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C-Channel Issue 11

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C-Channel header  July 2009

Dear Colleagues,

C-Channel 11, the monthly e-newsletter from C-Change, connects readers to current research findings in the peer-reviewed literature on social and behavior change communication (SBCC) in the health sector, in particular reproductive health and family planning (RH/FP), HIV prevention, malaria, and maternal health and antenatal care. C-Change is implementing programs and conducting research in Africa, Asia, and Eastern Europe on SBCC that encompass these health areas.

This month’s issue highlights research on gender norms in the context of family planning and HIV prevention. The first four articles discuss gender norms research findings, including the demonstrated effectiveness of using gender-transformative approaches (defined as efforts to transform gender roles and promote more gender equitable relationships between men and women) in programming. Other articles explore married couple communication about contraception and male involvement in antenatal health in the context of voluntary counseling and testing (VCT) and prevention of mother-to-child transmission of HIV (PMTCT). Multiple current partnerships (MCP) are a key driver of HIV in southern Africa and the focus of C-Change work in Lesotho and Swaziland. An article on multiple current partnerships (MCP) calls for understanding the role of culture in developing approaches to risk reduction for HIV prevention.

Eleven articles cover research carried out in Africa and Asia, including Bangladesh, India, Kenya, Malawi, South Africa, Tanzania, Uganda, and Zimbabwe. For information about C-Change’s work on gender norms, visit http://www.c-changeprogram.org/our-approach/research/social-norms.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel


Gender Norms–In the context of Family Planning/Reproductive Health and HIV and AIDS

1. Questioning gender norms with men to improve health outcomes: Evidence of impact

2. The contextual effects of gender norms, communication, and social capital on family planning behaviors in Uganda: A multilevel approach

3. Sexual pleasure, gender power and microbicide acceptability in Zimbabwe and Malawi

4. Gender norms in South Africa: Implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution

Family Planning/Reproductive Health

5. 'Marriage means having children and forming your family, so what is the need of discussion?' Communication and negotiation of childbearing preferences among Bangladeshi couples

6. The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India

Family Planning/Reproductive Health and HIV and AIDS

7. Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: Implications for preventive programs

8. Male involvement in PMTCT services in Mbeya Region, Tanzania

HIV and AIDS

9. Cultural scripts for multiple and concurrent partnerships in southern Africa: Why HIV prevention needs anthropology

10. Social context, sexual risk perceptions and stigma: HIV vulnerability among male sex workers in Mombasa, Kenya

11. Scaling sexual behavior or "sexual risk propensity" among men at risk for HIV in Kisumu, Kenya
 


Gender Norms–In the context of Family Planning/Reproductive Health and HIV and AIDS

1. Questioning gender norms with men to improve health outcomes: Evidence of impact

Authors: Barker, G; Ricardo, C; Nascimento, M; Olukoya, A; Santos, C
Source: Global Public Health 09 June 2009: 1-15.

This article describes a review of 58 evaluation studies of programmes with men and boys in sexual and reproductive health (including HIV prevention, treatment, care and support); father involvement; gender-based violence; maternal, newborn and child health; and gender socialisation more broadly. While few of the programmes go beyond the pilot stage, or a relatively short-term timeframe, they offer compelling evidence that well-designed programmes with men and boys can lead to positive changes in their behaviours and attitudes related to sexual and reproductive health; maternal, newborn and child health; their interaction with their children; their use of violence against women; their questioning of violence with other men; and their health-seeking behaviour. The evidence indicates that programmes that incorporate a gender-transformative approach and promote gender-equitable relationships between men and women are more effective in producing behaviour change than narrowly focused interventions, as are programmes which reach beyond the individual level to the social context.

To link to the website containing this article, click here.

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2. The contextual effects of gender norms, communication, and social capital on family planning behaviors in Uganda: A multilevel approach

Authors: Paek, HJ; Lee, B; Salmon, CT; Witte, K
Source: Health Education and Behavior 1 Aug 2008, 35(4): 461-77.

This study hypothesized a multilevel model to examine the contextual effects of gender norms, exposure to health-related radio programs, interpersonal communication, and social capital on family planning behavior in Uganda. The results of hierarchical linear modeling showed that all of the four variables were significant predictors of family planning behavior. The authors found that gender norms as a contextual factor significantly interacted with the individual-level perceived benefit. The significant cross-level interaction effect was also observed between individuals' interpersonal communication and contextual variation in listening to a health-related radio program. Practical implications for family planning communication campaigns are discussed.

Key Words: family planning, hierarchical linear modeling, social capital, gender norm

To link to the website containing this article, click here.

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3. Sexual pleasure, gender power and microbicide acceptability in Zimbabwe and Malawi

Authors: Woodsong, C; Alleman, P
Source: AIDS Education and Prevention April 2008, 20(2): 171-87.

ABSTRACT

Topical vaginal microbicides are being developed to reduce HIV infection in women for whom correct and consistent condom use is impossible or undesirable. Although microbicides have been heralded as a "women-initiated" method that requires no action of the male partner, gender norms for sexual relationships and sexual practices could impede acceptability and use. To facilitate development of microbicides and look ahead to their eventual introduction, it is necessary to understand couples' sexual dynamics, including power and pleasure. This article presents data from a study of microbicide acceptability ancillary to a microbicide clinical trial in Malawi and Zimbabwe. Female trial participants, male partners, health care professionals and community stakeholders were interviewed about norms for sexual decision-making, sexual pleasure, and associated intravaginal practices that ensure this pleasure. Even though acceptability of microbicides was found to be high, sexual intercourse is accompanied by issues of power and gender norms that place women, particularly those in stable union, at a disadvantage for enactment of risk reduction strategies. Although woman-initiated use is an important goal in development of microbicides, the need for men's cooperation or agreement must be addressed in strategies for future product introduction.

To link to the website containing this article, click here. Full Text is freely available.

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4. Gender norms in South Africa: Implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution

Authors: Mantell, JE; Needham, SL; Smit, JA; Hoffman, S; Cebekhulu, Q; Adams-Skinner, J; Exner, TM; Mabude, Z; Beksinska, M; Stein, ZA; Milford, C
Source: Culture, Health & Sexuality Feb 2009, 11(2): 139-57.

ABSTRACT

In post-Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively 'privileged' group, there is little information on gender norms that might shape responses to HIV-prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi-structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV- and pregnancy-prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post-Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co-existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.

To link to the website containing this article, click here.

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Family Planning/Reproductive Health

5. 'Marriage means having children and forming your family, so what is the need of discussion?' Communication and negotiation of childbearing preferences among Bangladeshi couples

Authors: Gipson, JD; Hindin, MJ
Source: Culture, Health & Sexuality Mar-Apr 2007, 9(2): 185-98.

ABSTRACT

This paper explores communication and negotiation regarding contraception and childbearing based on multiple semi-structured interviews with 19 married couples in southwestern Bangladesh. The narratives of three couples are presented to describe how sociocultural context and gender-based norms influence interactions between husbands and wives and their fertility decision-making. Despite national-level declines in fertility, the couples' stories illustrate the ongoing struggles to balance their desired number of male and female children with their financial and social well-being. The stories also indicate that the nature of the interactions between spouses evolves throughout the course of their marital and reproductive lifespans, resulting in a shift in fertility decision-making power. Both wives and husbands described the relative powerlessness of new wives in negotiating fertility with husbands and extended family; however, wives' preferences appeared to dominate as they became more established in their households. Many wives acted independently and often contrary to their husbands' desires, through their covert use or non-use of contraception and pregnancy termination. These findings illustrate that, despite efforts to increase contraceptive availability within Bangladesh, without concurrent changes in the opportunities available for women beyond their reproductive capacities, the demand for children, and particularly for male children, is not likely to change.

Keywords: fertility decision-making, couples, Bangladesh, gender, contraception, pregnancy intention

To link to the website containing this article, click here.

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6. The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India

Authors: Daniel, EE; Masilamani, R; Rahman, M
Source: International Family Planning Perspectives 2008, 34(4): 189-197.

CONTEXT: Contraceptive use among young couples in India is low, and early childbearing and short birth intervals are common. The PRACHAR Project, an ongoing intervention in Bihar, seeks to increase contraceptive use for delaying and spacing births through communication interventions.

METHODS: Random samples of married women younger than 25 with no more than one child were surveyed in 2002-2003, before PRACHAR was implemented (N=1,995), and in 2004, 21-27 months after implementation (N=2,080). Contraceptive demand and use, and related attitudes and knowledge, were assessed in the two surveys in both intervention areas and comparison areas. Logistic regression was used to assess the effect of the interventions on these indicators.

RESULTS: Contraceptive use was very low (2-6%) at baseline in both comparison and intervention areas. Demand for contraception increased from 25% at baseline to 40% at follow-up in intervention areas, but remained virtually unchanged in comparison areas. At follow-up, contraceptive use had risen in both areas, but the adjusted odds of use in intervention areas were 3.8 times those in comparison areas. Women in intervention areas had elevated odds of knowing that fertility varies during the menstrual cycle, and of agreeing that early childbirth can be harmful and that contraceptive use is necessary and safe for delaying first births (odds ratios, 1.6-3.0).

CONCLUSION: Culturally appropriate, community-based communication programs that target youth and those who influence their decisions can create demand for contraception among young couples and lead to increased contraceptive use.

To link to the website containing this article, click here. Full Text is freely available.

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Family Planning/Reproductive Health and HIV and AIDS

7. Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: Implications for preventive programs

Authors: Msuya, SE; Mbizvo, EM; Hussain, A; Uriyo, J; Sam, NE; Stray-Pedersen, B
Source: AIDS Care July 2008, 20(6): 700-709.

This study aimed to describe the prevalence and predictors for male partner participation in HIV voluntary counselling and testing (VCT) at two primary healthcare clinics in Moshi urban, Tanzania as well as the effect of partner participation on uptake of HIV perinatal interventions. Pregnant women (n = 2654) in their third trimester, participating in a prevention of mother to child tranmission (PMTCT) program between June 2002 and March 2004 were encouraged to inform and invite their partners for HIV-VCT. Trained nurses conducted pre-test counselling, interviews, clinical examinations and blood sampling from the participating women and their partners. Test results were presented and post-test counselling was conducted individually or in couples, depending on the wishes of the participants. Three-hundred-and-thirty-two male partners (12.5%) came for HIV-VCT. A high proportion (131; 40%) came after the woman had delivered. HIV-seropositive women whose partners attended were three times more likely to use Nevirapine prophylaxis, four times more likely to avoid breastfeeding and six times more likely to adhere to the infant feeding method selected than those whose partners didn't attend. Women were more likely to bring their partner for VCT if they collected their own test results, were living with their partner, had a high monthly income and had expressed at enrolment the intention to share HIV results with their partner. Although PMTCT programs are presumably a good entry point for male involvement in prevention of sexual and perinatal HIV transmission, this traditional clinic-based approach reaches few men. Given the positive influence male participation has on the acceptance of perinatal interventions, a different approach for promoting male participation in VCT is urgently required. Within PMTCT programs, counseling should emphasize the advantages of partner participation to encourage women to inform and convince male partners to come for VCT. Also, promotion of couple VCT outside antenatal settings in male friendly and accessible settings should be given priority.

To link to the website containing this article, click here.

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8. Male involvement in PMTCT services in Mbeya Region, Tanzania

Authors: Theuring, S; Mbezi, P; Luvanda, H; Jordan-Harder, B; Kunz, A; Harms, G Source: AIDS and Behavior 24 March 2009, 13(1): 92-102.

Throughout all stages of programmes for the prevention of mother-to-child-transmission of HIV (PMTCT), high dropout rates are common. Increased male involvement and couples' joint HIV counselling/testing during antenatal care (ANC) seem crucial for improving PMTCT outcomes. Our study assessed male attitudes regarding partner involvement into ANC/PMTCT services in Mbeya Region, Tanzania, conducting 124 individual interviews and six focus group discussions. Almost all respondents generally supported PMTCT interventions. Mentioned barriers to ANC/PMTCT attendance included lacking information/knowledge, no time, neglected importance, the services representing a female responsibility, or fear of HIV-test results. Only few perceived couple HIV counselling/testing as disadvantageous. Among fathers who had refused previous ANC/PMTCT attendance, most had done so even though they were not perceiving a disadvantage about couple counselling/testing. The contradiction between men's beneficial attitudes towards their involvement and low participation rates suggests that external barriers play a large role in this decision-making process and that partner's needs should be more specifically addressed in ANC/PMTCT services.

To link to the website containing this article, click here.

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HIV and AIDS

9. Cultural scripts for multiple and concurrent partnerships in southern Africa: Why HIV prevention needs anthropology

Author: Leclerc-Madlala, S
Source: Sexual Health June 2009, 6(2): 103-10. [PubMed]

Background: Multiple and concurrent sexual partnerships have been identified as southern Africa's key behavioural driver of HIV, resulting in calls to make partner reduction programming central to an intensified HIV prevention focus. Various efforts are currently being made in the region in response to this call. Such efforts will likely have as limited success as past prevention efforts if the cultural milieu in which sexual partnering practices are located and reproduced remains poorly understood, unaccounted for, and unaddressed in prevention programming.

Methods: Focussed ethnographic discussions were held between October 2007 and November 2008 with 228 members of southern African non-government organisations representing seven countries. Discussions formed part of follow-up activities to a high level regional meeting and were aimed at exploring contextual factors in HIV transmission, most especially the role of culture in relation to multiple and concurrent partnerships.

Results: Common patterns in cultural scripts for the performance of sexuality were discernable. Several predominant scripts that tend to affirm and lend cultural legitimacy to multiple and concurrent partnering were identified, discussed and analysed.

Conclusion: Effectuating change at the level of cultural scripting to discourage multiple and concurrent partnerships is required for sustainable long-term protection of people and communities against HIV. The success of partner reduction programs will be largely determined by the extent to which they are informed by anthropological knowledge and work with cultural logics to allow people to envision how they can transform obstacles into support for risk reduction.

To link to the website containing this article, click here.

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10. Social context, sexual risk perceptions and stigma: HIV vulnerability among male sex workers in Mombasa, Kenya

Authors: Okal, J; Luchters, S; Geibel, S; Chersich, MF; Lango, D; Temmerman, M
Source: Culture, Health & Sexuality May 2009, 29:1. [Epub ahead of print]

ABSTRACT

Knowledge about sexual practices and life experiences of men having sex with men in Kenya, and indeed in East Africa, is limited. Although the impact of male same-sex HIV transmission in Africa is increasingly acknowledged, HIV prevention initiatives remain focused largely on heterosexual and mother-to-child transmission. Using data from ten in-depth interviews and three focus group discussions (36 men), this analysis explores social and behavioural determinants of sexual risks among men who sell sex to men in Mombasa, Kenya. Analysis showed a range and variation of men by age and social class. First male same-sex experiences occurred for diverse reasons, including love and pleasure, as part of sexual exploration, economic exchange and coercion. Condom use is erratic and subject to common constraints, including notions of sexual interference and motivations of clients. Low knowledge compounds sexual risk taking, with a widespread belief that the risk of HIV transmission through anal sex is lower than vaginal sex. Traditional family values, stereotypes of abnormality, gender norms and cultural and religious influences underlie intense stigma and discrimination. This information is guiding development of peer education programmes and sensitisation of health providers, addressing unmet HIV prevention needs. Such changes are required throughout Eastern Africa. 

Keywords: Kenya, male sex work, men who have sex with men, HIV/AIDS, HIV prevention

To link to the website containing this article, click here.

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11. Scaling sexual behavior or "sexual risk propensity" among men at risk for HIV in Kisumu, Kenya

Authors: Mattson, CL; Campbell, RT; Karabatsos, G; Agot, K; Ndinya-Achola, JO; Moses, S; Bailey, RC
Source: AIDS and Behavior 24 July 2008, doi 10.1007/s10461-008-9423-z.

ABSTRACT

We present a scale to measure sexual risk behavior or "sexual risk propensity" to evaluate risk compensation among men engaged in a randomized clinical trial of male circumcision. This statistical approach can be used to represent each respondent’s level of sexual risk behavior as the sum of his responses on multiple dichotomous and rating scale (i.e. ordinal) items. This summary "score" can be used to summarize information on many sexual behaviors or to evaluate changes in sexual behavior with respect to an intervention. Our 18 item scale demonstrated very good reliability (Cronbach’s alpha of 0.87) and produced a logical, unidimensional continuum to represent sexual risk behavior. We found no evidence of differential item function at different time points (except for reporting a concurrent partners when comparing 6 and 12 month follow-up visits) or with respect to the language with which the instrument was administered. Further, we established criterion validity by demonstrating a statistically significant association between the risk scale and the acquisition of incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV at the 12 month follow-up visits. This method has broad applicability to evaluate sexual risk behavior in the context of other HIV and STI prevention interventions (e.g. microbicide or vaccine trials), or in response to treatment provision (e.g., anti-retroviral therapy).

Keywords: Non-parametric item response theory, Male circumcision, Risk compensation, HIV/AIDS, Africa

To link to the website containing this article, click here.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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