2. Addressing Gender Norms to Foster HIV and Violence Prevention Julie Pulerwitz, ScD Director, HIV/AIDS & TB Global Program, PATH HHS Briefing June 18, 2010

3. Why gender Gender-related dynamics place both women and men at risk of negative health outcomes such as HIV/STI, unwanted pregnancy, and intimate partner violence (WHO, 2000)  Men: e.g., norms that encourage multiple sexual partners  Women: e.g., power imbalaces resulting in reduced ability to negotiate condom use and mutual monogamy

4. Addressing Gender in Programs  Substantial interest in addressing gender (e.g., ICPD conference, PEPFAR, Global Health Initiative)  Increasingly SRH, HIV prevention, and other interventions seek to take gender into account and/or alter gender dynamics  Yet, few evaluations of gender-focused activities, and limited use of tested tools

5. Challenges to Evaluation Conceptualization  Much agreement on gender/masculinity importance but no consensus on how to operationalize  Is complex and multi-faceted – on what to focus? Design  Difficult to attribute change to program due to e.g., many different activities  Rigorous designs rare and difficult to implement Instruments/tools  Need for tools to explicitly measure gender focus

6. Key Questions (2001-10) 1. How can we measure gender norms, and change in support for inequitable norms? 2. What is the relationship between support for gender equity and HIV risk, and other health outcomes? 3. How can we promote gender- equitable norms & HIV and violence risk reduction, for men and their partners? 4. How successfully can we adapt strategies to different cultural contexts?

7. Gender Equitable Men (GEM) Scale  Measures support for (in)equitable gender norms in key areas: sexuality, violence, SRH & domestic life  “There are times that a woman deserves to be beaten”  “Men are always ready to have sex”  “Women who carry condoms are ‘easy’”  “A man should have the final word about decisions in his home”

8. Scale Design in Brazil  Development: qualitative research, literature review, items designed, and tested  Representative sample of 749 men aged 15 – 60 in Rio de Janeiro  Factor and internal consistency analysis  Final scale: 24 items; alpha=.81  GEM Scale (higher equity) associated with partner violence, higher education level, and contraception use

9. Indian Adaptation of GEM Scale Formative research and administration of both original and new, culturally relevant items After testing, 15 items (alpha=.75)  11 original items  4 new, India-specific items Example of new item  “A married woman should not need to ask her husband for permission to visit her parents/family”

10. Ethiopian Adaptation of GEM Scale  Both original and new items administered to 522 married Ethiopian men  After testing, 24 items remain – 18 original and 6 new (alpha=.88)  Example of new item  A woman who has sex before she marries does not deserve respect

11. Gender Norms & Health Outcomes Brazilian urban young men supporting inequitable norms more likely to report STI symptoms & partner violence, less contraceptive use Indian rural young men supporting inequitable norms more likely to report multiple partners and partner violence Ethiopian married men supporting equitable norms more likely to report discussing and using contraceptives/condoms, and waiting for consensual sex with wife

12. Intervention Framework  Ecological model - men in social context  Focus on critical reflection of gender norms in intimate relationships, and ‘costs’ of inequity  Integrated components: interpersonal group education, BCC campaign to reinforce messages, community engagement/mobilization, male-friendly health services  Participation of target audience at all stages

13. ‘Program H’ Evaluation in Brazil Main objective:  Determine the outcomes of gender-focused activities (group education, education plus community-based BCC campaign) among young men. Data collection:  Pre- and post-test surveys with 3 groups of young men aged 15 - 24 followed over 1 year (n= 780 at baseline; over 75% response rate)  In-depth interviews with sub-sample of young men and their partners  Monitoring forms and cost analysis

14. Evaluation Design in Brazil Arm 1: Interactive group education sessions + community-based “lifestyle” social marketing campaign Arm 2: Interactive group education sessions Arm 3: Comparison group/delayed intervention

15. Increase in Support for Gender Equity In both intervention arms, young men significantly less likely to support inequitable gender norms (GEM Scale) at the 6- and 12-month follow-up. No change in comparison group. Men who decreased their support for inequitable norms significantly less likely to report STI symptoms and more likely to report condom use with primary partners over time.* *logistic regression for correlated data, controlling for age, family income, & education

16. Increase in Condom Use at Last Sex *p < 0.05 – Chi-square test *

17. “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.”

18. ‘Yaari-Dosti’ Evaluation in India  Adaptation of the Program H intervention (Yaari-Dosti: ‘bonding among men’)  Six-month peer-led pilot with young men (n = 126)  Evaluation of intervention in urban Mumbai (n = 537) and rural UP (n = 601)

19. Improvement in GEM Scale* Scores Among Indian Pilot Participants *p <.001; t-test on mean response of GEM Scale % in category

20. Evaluation Design in Mumbai Quasi-experimental design:  3 arms  Community campaign + group education, group education alone, comparison Data collection:  Pre/post survey  In-depth interviews Study population:  Cohort of young men aged 16-29 years

21. Increase* in % of High Equity Respondents Group ed + Campaign (n= 197) Group Ed Only (n= 175) Comparison (n= 165) *p < 0.05, Chi Square test

22. Increase in Condom Use Pre-test Post-test *p<0.001 - Chi square test * *

23. Decrease in Violence Pre-test Post-test *P <0.001- Chi square test ** *

24. ‘Male Norms Initiative’ Evaluation in Ethiopia Quasi-experimental intervention study with young men aged 15 – 24 years (n = 729 at baseline) in youth clubs Adaptation of Program H and Men as Partners 3 arms: Community mobilization (e.g., theater, marches) + group education, community mobilization alone, comparison group/delayed intervention

25. Increase in Support for Gender Equity In both intervention arms, young men less likely to support inequitable gender norms (GEM Scale) at the 6 month follow-up. No change in comparison group. When controlling for key variables (e.g., age, education), only combined intervention significant.

26. Reduction in Violence % of reported physical violence against partner over past 6 months *p < 0.05 * * *

27. “After I took this training, I made a lot of changes….that I should use a condom, I should be faithful to my ‘friend,’ that I should get tested for HIV….” “Women are not solely responsible for work on household chores but also men…I should do one thing while my spouse does another thing….”

28. Conclusions  Clear links between gender norms, and HIV and violence risk  GEM Scale: useful tool to measure changes in support for gender norms  Evidence that programming which addresses gender norms associated with reduced HIV/STI risk and partner violence  Interactive group education key strategy for increasing support for gender equity; combined interventions with community-based component often most successful in leading to change

29. Egs. Of Ongoing Projects Promoting gender equity among men/boys and women/girls via gender ‘badge’ with Scouts in Kenya, and with migrant workers in factories in China (Nike Foundation funded) Male Norms Initiative evaluation of group education activities with prison guards and capacity-building of local NGOs in Namibia (PEPFAR funded)

30. Partners  Technical:  PATH, Population Council, PROMUNDO (Brazil)  PATH, Population Council, PROMUNDO, CORO (India)  PATH, AED, JHU/CCP, Miz-Hasab (Ethiopia)  PATH, EngenderHealth, PROMUNDO, LifeLine/ChildLine, Hiwot, RFS, Miz-Hasab (Namibia & Ethiopia)  PATH, China Family Planning Association, Kenya Scouts Association (Kenya & China)  Funding sources:  PEPFAR, Nike Foundation, MacArthur Foundation, Durex

31. References 1  Pulerwitz, Michaelis, Verma, and Weiss. (2010) Addressing gender dynamics and engaging men in HIV programs: Lessons learned from Horizons research. Public Health Reports. 125: 282-292.  Pulerwitz and Barker. (2008) Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale. Men and Masculinities. 10: 322-338.  Verma, Pulerwitz, Mahendra et al. (2006) "Challenging and Changing Gender Attitudes Among Young Men in India", Reproductive Health Matters, 14(28); 1-10  Middlestadt, Pulerwitz, Nanda, Acharya, and Lombardo. Gender Norms as a Key Factor that Influences SRH Behaviors Among Ethiopian Men, and Implications for Behavior Change Programs. Draft manuscript.

32. References 2  Barker, Nascimento, Pulerwitz, Ricardo, Segundo, and Verma. (2006) Engaging young men in violence prevention: Reflections from Latin America and India. In Combating gender violence in and around schools. (Ed. Leach, F and Mitchell, C). Cromwell Press Ltd, UK. pp. 143-151.  Pulerwitz, Barker, Segundo, and Nascimento. (2006) Promoting more gender-equitable norms and behaviors among young men as an HIV/AIDS prevention strategy. Horizons Report. Washington, DC: Population Council.  Verma, Mahendra, Pulerwitz, Barker, Van Dam, and Flessenkaemper. (2005) From research to action: Addressing masculinity and gender norms. Indian Journal of Social Work. Vol 1.  Barker with Nascimento, Segundo, Pulerwitz. (2004) How do we know if men have changed? Promoting and measuring attitude change with young men. In Gender Equality and Men. (Ed. Sandy Ruxton). Oxford: Oxfam.