Gender Norms, Masculine Gender-Role Strain, and HIV Risk Behaviors Among Men in Rural South Africa

Introduction: Studies suggest strong links between inequitable gender norms and men’s HIV risk behaviors in South Africa, where one-fifth of adults are HIV-positive. Masculine gender-role strain (MGRS), the psychological strain men experience from trying to live up to expectations of themselves as men, had not previously been measured or applied in HIV prevention research in the African setting. The aims of this mixed-methods study among men in Mpumalanga province were to evaluate measures of gender norms and MGRS, examine relationships between these constructs and key HIV risk behaviors, and qualitatively explore men’s experience of MGRS. Methods: Quantitative data came from community surveys with 581 men ages 18 to 35. We conducted factor analyses to assess the factor structure, validity, and reliability of the Gender Equitable Men’s scale (GEMS) and Gender Role Conflict/Stress (GRC/S) scale. We then used logistic regression to examine the impact of inequitable gender norms and MGRS on three HIV risk behaviors. Finally, we conducted qualitative interviews with 18 men and analyzed data using both narrative and coding procedures. Results: The unidimensional GEMS and multidimensional GRC/S scale were valid and reliable. Prevalence of sexual partner concurrency in the previous last 12 months was 38.0%, 13.4% of men reported perpetrating intimate partner violence (IPV) in that period, and 19.9% abused alcohol. In multivariate analyses, more inequitable gender norms and higher MGRS were each significantly associated with an increased odds of concurrency, IPV perpetration, and alcohol abuse. Qualitative findings supported the salience of MGRS in men’s lives. Men experienced all three theoretical sub-types of MGRS. Most common was discrepancy strain from unemployment; twothirds of men were unmarried and unable to establish their own households and become providers. Some men also experienced trauma strain from intense peer pressure to sexually exploit women. Finally, participants described dysfunction strain from restricting emotions and abusing alcohol, which contributed to family violence. Conclusion: Social constructions of masculinity shape HIV risk in Mpumalanga. We underscore recent calls to scale up gender transformative programs and recommend exploring complementary strategies to reduce the three sub-types of MGRS grounded in a local understanding of male vulnerabilities.Doctor of Philosoph

Building evidence to guide PrEP introduction for adolescent girls and young women

This document was developed by the Population Council, with support from the Bill & Melinda Gates Foundation, to provide DREAMS country teams with practical guidance on building evidence to guide pre-exposure prophylaxis (PrEP) introduction for adolescent girls and young women (AGYW). The primary audiences for this document are health policymakers and program planners who will be making decisions about how PrEP is introduced and the researchers who will assess AGYW’s specific needs and experiences. Our aim is to complement emerging global guidance on PrEP and ongoing work regarding delivery platforms, marketing, and policy and regulatory frameworks for PrEP introduction more generally. We focus on examining the factors that influence informed choice, demand, and use of PREP by young women and that influence client–provider interactions. Further, this document can serve as a useful guide to gather data on user, community, and provider perspectives as countries move from introduction to broad-based implementation of PrEP

Expanding delivery of and access to evidence-based comprehensive HIV/SRH services among men who have sex with men (MSM) and transgender persons in Nigeria

The goals of this project were to: i) increase comprehensive HIV service delivery among MSM, transgender women, and their sexual partners, ii) build the capacity of a local NGO to function as a one-stop-shop for HIV and STI services, and iii) build evidence around the “hub and spokes” service delivery model, how to best reach transgender populations, and to pilot an intervention intended to promote mental health and reduce intersectional, internalized stigma experienced by sexual and gender minorities (both living with HIV and at risk of HIV acquisition). The project implemented a “hub and spokes” model of service provision of comprehensive HIV, sexual and reproductive health and support services to MSM and transgender women in Lagos. Key opinion leaders were essential in creating demand among their large social networks for services at the hub (a one-stop-shop facility) and public health facilities (spokes) that were trained to be a key-population friendly facility. Public health facilities can be capacitated to provide key population friendly services. The project also piloted a mental health promotion and stigma reduction intervention for MSM and transgender women, that addressed the mutiple stigmas experienced by sexual and gender minorities (i.e. intersectional stigma). The intervention determined that there is great need for and interest in such a stigma reduction intervention. The project also highlighted the need for more transgender-inclusive programming given the multiple levels of stigma that the community experiences. To reach more key populations, the hub and spokes model of service delivery should be expanded to other regions

African American community, Rockingham County: an action-oriented community diagnosis: findings and next steps of action

In October 2007, a team of five graduate students from the University of North Carolina at Chapel Hill School of Public Health began an Action-Oriented Community Diagnosis (AOCD) with the African American community in Rockingham County. An AOCD is a community-based process by which the resources, strengths, needs, and challenges of a community are identified. After identification, the process transitions to generating dialogue and creating action steps to build on community strengths and address challenges. Guided by preceptors Debbie Mason of Rockingham County Healthy Carolinians and Katrina White of the Rockingham County Department of Public Health, the student team spent the next seven months attending community events, examining data about Rockingham County from websites and government documents, and conducting interviews and focus groups with both service providers and community members regarding community strengths and community challenges. After analyzing the responses, the team identified thirteen common themes. With the help of a community advisory committee (CAC), the team planned and held a public forum, “Community Dialogue for Change,” on April 14, 2008. The CAC selected five of the original thirteen themes for focused discussion at the forum based on their importance to the community and how easily they could be addressed. Five themes were chosen so that the five student team members could each lead a discussion group on one theme..At the forum, the team highlighted the community‟s strengths such as churches and spirituality, caring people, and leadership capacity as well as challenges related to the five themes chosen for discussion. The approximately 70 people in attendance broke into smaller discussion groups and generated action steps to address each theme. The following challenges and action steps were presented at the forum: Employment- The lack of job opportunities for African Americans within the county is a concern. This affects both adults who have lost jobs and youth seeking jobs. Develop a mentoring program that would place youth in government, corporate, and small business environments. Survey students to determine their career interests so that job fairs and career programs would be more appealing. Create a resource listing of employers willing to hire ex-offenders. Attitudes Towards Education- There is concern that education is not a priority in the county, as seen by high drop-out rates and not enough students going to college. Approach the school board about offering diversity training to teachers and other employees. Approach local colleges that train teachers about offering diversity training in their curricula. Guidance for Youth- Too many African American youth, especially young men, lack positive guidance for their futures. Set up a forum for youth-adult conversation as a starting point for better understanding. Use the media, church newsletters, and organizations to spread the word about the need to come together for better guidance for youth. Find out what mentoring programs churches currently have in place, and increase the number and quality of these programs. Include volunteering for school mentoring programs in regular church service projects, with an emphasis on peer mentors. Establish programs to re-train parents and include professionals in the community with different skill sets for parenting. Racial Discrimination- Community members noted various ways in which racial discrimination happens in the county, such as differences in pay, ability to get loans, and treatment of students. Create a forum to increase dialogue between parents of school children to address issues such as racial discrimination in schools. Increase parental and community involvement in volunteer opportunities in schools. Create guidelines for fair treatment of students for use by teachers and administrators. Preventive Health Care- Low use of preventive health care services for conditions such as diabetes and high blood pressure leads to an increased need for treatment and poor health. Form a group in charge of developing educational flyers with health messages to be placed in grocery stores, doctors‟ offices, daycares, churches, schools, and recreational facilities. This education campaign would also incorporate the use of nutritionists to develop health messages for church newsletters. Form a “take a friend to the doctor” program to assist those without their own personal transportation in getting to preventive health care appointments. This would build upon existing resources available in the community such as Caregivers of Rockingham County and Pelham Transportation in order to make transportation to medical appointments more convenient for community members. The purpose of this final report is to give the African American community of Rockingham County and other concerned individuals a tangible resource that presents the findings of the community assessment as well as a report of the discussions and action steps which emerged at the community forum. It is divided into six sections: Introduction; Background on Rockingham County; Primary Data Findings; Methods; The Forum; and Recommendations and Conclusions. This document should be a tool which all community members can continuously refer to as they address various challenges and work towards progress.Master of Public Healt

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

Abstract 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

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

Abstract Background Community mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa. Methods Community Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18–35 years at baseline and endline about two years later. Conclusions This is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective. Trial registration ClinicalTrials.gov NCT0212953