Impact of a Gender-Transformative HIV and Antiviolence Program on Gender Ideologies and Masculinities in Two Rural, South African Communities

"We help people change harmful norms": Working with key opinion leaders to influence MNCH+N behaviors in Nigeria

BACKGROUND

Nigeria's Maternal, newborn, and child health and nutrition (MNCH+N) outcomes rank among the world's poorest. Engaging traditional and religious leaders shows promise in promoting related behaviors. The Breakthrough ACTION/Nigeria project worked with leaders in northern Nigeria to implement the Advocacy Core Group (ACG) model, a social and behavior change (SBC) approach aimed at influencing community norms and promoting uptake of MNCH+N behaviors. Qualitative assessment of the model contributes to evidence on SBC approaches for enhancing integrated health behaviors.

METHODOLOGY

This qualitative study was conducted in Nigeria's Bauchi and Sokoto states in May 2021. It involved 51 in-depth interviews and 24 focus group discussions. The study was grounded in the social norms exploration (SNE) technique to examine normative factors influencing behavior change within the ACG model context. Data analysis used a reflexive thematic analysis approach. Ethical approvals were received from all involved institutions and informed consent was obtained from participants.

RESULTS

The ACG model was vital in the uptake of MNCH+N behaviors. The influence of ACG members varied geographically with greater impact observed in Sokoto State. Normative barriers to improving MNCH+N outcomes included perceived religious conflicts with family planning, preference for traditional care in pregnancy, misinformation on exclusive breastfeeding (EBF), and gender-based violence resulting from women's decision-making. The study demonstrated positive progress in norm shifting, but EBF and GBV norms showed slower changes. Broader challenges within the health system, such as inadequate services, negative attitudes of healthcare providers, and workforce shortages, hindered access to care.

CONCLUSION

The ACG model increased awareness of health issues and contributed to potential normative shifts. However, slower changes were observed for EBF and GBV norms and broad health system challenges were reported. The model appears to be a promising strategy to further drive SBC for better health outcomes, especially where it is combined with supply-side interventions.

"It's a 50/50 Thing You Know": Exploring the Multileveled Intersections of Gender and Power Within the Relationships of Young South African Men and Women

Efforts to advance sexual health globally require greater understandings of youth intimate relationship dynamics. Among 38 South African youth (21 women/17 men aged 21-30 from Durban and Soweto) we conducted qualitative cognitive interviews to explore how gender and power intersect to shape intimate relationship dynamics (October 2019-March 2021). Participants discussed perceptions and relevance of each of 13 items comprising the Sexual Relationship Power (SRP) scale, a widely used measure of gender equity, and the influence of SRP on youth sexual health. Data analysis was guided by constructivist grounded theory. The findings were organized using the socio-ecological model, revealing how gender and power intersected at multiple levels to influence youth intimate relationships. Key influencing factors included individual-level gender attitudes, male partner expectations, and women's resistance to dominance; intimate relationship-level power dynamics, consent, and intimacy; family-level household configurations and parental monitoring of daughters; and societal-level traditional gender norms. At all levels, women discussed resisting power inequities through communication and rejection of inequitable relationships. While men also displayed resistance to inequitable power structures, most upheld traditional gender norms through institutional affiliation (e.g. church) and deep-rooted socialized beliefs and attitudes. Efforts to improve youth sexual health require multileveled approaches that address inequitable power dynamics.

Transforming masculine norms to improve men's contraceptive acceptance: results from a pilot intervention with men in western Kenya

Men's adherence to constraining male gender norms can lead them to resist contraceptive use. Very few interventions have attempted to transform masculine norms to encourage greater contraceptive acceptance and gender equality. We designed and evaluated a small-scale community-based intervention targeting the masculine norms tied to contraceptive resistance among partnered men (N = 150) in two western Kenya communities (intervention vs. control). Pre-post survey data fit to linear and logistic regression models evaluated differences in post-intervention outcomes, accounting for pre-intervention differences. Intervention participation was associated with increases in contraceptive acceptance scores (adjusted coefficient (aβ) 1.04; 95% confidence interval (CI) 0.16, 1.91; p = 0.02) and contraceptive knowledge scores (aβ 0.22; 95% CI 0.13, 0.31; p < 0.001) and with contraceptive discussions with one's partner (adjusted Odds Ratio (aOR) 3.96; 95% CI 1.21, 12.94; p = 0.02) and with others (aOR 6.13; 95% CI 2.39, 15.73; p < 0.001). The intervention was not associated with contraceptive behavioural intention or use. Our findings demonstrate the promise of a masculinity-driven intervention on increasing men's contraceptive acceptance and positive contraceptive involvement. A larger randomised trial is needed to test the effectiveness of the intervention among men as well as among couples.

Operationalising masculinities in theories and practices of gender-transformative health interventions: a scoping review

Gender-transformative health interventions that involve men and boys are gaining global reach, adaptability to specific geographical, population and epidemiological contexts, public endorsement, and conceptual sophistication. However, the ways in which masculinities are conceptualised and operationalised in theory and practice across these interventions remains unclear. The purpose of this scoping review is to map intervention studies that conceptually grapple with masculinities and analyse: a) how the concept of masculinities is adapted and operationalised in gender-transformative interventions, with respect to intervention population and context, b) what the relationship between the concept of masculinities and its wider theoretical embedding is, and c) on which levels transformation can be observed when working with 'masculinities'.We conducted a search in APA Psych Articles, APA PsycINFO, and CINAHL via EBSCO, MedLine, PubMed, and Web of Sciences (December 2021) looking for peer-reviewed studies on gender-transformative health interventions which engaged with masculinities conceptually. There were no restrictions regarding language, publication date, or geography. Forty-two articles were included in this review. Our abductive analysis finds that 'hegemonic masculinities' is a central concept in almost all included studies. This shows how the concept is adaptable to a range of different intervention contexts. The review further identifies five theoretical approaches, that help operationalise masculinities on an analytical level: feminist framework, affect theory, critical pedagogy, theories of social change, and ecological approaches. Lastly, this review draws out six levels on which transformation can be observed in the intervention outcomes: relational level, symbolic level, material level, affective level, cognitive-behavioural level, and community-structural level. The discussion underlines that processes and practices of (gender) transformation also require engagement with theories of transformation more widely and advocates for theoretical pluralism. Lastly, implications for practice, including preventative, ecological and community-based care models, are drawn out.

Positive Masculinities and Gender-Based Violence Educational Interventions Among Young People: A Systematic Review

BACKGROUND

Hegemonic masculinity has been recognized as contributing to the perpetration of different forms of gender-based violence (GBV). Abandoning hegemonic masculinities and promoting positive masculinities are both strategies used by interventions that foreground a "gender-transformative approach." Preventing GBV among young people could be strengthened by engaging young men. In this article, we aim to systematically review the primary characteristics, methodological quality, and results of published evaluation studies of educational interventions that aim to prevent different forms of GBV through addressing hegemonic masculinities among young people.

MAIN BODY

We conducted a systematic review of available literature (2008-2019) using Medline (PubMed), Scopus, Web of Science, PsycInfo, the CINAHL Complete Database, and ERIC as well as Google scholar. The Template for Intervention Description and Replication was used for data extraction, and the quality of the selected studies was analyzed using the Mixed Method Appraisal Tool. More than half of the studies were conducted in Africa (n = 10/15) and many were randomized controlled trials (n = 8/15). Most of the studies with quantitative and qualitative methodologies (n = 12/15) reported a decrease in physical GBV and/or sexual violence perpetration/victimization (n = 6/15). Longitudinal studies reported consistent results over time.

CONCLUSIONS

Our results highlight the importance of using a gender-transformative approach in educational interventions to engage young people in critical thinking about hegemonic masculinity and to prevent GBV.

Sex, Sexuality, and Intimate Relationships Among Afghan Women and Men of Refugee Background Living in Melbourne, Australia: Experiences, Opportunities, and Transcultural Tensions

Over the last two decades, Afghanistan has been a leading country of origin for asylum seekers and refugees arriving in Australia. It is widely recognized that humanitarian migrants experience poorer sexual and reproductive health than the broader population. In turn, a body of research has emerged exploring the sexual and reproductive health of the local Afghan community. However, this has predominantly focused on youth or perinatal experiences, and less attention has been given to the broader relational and social dimensions of sexuality. Accordingly, this research aimed to explore the perspectives and experiences of married Afghan women and men as they navigate and negotiate sex, sexuality, and intimate relationships following settlement in Melbourne, Australia. A total of 57 Afghan women and men participated in six focus group discussions and 20 semi-structured interviews. Male participants described the ways that having increased access to sex and sexually explicit materials in Australia is creating opportunities for them to establish more fulfilling sex lives. Many women also described a growing awareness of sexuality, although often expressed difficulty prioritizing and claiming more pleasurable sexual encounters for themselves. However, concerns about sexual freedom are also creating new challenges for the Afghan community living in Australia in relation to sex and relationships. For example, men expressed fears about women exercising sexual liberties outside of the home, and this appeared to place women's everyday behavior under increased scrutiny. Women also voiced concerns about how easily men can access sex outside of marriage within Australia, and described how this amplified their sense of obligation to be sexually compliant and meet their husband's desires. This study provides new insights into the ways that Afghan community members are moving between societies, and how their understandings of sexual participation, pleasure, desire, health, consent, and capacity for self-determination are being challenged, reshaped, and reconstructed throughout this process.

Male and Female Perceptions and Experiences of Sexual and Gender-based Violence in South Kivu, Eastern DRC

Conflict settings are often the context of some of the highest rates of sexual and gender-based violence (SGBV). Although women are disproportionately the victims of SGBV, they are not the only victims. Indirect impacts of SGBV also impact men, families, and communities. Examining SGBV as only a woman's concern reinforces the hegemonic gender-binary view that SGBV somehow does not include men, who can be direct victims of SGBV, family members of female victims of SGBV, and/or perpetrators of SGBV. This qualitative study seeks to fill a gap by exploring the impact of SGBV on individuals, families, and communities, and potential options to ameliorate those issues. Data were collected in 2019 from community-based discussions in South Kivu, Democratic Republic of Congo. Women described being direct victims of SGBV, as well as the burden of being at constant alert to the possible threat of violence. Men talked more about SGBV being perpetrated against women, and the indirect effect on men's perception of their social husband and/or father role to protect and provide for their family. Taken together, women and men describe three types of violence: sexual violence by an unknown assailant who is often associated the rebel groups or the military; sexual violence from a known assailant within one's community; and sexual or physical violence within intimate partnerships (i.e., intimate partner violence). Women focused more on community-based solutions to reduce their exposure to violence, while men discussed the government's responsibility to end the long-standing conflict that has severely disrupted lives. Practically, these findings support the need to specify different types of SGBV, and the opportunity to tailor interventions by type.

Moving Beyond a Reliance on Criminal Legal Strategies to Address the Root Causes of Domestic and Sexual Violence

This article is intended to support discussions about how to effectively address domestic and sexual violence. It proposes the following key strategies: expanding beyond police, courts, and prisons; adopting upstream approaches to address the social, structural, institutional, and historical drivers of violence; and using evidence-based strategies to prevent violence from happening in the first place. Comparing the United States, South Africa, India, and Brazil, the article makes the case that advocates working to address domestic and sexual violence have relied too heavily on criminal legal sanctions. Not only does this result in unmet needs of both survivors and their communities but it also expands the repressive powers of police and prosecutors and contributes to steadily growing levels of incarceration. The article concludes by calling for services that better meet the needs of survivors and for the rapid scale-up of prevention strategies, both evidence-based interventions and legal and policy approaches that address the root causes of men's violence.

Examining Masculinities to Inform Gender-Transformative Violence Prevention Programs: Qualitative Findings From Rakai, Uganda

While the majority of men in rural Uganda upheld 2 conflicting masculine norms that are conceptualized as reputation (“cool man”) and respectability (“responsible man”), men in younger age groups who participated in a gender-transformative program expressed gender-equitable beliefs and attitudes.

Introduction:

Evidence-based programs are needed to engage men and boys that encourage the transformation of concepts of masculinity that uphold patterns of intimate partner violence (IPV). This study explores the constructs of masculinity and male gender norms surrounding sexual attitudes and IPV among men and boys living in Rakai, Uganda.

Methods:

Between April and August 2017, we conducted 38 interviews and 5 focus group discussions with men and boys aged 15 to 49 years and 4 focus groups with key stakeholders to understand how male use of violence is influenced by personal, community, and society-level concepts of masculinity. We adapted 2 constructs of masculinities, reputation and respectability, in the analysis to examine masculinities in relation to IPV in the rural Ugandan setting.

Results:

Findings suggest men and boys upheld 2 types of masculinities: respectability versus reputation. Masculine attributes related to respectability (referred to as “responsible men”) included having a job, house, wife, and many children and taking care of family. Masculine attributes related to reputation (referred to as “cool men”) included having sexual prowess, multiple sexual partners, and the resources to buy nice things. Both masculine norms were used to justify dominance over women and IPV. The divergence of masculinity was observed among youth and young adults who participated in a gender-transformative program, suggesting the effectiveness of the program.

Discussion:

The gender-transformative approach should provide men and boys a chance to reflect on dynamic, often conflicting, images of a man and should empower individuals to renegotiate and reconceptualize masculine norms. This critical reflection on masculinity, which resonates with men and boys, needs to be included when engaging men within HIV and IPV prevention programs.

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.

"Change Really Does Need to Start From Home": Impact of an Intimate Partner Violence Prevention Strategy Among Married Couples in Nepal

Approximately 54% of women in rural Nepal report lifetime physical or sexual violence. The Change Starts at Home project is a primary prevention strategy to reduce and prevent marital intimate partner violence (IPV). This study analyzed in-depth interviews with 17 married couples (n = 34 individuals) at intervention midline and end line. Case-based analysis and thematic summaries were used to assess change, couple concordance, and gendered reporting patterns at midline. Individual changes included husband's alcohol use and roaming tendencies. Relationship-level changes comprised labor roles, communication, decision making, conflict resolution, and experience of IPV. End line interviews were analyzed to understand sustenance of change within these same individual and relationship dynamics. Results indicate promising shifts in men's individual behavior and marital dynamics, which underpin IPV risk.

Measuring Men's Gender Norm Beliefs Related to Contraception: Development of the Masculine Norms and Family Planning Acceptance Scale

Male partner resistance is identified as a key factor that influences women's contraceptive use. Examination of the masculine norms that shape men's resistance to contraception-and how to intervene on these norms-is needed. To assess a gender-transformative intervention in Kenya, we developed and evaluated a masculinity-informed instrument to measure men's contraceptive acceptance-the Masculine Norms and Family Planning Acceptance (MNFPA) scale. We developed draft scale items based on qualitative research and administered them to partnered Kenyan men (n = 150). Item response theory-based methods were used to reduce and psychometrically evaluate final scale items. The MNFPA scale had a Cronbach's α of 0.68 and loaded onto a single factor. MNFPA scores were associated with self-efficacy and intention to accept a female partner's use of contraception; scores were not associated with current contraceptive use. The MNFPA scale is the first rigorously developed and psychometrically evaluated tool to assess men's contraceptive acceptance as a function of male gender norms. Future work is needed to test the MNFPA measure in larger samples and across different contexts. The scale can be used to evaluate interventions that seek to shift gender norms to increase men's positive engagement in pregnancy spacing and prevention.

Subordinated agency: Negotiating the biomedicalisation of masculinity among gay men living with HIV

Health practices are shaped by gender relations and constructs. Utilising qualitative data, this study explores a shift in medication practices among gay men living with HIV (GMLH) in light of changing HIV/AIDS responses in Taiwan. In the 1980s and 1990s, the mobilisation of moralising discourses forged a gender hierarchy that subordinated HIV-positive gay males. In the 2000s, new state programmes on HIV/AIDS were implemented to enhance patients' adherence to treatment, but GMLH often expressed ambivalence towards medication, which could lead to HIV disclosure and, consequently, social exclusions under the gender hierarchy. Starting in the 2010s, the knowledge of HIV 'treatment as prevention' and a policy on early treatment have offered a new path for GMLH to navigate gender power dynamics and to strive towards an inclusive social life by taking medicine and optimising health, which facilitates a biomedicalisation of subordinated masculinity. This study contributes to the scholarship on HIV/AIDS by underscoring the significance of biomedicine for configuring masculine identities and practices among a subordinated group of men, as well as by highlighting the gender power relations and everyday 'nonbiomedical' negotiating practices that legitimise biomedicalisation.

He for she? Variation and exaggeration in men's support for women's empowerment in northern Tanzania

Achieving gender equality fundamentally requires a transfer of power from men to women. Yet data on men's support for women's empowerment (WE) remains scant and limited by reliance on self-report methodologies. Here, we examine men's support for WE as a sexual conflict trait, both via direct surveys (n = 590) and indirectly by asking men's wives (n = 317) to speculate on their husband's views. Data come from a semi-urban community in Mwanza, Tanzania. Consistent with reduced resource competition and increased exposure to relatively egalitarian gender norms, higher socioeconomic status predicted greater support for WE. However, potential demographic indicators of sexual conflict (high fertility, polygyny, large spousal age gap) were largely unrelated to men's support for WE. Contrasting self- and wife-reported measures suggests that men frequently exaggerate their support for women in self-reported attitudes. Discrepancies were especially pronounced among men claiming the highest support for WE, but smallest among men who held a professional occupation and whose wife participated in wage labour, indicating that these factors predict genuine support for WE. We discuss the implications of these results for our understanding of both individual variation and patriarchal gender norms, emphasising the benefits of greater exchange between the evolutionary human sciences and global health research on these themes.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

"I'd Rather Use a Refuse Bag:" A Qualitative Exploration of a South African Community's Perceptions of Government-Provided Condoms and Participant-Preferred Solutions

Despite South Africa experiencing one of the largest HIV epidemics in the world, condom use has decreased since 2008. However, condoms are the only low-cost HIV prevention technology widely available in South Africa. This study aims to explore a South African community's perceptions of condoms, recent condom use decrease, and suggestions for increasing condom use. In 2014, we conducted seven focus groups (n = 40 men) and 20 in-depth interviews (n = 9 men, n = 11 women) with participants aged ≥ 18 years recruited from four urban settlement health clinics in Cape Town, South Africa. Data were collected, coded, and analysed using a general inductive approach. Participants perceived government-provided condoms negatively, with themes including "disgust" for condom physical properties, concerns with social status associated with free condoms, and performance concerns. There was an intersection of themes surrounding masculinity, condom use, and sexual pleasure. Solutions to increase condom use included improving the quality and variety of free condoms and rebranding free condoms. Participants suggested that condoms are distributed with novel attributes (e.g., more colors, smells/flavors, sizes, and in-demand brands) and that government programs should consider offering all brands of condoms at no or low cost. This study suggests a substantial rethinking of condom branding for government-provided condoms. Our findings suggest that condom dissemination and promotion programs should proactively address public concerns regarding condoms. Existing societal and structural norms such as hegemonic masculinity must also be addressed using gender-transformative interventions. We also strongly suggest the creation of a Male Condom Acceptability Scale to understand condom users' needs.

"As young men we have a role to play in preventing sexual violence": Development and relevance of the men with conscience intervention to prevent sexual violence

Sexual violence against women and girls is a major public health problem globally and in South Africa. Although young men have been identified as an important risk group for prevention interventions, scant attention have been given to this age cohort in low and middle-income countries. There is strong evidence that perpetration starts early and increasing attention is being drawn to Higher Education Institutions (HEIs) as settings for prevention interventions. The main objective of this study was to adapt the One Man Can Intervention for use with male university students in residences and develop materials for implementation. This paper presents the qualitative findings of the adaptation process of the One Man Can Intervention with 15 young male student leaders at a HEI in South Africa. The same participants who started in the study, participated throughout. Only five of the 15 participants were located and participated in the interviews six months post intervention. The results show the emergence of a six-hour session adapted intervention that addresses key drivers of violence against women and girls (VAWG). Critical engagement and dialogue on sexual violence is shown to shift key norms on gender equality, on being a man and reflection on their role in preventing sexual violence. This paper contributes to the field where much learning, refining and improvement of prevention interventions for VAWG are ongoing.

PositivMasc: masculinities and violence against women among young people. Identifying discourses and developing strategies for change, a mixed-method study protocol

INTRODUCTION

Despite public policies and legislative changes aiming to curtail men's violence against women (VAW) around the world, women continue to be exposed to VAW throughout their life. One in three women in Europe has reported physical or sexual abuse. Men who display unequitable masculinities are more likely to be perpetrators. VAW is increasingly appearing at younger ages. The aims of the project are fourfold: (1) to explore and position the discourses that young people (men and women, 18-24 years) in Sweden, Spain, Ireland and Israel use in their understanding of masculinities, (2) to explore how these discourses influence young people's attitudes, behaviours and responses to VAW, (3) to explore individual and societal factors supporting and promoting anti-VAW masculinities discourses and (4) to develop actions and guidelines to support and promote anti-VAW masculinities in these settings.

METHODS AND ANALYSIS

A participatory explorative mixed-method study will be used. In Phase 1, qualitative methods will be used to identify the discourses that young people and stakeholders use to conceptualise masculinities, VAW and the actions that are needed to support and promote antiviolence masculinities. In Phase 2, concept mapping will be used to quantify the coherence, relative importance and perceived relationship between the different actions to support and promote anti-VAW masculinities. Phase 3 is a knowledge creation and translation phase, based on findings from Phases 1 and 2, where actions and guidelines to promote and support anti-VAW masculinities will be developed.

ETHICS AND DISSEMINATION

Ethical clearance has been obtained from ethics review boards in each country. Results will be disseminated through peer-reviewed publications, presentations at international conferences, policy briefs, social media and through the project online hub. With its multicountry approach, our project results seek to inform policies and interventions aimed at promoting discourses which challenge hegemonic masculinities.

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.

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.

Impacts of Men's Gender-transformative Personal Narratives: A Qualitative Evaluation of the Men's Story Project

Gender-transformative interventions have been found to help ameliorate gender-inequitable norms and improve health outcomes for women and men. While narrative-based strategies are increasingly being used in public health programs, no evaluation publications exist to date for gender-transformative programming that employs men's public narrative-sharing as a central means for promoting healthy masculinities. The Men's Story Project (MSP) creates live productions in which diverse men publicly perform personal narratives that challenge hegemonic masculinity, promote gender equality, and highlight intersections of masculinity with other social identities. This study draws upon six focus groups with thirty-one audience members (AMs), two weeks after an MSP production at a US public university. The MSP led AMs to reevaluate key pillars of hegemonic masculinity, including a singular conception of masculinity, essentialist notions of gender, restricted emotional expression, and use of violence; AMs also gained an expanded understanding of intersectionality. Directions for future research are discussed.

Gender inequity as a barrier to women's access to skilled pregnancy care in rural Nigeria: a qualitative study

BACKGROUND

Maternal mortality has been an issue of global importance, with continued efforts by the international development community towards its reduction. The provision of high quality maternal healthcare has been identified as a key strategy in preventing maternal mortality. Gendered intrahousehold power structures, gendered dynamics of resource allocation and women's limited ability in decision-making can have a huge impact on maternal health-seeking behaviour and overall health status. Using a gender lens, this study explores the root causes of women's limited access to and utilisation of maternal healthcare services in rural areas of Edo State, Nigeria.

METHODS

This qualitative study involved the analysis of data collected from gender- and age-desegregated focus group discussions (FDGs) in 20 communities in Etsako East and Esan South East local government areas of Edo State, Nigeria. Focus group participants comprised women between the ages of 15-45 y who have been pregnant within the last 5 y and their male spouses and partners of varying ages. A total of 20 FGDs were conducted. Coded transcripts were reviewed and analysed using the gender framework as an analytical guide.

RESULTS

Most responses indicated that women did not entirely have the power to make decisions regarding when to seek care during pregnancy. Women's experiences of access to quality care showed intersecting areas of gender and social economic status (SES) and how they impact on access to health. Many of the responses suggested high levels of economic marginalisation among women with women being financially dependent on their spouses and partners for pregnancy healthcare-related costs. Furthermore, a man's financial status determined the type of care his spouse or partner sought. Women identified a high workload as an issue during pregnancy and a barrier to accessing maternal healthcare services. The role of men within households was generally perceived as that of financial providers, therefore a husband's support was commonly constructed to solely mean financial support.

CONCLUSION

This paper brings attention to the role of gender and SES in producing and sustaining limitations to women's access to quality care. Interventions geared towards supporting women's financial independence is an important step towards improving their access to skilled healthcare, more so are interventions that improve women's decision-making capacities.

Gender role conflict and sexual health and relationship practices amongst young men living in urban informal settlements in South Africa

Qualitative research suggests that men's inability to achieve dominant forms of masculinity may be related to HIV-risk behaviours and intimate partner violence (IPV) perpetration. Using clustered cross-sectional data, we assessed how young men's gender role conflict was associated with HIV-risk behaviours in urban informal settlements in KwaZulu-Natal, South Africa. Gender Role Conflict and Stress (GRC/S) was measured using a South African adaptation of the GRC/S scale comprising three sub-scales: subordination to women; restrictive emotionality; and success, power and competition. In random-effect models adjusting for socio-demographics, we tested the relationship with GRC/S sub-scales and sexual health behaviours (transactional sex, use of sex workers, ≥2 main partners and ≥2 casual/once off partners), and relationship practices (relationship satisfaction, relationship control, partnership type and perpetration of IPV). Overall, 449 young men (median age = 25, Q1, Q3 = 23-28) were included in the analysis. Higher GRC/S scores, denoting more GRC/S, were associated with increased relationship control and increased odds of having ≥2 casual or one-off partners and engaging in transactional sex. We found differences in associations between each sub-scale and sexual health and relationship practices, highlighting important implications for informing both theoretical understandings of masculinity and gender transformative efforts.

Zwakala Ndoda: a cluster and individually randomized trial aimed at improving testing, linkage, and adherence to treatment for hard-to reach men in KwaZulu-Natal, South Africa

BACKGROUND

Men in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men.

METHODS

This study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load.

DISCUSSION

A priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men's individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.

The Men's Story Project: Promoting Healthy Masculinities via Men's Public, Personal Narrative-Sharing

The Men's Story Project (MSP) is a scalable social and behavior change communication initiative that fosters critical reflection and dialogue about masculinities by creating public forums where men share non-fiction, personal narratives that challenge male norms and model healthy, gender-equitable masculinities. Via focus groups and in-depth interviews, this qualitative evaluation study examined impacts of the MSP for twenty MSP presenters and thirty-one college audience members who attended an MSP production at a public university in California in the Spring 2009 semester. Key thematic findings for MSP presenters included value placed on the men's group experience; having their stereotypes and prejudices challenged; empowerment and healing; reinforced commitment to cease/prevent men's violence; and expanded gender justice engagement. For audience members, key thematic findings included gaining an expanded conceptualization of masculinity; learning about intersectionality; having their stereotypes and prejudices challenged; and finding significant overall educational and social value in the MSP. The MSP's effects on audience members were facilitated by experiences of emotion, empathy, parafriendship and role modeling elicited by the first-person narratives, and the social learning environment fostered by the collective, public experience. Directions for further international research and practice are discussed.

Understanding the Relationship Between Male Gender Socialization and Gender-Based Violence Among Refugees in Sub-Saharan Africa

Gender-based violence (GBV) in humanitarian emergencies is progressively recognized as a global public health problem. Detrimental gender norms influence male perpetrated GBV against women, and social and structural contexts of forced migration and camp resettlement contribute to problematic gender norm development. The review sought to elucidate the dynamics that link gender socialization among male youth in sub-Saharan Africa with violent sexual behaviors. Two concepts were explored: (1) male gender socialization in sub-Saharan Africa related to GBV perpetration patterns and (2) the effect of forced migration on male socialization and GBV. We reviewed articles using a standard systematic review methodology, searching academic databases for peer-reviewed articles, and contacting experts for gray literature. Our initial search identified 210 articles. We manually reviewed these, and 19 met the review inclusion criteria. We identified 20 variables from the first concept and 18 variables from the second. GBV perpetration by male youth is positively associated with social pressures as well as cultural and religious beliefs. Amid forced migration, personal, societal, and cultural preexisting gender inequalities are often amplified to encourage GBV perpetration. The literature revealed aspects of culture, language, role modeling, religion, and the context of violence as important factors that shape young men's perspectives regarding the opposite sex and gender relations as well as sexual desires and dominance. Overall, though, literature focusing on male socialization and GBV prevention is limited. We made recommendations for future studies among refugee male youth in order to better understand these relationships.

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.

Generating CHARISMA: Development of an Intervention to Help Women Build Agency and Safety in Their Relationships While Using PrEP for HIV Prevention

This article describes the development of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence intervention (CHARISMA), an intervention designed to address the ways in which gender norms and power differentials within relationships affect women's ability to safely and consistently use HIV pre-exposure prophylaxis (PrEP). CHARISMA development involved three main activities: (1) a literature review to identify appropriate evidence-based relationship dynamic scales and interventions; (2) the analysis of primary and secondary data collected from completed PrEP studies, surveys and cognitive interviews with PrEP-experienced and naïve women, and in-depth interviews with former vaginal ring trial participants and male partners; and (3) the conduct of workshops to test and refine key intervention activities prior to pilot testing. These steps are described along with the final clinic and community-based intervention, which was tested for feasibility, acceptability, and preliminary effectiveness in Johannesburg, South Africa.

Men's perception of barriers to women's use and access of skilled pregnancy care in rural Nigeria: a qualitative study

BACKGROUND

Greater paternal engagement is positively associated with improved access to and utilization of maternal services. Despite evidence that male involvement increased uptake of maternal and child services, studies show that few men are participating in MNCH programs. Community leaders have long been engaged in public health promotion in rural settings and have been shown to mobilize communities to enhance changes in cultural practices related to public health. With the ultimate goal of increasing men's involvement in maternal health, this study seeks to understand men's perceptions of community and health systems barriers to maternal access and usage of skilled care in rural Edo, Nigeria.

METHODS

This qualitative study involved the analysis of data collected from community conversations with male elders in Etsako East and Esan South East Local Government Areas of Edo State, Nigeria. Community conversations participants (n = 128) comprised of elders between the ages of 50-101. A total of 9 community conversations were conducted. Discussions were audio recorded, transcribed and imported into Atlas.ti 6.2 for content analysis.

RESULTS

Men's perceptions of barriers to maternal use of skilled care are presented in two overarching themes: community systems and health systems. Three sub themes were generated as community systems barriers to maternal healthcare use, they include: gender roles, traditional treatment and policy changes. Three sub themes emerged under health system barriers and they include: cost of health facilities, dissatisfaction with facilities and distance from facilities.

CONCLUSION

Findings suggest that community elders are not only in a good position to influence men's behavior, they are also a source of information to policy makers on strategies to overcome barriers to maternal health, especially at the community level. Furthermore, community elders need support to enact regulations that will promote men's involvement in maternal health, thereby increasing maternal use of skilled care.

Competition and humiliation: how masculine norms shape men's sexual and violent behaviors

We use data collected from in-depth interviews with men (n=30) in the Dominican Republic to explore how men's concern about being perceived as masculine influences their interactions with their social networks and how those interactions drive men's sexual behaviors and use of violence. Men's sexual and violent behaviors were shaped by the need to compete with other men for social status. This sense of competition also generated fear of humiliation for failing to provide for their families, satisfy sexual partners, or being openly disrespected. In an effort to avoid humiliation within a specific social group, men adapted their behaviors to emphasize their masculinity. Additionally, men who were humiliated recouped their masculinity by perpetrating physical or emotional violence or finding new sexual partners. These findings emphasize the need for understanding these social dynamics to better understand men's violent and sexual behaviors.

Strategies for engaging men in HIV services

The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.

Prevalence and correlates of gender inequitable norms among young, church-going women and men in Kinshasa, Democratic Republic of Congo

Background

Prolonged political instability may have exacerbated gender inequitable beliefs in the Democratic Republic of Congo (DRC). The aim of this study was to assess attitudes related to gender-equitable norms and its determinants among young, church-going women and men in Kinshasa, DRC.

Method

Data were collected through a cross-sectional survey with 291 church-going women and 289 men aged 18–24 years old, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality, and responses to issues related to the gender-equitable men (GEM) scale. The GEM scale is a 24 item-questionnaire developed to measure attitudes towards gender equitable norms. Logistic regression was applied to discover the associations between the independent variables and the GEM outcome.

Results

Our study reflected the existence of attitudes hampering gender equality that were endorsed by both women and men. For example, 91.4% of women and 83% of men agreed with the statement “a woman’s most important role is to take care of her home and cook for her family”. Similarly, 88.3% of women and 82.9% of men concurred with the idea that men need more sex than women. These findings coexisted with a few equitable norms, because 93.7% of women and 92.3% of men agreed that a man and a woman should decide together if they want to have children. A positive association was found in both women and men between being educated, being single and separated and having supportive attitudes towards gender equality and a higher GEM scale score. Residency in Camp Luka and Masina was also a significant social determinant associated with equitable gender norms among men whilst job status was only significant among women.

Conclusion

While both women and men had high levels of gender inequitable norms, those with more education, single, and with supportive attitudes to gender equality had high GEM scale scores. The results highlight an urgent need for the church to challenge and change gender norms among church youths.

The theory of masculinity in studies on HIV. A systematic review

This study aimed to describe the methodological characteristics of publications on HIV and masculinity, to identify possible information gaps and determine the main thematic areas. A systematic review was conducted of gender, masculinity, HIV infection and other sexually-transmitted infections in original articles published between 1992 and 2015. Original studies published from Pubmed and Scopus were included. A total of 303 articles were identified, of which 187 were selected. Most of the studies were qualitative and the most widely used technique was the interview. Twenty-nine-point five percent of studies were performed in South Africa, 20.8% in the USA, and 3.2% in Europe. Fifteen percent of the studies were performed in heterosexuals, 12.8% in men who have sex with men, and 60% did not specify the sexual orientation of the population. Eight thematic areas were defined, the most frequent being sexuality and risk behaviours, defined by men's need to demonstrate they were sexually active and a breadwinner. Most studies on HIV and masculinity show a gender bias by not specifying the sexual identity of the population. Studies should consider diversity in sexual and cultural identity in different contexts, including in Europe, to carry out more effective HIV interventions from a masculinity perspective.

Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: Efficacy of an intervention on the dyad

RATIONALE

South Africa continues to experience new HIV infections, with the highest risk among Black Africans living in poor communities. Most HIV prevention interventions target women or men separately and only a small number target couples jointly.

OBJECTIVE

This study examines varying strategies to engage women and men around HIV prevention and improved couple interactions.

METHODS

The study comprises three arms: (1) a couple-based intervention delivered to women and men jointly; (2) women and men both offered a gender-focused intervention that is delivered to them separately; and (3) an intervention offered to women only and their male partners receive standard HIV testing and counseling (comparison arm). Between June 2010 and April 2012, men were identified in and around drinking establishments in a large disadvantaged community in Cape Town and asked to participate in the study if they drink regularly, had recent unprotected sex with their partner, and have a female partner who was willing to participate in the study.

RESULTS

A total of 299 couples completed the baseline assessment and 276 were included in the analysis of sexual risk, partner communication, conflict resolution, and gender norm outcomes at baseline and six-month follow-up. Couples that participated in the couple-level intervention and couples where both partners received the intervention separately had better couple-level gender norms than couples in the comparison arm (women only receive intervention). Further, couples in the couple-level intervention and the both partners exposed separately arms were more likely to have the man only report consistent condom use than neither partner report consistent condom use than couples in the comparison arm.

CONCLUSION

Community-based HIV prevention intervention programs need to consider strategies to engage women and men and, if feasible, reach both partners jointly. Couple-level interventions are promising to improve gender norms and subsequently improve health outcomes, including reduced HIV risk among women, men, and couples.

The intersection of intimate partner violence and HIV risk among women engaging in transactional sex in Ugandan fishing villages

Intimate partner violence (IPV) may increase risk for HIV/AIDS among women engaging in transactional sex in Ugandan fishing communities. In this cross-sectional study, 115 women reporting engaging in transactional sex in Lake Victoria fishing communities completed a computerized interview. We tested associations between IPV and other HIV risk factors, with unprotected sex and HIV status, and tested moderators of the IPV-HIV risk relationship. Women reporting recent sexual IPV reported 3.36 times more unprotected sex acts (AdjExp[B] = 3.36, 95% CI = 1.29-8.69, p = 0.07). The effect of sexual IPV on sexual risk was significantly greater among alcohol and fish sellers compared to sex workers (interaction: Exp[B] = 12.29, 95% CI = 5.06-29.85, p < 0.001). Women reporting any sexual IPV were nearly four times more likely to report being HIV positive than women reporting no sexual IPV (AOR = 3.94, 95% CI = 1.22-12.66, p = 0.02). Integrated IPV and HIV interventions are needed in this context, especially among alcohol and fish sellers engaging in transactional sex.

A cluster randomised controlled trial to determine the effect of community mobilisation and advocacy on men's use of violence in periurban South Africa: study protocol

OBJECTIVE

This paper describes the design and methods of a cluster randomised controlled trial (C-RCT) to determine the effectiveness of a community mobilisation intervention that is designed to reduce the perpetration of violence against women (VAW).

METHODS AND ANALYSIS

A C-RCT of nine intervention and nine control clusters is being carried out in a periurban, semiformal settlement near Johannesburg, South Africa, between 2016 and 2018. A community mobilisation and advocacy intervention, called Sonke CHANGE is being implemented over 18 months. It comprises local advocacy and group activities to engage community members to challenge harmful gender norms and reduce VAW. The intervention is hypothesised to improve equitable masculinities, reduce alcohol use and ultimately, to reduce VAW. Intervention effectiveness will be determined through an audio computer-assisted self-interview questionnaire with behavioural measures among 2600 men aged between 18 and 40 years at baseline, 12 months and 24 months. The primary trial outcome is men's use of physical and/or sexual VAW. Secondary outcomes include harmful alcohol use, gender attitudes, controlling behaviours, transactional sex and social cohesion. The main analysis will be intention-to-treat based on the randomisation of clusters. A qualitative process evaluation is being conducted alongside the C-RCT. Implementers and men participating in the intervention will be interviewed longitudinally over the period of intervention implementation and observations of the workshops and other intervention activities are being carried out.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of the Witwatersrand Human Research Ethics Committee and procedures comply with ethical recommendations of the United Nations Multi-Country Study on Men and Violence. Dissemination of research findings will take place with local stakeholders and through peer-reviewed publications, with data available on request or after 5 years of trial completion.

TRIAL REGISTRATION NUMBER

NCT02823288; Pre-result.

Adolescent and Young Adult Male Mental Health: Transforming System Failures Into Proactive Models of Engagement

Adolescent and young adult men do poorly on indicators of mental health evidenced by elevated rates of suicide, conduct disorder, substance use, and interpersonal violence relative to their female peers. Data on global health burden clearly demonstrate that young men have a markedly distinct health risk profile from young women, underscoring different prevention and intervention needs. Evidence indicates that boys disconnect from health-care services during adolescence, marking the beginning of a progression of health-care disengagement and associated barriers to care, including presenting to services differently, experiencing an inadequate or poorly attuned clinical response, and needing to overcome pervasive societal attitudes and self-stigma to access available services. This review synthesizes key themes related to mental ill health in adolescent boys and in young adult men. Key social determinants are discussed, including mental health literacy, self-stigma and shame, masculinity, nosology and diagnosis, and service acceptability. A call is made for focused development of policy, theory, and evaluation of targeted interventions for this population, including gender-synchronized service model reform and training of staff, including the e-health domain. Such progress is expected to yield significant social and economic benefits, including reduction to mental ill health and interpersonal violence displayed by adolescent boys and young adult men.

Screening, management, and treatment of intimate partner violence among women in low-resource settings

The prevention of intimate partner violence continues to be a high priority for health practitioners and researchers around the world. Screening practices and intervention efforts utilized within high- and/or middle-income areas may not translate effectively to low-resource areas due to differences in financial, social, and physical context. However, little is known about the evidence-base of intervention efforts in such areas. Using the Arksey and O'Malley framework for scoping reviews, the purpose of this review was to synthesize what is known about intimate partner violence screening, management, and treatment in low-resource areas. A total of 31 programs reported across 34 articles were included in this scoping review. The programs incorporated a range of intervention activities, including group-based education and skill-development combined with microfinance to screening and referral to community resources. Slightly less than half of the studies (n = 14) were randomized controlled trials or clustered randomized controlled trials. Many barriers were common across the programs, including limited financial support, lack of community support, and lack of coordination across programs. Despite considerable barriers related to the limited available resources, the literature base had many strengths, such as strong evaluation methodologies, inclusion of a theoretical or conceptual framework to guide the intervention, and community engagement before and during the intervention implementation. However, insufficient statistical power and barriers related to cultural differences or inadequate cultural sensitivity were also common. With a variety of barriers to program implementation noted within the articles, it is important for researchers and practitioners to consider the geographic, social, cultural, and economic contexts when implementing intimate partner violence programs in low-resource areas. Given the significant differences in context across low-resource areas, additional research to establish effective protocols for tailoring and implementing evidence-based programs using a community-engaged framework would be beneficial to future research and practice.

Rethinking HIV-prevention for school-going young people based on current behaviour patterns

The aim of the research was to gain increased knowledge regarding the sexual risk behaviour of school-going young people in South Africa after two decades of HIV-education in schools, to contribute to the development of improved HIV prevention strategies. In collaboration with the Department of Education, a sample of 5305 learners (between 10 and 18 years in Grades 5-12) from high-risk communities were identified. They completed a survey that assessed self-reported sexual risk behaviour and variables that potentially underlie sexual risk, such as attitudes towards preventive behaviour, perceived social norms and self-efficacy (based on the theory of planned behaviour [TPB]) and social factors like caregiver relationships and gender norms (based on the social ecological theory). Lifetime sex was reported by 49.4% of boys and 30.5% of girls in Grades 8-12, while 56% of the sexually active young people reported consistent condom use. Accurate knowledge about HIV transmission was low (37.8%). Regression analysis showed that risk behaviour was more prominent among older male youths, who perceived social norms as encouraging sexual activity, who use alcohol excessively, and who have negative attitudes towards abstinence. Perceived traditional community gender norms and negative relationships with caregivers were also associated with sexual risk behaviour. This research showed that the TPB can be used in planning HIV prevention interventions for young people. It also revealed that HIV-prevention strategies should focus beyond educating the individual, to address community factors such as improving caregiver relationships, the culture of substance abuse, peer group norms and inequality in community gender norms. These community processes influence young people's behaviour and need to be addressed to allow the youth to make healthy behavioural choices.

Measurement of Social Norms Affecting Modern Contraceptive Use: A Literature Review

As a critical building block to developing social norms interventions to support healthy family planning and other reproductive health behaviors, we conducted a literature review to identify and evaluate social norm measures related to modern contraceptive use. Of 174 articles reviewed in full, only 17 studies met our criteria for inclusion. Across these articles, no single measure of norms was used in more than one study; failure to specify the boundaries of who was engaging in and influencing the behaviors of interest contributed to the variation. Most of the studies relied on cross-sectional data, only included condom use as their contraceptive use outcome, used individual- or interpersonal-level behavior change theories rather than social-level theories, and assumed a reference group, all of which limit the quality of the norm measures. We make several recommendations to bring greater consistency and comparability to social norm measures.

The invisibility of heterosexuality in HIV/AIDS prevention for men

Heterosexual men have been a forgotten group for HIV/AIDS interventions and research. Our goal was to identify the different elements that interfere in the prevention of HIV/AIDS among heterosexual men, covering both traditional methods of prevention (especially safe sex practices and testing) and new strategies for prevention (pre- and post-sexual exposure prophylaxis, prevention treatment, and circumcision) in this population. This exploratory article consists of a nonsystematic review of the literature. We discuss the invisibility of heterosexual men in policies, in programs, and in health services. The several interventions analyzed are still poorly monitored and evaluated, so there is a lack of consistent evidence regarding the impact of prevention strategies in this population. Different masculinities, including hegemonic conceptions of masculinity, must be the foundation for interventions targeting men. Men must not be seen merely as a "bridge" in the spread of the HIV/AIDS epidemic, but also as victims of gender patterns that make them vulnerable.

The influence of social constructs of hegemonic masculinity and sexual behaviour on acceptability of vaginal microbicides in Zambia

Vaginal microbicides are heralded as a woman's HIV prevention method. This study, conducted in a microbicide clinical trial setting in Zambia, explored how the social construction of masculinity and sexual behaviour influenced the acceptability of vaginal microbicides. The data were generated from 18 In-depth Interviews and 8 Focus Group Discussions. The data were analysed thematically. The study found that hegemonic masculinity influenced the use of vaginal microbicides positively and negatively, in multiple ways including: decision to initiate gel use, autonomous use of the gel, and consistent use of the gel. Men were seen as heads of households and decision-makers who approved their partners' intentions to initiate gel use. Autonomous gel use by women was not supported because it challenged men's dominant position in sexual matters and at a family level. The socially accepted notion that men engaged in multiple sexual relationships also influenced women's decision to use the gel. Sustained gel use depended on the perceived effect of the gel on men's sexual desires, sexual performance, fertility, and sexual behaviour. This study suggests that acceptability of microbicides partially lies within the realm of men, with use constrained and dictated by cultural constructs and practice of masculinity and gender.

Church representatives' perspectives on masculinities in the context of HIV: the case of the Ecumenical HIV and AIDS Initiative in Africa

Despite a growing body of literature related to church leaders challenging dominant norms of masculinities that may enable the spread of HIV, research on masculinity issues among African church representatives who are policy makers is scarce. The objectives of this study were to explore the perspectives on masculinities held by church representatives within the Ecumenical HIV and AIDS Initiative in Africa (EHAIA) and to identify strategies they used to transform masculinities in their respective churches. Qualitative interviews were carried out with 14 church representatives belonging to the EHAIA International Reference Group. These interviews were analysed using thematic analysis and four themes were identified: "barriers to challenge masculinities" may contribute to the spread of HIV; "counterproductive conservative church leadership" fails to challenge dominant forms of masculinities; "facilitators to challenge masculinities" perceived as slowly changing men and "an evolving hope for gender equality" would be perceived in certain marital relationships. The latter two were viewed as positive approaches resulting from masculinity workshops and male priests disclosing their HIV-positive status. This research highlights strategies that may help male church-goers challenge masculinities, support gender equality and, improve the lives of men and women in the context of HIV.

Advancing gender equality to improve HIV prevention: A study of practice

Addressing gender inequality as a social driver of HIV risk and vulnerability has become a key activity of non-governmental organisations (NGOs) in South Africa. This paper sheds light on the environmental factors that influence gender and HIV activities in this context. A multisite ethnographic study including 150 hours of participant observation and 32 in-depth interviews was conducted with 26 NGOs carrying out gender and HIV prevention interventions. Using thematic network analysis, 108 different intervention activities were identified, categorised and further analysed to explore environmental factors that influence the design and delivery of these activities. The findings highlight how practitioners draw on different theories of change about how to address the gender inequalities that contribute to HIV risk and vulnerability, which in turn influence the way interventions are delivered. Despite these theoretical differences, commonalities arise in practitioners' use of popular narratives about the right to health and lived experiences of AIDS to ensure interventions are contextually relevant and to gain buy-in from participants. Other environmental factors influencing intervention activities include the role that insecure funding for gender plays in undermining the capacity of practitioners to design interventions based on their local knowledge and experience by forcing NGOs to adapt to the priorities of international donors.

Gender, Health and Change in South Africa: Three Ways of Working with Men and Boys for Gender Justice

INTRODUCTION

This article addresses the question of how to "think about" and to "do" gender change in the context of HIV and public health interventions in South Africa. The issue of gender has been closely intertwined with the HIV epidemic in Southern Africa since the beginning of the epidemic. The need for more gender equitable practices and relationships has been a central theme of the response to the crisis. While much of this work has focused on efforts to reduce the uneven impact of HIV has on women and girls, there have also been important interventions with men and boys around gender and HIV. This article synthesizes findings from research projects with three such interventions.

METHODS

The findings presented here are drawn from three separate research projects conducted in South Africa in the last 10 years. The first was an ethnographic research project with the Khululeka Men's Support Group in Cape Town. The second was an independent program evaluation of the "One Man Can" campaign that was commissionned by Sonke Gender Justice, a gender transformation NGO in South Africa. The third project was a qualitative process evaluation of a trial that used male lay health workers to provide support and care to pregnant and postpartum women who were enrolled in a PMTCT program.

RESULTS

Gender and gender change were understood and promoted in contrasting ways across the three case studies. In the case of Khululeka, HIV-positive men were encouraged to become "better men" within the context of existing gender norms by doing things that would protect their health and allow them to achieve socially valued roles as strong family leaders and financial providers. They began with a conventional HIV support group model but adapted it to better suit local gender norms around masculinity. In Sonke's One Man Can (OMC) campaign, the focus was on the ways men and women could address the underlying gender inequities in their families and communities. Participants were encouraged to raise their awareness and critical understandding of gender-related rights issues and mobilize for progressive gender change. Sonke staff struggled, however, to find ways of sustaining the changes they witnessed in OMC workshops and an ideological tension persisted between "culture talk" and "rights talk" about gender. Finally, in the PMTCT program, men were recruited to serve as lay counselors for HIV-positive pregnant women. By carefully training and supporting men in the daily practice of providing care for these women, male counselors developed trusting relationships, offered effective services, and in general, undertook a form of gender-transformed practice that exceeded much of what was observed in the other two case studies.

DISCUSSION

There are many potential paths to gender transformation, and the HIV epidemic in Southern Africa has operated as a powerful catalyst for exploring and pursuing some of these paths. In the process, however, a number of political and conceptual limitations of gender transformation work emerged. There is a need to find ways of thinking about and acting on gender that isn't over-determined by the logics of public health and biomedicine. There is also a need to complement ideological arguments for "gender transformation" with more embodied opportunities for transformed gendered practice.

What role can gender-transformative programming for men play in increasing men's HIV testing and engagement in HIV care and treatment in South Africa?

Men are less likely than women to test for HIV and engage in HIV care and treatment. We conducted in-depth interviews with men participating in One Man Can (OMC) - a rights-based gender equality and health programme intervention conducted in rural Limpopo and Eastern Cape, South Africa - to explore masculinity-related barriers to HIV testing/care/treatment and how participation in OMC impacted on these. Men who participated in OMC reported an increased capability to overcome masculinity-related barriers to testing/care/treatment. They also reported increased ability to express vulnerability and discuss HIV openly with others, which led to greater willingness to be tested for HIV and receive HIV care and treatment for those who were living with HIV. Interventions that challenge masculine norms and promote gender equality (i.e. gender-transformative interventions) represent a promising new approach to address men's barriers to testing, care and treatment.

Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa

Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with "care" and "capability" among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.

Predictors of Condom Use Among Iranian Women at Risk of HIV

Sexual transmission of HIV/AIDS is increasing in Iran and is the main route of infection among women. In order to foster the development of future HIV prevention interventions for women, researchers need to understand the factors that influence sexual risk reduction behaviors in this group. The aim of this study was to explore the predictors of condom use among women at risk of HIV and develop a model of condom use in a sample of women at risk of HIV. We cross-sectionally examined predictors of condom use among 200 women at risk of HIV. Women were recruited from drop-in centers and voluntary counseling and testing centers in Tehran. Condom use among women at risk of HIV was examined using path analysis, and fit indices showed a good fit for the model. Condom use self-efficacy, social support, and less stereotypic gender roles influenced sexually protective behaviors of women at risk of HIV. Our results can provide a basis for future gender-specific intervention programs among women at risk of HIV. Researchers, practitioners, and organizations that play a central role in protecting the health of this population can make use of these results for the benefit of sexual and reproductive health programs.