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

Promoting Gender Equity Among
Men to Reduce HIV/STI Risk
Julie Pulerwitz, ScD
Horizons/Population Council & PATH
Partnership: Brazil & India

Horizons Program, Washington, DC & New Delhi
 Global HIV/AIDS Operations Research
 Implemented by the Population Council and partners


Instituto PROMUNDO, Brazil
CORO/VSKM, Mumbai
Support: USAID, Durex, MacArthur Foundation, Hewlett
Foundation
Gender Norms Questions
1.
How can we promote genderequitable norms & HIV/STI and
violence risk reduction among
young men?
2.
How can we measure change in
support towards inequitable
gender norms?
3.
Can tools and intervention
activities be successfully applied
in varied cultural settings?
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 (WHO, 2000)
 Men: norms that encourage multiple sexual
partners
 Women: power imbalaces resulting in reduced
ability to negotiate condom use and mutual
monogamy
 But, few evaluated interventions to promote
gender equity and HIV/STI risk reduction
Program H in Brazil: Framework
•
Ecological model: young men in social context
•
Focus on critical reflection of gender norms in
intimate relationships, and ‘costs’ of inequity
•
Three integrated components: group education,
mass media, ‘male-friendly’ health services
•
Participation of target audience at all stages
•
Age range 15 – 24 good intervention time
Evaluation Design in Brazil
(n = 750 at baseline; aged 15-24)
•
Arm 1: Interactive group
education sessions +
community-based “lifestyle”
social marketing campaign
•
Arm 2: Interactive group
education sessions
•
Arm 3: Comparison group
Gender Equitable Men (GEM) Scale
(Pulerwitz, Barker et al, Horizons Report, 2006; forthcoming in Men & Masculinities)
•
GEM Scale to measure support for (in)equitable
gender norms addressing: violence, sexuality,
reproductive health & domestic life.


“There are times that a woman deserves to be beaten”
“Men are always ready to have sex”
•
Development: Qualitative research, literature
review, and tested with 749 men in Rio de Janeiro
•
Scale (24 items) associated with partner violence,
education, and contraception use
HIV/STI Risk at Baseline
Mean age at first
sex
>= 2 Partners in
past month
STI symptoms
Condom use last
sex with primary
partner
Int 1 Bangu
13
Int 2 Maré
13
Compar MM
13
39%
45%
39%
23%
31%
18%
58%
69%
64%
Increased Support for Gender Equity
•
In both intervention arms, young men more likely
to support equitable gender norms (GEM Scale)
at the 6- and 12-month follow-up. No change in
comparison group.
•
Men who decreased their support for inequitable
gender norms were significantly less likely to
report STI symptoms over time.
Percent of use w/ primary partner
Change in Condom Use at Last Sex:
Reduced Risk
100
90
80
70
60
50
40
30
20
10
0
79 *
69 70
58
Int 1 - Bangu
Int 2 - Maré
64
Baseline
6 Months
59
Comparison MM
*p < 0.05 – Chi-square test
• “Used to be when I went out with a girl,
if we didn’t have sex within two weeks
of going out, I would leave her. But now
(after the workshops), I think differently.
I want to construct something (a
relationship) with her.”
Implementation in India
•
Formative research, and adaptation of the
GEM Scale and intervention (Yari-Dosti:
‘bonding among men’)
•
Six month peer-led pilot with young men (n
= 126)

•
Verma, Pulerwitz, Mahendra et al. "Challenging and
Changing Gender Attitudes Among Young Men in India",
Reproductive Health Matters, 2006, 14(28); 1-10
Evaluation of intervention in urban Mumbai
(n = 750 at baseline) and rural UP (n = 500
at baseline)
Indian Adaptation of GEM Scale
•
Original GEM Scale includes 17 ‘inequitable’
items on violence, sexuality, domestic life, and
reproductive health
•
Adaptation in India consists of 15 items (alpha=.75)
 11 original items
 4 new, India-specific items
•
Examples
 “There are times that a woman deserves to be beaten”
 “A married woman should not need to ask her husband
for permission to visit her parents/family”
Overall GEM Responses in Pilot
% in category
82
Low equity
59
Pretest
Post test
18
Moderate
equity
39
0
2
High equity
0
20
40
60
80
100
***p <.001; t-test on mean response
Evaluation Design in Mumbai
•
Study design:

•
Data collection:

•
Quasi-experimental; 3 arms
(similar to Brazil)
Survey (pre and post) on key
indicators
Study population:

Cohort of young men aged
16-29 years (n = 750 at
baseline) from three ‘slums’
Socio-demographic Profile at Baseline
Group ed +
Campaign
Group ed Only
Comparison
Mean age (yrs)
21
20
22
Marital Status (in %)
Married
Un married
11
89
10
90
21
79
Median years of Education
9
10
8
Occupation (in %)
Unemployed
Employed
30
70
43
57
21
79
Mean age at first sex (yrs)
18
18
18
Group ed + Campaign
(N= 197)
Change in GEM Scale Scores
39
31
Pre test
30
32
26
Post test
Group Ed Only
(N= 175)
Pre test
26
42
47
27
29
35
36
Post test
Comparison
(N= 165)
33
32
Pre test
35
37
Post test
43
19
0
10
Low Equity
P<0.05, Chi Square test
20
30
Moderate Equity
40
High Equity
50
Changes in select behaviors
Pre-test
Post-test
Condom use with all partners
during last sex
27*
30
20
10
0
25*
16
14
Group ed +
Campaign
Violence against any partner over
last 3 months
15
Group ed Only
16
50
40
30
20
10
0
Comparison
47*
29
30
29
9*
Group ed +
Campaign
8*
Group ed Only
Comparison
Communicated with wife on condom, sex, or
HIV/STI during last 3 months
100*
96*
100
80
60
43
45
32
40
24*
20
0
Group ed +
Campaign
Group ed Only
Comparison
*P <0.001- Chi square
test
Impact
•
GEM Scale: useful tool to measure changes in
support for gender norms.
•
Programming that addresses gender norms can
reduce HIV/STI risk.
•
Group education most successful in shifting
attitudes toward gender norms, and combined
intervention sometimes more successful in
leading to HIV/STI behavior change.
Expansion of Activities
•
Mexico: PROMUNDO and Salud y Genero on Program H
evaluation with young men (MacArthur funded).
•
Ethiopia: Horizons/PATH and HCP on adaptation of GEM
Scale with married men (USAID funded).
•
Namibia, Ethiopia, and Tanzania: PATH, EngenderHealth
and PROMUNDO on evaluation of national strategic
planning, capacity-building and activities with men
(OGAC-funded).
•
Brazil and India: activities for women, combined with men
(Nike and MacArthur funded)