Promoting Gender Equity Among Men to Reduce HIV/STI Risk

1. Promoting Gender Equity Among Men to Reduce HIV/STI Risk Julie Pulerwitz, ScD Horizons/Population Council & PATH

2. 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

3. Gender Norms Questions • How can we promote gender-equitable norms & HIV/STI and violence risk reduction among young men? • How can we measure change in support towards inequitable gender norms? • Can tools and intervention activities be successfully applied in varied cultural settings?

4. 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

5. 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

6. 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

7. 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

8. HIV/STI Risk at Baseline

9. 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.

10. Change in Condom Use at Last Sex: Reduced Risk * *p < 0.05 – Chi-square test

11. “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.”

12. 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)

13. 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”

14. Overall GEM Responses in Pilot % in category ***p <.001; t-test on mean response

15. Evaluation Design in Mumbai • Study design: • Quasi-experimental; 3 arms (similar to Brazil) • Data collection: • Survey (pre and post) on key indicators • Study population: • Cohort of young men aged 16-29 years (n = 750 at baseline) from three ‘slums’

16. Socio-demographic Profile at Baseline

17. High Equity Low Equity Moderate Equity Change in GEM Scale Scores Group ed + Campaign (N= 197) Group Ed Only (N= 175) Comparison (N= 165) P<0.05, Chi Square test

18. Changes in select behaviors Pre-test Post-test *P <0.001- Chi square test

19. 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.

20. 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)