Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa

Audrey Pettifor, Sheri A Lippman, Ann Gottert, Chirayath M Suchindran, Amanda Selin, Dean Peacock, Suzanne Maman, Dumisani Rebombo, Rhian Twine, Francesc Xavier Gómez-Olivé, Stephen Tollman, Kathleen Kahn, Catherine MacPhail, Audrey Pettifor, Sheri A Lippman, Ann Gottert, Chirayath M Suchindran, Amanda Selin, Dean Peacock, Suzanne Maman, Dumisani Rebombo, Rhian Twine, Francesc Xavier Gómez-Olivé, Stephen Tollman, Kathleen Kahn, Catherine MacPhail

Abstract

Introduction: Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk.

Methods: Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (post-intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes.

Results: Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16).

Conclusion: Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly.

Clinical trials number: ClinicalTrials.gov NCT02129530.

Keywords: HIV; South Africa; community mobilization; gender norms; gender-based violence.

© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

Figures

Figure 1
Figure 1
Conceptual Framework for Community Mobilization Intervention.
Figure 2
Figure 2
Trial profile.

References

    1. UNAIDS . UNAIDS Data 2017. 2017.
    1. Camlin CS, Ssemmondo E, Chamie G, El Ayadi AM, Kwarisiima D, Sang N, et al. Men “missing” from population‐based HIV testing: insights from qualitative research. AIDS Care. 2016;28 Suppl 3:67–73.
    1. Sharma M, Barnabas RV, Celum C. Community‐based strategies to strengthen men's engagement in the HIV care cascade in sub‐Saharan Africa. PLoS Med. 2017;14(4):e1002262.
    1. Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson S. Masculinity as a barrier to men's use of HIV services in Zimbabwe. Global Health. 2011;7(1):13.
    1. UNAIDS . Addressing a blind spot in the response to HIV — Reaching out to men and boys. Geneva: 2017.
    1. Greig A, Peacock D, Jewkes R, Msimang S. Gender and AIDS: time to act. AIDS (London, England). 2008;22 Suppl 2:S35.
    1. Gupta GR. Gender, sexuality, and HIV/AIDS: the what, the why, and the how. Can HIV AIDS Policy Law Rev. 2000;5(4):86–93.
    1. Wood K, Jewkes R. ‘Dangerous Love’: reflections on violence among Xhosa township youth In: Changing men in southern Africa. Morrell R. (ed). Pietermaritzburg, South Africa: University of Natal Press; 2001: pp. 317–36.
    1. Harrison A, O'Sullivan LF, Hoffman S, Dolezal C, Morrell R. Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. J Urban Health. 2006;83(4):709–22.
    1. Gottert A, Barrington C, McNaughton‐Reyes HL, Maman S, MacPhail C, Lippman SA, et al. Gender norms, gender role conflict/stress and HIV risk behaviors among men in Mpumalanga, South Africa. AIDS Behav. 2018;22:1858–69.
    1. Barker G, Contreras JM, Heilman B, Singh AK, Verma RK, Nascimento M. Evolving men: initial results from the international men and gender equality survey (IMAGES). Washington, DC: International Center for Research on Women (ICRW) and Instituto Promundo, 2011.
    1. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet. 2010;376(9734):41–8.
    1. Kouyoumdjian FG, Calzavara LM, Bondy SJ, O'campo P, Serwadda D, Nalugoda F, et al. Intimate partner violence is associated with incident HIV infection in women in Uganda. AIDS. 2013;27(8):1331–8.
    1. Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, et al. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med. 2014;12(1):122.
    1. Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. Intimate partner violence and HIV infection among women: a systematic review and meta‐analysis. J Int AIDS Soc. 2014;17(1):18845.
    1. Lippman SA, Maman S, MacPhail C, Twine R, Peacock D, Kahn K, et al. Conceptualizing community mobilization for HIV prevention: implications for HIV prevention programming in the African context. PLoS ONE. 2013;8(10):e78208.
    1. Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, et al. Towards an improved investment approach for an effective response to HIV/AIDS. The Lancet. 2011;377(9782):2031–41.
    1. Basu I, Jana S, Rotheram‐Borus MJ, Swendeman D, Lee S‐J, Newman P, et al. HIV prevention among sex workers in India. J Acquir Immune Defic Syndr. 2004;36(3):845.
    1. Lippman SA, Chinaglia M, Donini AA, Diaz J, Reingold A, Kerrigan DL. Findings from Encontros: a multi‐level STI/HIV intervention to increase condom use, reduce STI, and change the social environment among sex workers in Brazil. Sex Transm Dis. 2012;39(3):209.
    1. Kegeles SM, Hays RB, Pollack LM, Coates TJ. Mobilizing young gay and bisexual men for HIV prevention: a two‐community study. AIDS. 1999;13(13):1753–62.
    1. Ramesh B, Beattie TS, Shajy I, Washington R, Jagannathan L, Reza‐Paul S, et al. Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India. Sex Transm Infect. 2010;86 Suppl 1:i17–24.
    1. Reza‐Paul S, Beattie T, Syed HUR, Venukumar KT, Venugopal MS, Fathima MP, et al. Declines in risk behaviour and sexually transmitted infection prevalence following a community‐led HIV preventive intervention among female sex workers in Mysore, India. AIDS. 2008;22:S91–100.
    1. Beeker C, Guenther‐Grey C, Raj A. Community empowerment paradigm drift and the primary prevention of HIV/AIDS. Soc Sci Med. 1998;46(7):831–42.
    1. Parker RG. Empowerment, community mobilization and social change in the face of HIV/AIDS. AIDS 1996;10 Suppl 3:S27–31.
    1. Evans C, Jana S, Lambert H. What makes a structural intervention? Reducing vulnerability to HIV in community settings, with particular reference to sex work. Global Public Health. 2010;5(5):449–61.
    1. Barker G, Ricardo C, Nascimento M, Olukoya A, Santos C. Questioning gender norms with men to improve health outcomes: evidence of impact. Global Public Health. 2010;5(5):539–53.
    1. Hossain M, Zimmerman C, Kiss L, Abramsky T, Kone D, Bakayoko‐Topolska M, et al. Working with men to prevent intimate partner violence in a conflict‐affected setting: a pilot cluster randomized controlled trial in rural Cote d'Ivoire. BMC Public Health. 2014;14(1):339.
    1. Lippman SA, Neilands TB, Leslie HH, Maman S, MacPhail C, Twine R, et al. Development, validation, and performance of a scale to measure community mobilization. Soc Sci Med. 2016;157:127–37.
    1. Lambert H. Balancing community mobilisation and measurement needs in the evaluation of targeted interventions for HIV prevention. J Epidemiol Community Health. 2012;66 Suppl 2:ii3–4.
    1. Pettifor A, Lippman SA, Selin AM, Peacock D, Gottert A, Maman S, et al. A cluster randomized‐controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention. BMC Public Health. 2015;15(1):752.
    1. Atienza AA, King AC. Community‐based health intervention trials: an overview of methodological issues. Epidemiol Rev. 2002;24(1):72–9.
    1. Feldman HA, McKinlay SM. Cohort versus cross‐sectional design in large field trials: precision, sample size, and a unifying model. Stat Med. 1994;13(1):61–78.
    1. Murray DM. Monographs in Epidemiology and Biostatistics. New York: Oxford University Press; 1998.
    1. Hayes R, Moulton L. Cluster randomised trials. Boca Raton, FL: CRC Press, Taylor & Francis; 2009.
    1. Kahn K, Collinson MA, Gómez‐Olivé FX, Mokoena O, Twine R, Mee P, et al. Profile: agincourt health and socio‐demographic surveillance system. Int J Epidemiol. 2012;41(4):988–1001.
    1. Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S, Zungu N, et al. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSRC Press; 2014.
    1. Gómez‐Olivé FX, Angotti N, Houle B, Klipstein‐Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care. 2013;25(9):1122–8.
    1. NIMH Collaborative HIV/STD Prevention Trial Group . The community popular opinion leader HIV prevention programme: conceptual basis and intervention procedures. AIDS. 2007;21:S59–68.
    1. Masters GN, Wright BD. The partial credit model. Handbook of modern item response theory. 1997:101–22.
    1. Warm TA. Weighted likelihood estimation of ability in item response theory. Psychometrika. 1989;54(3):427–50.
    1. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil. Men Masculinities. 2008;10(3):322.
    1. Pulerwitz J, Hughes L, Mehta M, Kidanu A, Verani F, Tewolde S. Changing gender norms and reducing intimate partner violence: results from a quasi‐experimental intervention study with young men in Ethiopia. AJPH. 2015;105(1):132–7.
    1. Jewkes R, Sikweyiya Y, Morrell R, Dunkle K. Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross‐sectional study. PLoS ONE. 2011;6(12):e29590.
    1. Dworkin SL, Treves‐Kagan S, Lippman SA. Gender‐transformative interventions to reduce HIV risks and violence with heterosexually‐active men: a review of the global evidence. AIDS Behav. 2013;17(9):2845–63.
    1. Gottert A. Gender norms, masculine gender‐role strain, and HIV risk behaviors among men in rural South Africa [Dissertation]: Univerisity of North Carolina at Chapel Hill; 2014 [cited 10 January 2017]. Available at: .
    1. Pulerwitz J, Hughes L, Mehta M, Kidanu A, Verani F, Tewolde S. changing gender norms and reducing intimate partner violence: results from a Quasi‐Experimental Intervention Study with young men in ethiopia. Am J Public Health. 2014;e1–6.
    1. Pulerwitz J, Michaelis A, Verma R, Weiss E. Addressing gender dynamics and engaging men in HIV programs: lessons learned from Horizons research. Public Health Rep. 2010;125(2):282.
    1. Shattuck D, Burke H, Ramirez C, Succop S, Costenbader B, Attafuah JD, et al. Using the Inequitable Gender Norms scale and associated HIV risk behaviors among men at high risk for HIV in Ghana and Tanzania. Men Masculinities. 2013;16(5):540–59.
    1. Gottert A, Barrington C, Pettifor A, McNaughton‐Reyes HL, Maman S, MacPhail C, et al. Measuring men's gender norms and gender role conflict/stress in a high hiv‐prevalence South African setting. AIDS Behav. 2016;20(8):1785–95.
    1. Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): wHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction. 1993;88(6):791–804.
    1. Dunkle KL, Jewkes RK, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS. 2006;20(16):2107.
    1. Mulawa MI, Reyes HLM, Foshee VA, Halpern CT, Martin SL, Kajula LJ, et al. Associations between peer network gender norms and the perpetration of intimate partner violence among urban Tanzanian men: a multilevel analysis. Prev Sci. 2018;19(4):427–36.
    1. Fleming PJ, DiClemente RJ, Barrington C. Masculinity and HIV: dimensions of masculine norms that contribute to men's HIV‐related sexual behaviors. AIDS Behav. 2016;20(4):788–98.
    1. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Soc Sci Med. 2000;50(4):459–78.
    1. Pettifor AE, Measham DM, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg Infect Dis. 2004;10(11):1996.
    1. Pitpitan EV, Kalichman SC, Eaton LA, Sikkema KJ, Watt MH, Skinner D. Gender‐based violence and HIV sexual risk behavior: alcohol use and mental health problems as mediators among women in drinking venues, Cape Town. Soc Sci Med. 2012;75(8):1417–25.
    1. Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol use and sexual risks for HIV/AIDS in sub‐Saharan Africa: systematic review of empirical findings. Prev Sci. 2007;8(2):141.
    1. Foran HM, O'Leary KD. Alcohol and intimate partner violence: a meta‐analytic review. Clin Psychol Rev. 2008;28(7):1222–34.
    1. Abramsky T, Devries KM, Michau L, Nakuti J, Musuya T, Kiss L, et al. Ecological pathways to prevention: how does the SASA! community mobilisation model work to prevent physical intimate partner violence against women? BMC Public Health. 2016;16(1):339.
    1. Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, et al. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort. Lancet Global Health. 2015;3(1):e23–33.
    1. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate‐partner violence and HIV in rural South Africa: a cluster randomised trial. The Lancet. 2006;368(9551):1973–83.
    1. Collinson MA, White MJ, Bocquier P, McGarvey ST, Afolabi SA, Clark SJ, et al. Migration and the epidemiological transition: insights from the Agincourt sub‐district of northeast South Africa. Global Health Action. 2014;7(1):23514.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir