Intimate partner violence (IPV) affects one in four women globally and is more commonly enacted by men than women. Rates of IPV in South Africa exceed the global average. Exploring the background and ...context regarding why men use violence can help future efforts to prevent IPV.
We explored adult men's perspectives of IPV, livelihoods, alcohol use, gender beliefs, and childhood exposure to abuse through a secondary analysis of qualitative interviews that were conducted in South Africa. The setting was a peri-urban township characterized by high unemployment, immigration from rural areas, and low service provision. We utilized thematic qualitative analysis that was guided by the social ecological framework.
Of 30 participants, 20 were residents in the neighborhood, 7 were trained community members, and 3 were program staff. Men reported consumption of alcohol and lack of employment as being triggers for IPV and community violence in general. Multiple participants recounted childhood exposure to abuse. These themes, in addition to culturally prescribed gender norms and constructs of manhood, seemed to influence the use of violence.
Interventions aimed at reducing IPV should consider the cultural and social impact on men's use of IPV in low-resource, high-IPV prevalence settings, such as peri-urban South Africa. This work highlights the persistent need for the implementation of effective primary prevention strategies that address contextual and economic factors in an effort to reduce IPV that is primarily utilized by men directed at women.
Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV ...testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.
We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.
We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men's fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men's expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family's health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner's results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.
Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men's and women's engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.
Men's perpetration of intimate partner violence (IPV) limits gains in health and wellbeing for populations globally. Largely informal, rapidly expanding peri-urban settlements, with limited basic ...services such as electricity, have high prevalence rates of IPV. Evidence on how to reduce men's perpetration, change social norms and patriarchal attitudes within these settings is limited. Our cluster randomised controlled trial aimed to determine the effectiveness of the Sonke CHANGE intervention in reducing use of sexual and/or physical IPV and severity of perpetration by men aged 18-40 years over 2 years.
The theory-based intervention delivered activities to bolster community action, including door-to-door discussions, workshops, drawing on the CHANGE curriculum, and deploying community action teams over 18 months. In 2016 and 2018, we collected data from a cohort of men, recruited from 18 clusters; nine were randomised to receive the intervention, while the nine control clusters received no intervention. A self-administered questionnaire, using audio-computer assisted software, asked about sociodemographics, gender attitudes, mental health, and the use and severity of IPV. We conducted an intention-to-treat analysis at the cluster level comparing the expected risk to observed risk of using IPV while controlling for baseline characteristics. A secondary analysis used latent classes (LCA) of men to see whether there were differential effects of the intervention for subgroups of men.
Of 2406 men recruited, 1458 (63%) were followed to 2 years. Overall, we saw a reduction in men's reports of physical, sexual and severe IPV from baseline to endpoint (40.2% to 25.4%, 31.8% to 15.8%, and 33.4% to 18.2%, respectively). Intention-to-treat analysis showed no measurable differences between intervention and control clusters for primary IPV outcomes. Difference in the cluster-level proportion of physical IPV perpetration was 0.002 (95% confidence interval CI - 0.07 to 0.08). Similarly, differences between arms for sexual IPV was 0.01 (95% CI - 0.04 to 0.06), while severe IPV followed a similar pattern (Diff = 0.01; 95% CI - 0.05 to 0.07). A secondary analysis using LCA suggests that among the men living in intervention communities, there was a greater reduction in IPV among less violent and more law abiding men than among more highly violent men, although the differences did not reach statistical significance.
The intervention, when implemented in a peri-urban settlement, had limited effect in reducing IPV perpetrated by male residents. Further analysis showed it was unable to transform entrenched gender attitudes and use of IPV by those men who use the most violence, but the intervention showed promise for men who use violence less.
ClinicalTrials.gov, NCT02823288. Registered on 30 June 2016.
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 2018-endline (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 (p0.001) and women (p0.001). Younger women (ages 18-29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53; p0.05). Qualitative data suggest that gender norms shifts may be linked to increased media access (via satellite TV/smartphones) and consequent exposure to serial dramas modeling equitable relationships and negatively portraying violence. Tsimas couple communication/conflict resolution skills-building activities, eagerly received by intervention participants, appear to have further supported IPV reductions. Conclusions There was a population-level shift towards greater endorsement of equitable gender norms between 2014-2018, potentially linked with rapid escalation in media access. There was also an intervention effect on reported IPV among young women, likely owing to improved couple communication. Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change.
Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the ...'One Man Can' intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a 'better life' and associated with behaviour change in the intervention's main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization-specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.
BackgroundAlthough food insecurity has been associated with intimate partner violence (IPV), few studies examine it longitudinally or among male perpetrators.MethodsWe used secondary data from a ...trial that followed 2479 men in a peri-urban settlement in South Africa (February 2016–August 2018). Men self-completed questionnaires at baseline (T0), 12 months (T1) and 24 months (T2) on food security, household type, relationship status, childhood abuse exposure, alcohol use, and perpetration of physical and/or sexual IPV. Cross-lagged dynamic panel modelling examines the strength and direction of associations over time.ResultsAt baseline, rates of IPV perpetration (52.0%) and food insecurity (65.5%) were high. Food insecure men had significantly higher odds of IPV perpetration at T0, T1 and T2 (ORs of 1.9, 1.4 and 1.4, respectively). In longitudinal models, food insecurity predicted men’s IPV perpetration 1 year later. The model had excellent fit after controlling for housing, relationship status, age, childhood abuse and potential effect of IPV on later food insecurity (standardised coefficient=0.09, p=0.031. root mean squared error of approximation=0.016, comparative fit index=0.994). IPV perpetration did not predict later food security (p=0.276).ConclusionFood insecurity had an independent, longitudinal association with men’s IPV perpetration in a peri-urban South African settlement. These findings suggest food security could be a modifiable risk factor of partner violence.Trial registration number NCT02823288.
While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the ...effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the know value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics.
Men whose sexual behaviors place them at risk of HIV often exhibit a “cluster” of behaviors, including alcohol misuse and violence against women. Called the “Substance Abuse, Violence and AIDS (SAVA) ...syndemic,” this intersecting set of issues is poorly understood among heterosexual men in sub-Saharan Africa. We aim to determine cross-sectional associations between men's use of alcohol, violence, and HIV risk behaviors using a gendered syndemics lens. We conducted a baseline survey with men in an informal, peri-urban settlement near Johannesburg (Jan–Aug 2016). Audio-assisted, self-completed questionnaires measured an index of risky sex (inconsistent condom use, multiple partnerships, transactional sex), recent violence against women (Multicountry Study instrument), alcohol misuse (Alcohol Use Disorders Tool), and gender attitudes (Gender Equitable Men's Scale). We used logistic regression to test for syndemic interaction on multiplicative and additive scales and structural equation modeling to test assumptions around serially causal epidemics. Of 2454 men, 91.8% reported one or more types of risky sex. A majority of participants reported one or more SAVA conditions (1783, 71.6%). After controlling for socio-demographics, higher scores on the risky sex index were independently predicted by men's recent violence use, problem drinking, and inequitable gender views. Those men reporting all three SAVA conditions had more than 12-fold greater odds of risky sex compared to counterparts reporting no syndemic conditions. Each two-way interaction of alcohol use, gender inequitable views, and IPV perpetration was associated with a relative increase in risky sex on either a multiplicative or additive scale. A structural equation model illustrated that gender norms predict violence, which in turn predict alcohol misuse, increasing both IPV perpetration and risky sex. These data are consistent with a syndemic model of HIV risk among heterosexual men. Targeting intersections between syndemic conditions may help prevent HIV among heterosexual men in peri-urban African settings.
•Heterosexual men's risky sex overlaps with alcohol and violence against women.•We used a “gendered syndemic” lens to explore substance use, violence, and HIV/AIDS.•We found gender norms predict violence, which leads to alcohol and risky sex.•Targeting syndemics among heterosexual men may ensure health in peri-urban settings.•This is among the first papers to offer quantitative support for syndemic theory.
Despite HIV testing having improved globally, men remain disproportionately less likely to test for HIV. While violence against women (VAW) and HIV risk have a strong association among women, few ...studies explore men around VAW perpetration, risky-sexual behaviour, and HIV testing. Males aged 18-42 years were recruited from a peri-urban settlement near Johannesburg, South Africa. Data were from an endline of a trial. We used logistic regression to assess odds of non-HIV testing using STATA 13. At endline, 1508 men participated in the study. Of these nearly one-third (31.6%, n = 475) had not tested for HIV in the past year. HIV non-testing was significantly lower among men who were single, older, did not complete high school and were less food secure. VAW perpetration retained a significant association with HIV non-testing after controlling for socio-demographics (AOR = 0.73, 95%CI = 0.58-0.93). In multivariate models, HIV non-testing was also associated with inconsistent condom use (AOR = 0.64, 95%CI = 0.48-0.85), problem drinking (AOR = 0.72, 95%CI = 0.55-0.94) and reporting of all four risky sexual behaviours (AOR = 0.70, 95%CI = 0.49-1.01). Data suggests that one-third of men who never test for HIV in this setting may represent a high-risk group. Future campaigns could consider behaviour change around non-violence, relationship quality, and gender norms alongside HIV testing.
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