Transcript Impacting HIV-related Stigma, Gender, and HIV Risk via

Measuring the impact of
gender-focused interventions
Julie Pulerwitz, ScD
Horizons Program/PATH
At Risk Due to Gender

Gender-related dynamics place both women
and men at risk of negative health outcomes
such as HIV/STI and violence
 Women: power imbalances resulting in
inability to negotiate condom use and
mutual monogamy
 Men: norms that encourage multiple
partners
Addressing Gender in Programs

Increasingly HIV/STI and violence
prevention interventions are seeking to
change gender dynamics in relationships,
posing challenges for evaluators

Few evaluations of programs, and fewer
use evaluated measures to do so
Major Challenges of
Intervention Research
 Design Issues - How to attribute change
 Many activities ongoing so difficult to attribute
change to program
 Control/comparison group not possible when
program provides complete coverage
 Instruments for Gender Focus
 Many agree on importance but no consensus
on definitions and how to operationalize
 Gender is complex and multi-faceted
Examples
Measuring Gender-related Dynamics and
Designing Studies of Program Impact
Development of SRPS
(Pulerwitz et al 2000, Sex Roles)

Sexual Relationship Power Scale (SRPS) to
measure power in sexual relationships

Focus groups with women and theoretical
framework to design items

50 initial items administered to 388 mainly Latina
women at reproductive health clinic in US

Key results with SRPS (23 items)



Highly reliable (alpha > .80)
Negatively associated with sexual and physical violence
Positively associated with education, condom use
Items in SRPS

23 item SRPS with 2 subscales

Relationship Control

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My partner always wants to know where I am.
My partner does what he wants, even if I don’t want him
to.
My partner would get angry if I suggested condom use.
Decision-making Dominance

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Who usually has more say about whether you have sex?
Who usually has more say about important decisions?
SRPS by % Consistent Condom Use*
16
14
13
High Pow er
Moderate Pow er
Low Pow er
12
10
8
8
6
4
2
2
0
SRPS
*p < 0.01 - Mantel-Haenszel chi-square test for trend
Logistic Regression Model Predicting
Consistent Condom Use (*p < 0.05)
Sexual Relationship
Power Scale
High
Moderate
Low
OR
95% CI
4.95*
4.12*
1.00
(1.20, 20.42)
(1.02, 16.96)
Controlling for socio-demographic and psycho-social variables.
Other significant variables: Peer support for condom use.
Egs of use of the SRPS

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School-based young men & women in inner-city
NY (Bauman & Silver 2003, Albert Einstein College of Medicine)
Adult men & women at STI clinic in Boston (Pulerwitz
et al 1999, unpublished manuscript)

Gang-affiliated young women in Texas (Excerpted from
chapter by Amaro, Dai & Arevalo 2003; Study led by Valdez, U of Texas)

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ANC clients in South Africa (Dunkle et al, Lancet May 2004)
Community-based youth in Thailand (ongoing)
OVC in Zimbabwe (ongoing UCSF study)
SRPS in “Stepping Stones” Study
(Jewkes et al 2002, Medical Research Council, South Africa)

HIV intervention study in South Africa with
Stepping Stones package - focused on
gender inequalities and communication

Surveys at baseline and 3 months post
intervention

Sample: 95 women and 107 men (pilot study),
94% response rate for women and 67% for
men
Findings from Stepping Stones

SRPS items relevant and reliable (alpha > .80)
for women, but less so for men

At baseline, less power associated with less
condom use, physical and sexual violence for
women

Post intervention, significant improvement in
relationship power for women, especially
among new condom users

Ongoing large intervention study
Lessons Learned about the SRPS

SRPS appears a useful measure for
relationship power...for adults and youth, for
different ethnicities and cultures.

Relationship Control subscale is sometimes
more useful than Decision-making
Dominance subscale.

SRPS is sometimes more useful for women
than men.
Development of GEM Scale
(Pulerwitz, Barker et al 2004, Horizons Report)

Gender Equitable Men (GEM) Scale to measure
attitudes toward gender norms

Qualitative research with young men in Brazil
(Barker 2000) and lit review to design items

35 initial items tested with 749 men aged 15-60 in
Rio de Janeiro (PROMUNDO, NOOS, and TA from Horizons)

At baseline, GEM Scale (24 items) associated
with partner violence, education, and
contraception use
Gender Norms Scale Domains

Home & child-care

Sexual relationship

Health & disease prevention

Violence

Homophobia & relations with
other men
Items in GEM Scale

24 item GEM Scale with 2 subscales (alpha
> .80)

‘Traditional’ Norms

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Men are always ready to have sex.
There are times when a woman deserves to be
beaten.
I would be outraged if my partner asked me to use
a condom.
‘Egalitarian’ Norms

A man and a woman should decide together what type
of contraceptive to use.
Egs of use of GEM Scale
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Intervention study with young men in India CORO and Horizons/PROMUNDO
National survey with adults in Zambia - HCP
Intervention study with young men in Mexico Salud y Genero
Intervention study with adult men in South
Africa - MAP and Frontiers/Population Council
‘Program H’ Intervention Study in Brazil
(Instituto PROMUNDO, Horizons, and partners)
Main objectives:

Determine the impact of different combination of
gender-focused activities (group education,
education plus community-based ‘lifestyle’ social
marketing campaign) on attitudes toward gender
norms, and HIV/STI and violence risk among young
men
Data collection:


Pre and post surveys with 3 groups (2 intervention, 1
control) followed over 1 year (n= 780 at baseline;
over 75% response rate)
In-depth interviews with sub-sample and partners,
for triangulation and validation from partners
Study Design
INTERVENTION 1
6 months
Pre-test
N = 258
6 months
Post-test 1
N = 230
INTERVENTION 2
6 months
Pre-test
N = 250
6 months
Post-test 1
N = 217
6 months
CONTROL
Pre-test
N = 272
Post-test 2
N = 217
Post-test 2
N = 172
3 months
Post-test 1
N = 180
Delayed
intervention
Change in GEM Items*
62
44
43
Men need sex more
than women do.
Baseline (Maré)
52
6 months (Maré)
43
1 year (Maré)
37
38
Baseline (Bangu)
29
Changing diapers, giving
the kids a bath, and
feeding the kids are the
mother's responsibility.
6 months (Bangu)
26
1 year (Bangu)
31
23
21
0
20
40
60
80
*p < .05 for individual items and full Scale; No significant change in control site
Association Between ‘Traditional’ Norms
and STI Symptoms Over Time

At one year, young men that become
more supportive of equitable norms
report fewer STI symptoms:

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4.6* times more likely to report no STI
symptoms in Intervention 1 site
8.3* times more likely to report no STI
symptoms in Intervention 2 site
*p < 0.05 – logistic regression for correlated data;
controlling for age, family income, and education
Lessons Learned about Research
with the GEM Scale

Findings suggest GEM Scale a
sensitive and cross-culturally relevant
tool

Findings suggest change in attitudes
towards gender norms possible via
interventions, as well as subsequent
changes in HIV/STI risk
‘SDSI’ Intervention Study in Nicaragua
(Puntos de Encuentro, Horizons, PATH, CIDS)

Communication for
social change
program to empower
youth, promote
gender equity, and
reduce violence and
HIV/STI risk
Intervention Activities
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Weekly national edutainment
telenovela (Sexto Sentido)
Daily call-in radio show to discuss
show themes
Community-based activities
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Coordination across organizational
networks
Cast visits to schools
Youth training camps
IEC materials
Research Methodology

Longitudinal sample in three representative cities
– Esteli, Leon, Juigalpa

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Triangulation of results

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Track change of individual people, not just group
overall
Pre, mid-term and post surveys with 4567 male and
female youth aged 13-24 at baseline (over 80%
response rate at mid-term), in-depth interviews and
focus group discussions, Participatory Action Research
Multivariate and multi-level analyses
Emerging Results

At baseline, HIV/STI risk behaviors substantial
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At mid-term:
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40% of sexually active had recent occasional partner
69% did not use condoms consistently with occasional
partners
Exposure to activities associated with better outcomes
More support for gender equity (GEM items) over time
Communication with others about HIV prevention and
sexual behavior increased
Increase in condom use among some groups
Longitudinal analysis ongoing
Conclusions: the Role of
Gender Dynamics

Empirical support that both relationship
power and inequitable gender norms are
key factors in HIV/STI and violence risk.

Evidence that interventions can influence
both relationship power and attitudes
towards gender norms, and subsequent
HIV risk behaviors.
Conclusions:
Evaluation Issues

Evidence of measures and designs
that capture impact of BCC and other
interventions focused on gender
dynamics.

Measuring impact challenging, but
attempts ongoing and growing.