A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention

Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial

INTRODUCTION

Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries.

METHODS

We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling.

RESULTS

Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure.

CONCLUSIONS

Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions.

TRIAL REGISTRATION NUMBER

NCT03447912.

HIV Focused Sexual Risk-Reduction Interventions Targeting Adolescent Boys and Young Men in Sub-Saharan Africa: A Scoping Review

Adolescent girls and young women's exceptionalism with HIV interventions has left adolescent boys and young men (ABYM) trailing behind, thus becoming a marginalized and underserved population. The scoping review aimed to provide an overview of interventions that have targeted sexual risk behaviors in ABYM in Sub-Saharan Africa (SSA) over the previous 21 years with critical insights on 'what works' in preventing the sexual transmission of HIV. A scoping review guided by Arksey and O'Malley's (in Int J Soc Res Methodol 8(1):19-32, 16) framework and the 2015 Johanna Briggs Institute's guidelines was conducted. A search of literature published between 2000 and 2020 was reviewed and twenty nine interventions from nine Sub Saharan African countries that met the eligibility criteria were reviewed. The review provides evidence on the successes and the limitations of sexual risk behavior interventions for ABYM in SSA. There is clear and consistent evidence that interventions reduce sexual risk behaviors in adolescent boys and young men. Their efficiency seems to grow with the length and intensity of the intervention. Positive effects were generally observed in condom use and on measures of HIV knowledge, attitudes and sexual behaviors as well as uptake of HIV tests and voluntary male circumcision. This review shows that sexual-risk interventions engaging men and boys in SSA are promising and warrant further rigorous development in terms of conceptualization, design and evaluation.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power

INTRODUCTION

Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power.

METHODS

Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed.

RESULTS

The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures.

CONCLUSION

This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort

We previously demonstrated that village community mobilization (CM) was associated with reduced HIV incidence among adolescent girls and young women (AGYW) in South Africa. Little remains known about the mechanisms linking CM to HIV incidence. Using longitudinal data from 2292 AGYW in the HPTN 068 cohort (2011-2017), we examined whether school attendance, pro-social engagement, and hope for the future mediated the relationship between CM and HIV incidence. CM was measured at the village-level via two population-based surveys (2012 and 2014). Mediators and incident HIV infection were measured through HPTN 068 surveys and HIV testing. Mediation analyses were conducted using Mplus 8.5, adjusting for village-level clustering and covariates. Hope for the future mediated the relationship between CM and HIV incidence (indirect effect-RR 0.98, bias-corrected 95% CI 0.96, 0.99). Pro-social engagement and school attendance did not demonstrate indirect effects. CM reduces AGYW's HIV acquisition risk, in part, by engendering hope.

Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery

STUDY OBJECTIVE

We investigated two peer distribution models of HIV self-testing (HIVST) in HIV prevention demand creation compared with trained young community members (peer navigators).

METHODS

We used restricted randomisation to allocate 24 peer navigator pairs (clusters) in KwaZulu-Natal 1:1:1: (1) standard of care (SOC): peer navigators distributed clinic referrals, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) information to 18-30 year olds. (2) peer navigator direct distribution (PND): Peer navigators distributed HIVST packs (SOC plus two OraQuick HIVST kits) (3) incentivised peer networks (IPN): peer navigators recruited young community members (seeds) to distribute up to five HIVST packs to 18-30 year olds within their social networks. Seeds received 20 Rand (US$1.5) for each recipient who distributed further packs. The primary outcome was PrEP/ART linkage, defined as screening for PrEP/ART eligibility within 90 days of pack distribution per peer navigator month (pnm) of outreach, in women aged 18-24 (a priority for HIV prevention). Investigators and statisticians were blinded to allocation. Analysis was intention to treat. Total and unit costs were collected prospectively.

RESULTS

Between March and December 2019, 4163 packs (1098 SOC, 1480 PND, 1585 IPN) were distributed across 24 clusters. During 144 pnm, 272 18-30 year olds linked to PrEP/ART (1.9/pnm). Linkage rates for 18-24-year-old women were lower for IPN (n=26, 0.54/pnm) than PND (n=45, 0.80/pnm; SOC n=49, 0.85/pnm). Rate ratios were 0.68 (95% CI 0.28 to 1.66) for IPN versus PND, 0.64 (95% CI 0.26 to 1.62) for IPN versus SOC and 0.95 (95% CI 0.38 to 2.36) for PND versus SOC. In 18-30 year olds, PND had significantly more linkages than IPN (2.11 vs 0.88/pnm, RR 0.42, 95% CI 0.18 to 0.98). Cost per pack distributed was cheapest for IPN (US$36) c.f. SOC (US$64). Cost per person linked to PrEP/ART was cheaper in both peer navigator arms compared with IPN.

DISCUSSION

HIVST did not increase demand for PrEP/ART. Incentivised social network distribution reached large numbers with HIVST but resulted in fewer linkages compared with PrEP/ART promotion by peer navigators.

TRIAL REGISTRATION NUMBER

NCT03751826.

Discrimination, HIV conspiracy theories and pre-exposure prophylaxis acceptability in gay men

Background Combination prevention, which includes pre-exposure prophylaxis (PrEP), is essential for achieving the zero HIV infections target in the UK by 2030. It is important to assess attitudes towards PrEP in at-risk populations. This study focuses on the effect of discrimination and HIV conspiracy theorising on attitudes towards PrEP in gay men in the UK.

METHODS

In total, 244 White British gay men completed a survey that included demographic questions and measures of sexual health screening, hypervigilance, sexual orientation discrimination, quality of contact with healthcare professionals, belief in conspiracy theories and attitudes towards PrEP. Data were analysed using multiple linear regression and mediation analysis.

RESULTS

Discrimination was positively correlated with HIV conspiracy beliefs and negatively correlated with PrEP acceptance. Mediation analyses demonstrated that the relationship between discrimination and attitudes towards PrEP was explained by HIV conspiracy theorising. Gay men who had attended a sexual health screening (vs never attended) reported higher belief in HIV conspiracy theories. A further mediation analysis showed that reported poor contact with a healthcare professional was associated with an increased belief in HIV conspiracy theories, which was associated with negative attitudes towards PrEP. Both perceived discrimination and poor contact with a healthcare professional were exacerbated by hypervigilance.

CONCLUSIONS

HIV conspiracy theorising is an important variable in understanding attitudes towards PrEP among gay men. Its roots are in adverse social experiences (e.g. discrimination, poor contact with healthcare professionals) and its consequences may be the rejection of PrEP. HIV prevention and PrEP campaigns must focus on prejudice reduction and on challenging conspiracy beliefs.

Changes in Family-Level Attitudes and Norms and Association with Secondary School Completion and Child Marriage Among Adolescent Girls: Results from an Exploratory Study Nested Within a Cluster-Randomised Controlled Trial in India

We evaluated the impact of Samata, a 3-year multilayered intervention among scheduled caste/scheduled tribe (SC/ST) adolescent girls in rural northern Karnataka, on family-level (parents or guardian) attitudes and direct and indirect norms related to child marriage and girl's education. Endline data from 1840 family members were used to assess the effect of Samata on attitudes and norms related to schooling and child marriage, while data from 4097 family members (including 2257 family members at baseline) were used to understand the shifts in attitudes and norms over the period 2014-2017. Overall, we found that the programme had little impact on family-level attitudes and norms. However, there were shifts in some attitudes, norms and perceived sanctions between baseline (when girls were aged 13-14 years) and endline (when girls were aged 15-16 years), with some becoming more progressive (e.g. direct norms related to child marriage) and others more restrictive (e.g. norms around girls completing secondary education and norms related to child marriage and educational drop-out, blaming girls for eve teasing and limiting girls' mobility so as to protect family honour). Moreover, non-progressive norms related to marriage and education were strongly associated with child marriage and secondary school non-completion among adolescent girls in this rural setting. Norms hypothesised to be important for marriage and schooling outcomes were indeed associated with these outcomes, but the intervention was not able to significantly shift these norms. In part, this may have been due to the intervention focusing much of its initial efforts on working with girls alone rather than family members, the relevant reference group. Future interventions that seek to affect norms should conduct formative research to clarify the specific norms affecting the outcome(s) of interest; likewise, programme planners should ensure that all activities engage those most influential in enforcing the norm(s) from the beginning. ClinicalTrials.gov registration number: NCT01996241.

Longitudinal Trajectories of Physical Intimate Partner Violence Among Adolescent Girls in Rural South Africa: Findings From HPTN 068

PURPOSE

Little is known about temporal patterns of physical intimate partner violence (PIPV) among South African adolescent girls. We sought to identify and describe PIPV risk trajectories and related correlates in this population.

METHODS

Our analytical cohort came from the HPTN 068 Cash Transfer Trial in Mpumalanga Province, South Africa. Cohort members were eighth and ninth graders (median age 14 years) who enrolled in 2011 and had three to four annual, self-reported PIPV measurements. We used group-based trajectory models to identify groups of girls with similar longitudinal patterns of PIPV risk over 4 years and potential correlates of group membership.

RESULTS

We identified two trajectory groups (n = 907): a higher-risk group (~52.8% of the cohort) with predicted PIPV probabilities of 13.5%-41.1% over time and a lower-risk group (~47.2% of the cohort) with predicted probabilities of 2.3%-10.3%. Baseline correlates of higher-risk group membership were ever having had sex (adjusted odds ratio [aOR]: 4.42, 95% confidence interval [CI]: 1.56-12.57), borrowing money (aOR: 1.95, 95% CI: 1.01-3.79), and older age (aOR per 1-year increase: 1.39, 95% CI: 1.11-1.73), while being in the 068 intervention arm (aOR: .29, 95% CI: .17-.51) and supporting more gender-equitable norms (aOR per 1-unit score increase: .89, 95% CI: .81-.97) were inversely associated.

CONCLUSIONS

A high proportion of adolescent girls experience sustained PIPV risk in rural South Africa, suggesting a need for interventions in late primary school that encourage gender-equitable norms, healthy relationships, and safe ways to earn income during adolescence.

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.

Consistent Provisions Mitigate Exposure to Sexual Risk and HIV Among Young Adolescents in South Africa

Exposure to sexual risk in early adolescence strongly predicts HIV infection, yet evidence for prevention in young adolescents is limited. We pooled data from two longitudinal South African surveys, with adolescents unexposed to sexual risk at baseline (n = 3662). Multivariable logistic regression tested associations between intermittent/consistent access to eight provisions and reduced sexual risk exposure. Participants were on average 12.8 years, 56% female at baseline. Between baseline and follow-up, 8.6% reported sexual risk exposure. Consistent access to caregiver supervision (OR 0.53 95%CI 0.35-0.80 p = 0.002), abuse-free homes (OR 0.55 95%CI 0.37-0.81 p = 0.002), school feeding (OR 0.55 95%CI 0.35-0.88 p = 0.012), and HIV prevention knowledge (OR 0.43, 95%CI 0.21-0.88 p = 0.021) was strongly associated with preventing early sexual risk exposure. While individual factors reduced the odds of sexual risk exposure, a combination of all four resulted in a greater reduction, from 12.9% (95%CI 7.2-18.7) to 1.0% (95%CI 0.2-1.8). Consistent access to provisions in early adolescence may prevent sexual risk exposure among younger adolescents.

Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial

BACKGROUND

In a cluster randomised controlled trial in Mumbai slums, we will test the effects on the prevalence of violence against women and girls of community mobilisation through groups and individual volunteers. One in three women in India has survived physical or sexual violence, making it a major public health burden. Reviews recommend community mobilisation to address violence, but trial evidence is limited.

METHODS

Guided by a theory of change, we will compare 24 areas receiving support services, community group, and volunteer activities with 24 areas receiving support services only. These community mobilisation activities will be evaluated through a follow-up survey after 3 years. Primary outcomes will be prevalence in the preceding year of physical or sexual domestic violence, and prevalence of emotional or economic domestic violence, control, or neglect against women 15-49 years old. Secondary outcomes will describe disclosure of violence to support services, community tolerance of violence against women and girls, prevalence of non-partner sexual violence, and mental health and wellbeing. Intermediate theory-based outcomes will include bystander intervention, identification of and support for survivors of violence, changes described in programme participants, and changes in communities.

DISCUSSION

Systematic reviews of interventions to prevent violence against women and girls suggest that community mobilisation is a promising population-based intervention. Already implemented in other areas, our intervention has been developed over 16 years of programmatic experience and 2 years of formative research. Backed by public engagement and advocacy, our vision is of a replicable community-led intervention to address the public health burden of violence against women and girls.

TRIAL REGISTRATION

Controlled Trials Registry of India, CTRI/2018/02/012047. Registered on 21 February 2018. ISRCTN, ISRCTN84502355. Registered on 22 February 2018.

Process elements contributing to community mobilization for HIV risk reduction and gender equality in rural South Africa

Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the ‘One Man Can’ intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a ‘better life’ and associated with behaviour change in the intervention’s main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization—specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.

Multilevel Gender-Equitable Norms and Risk of HIV and Herpes Simplex Virus Type 2 Acquisition Among Young South African Women: A Longitudinal Analysis of the HIV Prevention Trials Network 068 Cohort

PURPOSE

Adolescent girls and young women (AGYW) in South Africa experience a disproportionately high burden of HIV acquisition. National HIV prevalence among AGYW increases nearly three-fold during the transition from late teenage years to their early twenties. We investigated whether beliefs about gender equity influence subsequent HIV acquisition among AGYW in South Africa.

METHODS

We used data from the HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of AGYW in Mpumalanga Province, South Africa. Gender-equitable beliefs were measured at the level of the individual and summarized among school peers and adults in the community using the Gender Equitable Men's Scale (GEMS). Generalized estimating equation regression was used to assess the association between individual, peer and community GEMS and HIV incidence, herpes simplex virus type 2 (HSV-2) incidence, and other HIV risk factors while accounting for repeated observations and clustering.

RESULTS

A total of 2,533 AGYW were followed up for up to 5 years. Adjusting for potential confounders, a unit increase in peer GEMS scores (i.e. more equitable) were significantly protective against subsequent HIV acquisition (risk difference = -.019; 95% confidence interval: -.032, -.006) and subsequent HSV-2 acquisition (risk difference = -.020; 95% confidence interval: -.040, -.000). Low individual and community GEMS scores were associated with multiple HIV risk factors but not with HIV or HSV-2 incidence directly.

CONCLUSION

School-level peer endorsement of gender equity may be protective against HIV and HSV-2 incidence among AGYW. Interventions that increase gender equity at the individual level and at the level of the social environment, particularly among school peers, have the potential for protective effects on the health of AGYW.

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.

Cluster randomised trials with different numbers of measurements at baseline and endline: Sample size and optimal allocation

BACKGROUND/AIMS

Published methods for sample size calculation for cluster randomised trials with baseline data are inflexible and primarily assume an equal amount of data collected at baseline and endline, that is, before and after the intervention has been implemented in some clusters. We extend these methods to any amount of baseline and endline data. We explain how to explore sample size for a trial if some baseline data from the trial clusters have already been collected as part of a separate study. Where such data aren't available, we show how to choose the proportion of data collection devoted to the baseline within the trial, when a particular cluster size or range of cluster sizes is proposed.

METHODS

We provide a design effect given the cluster size and correlation parameters, assuming different participants are assessed at baseline and endline in the same clusters. We show how to produce plots to identify the impact of varying the amount of baseline data accounting for the inevitable uncertainty in the cluster autocorrelation. We illustrate the methodology using an example trial.

RESULTS

Baseline data provide more power, or allow a greater reduction in trial size, with greater values of the cluster size, intracluster correlation and cluster autocorrelation.

CONCLUSION

Investigators should think carefully before collecting baseline data in a cluster randomised trial if this is at the expense of endline data. In some scenarios, this will increase the sample size required to achieve given power and precision.

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.

Gender Norms and HIV Testing/Treatment Uptake: Evidence from a Large Population-Based Sample in South Africa

How does the endorsement of different dimensions of gender norms by men and/or women influence their use of HIV testing and antiretroviral treatment? This question was examined using data from a 2014 population-based survey of 1053 women and 1004 men, ages 18-49, in rural South Africa. We used a global measure for views toward gender norms (the GEM Scale), plus four subsets of scale items (all reliabilities ≥ 0.7). In multivariate analyses using the global measure, endorsement of inequitable gender norms was associated with more testing (AOR 2.47, p < 0.01) and less treatment use (AOR 0.15, p < 0.01) among women but not men. When examining specific subsets of inequitable norms (e.g., endorsing men as the primary decision-maker), decreased odds of treatment use was found for men as well (AOR 0.18, p < 0.01). Careful attention to the role specific gender norms play in HIV service uptake can yield useful programmatic recommendations.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

Disrupting gender norms in health systems: making the case for change

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.

Community collective efficacy is associated with reduced physical intimate partner violence (IPV) incidence in the rural province of Mpumalanga, South Africa: findings from HPTN 068

BACKGROUND

Intimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common.

METHODS

We collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates.

RESULTS

Thirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94; 95% CI 0.89 to 0.98) among AGYW after adjusting for covariates.

CONCLUSIONS

Community-level interventions that foster the development of collective efficacy may reduce IPV among AGYW.

Village community mobilization is associated with reduced HIV incidence in young South African women participating in the HPTN 068 study cohort

INTRODUCTION

Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW.

METHODS

We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates.

RESULTS

There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role.

CONCLUSIONS

These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.

Understanding men's networks and perceptions of leadership to promote HIV testing and treatment in Agincourt, South Africa

Understanding informal leadership in high HIV prevalence settings is important for the success of popular opinion leader (POL) and other HIV testing and treatment promotion strategies which aim to leverage the influence of these leaders. We conducted a study in Mpumalanga province, South Africa, in which we aimed to: (1) describe men's personal networks and key social relationships; and (2) describe the types of individuals men identify as leaders. We administered a structured questionnaire with 45 men (15 HIV-positive and 30 HIV-negative) in which men enumerated and described characteristics of individuals they share personal matters with, and people they considered as leaders. We further conducted in-depth interviews with 25 of these men to better understand men's conceptualisation of leadership in their community. Family members were prominent in men's personal networks and among the leaders they nominated. Men living with HIV were much more likely to know others living with HIV, and described friendships on the basis of the shared experience of HIV treatment. Future POL interventions aiming to promote HIV testing and care among men in rural South Africa should consider the importance of family in community leadership, and seek to leverage the influence of connections between men living with HIV.

The effect of a community based health promotion intervention to change gender norms among women in a rural community in Sri Lanka

BACKGROUND

Gender norms practiced by respective societies increase the risk of violence by men against women. To date, there is a dearth of research evidence on changing gender norms through health promotion approaches around the globe, including in Sri Lanka. This study provides an evaluation of effectiveness of a health promotion intervention in changing the acceptance of gender norms among women.

METHODS

A quasi-experimental study was conducted in two rural villages in Anuradhapura district in Sri Lanka including women who have a child under five years of age. One village was allocated to receive an intervention developed based on a health promotion approach and the other village was a control. A community based mechanism to question selected gender norms among women was developed as the intervention. The pre- and post-intervention assessments of the level of acceptance of gender norms were done using an interviewer administered questionnaire and by using focus group discussions.

RESULTS

Following the intervention, acceptances of prominent gender norms were changed significantly among the women receiving the intervention method. The control group showed no changes towards the acceptance of gender norms during this period. Women in the intervention group had higher levels of self-reported positive behavior changes and greater understanding of gender concepts compared to the control group.

CONCLUSION

The acceptance of gender norms among women in rural villages in Sri Lanka can be changed by a community based intervention targeting gender norms.

Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa

INTRODUCTION

Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk.

METHODS

Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (post-intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes.

RESULTS

Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16).

CONCLUSION

Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly.

CLINICAL TRIALS NUMBER

ClinicalTrials.gov NCT02129530.

Gender Norms, Gender Role Conflict/Stress and HIV Risk Behaviors Among Men in Mpumalanga, South Africa

Men's gender role conflict and stress (GRC/S), the psychological strain they experience around fulfilling expectations of themselves as men, has been largely unexplored in HIV prevention research. We examined associations between both men's gender norms and GRC/S and three HIV risk behaviors using data from a population-based survey of 579 18-35 year-old men in rural northeast South Africa. Prevalence of sexual partner concurrency and intimate partner violence (IPV) perpetration in the last 12 months were 38.0 and 13.4%, respectively; 19.9% abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with an increased odds of concurrency (p = 0.01; p < 0.01, respectively), IPV perpetration (p = 0.03; p < 0.01), and alcohol abuse (p = 0.02; p < 0.001), controlling for demographic characteristics. Ancillary analyses demonstrated significant positive associations between: concurrency and the GRC/S sub-dimension subordination to women; IPV perpetration and restrictive emotionality; and alcohol abuse and success, power, competition. Programs to transform gender norms should be coupled with effective strategies to prevent and reduce men's GRC/S.

Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women

Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at individual and community levels and recent testing using a population-based sample (n = 1126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14-0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6-10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97-2.03; p = 0.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (p < 0.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately.

Men's Perceptions of Treatment as Prevention in South Africa: Implications for Engagement in HIV Care and Treatment

While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the know value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics.

Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial

BACKGROUND

HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care.

METHODS/DESIGN

Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM.

DISCUSSION

Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa.

TRIAL REGISTRATION

NCT02197793 Registered July 21, 2014.

Community Mobilization for HIV Testing Uptake: Results From a Community Randomized Trial of a Theory-Based Intervention in Rural South Africa

BACKGROUND

HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action.

METHODS

We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization.

RESULTS

Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores.

CONCLUSIONS

There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.

Qualitative evaluation of selected social factors that impact sexual risk-taking behaviour among African students in Kwazulu-Natal, South Africa

BACKGROUND

The incidence of HIV and AIDS continues to be a source of great concern within universities in South Africa. Furthermore, university students constitute an important community in the intervention against the HIV/AIDS epidemic. Students in the age group of 15-24 years are at a greater risk of HIV infection than any other group in the country; yet, little is known about why they continue to engage in risky sexual practices.

OBJECTIVES

This study was designed to explore the sexual behaviour of students in a metropolitan Durban University of Technology in KwaZulu-Natal to understand the social factors underlying their risk of HIV infection.

METHODS

This is a qualitative study that used cluster sampling where the population was stratified by campus and faculty. The study population was selected using a standard randomization technique. This was a part of a multi-phased research project aimed at providing a sero-prevalence baseline and an analysis of risk-taking behaviour at a Durban University of Technology in the eThekwini Metropolitan Municipality area.

RESULTS

The study highlights peer pressure among students as an influence in promoting high-risk sexual behaviour. Within this context, the findings revealed that university students lack the ability to negotiate risk-aware decisions especially regarding sexual relationships.

CONCLUSION

This study draws attention to the perspectives of African university students regarding their risk-taking sexual practices and selected factors which influence such behaviour. The findings are not exhaustive in exploring contextual antecedents that shape students' sexual practices. However, they provide an important basis in understanding key factors which expose students to HIV infections. The study provides insights into opportunities for further studies as well as preventative implications.

"Generally the young mom suffers much:" Socio-cultural influences of maternal capabilities and nutrition care in Uganda

We conducted 40 in-depth interviews and eight focus groups among mothers and fathers (n = 91) of diverse ages in western Uganda to define the relevant domains of maternal capabilities and their relationship to infant and young child feeding practices. This study was directed by a developing theory of maternal capabilities that posits that the impact of health-directed interventions may be limited by unmeasured and poorly understood maternal characteristics. Ugandan caregivers defined three major life events that constrain women's capabilities for childcare: early pregnancy, close child spacing, and polygamous marriage. Women describe major constraints in their decision-making capabilities generally and specifically to procuring food for young children. Future nutrition programs may improve their impact through activities that model household decision-making scenarios, and that strengthen women's social support networks. Findings suggest that efforts to transform gender norms may be one additional way to improve nutrition outcomes in communities with a generally low status of women relative to men. The willingness of younger fathers to challenge traditional gender norms suggests an opportunity in this context for continued work to strengthen resources for children's nutritional care.

SIGNIFICANCE

Maternal factors such as autonomy are associated with child feeding practices and nutritional status, with varying degrees depending on the definition of maternal-level constructs and context. This study describes the events and processes that constrain maternal capabilities-intrapersonal factors that shape mother's abilities to leverage resources to provide care to children-as they relate to nutrition and hygiene practices. We report community beliefs and understandings about which capabilities have meaning for child nutrition and hygiene, and develop a conceptual framework to describe how these capabilities are formed and describe implications for future nutrition programs in East Africa and similar settings.

Predicting the Population Health Impacts of Community Interventions: The Case of Alcohol Outlets and Binge Drinking

A substitution estimator can be used to predict how shifts in population exposures might change health. We illustrated this method by estimating how an upper limit on alcohol outlet density might alter binge drinking in the New York Social Environment Study (n = 4000), and provided statistical code and sample data. The largest differences in binge drinking were for an upper limit of 70 outlets per square mile; there was a -0.7% difference in binge drinking prevalence for New York City overall (95% confidence interval [CI] = -0.2%, -1.3%) and a -2.4% difference in binge drinking prevalence for the subset of communities the intervention modified (95% CI = -0.5%, -4.0%). A substitution estimator is a flexible tool for estimating population intervention parameters and improving the translation of public health research results to practitioners.

Measuring Men's Gender Norms and Gender Role Conflict/Stress in a High HIV-Prevalence South African Setting

Gender norms and gender role conflict/stress may influence HIV risk behaviors among men; however scales measuring these constructs need further development and evaluation in African settings. We conducted exploratory and confirmatory factor analyses to evaluate the Gender Equitable Men's Scale (GEMS) and the Gender Role Conflict/Stress (GRC/S) scale among 581 men in rural northeast South Africa. The final 17-item GEMS was unidimensional, with adequate model fit and reliability (alpha = 0.79). Factor loadings were low (0.2-0.3) for items related to violence and sexual relationships. The final 24-item GRC/S scale was multidimensional with four factors: Success, power, competition; Subordination to women; Restrictive emotionality; and Sexual prowess. The scale had adequate model fit and good reliability (alpha = 0.83). While GEMS is a good measure of inequitable gender norms, new or revised scale items may need to be explored in the South African context. Adding the GRC/S scale to capture men's strain related to gender roles could provide important insights into men's risk behaviors.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Development, validation, and performance of a scale to measure community mobilization

RATIONALE

Community mobilization approaches (CMAs) are increasingly becoming key components of health programming. However, CMAs have been ill defined and poorly evaluated, largely due to the lack of measurement tools to assess mobilization processes and impact.

OBJECTIVE

We developed the Community Mobilization Measure (CMM), composed of a set of scales to measure mobilization domains hypothesized to operate at the community-level. The six domains include: shared concerns, critical consciousness, leadership, collective action, social cohesion, and organizations and networks. We also included the domain of social control to explore synergies with the related construct of collective efficacy.

METHOD

A survey instrument was developed and pilot tested, then revised and administered to 1181 young people, aged 18-35, in a community-based survey in rural South Africa. Item response modeling and exploratory factor analyses were conducted to assess model fit, dimensionality, reliability, and validity.

RESULTS

Results indicate the seven-dimensional model, with linked domains but no higher order construct, fit the data best. Internal consistency reliability of the factors was strong, with ρ values ranging from 0.81 to 0.93. Six of seven scales were sufficiently correlated to represent linked concepts that comprise community mobilization; social control was less related to the other components. At the village level, CMM sub-scales were correlated with other metrics of village social capital and integrity, providing initial evidence of higher-level validity, however additional evaluation of the measure at the community-level is needed.

CONCLUSION

This is the first effort to develop and validate a comprehensive measure for community mobilization. The CMM was designed as an evaluation tool for health programming and should facilitate a more nuanced understanding of mechanisms of change associated with CM, ultimately making mobilizing approaches more effective.