Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa

Abstract

Background HIV and violence prevention programs increasingly seek to transform gender norms among participants, yet how to do so at the community level, and subsequent pathways to behavior change, remain poorly understood. We assessed shifts in endorsement of equitable gender norms, and intimate partner violence (IPV), during the three-year community-based trial of Tsima, an HIV 'treatment as prevention' intervention in rural South Africa. Methods Cross-sectional household surveys were conducted with men and women ages 18-49 years, in 8 intervention and 7 control communities, at 2014-baseline (n = 1,149) and 2018endline (n = 1,189). Endorsement of equitable gender norms was measured by the GEM Scale. Intent-to-treat analyses assessed intervention effects and change over time. Qualitative research with 59 community members and 38 staff examined the change process. Results Nearly two-thirds of men and half of women in intervention communities had heard of the intervention/seen the logo; half of these had attended a two-day workshop. Regression analyses showed a 15% improvement in GEM Scale score over time, irrespective of the intervention, among men (p<0.001) and women (p<0.001). Younger women (ages 18-29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53;

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa

“…Our findings also suggest that Tsima resulted in a notable shift towards more equitable decision making and improved communication among couples involved in the intervention, including open discussion and support for HIV testing and treatment. Further, our qualitative findings support the results from our quantitative research which documented a significant reduction in reported IPV among women enrolled in the Tsima intervention arm, as compared to the control [47]. Tsima activities that provided communication and conflict resolution skills-building seemed to play an important role in facilitating these changes.…”

“…Tsima activities that provided communication and conflict resolution skills-building seemed to play an important role in facilitating these changes. Prior research, including at the study site, has also recognized the role of couple communication and conflict resolution in facilitating HIV prevention, testing and treatment [3,48,49], as well as reducing IPV [47,50,51]. For example, previous interventions have had success in increasing…”

“…Also, the purposive sampling of intervention participants and staff may limit generalizability of findings to the community more broadly. In fact, in analyses that explored changes in gender norms using household survey data from the 2014 baseline to the 2018 endline for the Tsima trial, we found that there was a strong secular trend towards more equitable gender norms in both intervention and control villages [47]. In addition, it is possible that participants may not have felt comfortable providing critical feedback related to the intervention or openly discussing the socially charged topic of gender norms and HIV service uptake with the interviewers.…”

Evaluating the Validity and Reliability of the Gender Equitable Men’s Scale Using a Longitudinal Cohort of Adolescent Girls and Young Women in South Africa

“…Even after accounting for some of these life experiences, increasing age has been shown to be independently associated with greater endorsement of gender equity among young women in other settings [ 38 ]. Results from an overlapping community randomized controlled trial in the study area also suggest that background gender norms in the community were improving irrespective of the community intervention, which included an equitable gender norms component [ 39 ]. The overall shift in community endorsement of gender equity is likely due to increased media exposure through increased access to TV programming and smartphones in the study area.…”

Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort

“…Thus, the protective effect of community mobilization on AGYW HIV incidence may reflect the impact of the CM intervention on men’s behaviors. Indeed, AGYW enrolled in the CM intervention reported reduced rates of IPV at follow-up compared to AGYW in the control [ 38 ]. Our past research has also demonstrated that community collective efficacy, a component of community mobilization, is associated with reduced incidence of IPV among AGYW in this setting [ 39 ].…”