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

3. 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

4. Gender Norms Questions 1. How can we promote gender- equitable 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?

5. 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

6. 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

7. 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

8. 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

9. HIV/STI Risk at Baseline Int 1 - Bangu Int 2 - Maré Compar - MM Mean age at first sex 13 >= 2 Partners in past month 39%45%39% STI symptoms23%31%18% Condom use last sex with primary partner 58%69%64%

10. 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.

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

12. “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.”

13. 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)

14. 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”

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

16. 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’

17. Socio-demographic Profile at Baseline Group ed + Campaign Group ed OnlyComparison Mean age (yrs)212022 Marital Status (in %) Married Un married 11 89 10 90 21 79 Median years of Education9108 Occupation (in %) Unemployed Employed 30 70 43 57 21 79 Mean age at first sex (yrs)18

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

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

20. 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.

21. 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)