework to categorise services, interventions, or programs according to their gender-responsiveness was adapted and used for the latter analysis.

RESULTS

From the included studies, we distinguished four principal ways in which men were conceptualized in programs and interventions: men are variously depicted as 'gatekeepers'; 'masculine' men, 'marginal' men and as 'clients. Additionally, we classified the gender-responsiveness of interventions, services or programmes described in the studies within the following categories: gender-neutral, -partnering, -sensitive and -transformative. Interventions described are predominantly gender-neutral or gender-partnering, with limited data available on transformative interventions. Health systems design features - focused mainly on achieving women's access to, and uptake of services - may contribute to the latter gap leading to poor access and engagement of men with health services.

CONCLUSION

This review highlights the need for transformation in sub-Saharan African health systems towards greater consideration of men's health issues and health-seeking patterns.

Democratic South Africa at 25 - a conceptual framework and narrative review of the social and structural determinants of adolescent health

Twenty-five years into South Africa's constitutional democracy provides an opportunity to take stock of the social and structural determinants of adolescent health. Those born in democratic South Africa, commonly known as the 'Born Frees', are perceived to be able to realise equal rights and opportunities, yet many factors constrain their lives. In bringing together approaches to understanding context in health policy and systems research and the social determinants of health, the paper develops a conceptual framework to guide the narrative review examining the key contextual social and structural determinants of adolescent health in South Africa. Illustrative examples drawing from 65 papers from public health and the social sciences describe and link these determinants across micro, meso and macro levels of society, their global determinants, and their intersections with compounding axes of power and inequality.At a micro level individual adolescent sexual and gender identities are expressed through multiple and evolving forms, while they experience growing autonomy and agency, they do so within a broader context characterised by regressive social norms, gender inequality and other intersecting power relationships. At the meso level, organisational and sectoral determinants shape adolescents health and rights, both in being supportive, but they also replicate the biases and inequalities that characterise South African society. In addition, the macro level national and global determinants, such as the structural colonial and apartheid legacies, shape adolescents' health. Despite constitutional and other legislative rights, these determinants and compound economic, geographic, gender and other intersecting inequalities.A key finding is that current experiences and health of adolescents is shaped by past social and structural determinants and power relations, with apartheid inequalities still echoing in the lives of the adolescents, 25 years into democracy. More research and work is needed to provide insights into determinants of adolescent health beyond just the micro level, but also at the interrelated and dynamic meso and macro levels, nested in global determinants. The findings raise critical considerations and implications for understanding the social and structural determinants in the South African context and what this means for adolescent health in the SDG era.

Exploration of Gender-Sensitive Care in Vocational Rehabilitation Providers Working With Youth With Disabilities: Codevelopment of an Educational Simulation

Background

Although research shows that there is a need for gender-specific vocational support to help youth with disabilities find employment, health care providers often report needing more training in this area. Currently, there are no existing educational simulations of gender-sensitive care within vocational rehabilitation for clinicians who provide care to youth with disabilities. Therefore, developing further educational tools that address gender-sensitive care could help them enhance the care they provide while optimizing patient outcomes.

Objective

This study aims to codevelop an educational simulation and identify issues relevant to providing gender-sensitive care within the context of vocational rehabilitation for youth with disabilities.

Methods

We used a qualitative co-design approach with a purposive sampling strategy that involved focus group discussions and journal reflections to understand and address issues relevant to gender-sensitive care within vocational rehabilitation for those working with youth with disabilities. A total of 10 rehabilitation providers participated in two sessions (5 participants per session) to design the web-based simulation tool. The sessions (2.5 hours each) were audio recorded, transcribed, and analyzed thematically.

Results

Two main themes arose from our analysis of codeveloping a simulation focusing on gender-sensitive care. The first theme involved the relevance of gender within clinical practice; responses varied from hesitance to acknowledging but not talking about it to those who incorporated gender into their practice. The second theme focused on creating a comfortable and safe space to enable gender-sensitive care (ie, included patient-centered care, effective communication and rapport building, appropriate language and pronoun use, respecting gender identity, awareness of stereotypes, and responding to therapeutic ruptures).

Conclusions

Our web-based gender-sensitive care simulation that addressed vocational rehabilitation among youth with disabilities was cocreated with clinicians. The simulation highlights many issues relevant to clinical practice and has potential as an educational tool for those working with young people with disabilities.

Intersecting stigma and HIV testing practices among urban refugee adolescents and youth in Kampala, Uganda: qualitative findings

Introduction

HIV‐related risks may be exacerbated in humanitarian contexts. Uganda hosts 1.3 million refugees, of which 60% are aged under 18. There are knowledge gaps regarding HIV testing facilitators and barriers, including HIV and intersecting stigmas, among urban refugee youth. In response, we explored experiences and perspectives towards HIV testing strategies, including HIV self‐testing, with urban refugee youth in Kampala, Uganda.

Methods

We implemented a qualitative study with refugee cisgender youth aged 16 to 24 living in Kampala's informal settlements from February‐April 2019. We conducted five focus groups with refugee youth, including two with adolescent boys and young men, two with adolescent girls and young women and one with female sex workers. We also conducted five key informant (KI) interviews with government, non‐government and community refugee agencies and HIV service providers. We conducted thematic analyses to understand HIV testing experiences, perspectives and recommendations.

Results

Participants (n = 49) included young men (n = 17) and young women (n = 27) originally from the Democratic Republic of Congo [DRC] (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1), in addition to five KI (gender: n = 3 women, n = 2 men; country of origin: n = 2 Rwanda, n = 2 Uganda, n = 1 DRC). Participant narratives revealed stigma drivers included fear of HIV infection; misinformation that HIV is a “Ugandan disease”; and blame and shame for sexual activity. Stigma facilitators included legal precarity regarding sex work, same‐sex practices and immigration status, alongside healthcare mistreatment and confidentiality concerns. Stigma experiences were attributed to the social devaluation of intersecting identities (sex work, youth, refugees, sexual minorities, people living with HIV, women). Participants expressed high interest in HIV self‐testing. They recommended HIV self‐testing implementation strategies to be peer supported and expressed concerns regarding sexual‐ and gender‐based violence with partner testing.

Conclusions

Intersecting stigma rooted in fear, misinformation, blame and shame, legal precarity and healthcare mistreatment constrain current HIV testing strategies with urban refugee youth. Findings align with the Health Stigma and Discrimination Framework that conceptualizes stigma drivers and facilitators that devalue intersecting health conditions and social identities. Findings can inform multi‐level strategies to foster enabling HIV testing environments with urban refugee youth, including tackling intersecting stigma and leveraging refugee youth peer support.

Dimensions of Masculine Norms, Depression, and Mental Health Service Utilization: Results From a Prospective Cohort Study Among Emerging Adult Men in the United States

The purpose of this study was to examine the role of multidimensional masculine norms (“status,” “toughness,” “anti-femininity”) on depression and mental health service utilization among emerging adult men in the Northeast United States. This study examines substance use and hostility as secondary outcomes and depression status as an effect moderator on the relationship between masculine norms and mental health service utilization. This study used data from a prospective cohort study that followed 18- to 25-year-old heterosexual men over 6 months. At baseline and 6 months, approximately 29% and 25% of the sample met the criteria for depression. The results of multivariate linear and logistic regression models found that greater endorsement of masculine status was associated with less depressive symptoms at baseline and 6 months, masculine toughness was associated with more substance use at baseline, and masculine anti-femininity was associated with greater hostility at baseline and 6 months. The multivariate Poisson model found that greater endorsement of status was associated with greater mental health service utilization in the prior year, especially for men not meeting the criteria for depression. In contrast, greater endorsement of anti-femininity and toughness norms was associated with less mental health service utilization; for men endorsing toughness norms, this effect was greater for those who were depressed. This study sheds light on the harmful and protective effects of masculine norms on depression, related mental health outcomes, and mental health service utilization, with implications for gender-tailored approaches to engage and retain young men in mental health services.

'We need other men to stand up and start the journey' engaging men as HIV community health workers - a gender transformative approach?

The HIV epidemic is strongly gendered. Women and girls are more likely to contract HIV for biological and social reasons in Sub-Saharan Africa and men living with HIV are more likely to be lost to follow-up and die on antiretroviral therapy (ART) than women. Care work is also gendered, with women shouldering the burden of HIV care-related work. This paper considers the potential of male delivered community health work to improve men's HIV-related health outcomes and shift gendered norms related to care work. It describes the experiences and perspectives of eight HIV community health workers and their clients from the Cape Town area, and reviews current evidence on male-focused HIV and sexual and reproductive health services, gender transformation and men and care. Findings suggest that meaningfully involving more men in HIV care work may be a way to shift damaging hegemonic masculine norms related to care and health, and that South Africa's roll-out of National Health Insurance could be an opportunity to do so. Barriers to engaging men in this feminised profession are also explored.

Adaptation of a gender-transformative sexual and reproductive health intervention for adolescent boys in South Africa and Lesotho using intervention mapping

Background: Rates of adolescent HIV and unintended pregnancy in southern Africa are amongst the highest in the world. Gender-transformative interventions that address underlying gender inequalities and engage both males and females have been emphasised by the World Health Organisation, amongst others, to target prevention. However, few such gender-transformative interventions have been rigorously developed or evaluated.Objective: To expedite potential impact and reduce development costs, we conducted a needs assessment to inform the co-design, in consultation with local stakeholders, of adapted versions of an existing gender-transformative Relationships and Sexuality Education intervention for use in South Africa and Lesotho.Methods: Adaptation of the intervention was guided by a modified version of Intervention Mapping (IM). This process involved consultation with separate adolescent, community and expert advisory groups and a collaboratively conducted needs assessment, which drew on focus groups with adolescents (8 groups, n = 55) and adults (4 groups, n = 22) in South Africa and Lesotho, and was informed by our systematic review of the literature on the determinants of condom use among adolescents in the region.Results: The findings clarified how the intervention should be adapted, which individual- and environmental-level determinants of condom use to target, and actions for facilitating successful adoption, evaluation and implementation in the new settings.Conclusions: The IM approach allows for a systematic appraisal of whether components and processes of an existing intervention are appropriate for a new target population before costly evaluation studies are conducted. The findings will be of interest to those wishing to rigourously develop and evaluate gender-transformative interventions engaging men to improve health for all.

Relationship Between Health-Promoting Lifestyle and Body Mass Index in Male Nurses Based on Demographic Variables

Behaviors such as an appropriate diet, physical activities, health responsiveness such as attending diagnoses and treatment recommendations, preventing from known health risks such as smoking, allocating time to rest and peace and managing stress are related to health-promoting lifestyles (HPLs). The objective of the current study was to determine the relationship between HPL and body mass index (BMI) of male nurses based on demographic variables. A descriptive correlation survey was conducted among 108 male nurses using the nonprobability sampling technique. Data were gathered through a questionnaire consisting of two parts: demographic characteristics and Pender's health promotion questionnaire. Data were analyzed by presenting measures, mean, standard deviation, independent t-test, Pearson's coefficient correlation, and one-way analysis of variance (ANOVA), using SPSS version 22. The mean score for male nurses' HPL was good (3.13). The highest mean was from spiritual growth (3.48) and the lowest was from physical activity (2.69). Approximately 24.07% participants were overweight and obese. The mean of HPL in normal-weight people was better than that of obese ones. Participants did not pay much attention to their family's health-promoting behaviors. They also were exposed to occupational hazards, including psychological (47.2%), ergonomic (21.7%), physical (20.8%), and biological hazards (10.4%). There was no significant relationship between age (p = .14), educational level (p = .95), marital status (p = .32), job experiences (p = .17), and HPL variables. As health providers, nurses should both provoke patients to attain their health and to strive to maintain and sustain their own health, especially for obesity prevention. From society's perspective, a nurse is one who knows more and acts better; therefore, paying attention to nurses' HPL is a professional and social expectation.

Understanding clinicians' strategies for providing gender-sensitive care: an exploration among pediatric rehabilitation health care providers

PURPOSE

Although there is an increasing awareness of the critical role of gender within pediatric rehabilitation, little is known about the strategies that clinicians use to provide such care. The purpose of this study was to explore clinicians' strategies for providing gender-sensitive care within a pediatric rehabilitation hospital.

METHODS

We used a qualitative needs assessment design and a convenience sampling strategy to recruit clinicians from a pediatric rehabilitation hospital. We conducted interviews with 23 pediatric rehabilitation health care providers from various disciplines. We applied a thematic analysis to the interview transcripts.

RESULTS

Our analysis revealed the following themes regarding clinicians' strategies in providing gender-sensitive care: (1) awareness of gender biases and not making assumptions; (2) recognizing gender-based vulnerabilities; (3) respecting patient values, preferences and needs; and (4) advocacy.

CONCLUSION

Health care providers working within pediatric rehabilitation have several strategies for providing a gender-sensitive care approach to clients.IMPLICATIONS FOR REHABILITATIONClinicians should seek training (i.e., appropriate terminology, creating inclusive spaces) in how to recognize gender-based health vulnerabilities, especially among patients who identify as non-binary or transgender.Clinicians should make an effort to try to be aware of their own biases and not make gender-based assumptions.Advocacy, respecting patient values, preferences and needs are important aspects of providing gender-sensitive care.

Applying a complex adaptive systems approach to the evaluation of a school-based intervention for intimate partner violence prevention in Mexico

Despite calls for evaluation practice to take a complex systems approach, there are few examples of how to incorporate complexity into real-life evaluations. This article presents the case for using a complex systems approach to evaluate a school-based intimate partner violence-prevention intervention. We conducted a post hoc analysis of qualitative evaluation data to examine the intervention as a potential system disruptor. We analysed data in relation to complexity concepts particularly relevant to schools: 'diverse and dynamic agents', 'interaction', 'unpredictability', 'emergence' and 'context dependency'. The data-two focus groups with facilitators and 33 repeat interviews with 14-17-year-old students-came from an evaluation of a comprehensive sexuality education intervention in Mexico City, which serves as a case study for this analysis. The findings demonstrate an application of complex adaptive systems concepts to qualitative evaluation data. We provide examples of how this approach can shed light on the ways in which interpersonal interactions, group dynamics, the core messages of the course and context influenced the implementation and outcomes of this intervention. This gender-transformative intervention appeared to disrupt pervasive gender norms and reshape beliefs about how to engage in relationships. An intervention comprises multiple dynamic and interacting elements, all of which are unlikely to be consistent across implementation settings. Applying complexity concepts to our analysis added value by helping reframe implementation-related data to focus on how the 'social' aspects of complexity influenced the intervention. Without examining both individual and group processes, evaluations may miss key insights about how the intervention generates change, for whom, and how it interacts with its context. A social complex adaptive systems approach is well-suited to the evaluation of gender-transformative interventions and can help identify how such interventions disrupt the complex social systems in which they are implemented to address intractable societal problems.

Trouble in Paradigm: "Gender Transformative" Programming in Violence Prevention

The World Health Organization encourages a "gender transformative" paradigm for preventing violence against women and girls. Gender transformative interventions engage men and boys to reflect critically on-and then to challenge and change-gender-inequitable attitudes and behaviors. To interpret the mixed findings of research evaluating such programs, we review the "social norms" model that informs the paradigm. We bolster the paradigmatic conceptualization of social norms through insights about how exposure to trauma shapes gendered patterns of victimization and perpetration, about gendered violence from research on homophobic bullying, and about transforming local regimes of gender accountability.

The role of gender and power dynamics in injection initiation events within intimate partnerships in the US-Mexico border region

Women's initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation; sub-themes were identified drawing on three concepts within the theory of gender and power. With reference to sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. With regard to structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in understanding the intersection of risk, gender and harm reduction within injection initiation events across socio-cultural contexts.

Young people's sexual readiness: insights gained from comparing a researchers' and youth advisory group's interpretation

This study explored young people's understandings of sexual readiness and what influenced their decision to initiate first sex. Interviews conducted with 20 heterosexual young people aged 16-18 years, attending sexual health clinics in Northern Ireland, were analysed using a combined approach. This included comparing a researchers and youth advisory group's interpretations of the same data. Thematic analysis enabled comparison to draw out insights across both interpretations. Three themes emerged from each analysis that aligned closely with one another: Mental/Intimate Contact; People/Peer Influences; Self/Socio-Cultural Influences. One additional theme, Adult Control, emerged from the researchers' understanding alone. Results suggest that young people actively deliberate about sex as inevitable and find it difficult to resist the peer and social influences that regulate their lives, with many initiating sex 'to-get-it-over-with'. Gender ideologies and relationship status influenced expectations, motivations and the context surrounding first sex. Sexual readiness was informed by whether first sex was 'good', 'not so good' or 'bad', highlighting the gaps in young people's understanding. Health, law, and education sectors should co-produce interventions with young people to provide relevant and realistic information that explores the effects of gender equality in everyday life on related concepts such as respect, rights, responsibility and resilience.

Age Moderates the Association Between Microfinance Membership and Physical Abuse, Relationship Power, and Transactional Sex in Haitian Women

Microfinance interventions may have differential effects on relationship dynamics among subpopulations of women. We estimated the association between microfinance participation duration and physical abuse, relationship power, and transactional sex in a sample of Haitian women (n = 304). Furthermore, we tested for moderation by age. In older women, microfinance tended to be associated with reduced risk of violence, low relationship power, and transactional sex. These associations were not observed for younger women. Thus, older Haitian women may benefit from microfinance in ways that younger women do not. Future studies should examine whether additional training and resources could improve outcomes in younger women.

Effectiveness of a peer education gender and health project for men in Timor-Leste

ISSUE ADDRESSED

In response to high rates of gender-based violence and poor sexual and reproductive health indicators in Timor-Leste, a 'Men's Health Project' was implemented in two rural communities in 2013. A peer education model was utilised to engage men in issues regarding health, relationships and well-being.

METHODS

Community-based baseline and endline surveys were undertaken to evaluate the project in the two communities.

RESULTS

In 2013, 401 men and boys completed a baseline survey, and 400 completed an endline survey in 2016. Significant differences were found in a number of areas, with more men in the endline survey aware of the negative impacts of alcohol, safe pregnancy practices, family planning and sexually transmitted infections. Many men reported making the major decisions in their family in both surveys.

CONCLUSIONS

The peer education approach engaged men in health awareness and contributed to increasing knowledge of sexual and reproductive health and other health issues. However, while education and positive attitudes are an important foundation for change, other enabling mechanisms including vital infrastructure, services and health personnel must be in place to facilitate change and increase access to information and healthcare. Findings highlight the importance of engaging both women and men in processes of challenging behaviours and structures that reinforce gender inequalities. SO WHAT?: Peer education appears to be an effective model for engaging community members in gender and health issues in Timor-Leste. The Men's Health Project enabled men to participate in health awareness and issues regarding health, relationships and well-being.

Translating the theory of intersectionality into quantitative and mixed methods for empirical gender transformative research on health

Intersectionality theory has been used primarily in legal research to provide a framework for understanding the experiences of populations situated within multiple systems of oppression, particularly in relation to anti-discrimination law and gender-based violence. Gender transformative approaches to health seek to move beyond individual-level change and instead centre on restructuring the power relationships that create and maintain gender inequalities. Intersectionality theory is well-suited for the study of gender transformation on health, but there is a lack of consensus on clearly defined intersectional methodology in the field of public health, particularly for quantitative studies. Because qualitative methodologies are well-developed and employed with regularity for intersectional health research, the objective of this paper is to describe innovative quantitative and mixed methods approaches underutilised in public health and provide researchers examples of how to design a study's methodology to adequately address intersectional research questions. The proposed methods provide a toolkit for the investigation of complex interactions across multiple levels, which may offer insight into effective points of intervention to reduce disparities, strengthen larger social movements, and ultimately alter structural and policy contexts. Despite challenges posed by the theory, intersectional approaches may be the key to addressing persistent inequalities that limit gender transformation.

Fostering gender equality and alternatives to violence: perspectives on a gender-transformative community mobilisation programme in rural South Africa

Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels.

Widening cracks in patriarchy: mothers and daughters navigating gender norms in a Mumbai slum

Inequitable gender norms can be harmful to girls' and boys' health and sexuality. Programmatic approaches that help renegotiate gendered power relationships are sorely needed. This qualitative study reveals how Parivartan, a sport-based intervention in a Mumbai informal settlement, helped families resist inequitable gender norms that limited girls' mobility in public spaces. Fifteen girl athletes were interviewed in two rounds of face-to-face in-depth interviews. Results identify the strategies girls' mothers used to support their daughters' participation in the programme when they feared their husbands' disapproval. Rather than openly confronting their husbands, mothers worked from within the patriarchal gender order, through its 'cracks', for instance initially hiding their daughters' participation from their husbands. At an appropriate moment, girls' mothers revealed to their husbands about their daughters playing sports, convincing them of the usefulness of the programme. Girls' participation profoundly and positively affected relationships between daughters, mothers and fathers. Over time, parents' trust that girls would not compromise family honour increased, eventually changing the acceptability of girls' playing sport in public in spite of the patriarchal gender order. Concluding remarks offer key implications for effective interventions, highlighting the historical nature of gender transformation processes.

Intersectional Stigma and Multi-Level Barriers to HIV Testing Among Foreign-Born Black Men From the Caribbean

Testing is the entry point into the HIV care continuum that includes linkage to and retention in prevention services, and adherence to prevention strategies, including repeat HIV testing. Despite US policy approaches to expand HIV testing to diverse clinical care and community settings, disparities in HIV testing among Black populations persist. Foreign-born (FB) Black persons from the Caribbean have higher annual rates of HIV diagnosis and a higher percentage of late-stage HIV diagnosis, compared with US-born Black persons; and most HIV infections among FB Blacks are among men. In this article, we provide an overview of HIV testing barriers among FB Black men who engage in HIV risk-taking behaviors (e.g., condomless sex with male and/or female partners of unknown HIV serostatus). Barriers to HIV testing for both FB and US-born Black men, include HIV stigma (anticipated, perceived, internalized), low perceived HIV risk, medical or government mistrust, and perceived low access to testing resources. We examine beliefs about masculinity and gender roles that may perpetuate heteronormative stereotypes associated with perceptions of low HIV risk and barriers to HIV testing. We also discuss the impact of recent immigration policies on accessing HIV testing and treatment services and how intersectional stigmas and structural forms of oppression, such as racism, prejudice against select immigrant groups, and homophobia that may further amplify barriers to HIV testing among FB Black men. Finally, we review comprehensive prevention approaches, and suggest innovative approaches, that may improve the uptake of HIV testing among FB Black men.

Resourceful masculinities: exploring heterosexual Black men's vulnerability to HIV in Ontario, Canada

Objectives: Heterosexually active Black men are alleged to endorse masculine norms that increase their and their female partners' vulnerability to HIV. These norms include Black men's inability or reluctance to productively engage their own health-related personal and interpersonal vulnerabilities. We draw on data from the iSpeak research study in Ontario, Canada, to assess whether and how heterosexual Black men cope with personal and inter-personal vulnerability, namely that heterosexual Black men: avoid emotionally supportive relationships with other men (and women), which diminishes their capacity to productively acknowledge and resolve their health-related challenges; are reticent to productively acknowledge and address HIV and health on a personal level; and are pathologically secretive about their health, which compounds their vulnerability and precipitates poor health outcomes.Design: iSpeak was implemented in 2011 to 2013, and included two focus groups with HIV-positive and HIV-negative self-identified heterosexual men (N = 14) in Toronto and London, a focus group with community-based health promotion practitioners who provide HIV-related services to Black communities in Ontario (N = 6), and one-on-one interviews with four researchers distinguished for their scholarship with/among Black communities in Toronto. Participants in the men's focus group were recruited discretely through word-of-mouth. Focus groups were audiotaped and transcribed verbatim. Team members independently read the transcripts, and then met to identify, discuss and agree on the emerging themes.Results: We demonstrate that iSpeak participants (a) engage their personal and interpersonal vulnerabilities creatively and strategically, (b) complicate and challenge familiar interpretations of Black men's allegedly transgressive masculinity through their emotional and practical investment in their health, and (c) demonstrate a form of resourceful masculinity that ambiguously aligns with patriarchy.Conclusion: We conclude with a range of actionable recommendations to strengthen the discursive framework for understanding heterosexual Black men in relation to HIV and health, and substantively engaging them in community responses to HIV.

Social ecological factors associated with experiencing violence among urban refugee and displaced adolescent girls and young women in informal settlements in Kampala, Uganda: a cross-sectional study

BACKGROUND

Research on violence targeting urban forcibly displaced adolescent girls and young women (AGYW) is limited, particularly regarding polyvictimization (exposure to multiple forms of violence). Yet there is a global trend of refugee urbanization, and urban AGYW are at the nexus of violence disparities among adolescents, forcibly displaced persons, and slum dwellers. This study explored factors associated with young adulthood violence (> 16 years) (YAV) and intimate partner violence (IPV) among forcibly displaced AGYW in Kampala, Uganda.

METHODS

We conducted a cross-sectional survey with forcibly displaced AGYW aged 16-24 from five informal settlement (slum) communities across Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya) using peer network sampling. We assessed YAV (experienced at age 16 or above) (sexual, physical, emotional violence) and recent (past 12-month) IPV (physical, sexual, control violence). We conducted descriptive statistics, followed by multinomial logistic regression analyses to explore social ecological factors (e.g., intrapersonal: depression; interpersonal: sexual relationship power, community: food insecurity) associated with experiencing YAV and YAV polyvictimization, and IPV and IPV polyvictimization.

RESULTS

Over half of participants (n = 333; mean age = 19.31; SD = 2.56, range = 16-24) reported YAV (n = 179; 53.7%) and 9.3% (n = 41) reported YAV polyvictimization. Most participants that were in an intimate relationship in the last 12 months (n = 200; 85.8%) reported IPV, among these, 45.5% reported one form of IPV and 54.5% reported IPV polyvictimization. In adjusted analyses, experiencing any YAV was significantly associated with: adolescent sexual and reproductive health (SRH) stigma; sexual relationship power; mobile app usage; depressive symptoms; childhood abuse; and childhood polyvictimization. In adjusted analyses YAV polyvictimization was associated with: depressive symptoms; childhood polyvictimization; sexual relationship power; and food insecurity. Recent IPV polyvictimization in adjusted analyses was associated with owning/using a mobile phone and depressive symptoms. Participants with higher sexual relationship power had lower odds of recent IPV polyvictimization.

CONCLUSION

Findings suggest that YAV and IPV polyvictimization require urgent attention among forcibly displaced AGYW in Kampala. Multi-level strategies are required to address intrapersonal e.g. (depression), interpersonal (e.g. childhood abuse, sexual relationship power) and community (e.g. adolescent SRH stigma, food insecurity) factors associated with experiencing violence. Future research can tailor approaches to advance health, agency and human rights among urban forcibly displaced AGYW.

Fathers' Views and Experiences of Creating a Smoke-Free Home: A Scoping Review

Enabling parents to create a smoke-free home is one of the key ways that children's exposure to second-hand smoke (SHS) can be reduced. Smoke-free home interventions have largely targeted mothers who smoke, and there is little understanding of the barriers and facilitators that fathers experience in creating a smoke-free home. Systematic searches combining terms for fathers, homes, and SHS exposure were run in April 2019 in Web of Science's Citation Indices, PsycINFO, and PubMed for English-language studies published since 2008. The searches identified 980 records for screening, plus 66 records from other sources. Twelve studies reported in 13 papers were included in this scoping review. Eight of the studies were conducted in Asian countries (five in China, one in India, one in Japan, and one in Iran), three were conducted in Canada, and one in Turkey. Findings were extracted in verbatim text for thematic analysis. The review identified that attitudes and knowledge, cultural and social norms, gender power relations, and shifting perceptions and responsibilities related to fatherhood can impact on fathers' views of their role in relation to creating and maintaining a smoke-free home. There were too few published studies that had assessed smoke-free home interventions with fathers to draw conclusions regarding effective approaches. Research is clearly needed to inform our understanding of fathers' roles, successes and challenges in creating and maintaining a smoke-free home, so that father-inclusive rather than mother-led interventions can be developed to benefit entire households and improve gender equity as well as health.

Knowledge, attitudes, and practices related to family planning and gender equity among husbands of adolescent girls in Niger

Despite having the highest fertility rate in the world, research on Niger men and family planning (FP) is limited. We collected survey data collected in the Dosso region of Niger in 2016 from 1136 men who are the husbands of adolescent girls. We report descriptive statistics, bivariate and multivariable logistic regression on three dichotomous outcomes: (a) knowledge of modern contraceptives, (b) beliefs that only husbands should make FP decisions, and (c) current FP use. About 56% had ever heard of the pill, 6% had ever heard of an intrauterine device, and 45% had ever heard of an injectable. In our multivariable analyses, we found: a man knowing at least one modern method was significantly associated with his age, wife’s education level, gender ideology, and wife’s say in healthcare decisions; men’s belief that men alone should make FP decisions was associated with husband’s Quranic education, gender ideology, and attitudes towards violence against women; men’s reports of adolescent wives’ current family planning use was associated with men’s Quranic education, women’s involvement in her own healthcare decisions, and belief that men alone should decide about family planning. Finding suggests that interventions should target aim to reduce gender inequities to increase family planning utilisation.

A scoping review on the role of masculine norms in men's engagement in the HIV care continuum in sub-Saharan Africa

Men living with HIV/AIDS in sub-Saharan Africa are less likely than women to be engaged at each stage of the HIV care continuum. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV care engagement in sub-Saharan Africa. Our review yielded a total of 17 qualitative studies from 8 countries. Six major themes emerged that demonstrated how norms of masculinity create both barriers and facilitators to care engagement. Barriers included the exacerbating effects of masculinity on HIV stigma, the notion that HIV threatened men's physical strength, ability to provide, self-reliance, and risk behavior, and the belief that clinics are spaces for women. However, some men transformed their masculine identity and were motivated to engage in care if they recognized that antiretroviral therapy could restore their masculinity by rebuilding their strength. These findings demonstrate masculinity plays an important role in men's decision to pursue and remain in HIV care across sub-Saharan Africa. We discuss implications for tailoring HIV messaging and counseling to better engage men and an agenda for future research in this area.

Evaluating a Tool to Support the Integration of Gender in Programs to Promote Men's Health

Men's disproportionate rate of suicide and substance use has been linked to problematic conformity to traditional masculine ideals. Mental health promotion interventions directed toward men should address the gender-specific needs of men; yet, no tools exist to provide such guidance. To address this need, the Check-Mate tool was developed as part of a global evaluation of the Movember Foundation's Social Innovators Challenge (SIC). The tool provides an initial set of evidence-based guidelines for incorporating gender-related influences in men's mental health promotion programs. This article describes the development of Check-Mate and an evaluation of its usability and usefulness. Using a qualitative descriptive approach, semistructured interviews were conducted with the leads for eight of the SIC projects; they used the tool for these. Data were analyzed using conventional content analysis. Overall, project leads found the tool user-friendly. Identified strengths of Check-Mate included its practicality, adaptability, usefulness for priming thinking on gender sensitization, and value in guiding program planning and implementation. With respect to limitations, project leads explained that the complexity of men's mental health promotion programming may limit applicability of some or all approaches included in Check-Mate. They also expressed concern about how using Check-Mate might reinforce hegemonic masculine ideals. It was suggested that examples illustrating the use of Check-Mate would be a helpful accompaniment to the tool. Findings indicate that Check-Mate is a useful guide in men's mental health promotion programming. In addition to future testing of the tool in different settings, links between the tool's approaches and program outcomes should be explored.

Gender-Transformative Approaches to Engaging Men in Reducing Gender-Based Violence: A Response to Brush & Miller's "Trouble in Paradigm"

Brush and Miller's paper is critical of gender-transformative interventions and they believe that the paradigm is in trouble. In this response, we examine the body of evidence and the conceptual frames that undergird gender-transformative interventions, along with the emergence of these interventions and their efficacy. We argue here that it is reductionist to state either (a) that gender-transformative programs do not work, or (b) that gender-transformative programs only rely on social norms theory. We reveal how these claims omit important developments emerging from research on homophobia, feminist thought, and intersectionality that have made their way into gender-transformative interventions in several countries. We show that the implementation of gender-transformative interventions is far from uniform and we examine how changing power relations, relationships, communities, and masculinities, as well as other structures and practices that negatively influence health and well-being are integrated into this large body of work. We highlight how gender-transformative interventions show solid promise on balance, as measured in several evaluation studies in several settings, when implemented well and sustained. Overall then, gender-transformative interventions represent a tremendous advance over the previous "risk group-focused," single-topic approaches with men that have been implemented in public and global health interventions.

Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews

OBJECTIVES

Working with men/boys, in addition to women/girls, through gender-transformative programming that challenges gender inequalities is recognised as important for improving sexual and reproductive health and rights (SRHR) for all. The aim of this paper was to generate an interactive evidence and gap map (EGM) of the total review evidence on interventions engaging men/boys across the full range of WHO SRHR outcomes and report a systematic review of the quantity, quality and effect of gender-transformative interventions with men/boys to improve SRHR for all.

METHODS

For this EGM and systematic review, academic and non-academic databases (CINAHL, Medline, PsycINFO, Social Science Citation Index-expanded, Cochrane Library, Campbell Collaboration, Embase, Global Health Library and Scopus) were searched using terms related to SRHR, males/masculinities, systematic reviews and trials (January 2007-July 2018) with no language restrictions for review articles of SRHR interventions engaging men/boys. Data were extracted from included reviews, and AMSTAR2 was used to assess quality. Outcomes were based on WHO reproductive health strategy.

RESULTS

From the 3658 non-duplicate records screened, the total systematic reviews of interventions engaging men/boys in SRHR was mapped through an EGM (n=462 reviews) showing that such interventions were relatively evenly spread across low-income (24.5%), middle-income (37.8%) and high-income countries (37.8%). The proportion of reviews that included gender-transformative interventions engaging men/boys was low (8.4%, 39/462), the majority was in relation to violence against women/girls (n=18/39, 46.2%) and conducted in lower and middle-income countries (n=25/39, 64%). Reviews of gender-transformative interventions were generally low/critically low quality (n=34/39, 97.1%), and findings inconclusive (n=23/39, 59%), but 38.5% (n=15/39) found positive results.

CONCLUSION

Research and programming must be strengthened in engagement of men/boys; it should be intentional in promoting a gender-transformative approach, explicit in the intervention logic models, with more robust experimental designs and measures, and supported with qualitative evaluations.

Measuring agency as a dimension of empowerment among young adolescents globally; findings from the Global Early Adolescent Study

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Agency, a domain of empowerment, is a measurable construct amongst early adolescents age 10-14.

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Three sub-scales - Voice, Freedom of Movement, and Behavioral Control and Decision-making – comprise the measurement of agency.

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Differences in the Freedom of Movement sub-scale show a growing equity gap between boys and girls across multiple countries.

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Users of the scales must consider context when adapting the items to account for differences in culture and environment.

Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial.