Transforming Gender Norms
1. Training, peer and partner discussions, and community-based education that questions harmful gender norms can improve HIV prevention, testing, treatment and care.
An evaluation of the Stepping Stones program for young people in the Eastern Cape Province of South Africa found that the program was effective in reducing sexual risk-taking and violence perpetration among young, rural African men. [See Addressing Violence Against Women]
The Yaari Dosti program in India replicated aspects of Program H in Brazil. Nearly 1,150 young men in Mumbai and rural Uttar Pradesh were exposed under the Yaari Dosti program to either peer- led group education activities alone, or combined with a community-based behavior change communication or a delayed intervention which promoted gender equity. The study found that in all intervention sites there was a significant increase in report of condom use at last sex, decreased partner violence and increased support for gender equitable norms. The sample of young men included married and unmarried young men ages 16-29 in the urban areas and ages 15-24 in the rural settings. Logistic regression showed that men in the intervention sites in Mumbai were 1.9 times more likely and in rural Uttar Pradesh 2.8 times more likely to have used condoms with all types of partners than were young men in the comparison sites in each place. Furthermore, self-reported violence against partners declined in the intervention sites.
In Tanzania, evaluation of Tuelimishane (Let’s Educate One Another), a community-based HIV and violence program for young men in Dar es Salaam that combined community-based drama and peer education, found that the project resulted in significant changes in attitudes and norms related to gender roles and partner violence and some risk behaviors, including condom use. Changes in two of the six measures of HIV risk behaviors were found to be significant. Men in the intervention community were significantly more likely to have used condoms during their last sexual experience, and they were less likely to report using condoms less than half the time in the past six months. There were no significant differences regarding reported use of violence, but men in the intervention village were significantly less likely to report that violence against women is justified under various scenarios. The program was designed based on formative research among young men and women regarding the context of sexual relationships among youth at risk for HIV, including gender norms and roles, partner violence, and sexual behavior. The theme of transactional sex and the active roles of young men and women in the practice also emerged in the formative research. The interventions for young men were designed around three themes that emerged from the formative research, namely, infidelity, sexual communication and conflict.
A peer group HIV prevention intervention that compared matched workplaces between an intervention group that addressed issues of gender inequality with a delayed control group for 300 urban employed women in Botswana found that the intervention group significantly increased their HIV prevention behaviors including personal safer sex practices, positive attitudes toward condoms and confidence in condom use;, greater knowledge of HIV transmission, sexually transmitted diseases and more positive attitudes towards persons living with HIV/AIDS. After the intervention, 76% of the intervention group felt confident about using condoms correctly, compared to 44% in the delayed control group. Almost half of the intervention group reported practicing safer sex compared to 34% of the delayed intervention group. The intervention group also had increased community HIV-related activities, with a mean of 6.1 activities compared to 4.7 activities for the delayed control group. The intervention group had an 83% positive response towards persons living with HIV/AIDS compared to 68% in the delayed intervention group, with stigma being “an important aspect of prevention that needs direct attention” (Norr et al., 2004: 222). The intervention consisted of six ninety-minute weekly or bi-weekly sessions with hands-on condom skills and partner negotiation skills. The peer group leaders sustained the program for more than five years after the end of research funding. As a preliminary phase of the study, 56 in-depth interviews were conducted with urban women in Gaborone, Botswana regarding their HIV prevention needs. A concern that mixed-gender groups might expose women to partner violence led to a decision to have women-only groups. The peer group sessions occurred in workplaces during lunch or after work.
An impact evaluation of Program H, undertaken by PROMUNDO, was conducted in Brazil to test the hypothesis that young men in slum areas of Rio de Janeiro can change their behavior and attitudes through participation in group education activities that encourage reflection on what it means to be a man. The program resulted in significantly smaller percentages of young men supporting inequitable gender norms over time. Improvements in gender norm scale scores were associated with changes in at least one key HIV/STI risk outcome. In two of the three intervention sites, positive changes in attitudes toward inequitable gender norms over one year were significantly associated with decreased reports of STI symptoms. In two of the three intervention sites young men were approximately four times and eight times less likely to report STI symptoms over time, respectively. No significant change was found in condom use. Those boys who reported that they had more equitable gender norms as measured by the GEM scale also reported a decrease in STI symptoms. Program H was developed on the premise that gender norms, which are passed on by families, peers, and institutions, among others, and are interpreted and internalized by individuals, can be changed. Furthermore, reinforcing these messages on the community level will have additional positive impacts. The quasi-experimental study, which followed three groups of young men ages over time, compared the impact of different combinations of program activities, including interactive education for young men led by adult male facilitators and a community-wide social marketing campaign to promote condom use as a lifestyle that used gender-equitable messages that reinforced the messages promoted in the education sessions.
A campaign in South Africa, One Man Can, by the Sonke Gender Justice Network, found that as a result of training workshops, 25% of the men and boys had accessed VCT, 61% increased condom use and 50% reported acts of gender-based violence that the men had witnessed so that appropriate action could be taken to protect women. Sonke provided training over the period of one year to engage men in gender awareness. The campaign implemented a range of communication strategies to shift social norms about men’s roles and responsibility, engaged in advocacy and worked with local government, resulting in men’s increased utilization of VCT and increased use of condoms. Phone surveys were conducted with 2000 randomly selected men and boys who had previously participated in the One Man Can Campaign workshops. Focus group discussions, in-depth interviews and key informant interviews were also conducted. Workshops included 20 to 30 participants and took place over four to five days, using interactive and experiential activities. The One Man Can Campaign used community events, workshops and peer education to create positive models of masculinity around PPT, VCT, HIV prevention, home-based care, violence, multiple concurrent partnerships and alcohol abuse. Pre- and post-test surveys showed positive changes toward gender equitable attitudes that would assist HIV prevention: prior to the workshop, all the men thought they as men had the right to decide when to have sex with their partners; after the workshop, this decreased to 75%. Prior to the workshop, 67% of the men thought they could get HIV from kissing that involved the exchange of saliva; after the workshop this decreased to none. Prior to the workshop, 63% of the men believed that it is acceptable for men to beat their partners; after the workshop, 83% disagreed with the statement. Prior to the workshop, 96% of the men believed that they should not interfere in other people’s relationships, even if there is violence; after the workshop, all believed they should interfere.
2. Mass media campaigns concerning gender equality as part of comprehensive and integrated interventions can increase HIV protective behaviors. [See also Mitigating Risk – many of the media interventions for young people promote equitable gender norms]
An evaluation of Somos Differentes, Somos Iguales (We’re Different, We’re Equal) that included a cohort of 4,800 young women and men ages randomly selected in three cities in Nicaragua who were interviewed at three times, 200 young women and men in focus group discussions and in-depth interviews with participants and non-participants of social action activities found that at baseline young women and men had good knowledge about HIV/AIDS and that AIDS-related stigma was prevalent and safer sex was not regularly practiced. The final survey found that exposure to the project, particularly the TV series Sexto Sentido, and greater exposure to project activities led to a significant reduction in stigmatizing and gender-inequitable attitudes, an increase in knowledge and use of HIV-related services, and a significant increase in interpersonal communication about HIV prevention and sexual behavior. Participants with greater exposure to the intervention had a 44 percent greater probability of having used a condom during last sex with a casual partner and men with greater exposure had a 56 percent greater probability of condom use with casual partners during the past six months. Somos Differentes, Somos Iguales project (2002-2005) used a communication for social change strategy aiming to promote the empowerment of young men and women and prevent HIV infection. The project considered machismo (dominant masculinity) as a risk factor for HIV/AIDS. Somos Differentes, Somos Iguales used the weekly drama TV series Sexto Sentido (Sixth Sense), which was also broadcast in Costa Rica, Guatemala, Honduras, Mexico and the US, and the call in radio program Sexto Sentido Radio to promote the gender transformative and HIV prevention messages and worked with more than 80 local service providers to increase access to SRH services for young women and men. The project also worked with about 200 collaborating organizations. Interventions included a weekly national educational program (telenovela); a daily call-in radio show; community-based activities; visits by the case to schools; youth training camps and informational materials.
An impact evaluation of Program H, undertaken by PROMUNDO, was conducted in Brazil and followed three groups of young men ages over time, compared the impact of different combinations of program activities, including interactive education for young men led by adult male facilitators and a community-wide social marketing campaign to promote condom use as a lifestyle choice, using gender-equitable messages that reinforced the ideas promoted in the education sessions. The program resulted in significantly smaller percentages of young men supporting inequitable gender norms over time. Improvements in gender norm scale scores were associated with changes in at least one key HIV/STI risk outcome.