Changing gender and social norms, attitudes and behaviours

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1 Helpdesk Reprt Changing gender and scial nrms, attitudes and behaviurs Huma Haider University f Birmingham 11 April 2017 Questin What rigrus evidence is there n what types f prgramming interventins wrk t bring abut changes in gender and scial nrms, and changes in wider attitudes and behaviurs (e.g. HIV/AIDs preventin and better sanitatin and hygiene). Cntents 1. Overview 2. Synthesis reprts 3. Interventins at the individual and relatinship level 4. Interventins at the cmmunity level 5. Interventins at the scietal level 6. Additinal references 1. Overview Scial nrms are infrmal rules and shared scial expectatins that shape individual attitudes and behaviur (Arias, 2015; Marcus and Harper, 2015). Gender nrms are scial nrms that relate specifically t gender differences. A cmmn gender nrm, fr example, is that wmen and girls will and shuld d the majrity f dmestic wrk (Marcus and Harper, 2015). This helpdesk reprt presents studies f prgrammes that aim t bring abut changes in gender and scial nrms, and changes in wider attitudes and behaviurs. Much f the literature and sme prgramme designs recgnise the need t change scial nrms in rder t change behaviurs, such as HIV/AIDs preventin and better sanitatin and hygiene. The K4D helpdesk service prvides brief summaries f current research, evidence, and lessns learned. Helpdesk reprts are intended t prvide an intrductin t the mst imprtant evidence related t a research questin. They draw n a rapid desk-based review f published literature and cnsultatin with subject specialists. Helpdesk reprts are cmmissined by the UK Department fr Internatinal Develpment and ther Gvernment departments, but the views and pinins expressed d nt necessarily reflect thse f DFID, the UK Gvernment, K4D r any ther cntributing rganisatin. Fr further infrmatin, please cntact helpdesk@k4d.inf.

2 The reprt lks at interventins targeting individual and inter-relatinal levels (e.g. wrkshps); cmmunity levels (e.g. cmmunity dialgue, cmmunity mbilisatin and yuth initiatives); and wider scietal levels (mass media and edutainment). It highlights the effects f such interventins, fcusing n rigrus evaluatins. 2. Synthesis reprts Marcus, R. (2014). Changing discriminatry nrms affecting adlescent girls thrugh cmmunicatins activities: Insights fr plicy and practice frm an evidence review. Lndn: Overseas Develpment Institute. There is strng evidence frm this review f 61 prgrammes that cmmunicatin prgrammes are an effective way t challenge gender discriminatry attitudes and practices. Prgrammes with mre than ne cmmunicatin cmpnent have achieved a higher prprtin f psitive utcmes. Integrated prgrammes with nn-cmmunicatin activities have als been slightly mre effective. Many prgrammes drew n best practice in cmmunicatin fr scial change, with sympathetic characters in radi and TV dramas and prvisin f new factual infrmatin and episde summaries Cmmunity dialgue-based prgrammes have created spaces fr reflectin and addressed key issues directly. Cmmunicatins prgrammes have been effective in shifting gender nrms affecting adlescents. Overall, 71% f utcmes recrded in the studies reviewed here were psitive (e.g. they indicated change in a gender egalitarian directin), with very little difference between changes in attitudes and changes in practices (respectively, 72% and 69% psitive). The gap between attitude change and practice change was greater fr mediabased interventins, and lwest fr nn-frmal educatin-based appraches than fr ther cmmunicatins appraches. This is cnsistent with a tentative finding frm these prgrammes: appraches that stimulate discussin within a peer grup are mre likely t have psitive utcmes and may help bridge the gap between attitude and practice change. Lnger r mre intense expsure t a cmmunicatins prgramme usually leads t greater and mre sustained change in gender nrms. An increase in the number f cmmunicatins cmpnents appears t be assciated with a greater prprtin f psitive utcmes. Integrated prgrammes (including nn-cmmunicatins activities) have verall been slightly mre effective than stand-alne cmmunicatins prgrammes. Wrking with multiple stakehlders (girls, family decisin makers and cmmunity influencers) is ften imprtant in achieving nrm change. 2

3 Pittman, A. and L. Haylck (2016). Assessing Oxfam s Cntributin t changes in scial nrms in VAWG/GBV prgramming glbally. Oxfam. Only a handful f Oxfam reprts presented infrmatin n the effectiveness f particular strategies and their cntributins t particular utcmes. The evaluatins highlighted the pwer f creative and interactive means f cmmunicatin thrugh rle plays, dramas and public hearings, rather than passive awareness-raising thrugh leaflets r infrmatinal channels. Mdelling psitive behaviur, especially thrugh the Edutainment mdel, was the fcus f tw evaluatins in Nigeria and Bangladesh. Innvative and interactive means f cmmunicatin (e.g. raising awareness f vilence against wmen thrugh rle play that cmbined culture and art) was als mentined by the evaluatins in India and Vietnam. Engaging influential cmmunity leaders, religius leaders and duty bearers appeared t be effective in awareness-raising. It was a key strategy used t vercme cmmunity resistance fr running GBV awareness campaigns and changing mindsets abut what cnstitutes vilence. While Oxfam aims t bring abut scial nrm change, prjects mst ften fcus slely n awareness and access issues. Shrt timelines decrease the effectiveness f prjects and prgrammes aiming t cntribute t scial nrm change. Lundgren, R. and A. Amin. (2015). Addressing intimate partner vilence and sexual vilence amng adlescents: Emerging evidence f effectiveness. Jurnal f Adlescent Health, 56(1), S42-S50. Prgrammes surveyed fr this research were cnsidered effective if they were evaluated with well-designed studies, which cntrlled fr threats t validity thrugh randmizatin f participants. A review f 142 articles and dcuments revealed 61 interventins, which aimed t prevent intimate partner vilence (IPV) and sexual vilence (SV) amng adlescents. Lack f rigrus evidence limits cnclusins n the effectiveness f adlescent IPV and SV preventin prgrams. Three prmising appraches emerge: Schl-based dating vilence interventins shw cnsiderable success. Hwever, they have nly been implemented in high-incme cuntries. 3

4 Cmmunity-based interventins t frm gender equitable attitudes amng bys and girls have successfully prevented IPV r SV. Results suggest that prgrammes with lnger term investments and repeated expsure t ideas delivered in different settings ver time have better results than single awareness-raising r discussin sessins. 3. Interventins at the individual and relatinship level Wrkshps and dialgue sessins Gender transfrmative strategies are ften implemented thrugh wrkshps directed at men and wmen, separately r tgether (Fulu, Kerr-Wilsn et al., 2015). Small grup wrkshps, targeting specific grups, can als frm the basis f wrking with the wider cmmunity using thse trained in such grups t diffuse messages (Alexander-Sctt, 2016). Develpment initiatives and inter-relatinal grup sessins Gupta, J. et al. (2013). Gender nrms and ecnmic empwerment interventin t reduce intimate partner vilence against wmen in rural Côte d Ivire: a randmized cntrlled pilt study. Internatinal Health and Human Rights, 13, The prgramme The interventin cmbined gender dialgue grups (GDG) fr bth wmen and their male partners with wmen s nly village savings and lans assciatins (VSLA) prgrammes, with the aim f reducing intimate partner vilence against wmen. The cntrl arm cnsisted f the VSLA and the treatment arm received VSLA and an 8-sessin GDG. The GDGs were develped fr wmen and their male partner and sught t address husehld gender inequities. The interventin aimed t cunter critiques f prgrammes aimed at reducing IPV thrugh ecnmic empwerment f wmen, withut addressing larger gender nrms that perpetuate gender inequalities and IPV. The tw-armed randmized cntrlled trial (RCT), cnducted in rural Côte d Ivire between , aimed t evaluate the incremental impact n levels f IPV f adding Gender Dialgue Grups fr wmen and their partners t ecnmic empwerment prgrammes fr wmen. 1,271 wmen cmpleted the baseline survey, after which 650 wmen were randmized t the treatment grup and 548 were randmized t the cntrl grup. Of these wmen, 934 (513 treatment; 421 cntrl) were included in the fllw-up analyses (95.2%). 4

5 measured past-year physical IPV, sexual IPV, ecnmic abuse, and attitudes twards justificatin f wife beating and a wman s ability t refuse sex with her husband. Adding a dialgue cmpnent explicitly addressing gendered scial inequalities and nrms alngside ecnmic empwerment prgramming had the fllwing effects: The dds f reprting physical and/r sexual IPV in the past year was lwer in the VSLA + GDG in cmparisn t the cntrl grup (20.7% vs. 21%), althugh this was nt statistically significant. Hwever, physical IPV decreased frm 15.4% t 7.5% amng wmen and their partners that attended at least 75% f the interventin sessins. VSLA + GDG wmen were significantly less likely t reprt ecnmic abuse than VSLA-nly cunterparts. The percentage f participants in the treatment grup wh reprted experiencing ecnmic abuse decreased by 11 percentage pints, cmpared with an increase f 7.2 percentage pints in the cntrl grup. Acceptance f justificatin twards wife beating was significantly reduced in the VSLA + GDG grup. Amng the partners that attended at least 75% f the interventin, the percent that reprted wife beating is justified decreased frm 4.2% t 3.6%. Falb, K. L. et al. (2014). Gender nrms, pverty and armed cnflict in Côte D Ivire: engaging men in wmen s scial and ecnmic empwerment prgramming. Health Educatin Research, 29 (6): Di: /her/cyu The prgramme The interventin cmbined gender dialgue grups (GDG) fr bth wmen and their male partners with wmen s nly village savings and lans assciatins (VSLA) prgrammes, with the aim f reducing intimate partner vilence against wmen. This investigatin fcuses n qualitative data cllected as part f a tw-armed randmized cntrlled trial. During endline data cllectin in 2012, qualitative in-depth interviews were cnducted amng a subsample f female study participants and male partners t understand their experiences with the interventin. Overall, a ttal f 32 male partners were invited t participate. 5

6 Men wh had participated in gender dialgue grups, alngside the VSLA, identified imprvements in their relatinships with their female partners, including: increased cmmunicatin with their wives; mre transparency f husehld finances; and greater respect fr their wives and their ability t cntribute t the husehld financially and therwise. They attributed increased jint financial decisin-making with their wives t the interventin. Alngside, there was als a decrease in wasteful spending, particularly n alchl. These qualitative findings are mirrred in quantitative findings: wmen wh participated in bth the VSLA and GDGs with their male partner reprted a 61% reductin in ecnmic abuse cmpared t wmen randmised t VSLA nly. While quantitative findings did nt demnstrate statistically significant reductins in intimate partner vilence, wmen wh attended at least six f eight GDG sessins with the male partner reprted a relative decrease in physical IPV by 55%, cmpared with wmen wh were in the VSLA nly grup. Kim, J. et al. (2009). Assessing the incremental effects f cmbining ecnmic and health interventins: the IMAGE study in Suth Africa. Bulletin f the Wrld Health Organisatin, 87, Di: /BLT The prgramme Carried ut in rural Suth Africa, IMAGE cmbined grup-based micrfinance with a 12-mnth gender and HIV training curriculum. Wmen received the training at lan meetings held every tw weeks. Data n IMAGE participants and cntrls were derived frm a cluster randmized trial. was cnducted between June 2001 and March 2005 in rural Limpp prvince, with a ttal f 1409 participants, all female, with a median age f 45. aimed t explre whether adding a gender and HIV training prgramme t micrfinance initiatives can lead t health and scial benefits beynd thse achieved by micrfinance alne. After 2 years, bth the micrfinance-nly grup and the IMAGE grup shwed ecnmic imprvements relative t the cntrl grup. Hwever, nly the IMAGE grup demnstrated cnsistent assciatins acrss all dmains with regard t wmen s empwerment, intimate partner vilence and HIV risk behaviur. 6

7 Levels f physical and sexual IPV were 55% lwer amng IMAGE participants cmpared with cntrls, and yung prgramme participants reprted higher levels f HIV-related cmmunicatin and HIV testing and greater cndm use with nnspusal partners. Initiatives targeting men and bys Pulerwitz, J. et al. (2015). Changing gender nrms and reducing HIV and vilence risk amng wrkers and students in China. Jurnal f Health Cmmunicatin, 20(8), Di: / The prgramme The China Family Planning Assciatin and PATH develped and evaluated a gender-fcused behaviur change cmmunicatin interventin fr HIV and vilence preventin. It is based n the understanding that inequitable gender nrms negatively influence key health utcmes and that men need t be invlved in preventin effrts. Eight participatry educatin sessins were implemented in factries and schls. Baseline and endline surveys were cnducted with 219 male factry wrkers and 496 male vcatinal students. Supprt fr (in)equitable nrms was measured by the Gender Equitable Men Scale, as well as partner vilence and cmmunicatin. Fcus grups with male and female wrkers, students, teachers, and factry managers were used t crrbrate findings. Findings The prgramme resulted in significant psitive changes in gender-related views and greater supprt fr equitable gender nrms (e.g. reductin frm 42% t 18% f wrkers agreeing that a wman shuld tlerate vilence in rder t keep her family tgether ). It als resulted in related reprted behaviural changes (e.g. reductin frm 15% t 7% f students reprting partner vilence ver the past 3 mnths). These findings suggest that a relatively lw intensity interventin can influence imprtant gender nrms and related behaviurs. 7

8 Dwrkin, S. L. et al. (2013). Impact f a gender-transfrmative HIV and anti-vilence prgramme n gender idelgies and masculinities in tw rural, Suth African cmmunities. Men and Masculinities 16(2), The prgramme One Man Can (OMC) is a rights-based gender equality and health prgramme implemented by Snke Gender Justice Netwrk (Snke) in Suth Africa. The prgramme seeks t reduce the spread and impact f HIV/AIDS and reduce vilence against wmen and men. T better understand hw the prgramme impacts men s individual and cllective practices centered n masculinities, the researchers cnducted sixty qualitative, indepth interviews in 2010 with men wh participated in OMC in rural Limpp and Eastern Cape, Suth Africa. Given that the men in this sample were recruited by partner rganizatins f the Snke Gender Justice Netwrk that were invested in gender equality and health, these men might nt be representative f the brader cmmunity. While mst OMC participants became supprtive f a shifting terrain f rights and shared pwer, a clear minrity als believed that the rights f wmen and children were being prmted and prtected at their wn expense. Van den Berg, W. et al. (2013). One Man Can : shifts in fatherhd beliefs and parenting practices fllwing a gender-transfrmative prgramme in Eastern Cape, Suth Africa. Gender & Develpment, 21(1), /di/abs/ / The prgramme The OMC Fatherhd Prject, the fcus f this article, was develped and implemented in t increase men s invlvement in meeting the needs f children affected by HIV and AIDS. OMC seeks t imprve men s relatinships with their partners, children, and families, reduce the spread and impact f HIV and AIDS, and reduce vilence against wmen, men, and children. aimed t understand whether and hw OMC wrkshps brught abut changes in men s attitudes and practices related t parenting. 8

9 Participants were interviewed nce during the six-mnth perid in 2010 fllwing their participatin in the prgramme. Mst participants reprted that OMC had influenced their way f thinking abut masculinity and fatherhd, and ascribed these changes specifically t the prject. Fr example, many men described hw OMC shifted their parenting style frm a financial prvidership rle t ne f increased invlvement, cmpaninship, nurturing, and affectin. Several fathers als described a shift twards being less vilent and being mre caring and prtective. In additin t influencing men s beliefs abut fatherhd, interviewees als revealed hw OMC led t changes in fur ther fatherhd-related practices: away frm being an absentee father and twards being a present, psitive rle mdel in their children s lives; imprved cmmunicatin with children; fewer crpral discipline strategies with their children; recgnitin f the rle they culd play in psitively scialising the next generatin f yuth t be respectful, gender-equitable, and t share husehld respnsibilities. 4. Interventins at the cmmunity level Changing individual attitudes may be insufficient t change behaviurs. Greater effrts are ften needed t engage the larger cmmunity in multi-cmpnent initiatives designed t change scial nrms (Fulu, Kerr-Wilsn et al., 2015). Cmmunity mbilisatin Cmmunity-level interventins ften have cmpnents aimed at mbilising specific peple (change agents) within a cmmunity t encurage thers t change by fstering dialgue and diffusing messages t peple beynd direct participants (Alexander-Sctt, 2016). There is sme evidence that cmmunity-wide mbilisatin appraches are effective and can have a wide reach (ibid). Abramsky, T. et al. (2014). Findings frm the SASA! Study: a cluster randmized cntrlled trial t assess the impact f a cmmunity mbilizatin interventin t prevent vilence against wmen and reduce HIV risk in Kampala, Uganda. BMC Medicine, 12, 122. Di: /s See als: Abramsky, T, et al. (2016). The impact f SASA!, a cmmunity mbilisatin interventin, n wmen's experiences f intimate partner vilence: secndary findings frm a cluster randmised trial in Kampala, Uganda. Jurnal f Epidemilgy and Cmmunity Health. 70, See als: Watts, C. et al. (2015). The SASA! study: a cluster randmised trial t assess the impact f a vilence and HIV preventin prgramme in Kampala, Uganda. 3ie 9

10 Impact Evaluatin Reprt 24. New Delhi: Internatinal Initiative fr Impact Evaluatin (3ie). The prgramme The SASA! Activist Kit fr Preventing Vilence against Wmen and HIV was a cmmunity mbilisatin interventin that sught t change cmmunity nrms and behaviurs that result in gender inequality, vilence and increased HIV vulnerability fr wmen in Kampala, Uganda. SASA! used fur strategies: lcal activism, media and advcacy (small-scale media and street theatre), cmmunicatin materials, and training f cmmunity activists. Cmmunity activists cnducted infrmal activities within their wn scial netwrks, amng their families, friends, clleagues and neighburs. In this way, cmmunity members were expsed t SASA! ideas repeatedly and in diverse ways within the curse f their daily lives, frm peple they knw and trust as well as frm mre frmal surces within their cmmunities. SASA! was aimed at bth primary vilence preventin (stpping the nset f vilence where it was nt previusly ccurring) and secndary vilence preventin (stpping vilence frm cntinuing where it was ccurring previusly). A pair-matched cluster randmized cntrlled trial was cnducted in eight cmmunities (fur interventin and fur cntrl) in Kampala frm 2007 t Surveys were undertaken at baseline (n = 1,583) and fur years pst interventin implementatin (n = 2,532). It lked at fur categries f IPV-related utcmes: physical and sexual IPV, emtinal aggressin, cntrlling behaviurs, and a wman s reprted fear f her partner. Secndary analysis f data frm the SASA! study assessed the ptential f a cmmunity mbilisatin interventin t reduce verall prevalence f IPV, new nset f abuse and cntinuatin f prir abuse. While the ultimate aim f preventin activities may be t entirely eradicate vilence, reductins in frequency and severity are als imprtant, especially in settings with high levels f vilence. The interventin was assciated with significantly lwer scial acceptance f IPV amng wmen and men; and significantly greater acceptance that a wman can refuse sex amng wmen and men. Wmen in interventin cmmunities were 52% less likely t reprt past year experience f physical intimate partner vilence (after just under 3 years f interventin prgramming), cmpared with wmen in cntrl cmmunities. 10

11 Wmen in interventin cmmunities were als much less likely than wmen in cntrl cmmunities t reprt severe/repeated episdes f physical IPV; injury assciated with physical/sexual IPV; high-intensity emtinal aggressin; and high-intensity cntrlling behaviurs. Wmen experiencing vilence in interventin cmmunities were mre likely t receive supprtive cmmunity respnses. Reprted past year sexual cncurrency by men was significantly lwer in interventin cmpared t cntrl cmmunities. At fllw-up, all types f IPV (including severe frms f each) were lwer in interventin cmmunities cmpared with cntrl cmmunities. Impacts were largest when the mre severe r intense frms f abuse were cnsidered, suggesting that in cases where IPV was nt cmpletely eliminated, SASA! may at least have reduced the frequency and/r severity f vilent episdes. SASA! was assciated with lwer nset f abuse and lwer cntinuatin f prir abuse. Quantitative and qualitative analyses indicate that key pathways thrugh which physical IPV was reduced include changes in cmmunity-level nrms relating t gender-related pwer dynamics and the acceptability f IPV, as well as imprved cmmunicatin within relatinships. als suggest that SASA! impacted significantly n the reprted levels f sexual cncurrency, with 27 per cent f partnered men in interventin cmmunities reprting having had ther sexual partners in the past year, cmpared t 45 per cent f men in the cntrl cmmunities. Quantitative findings are strngly supprted by in-depth interviews with stakehlders and cmmunity members, which suggest that these results were achieved thrugh SASA! s influence n the dynamics f individual relatinships, as well as its impact n brader cmmunity nrms. At the relatinship level, SASA! helped cuples explre the benefits f mutually supprtive gender rles and encuraged better cmmunicatin, jint decisin making and prblem slving between cuples. This resulted in reduced relatinship tensins and disharmny, a mre deliberate effrt by individuals t wrk tgether fr the gd f their relatinship and family, and an increase in intimacy within the relatinship. At the cmmunity level, SASA! helped fster a climate f nn-tlerance f vilence against wmen, by reducing the acceptability f vilence against wmen and imprving individuals skills, willingness and sense f respnsibility t reduce vilence against wmen in their cmmunities. It als helped t develp and imprve frmal and infrmal cmmunity-based supprt mechanisms and services t supprt this change. Wmen in interventin cmmunities wh had experienced vilence were mre than twice as likely as wmen in cntrl cmmunities t reprt that they experienced a supprtive cmmunity respnse, althugh this was nt significant due t small numbers in each cluster. 11

12 Wagman, J.A., et al. (2015). Effectiveness f an integrated intimate partner vilence and HIV preventin interventin in Rakai, Uganda: analysis f an interventin in an existing cluster randmised chrt. Lancet Glbal Health, 3, e The prgramme The Safe Hmes and Respect fr Everyne (SHARE) Prject aimed t reduce physical and sexual IPV and HIV incidence. SHARE used tw main appraches: cmmunity-based mbilisatin t change attitudes and scial nrms that cntribute t IPV and HIV risk, and a screening and brief interventin t reduce HIV-disclsure-related vilence and sexual risk in wmen seeking HIV cunselling and testing individuals (in fur interventin clusters) were randmly allcated int the SHARE plus HIV services grup and 6111 individuals (in seven cntrl clusters) were allcated int the HIV services nly grup. This study aims t assess the effect n past-year IPV against wmen, HIV incidence, and certain sexual risk behaviurs f adding SHARE int nging HIV treatment and preventin activities f the Rakai Health Sciences Prgramme in Rakai, Uganda. A baseline survey was cnducted in , and tw fllw-up surveys in ; and Primary endpints were self-reprted experience and perpetratin f past year IPV. Expsure t SHARE was assciated with significantly reduced reprts f wmen's physical IPV, sexual IPV, and frced sex. Hwever, male-reprted perpetratin f IPV was nt significantly affected by the interventin. Cmpared with cntrl grups, individuals in the SHARE interventin grups had fewer self-reprts f past-year physical IPV (346 [16%] f 2127 respnders in cntrl grups vs 217 [12%] f 1812 respnders in interventin grups. The interventin did nt significantly reduce wmen's experiences f emtinal IPV. Incidence f emtinal IPV did nt differ between interventin and cntrl grups (409 [20%] f 2039 vs 311 [18%] f Men's reprts f emtinal and physical IPV perpetratin decreased ver the curse f the trial in bth grups, but reprted final IPV rates at fllw-up did nt differ significantly. SHARE was assciated with significant increases in disclsure f HIV status in men and wmen. SHARE was assciated with a lwer HIV incidence during the interventin perid (pssibly thrugh a reductin in frced sex and increased disclsure f HIV results), 12

13 but this reductin was nt maintained after SHARE ended, suggesting that cntinued expsure t the interventin may be needed t achieve a sustained effect. Mentring and psitive rle-mdelling Miller, E. et al. (2014). Evaluatin f a gender-based vilence preventin prgramme fr student athletes in Mumbai, India. Jurnal f Interpersnal Vilence, 29(4), The prgramme The prgramme, Caching Bys Int Men, cnducted in Mumbai, India, trains caches t be messengers t yung athletes abut standing up against GBV and prmting gender-equitable attitudes and behaviurs. By engaging caches as psitive rle mdels, training them t deliver cnsistent messages abut respecting wmen, and cnveying the imprtance f stpping GBV, the prgramme encurages yuth t interrupt disrespectful, abusive behaviurs they witness amng their peers. The survey Baseline and 12 mnth fllw-up surveys were administered t 309 male cricket athletes aged 10 t 16 years in 46 urban middle schls in Mumbai, India (27 interventin, 19 cntrl). There were statistically significant increases in gender-equitable attitudes amng athletes receiving the interventin cmpared t athletes frm cmparisn schls. There were n differences in changes in attitudes disapprving f vilence against females. Fewer negative interventin behaviurs (e.g. laughing and ging alng with peers abusive behaviurs) were reprted by interventin athletes at fllw-up cmpared with cmparisn athletes, but this difference was nly marginally significant. Athletes whse caches were trained in the prgramme demnstrated greater imprvements in gender-equitable attitudes cmpared t athletes whse caches prvided standard caching nly. Marginally significant imprvements were seen in reductin f negative bystander behaviur. Middle schl age male athletes in urban India reprted high levels f abusive behaviurs in their hmes, schls, and cmmunities (verall prevalence f ver 80% in bth arms). This is in cntrast t their reprted sexual vilence perpetratin tward females (7% f interventin and 11% f the cmparisn grup). 13

14 Cmmunity dialgue, campaigns and media Skevingtn, S. M., Svetkina, E.C., and F. B. Gillisn FB. (2013). A systematic review t quantitatively evaluate Stepping Stnes : a participatry cmmunity-based HIV/AIDS preventin interventin. AIDS Behaviur, 17(3), The prgramme Stepping stnes (SS) is a gender transfrmative cmmunity training prgramme designed t address gender rles and prmte equitable relatinships, with the aim f reducing HIV transmissin. It uses a participatry learning apprach t empwer wmen and men t enhance cntrl ver their sexual and emtinal relatinships. Peer grups divided by gender and age band (yung/ld) wrk separately, then tgether intensively ver 3 4 mnths t build sexual health knwledge and reflect n behaviural mtivatin. Peer grup meetings prmte dialgue between genders and generatins n three ccasins. At the end f the prgramme, each peer grup presents its wn special request t the cmmunity utlining its mst imprtant prblem r need. The cmmunity analyses factrs that mutually affect their lives and behaviur, and different generatins f men and wmen engage with implementing psitive change that culd reduce HIV/AIDS vulnerability in their life and cmmunity. The interventin adpts critical reflectin and rle play techniques t build cmmunicatin and ther skills. The prgramme has been implemented in India, Gambia, S. Africa, Ethipia, Angla, Tanzania, Uganda and Fiji. This first independent systematic review examined evidence fr the effectiveness f the stepping stnes interventin in HIV preventin. It included published cmpleted evaluatins f SS interventins: randmised cntrl trials (RCTs), bservatinal and pilt studies. The RCT study investigated the effects f SS n bilgical utcmes: It did nt detect a significant reductin in HIV incidence fllwing prgramme cmpletin. Althugh yung wmen had 15% fewer new HIV infectins than cntrls, this was nt significant. SS participants were mre likely t btain their HIV test results (39%) than cntrls (30%). 14

15 The number f HIV infectins fr men was 4 times lwer than wmen verall. RCT results shwed a significant decrease in the incidence f herpes simplex type 2 (HSV-2) amng yung Suth Africans. Althugh this shrt-term reductin was similar fr gender grups, 2 years later yung wmen wh cmpleted the prgramme shwed 31% less HSV-2 infectins cmpared with 28% f yung men, althugh this was nt significant. Every cuntry demnstrated that SS decreased ne r mre self-reprted HIVrelated high risk behaviurs. This was bserved fr each peer grup. Cndm use tended t increase after the interventin, but nly tw studies fund significance (in India and Gambia), where mre men endrsed cndm use 16 mnths later. Other fllw-ups were incnclusive. Significant reductins in multiple partnering were recrded in Ethipia but were marginal fr Suth African men and absent in India. In three studies that investigated alchl, misuse was lwer fllwing SS and this was sustained at fllw-up. In India, misuse declined in the interventin grup by 43% ver tw years cmpared with 38% amng cntrls. In Ethipia, alchl befre sex decreased t zer after the interventin, cmpared with 27% f cntrls. Substance misuse by men decreased during the first year f the RCT. A cmmunity level analysis f Indian villages shwed that cmmunities participating in SS used less alchl (43%) than nn-ss villages (49%), demnstrating generalized lcal benefits. Each study investigated whether the interventin imprved knwledge and understanding f HIV/AIDS, transmissin mdes and persnal prtectin methds althugh significant results were limited. Only the Gambia shwed that SS imprved individual wmen s knwledge abut hw HIV is transmitted. In India, greater knwledge abut HIV transmissin mdes was bserved in participating villages. All studies investigated whether the SS interventin had imprved cmmunicatins, and psitive reprts were recrded fr all peer grups. Hwever nly three f the seven cuntries fund that skills in discussing HIV risks with partners and children significantly imprved. Gambian mthers in the interventin discussed sex mre ften with their children afterwards, changing frm 24% t 65% ver 4 mnths. SS in Gambia was mst effective in increasing the likelihd that wmen and men wuld discuss HIV risks with their spuse, and cndms with friends and relatives. After the Indian interventin, 46 % discussed sex with their partner, cmpared t 33% f cntrls. In Ethipia, 47% reprted imprved relatinships 6 mnths after SS, cmpared with 34% f cntrls. Sme 78% f SS participants discussed sex 15

16 with friends, cmpared with 62% f cntrls. Frty percent f yung Ethipians discussed sex with their parents pst-interventin but nly 20% f cntrls. Partners and children in Angla, Tanzania and Uganda als imprved their skills in discussing sex. Five studies investigated the effects f SS n gender equity. Gender inequity was reduced in India (ne in five studies), but stigma decreased in fur studies. In India, views that men always take the final decisin at hme were expressed by 53% f interventin grup and 64% f cntrls. Fewer SS participants (31%) than cntrls (40%) said that educated girls d nt make gd wives. In Fiji, men s attitudes twards gender nrms were imprved, and Tanzania shwed better gender relatins. Hwever attitudes twards gender equity were unchanged in Angla 18 mnths fllwing baseline, where 73% f participants (bth genders) believed that imprtant husehld decisins shuld nly be taken by men. There was limited evidence that physical r sexual intimate partner vilence was reduced by SS except fr marginal reductins fr Suth African men ver 2 years. Less wife-beating by men was reprted in the Gambia. Figuera, M. E. et al. (2016). Effectiveness f cmmunity dialgue in changing gender and sexual nrms fr HIV preventin: Evaluatin f the Tchva Tchva prgramme in Mzambique. Jurnal f Health Cmmunicatin, 21: Di: / The prgramme Tchva Tchva Histórias de Vida: Diálgs Cmunitáris (TTHV), which translates int Push Frward Life Stries: Cmmunity Dialgues, was designed t address underlying scial determinants, especially inequitable gender nrms, as a key step in reducing HIV risk behaviurs, increasing self-efficacy t talk abut and address HIV, and decreasing HIV stigma. The prgramme was implemented by cmmunity-based rganizatins and NGOs. They carried ut 1,134 cmmunity discussins/debates in 267 villages, reaching a ttal f 32,679 men and wmen participants in the prvinces f Zambezia and Sfala during 18 mnths between 2009 and The prgramme had tw main cmpnents: facilitated cmmunity dialgues (TTHV sessins) and the TT radi magazine. The prgramme adpted the view that knwledge cmes nt frm experts but rather frm cllective dialgue and frm within. Dialgue sessins included nine vide and written prfiles f real Mzambican trendsetters, wh tell their stries f hw they vercame gender, cultural, and scial 16

17 barriers, such as dmestic vilence, alchl abuse, and the subrdinatin f wmen, t make psitive changes in their lives that impacted HIV treatment and preventin. TTHV facilitatrs led a step-by-step prcess fr explring bth gender nrms and individual behaviurs in a safe envirnment. T expand the reach f TTHV activities, the TT radi magazine prvided reinfrcing messages and featured testimnies f TTHV participants wh had made changes in their lives and mdelled psitive behaviurs. Data fr this study came frm a pst-nly sample survey f 462 participants and 453 nnparticipants in the TTHV sessins in Zambezia and Sfala prvinces. The survey was fielded in July 2010 thrugh face-t-face interviews using a structured questinnaire that cllected infrmatin n expsure t and recall f the TTHV sessins, TTHV radi, and varius gender and HIV-related attitudes, perceptins, and behaviurs that the prgramme addressed, as well as a set f scidemgraphic and cntrl variables. The evaluatin results shw that the TT prgram cntributed significantly t bserved changes in three f the underlying structural factrs f HIV gender attitudes, gender rles, and HIV stigma. The prgramme als cntributed t changing HIV preventin knwledge and behaviurs that are assciated with HIV infectin, including discussin f HIV between sex partners. These results suggest that in a relatively shrt perid f time the prgramme created pprtunities t vice issues within the bunded TTHV grups that therwise may have remained drmant r taken lnger t surface. The stries f lcal Mzambicans as trendsetters/psitive deviants increased audience identificatin with the messages and made them mre credible. The vides and radi frmat helped ignite critical thinking and retentin f the stry lessns. Expsure t the TT radi prgram and frequency f listening was higher amng the interventin grup cmpared t the cntrl grup, evidence f the synergy that can be gained by crdinating cntent using different media frmats. Gender equity attitudes and behaviurs Respndents in the cntrl grup had lwer levels f agreement with gender equity attitudes (abve the median) at 35% cmpared t almst duble that (64%) in the interventin grup. Regarding behaviurs, the average number f shared husehld tasks was seven in the interventin grup cmpared t nly fur in the cntrl grup. 17

18 Fr sharing tasks traditinally differentiated by gender, such as ding laundry, bathing children, r fetching water, the percentage was mre than duble in the interventin grup cmpared t the cntrl grup. HIV preventin knwledge The number f crrect answers abut ways t prevent HIV was higher amng respndents in the interventin grup cmpared t the cntrl grup, except fr respnses abut using new blades r syringes, which have been addressed by ther health prgrammes. HIV stigma Abut 52% f thse in the interventin grup had attitudes abve the median that discurage HIV stigma cmpared t nly 30% in the cntrl grup. The prgramme was als successful in changing ther factrs assciated with HIV infectin, including HIV preventin knwledge, discussin f HIV between sex partners, and having multiple sex partners. Kaufman, M. R. et al. (2014). Using scial and behaviur change cmmunicatin t increase HIV testing and cndm use: the Malawi BRIDGE Prject. AIDS Care, 26(sup1), S46-S49. Di: / The prgramme The Bridge II prgramme was a multi-level HIV preventin interventin prgramme, implemented in the suthern regin f Malawi, where prevalence is highest. It sught t address barriers t individual actin and t cnfrnt scietal nrms related t sexual risk behaviur as a means f scaling up preventin activities (HIV testing and cndm use). Prgramme activities included cmmunity-based participatin (e.g., small grup discussins, interactive drama, cmmunity-wide events, cuples cunseling, cmmunity referral, capacity building f lcal structures t implement activities) and mass media messages delivered thrugh radi. This paper examines whether a chrt sample in the suthern regin was affected by the prgramme at the pint f midterm evaluatin, specifically regarding the three intermediate individual-level factrs f interest (HIV knwledge, self-efficacy, and risk perceptin) and the behaviurs f testing and cndm use at last sex. Baseline husehld-level surveys were cnducted in 2009 t assess knwledge, attitudes, and behaviurs, and midline data in Nvember

19 Prgramme/campaign expsure was a significant predictr f bth HIV testing in the past year and cndm use at last sex. This suggests that a cmmunicatin interventin may play an imprtant rle in nt nly affecting HIV-related behaviurs themselves, but als critical factrs that affect HIV behaviurs, including knwledge and self-efficacy. Tumwebaze, I. K. (2015). Effectiveness f grup discussins and cmmitment in imprving cleaning behaviur f shared sanitatin users in Kampala, Uganda slums. Scial Science & Medicine, 147, The prgramme This prgramme, invlving grup discussins and discussins + cmmitment. Interventins, was implemented fr 3 mnths with the aim f imprving cleaning behaviur. Grup discussins, facilitated by lcal leaders r village health wrkers, tk place nly nce in each grups amng users f the same sanitatin facility. The discussins enabled participants t talk with each ther abut hw they use and maintain the cleanliness f their sanitatin facilities. In the cmmitment cmpnent, each f the participants made a public pledge after the discussin cmmitting their participatin and that f ther husehld members t cleaning their shared sanitatin. They signed a cmmitment frm and ther discussin participants served as witnesses. The signed frm remained with the participant. evaluates the effectiveness f grup discussins and cmmitment in imprving the cleaning behaviur f shared sanitatin users in three urban slums in Kampala, Uganda. A pre- and pst-interventin survey was cnducted in the three slums between December 2012 and September analyses 119 respndents randmly allcated t discussins nly (n = 38), discussins + cmmitment (n = 41) and the cntrl (n interventin, n = 40) grups. Cmpared t the cntrl, discussins and discussins + cmmitment significantly imprved shared tilet users' cleaning behaviur. This was bserved thrugh behaviural determinants such as cleaning bligatin, cleaning ease, cleaning apprval and affective beliefs. 19

20 Grup discussins effected a psitive change n shared sanitatin users' perceptins that ther peple, such as relatives, friends, neighburs r leaders, supprt their participatin in cleaning their sanitatin facilities (cleaning apprval). This is cnsidered t be a behaviural determinant. Grup discussins supplemented with cmmitment als effect a psitive change n ther determinants such as cleaning affect (desire t clean their facilities) and cleaning bligatin, which cntributed t further imprvement in share sanitatin user s cleaning behaviur. McMichael, C. and P. Rbinsn, (2016). Drivers f sustained hygiene behaviur change: A case study frm mid-western Nepal. Scial Science & Medicine, 163, The prgramme This was a water, sanitatin and hygiene (WASH) interventin in mid-western Nepal. The research was cnducted during Octber Nvember 2014, tw and half years fllwing the interventin s endpint, with a particular fcus n key drivers. Qualitative data were cllected frm the target cmmunity (n = 112) via grup discussins, interviews and drawings/stries f mst significant change. Husehlds handwashing/water facilities and tilets were bserved. The interventin has supprted develpment f new nrms arund hygiene behaviurs. Key drivers f sustained hygiene behaviur were habit frmatin, emtinal drivers (e.g. disgust, affiliatin), and cllective actin and civic pride Key cnstraints included water scarcity and sciecnmic disadvantage. Bisung, E. (2015). Using phtvice as a cmmunity based participatry research tl fr changing water, sanitatin, and hygiene behaviurs in Usma, Kenya. BiMed Research Internatinal The prgramme Phtvice is a frm f cmmunity-based participatry research, aimed t prmte scial actin by equipping cmmunities t participate in the identificatin and analysis f lcal prblems. 20

21 Phtvice was cnducted with 8 wmen in Usma (Western Kenya) in 2013, with a fllw-up cmmunity meeting in 2014 t discuss findings with cmmunity members and gvernment fficials. The aim was t explre the applicatin and utility f phtvice fr understanding water, sanitatin, and hygiene behaviurs and catalysing cmmunity led slutins t change behaviurs. The first part f the study invlved phtvice ne-n-ne interviews t explre lcal perceptins and practices arund water-health linkages and hw the eclgical and sci-plitical envirnment shapes these perceptins and practices. The secnd part f the study used phtvice grup discussins t explre participants experiences with and (re)actin t the phtgraphs and the phtvice prject. Phtvice prvided an pprtunity fr researchers t fully understand the cmplexities f WASH related behaviurs in the cmmunity that ther research methds such as surveys and interviews may nt fully capture. finds that there was a demnstratin f adequate knwledge f the health impacts f WASH related behaviurs as well as a strng desire t address them bth at the individual and cmmunity levels. Hwever, individual and cmmunity desire t change behaviurs, as demnstrated in grup discussins, has nt been translated int cncrete actins with identifiable utcmes. This is cnsidered t be due t structural barriers, such as the diffusin f hygiene behaviurs and lack f financial resurces t invest in water and sanitatin facilities. Grup educatin Interventins that cmbine grup educatin with bys and men (smetimes in cmbinatin with wmen and girls) and adpt a gender transfrmative apprach and intense cmmunity mbilizatin are cnsidered prmising (Fulu, Kerr-Wilsne et al., 2015). Pulerwitz, J. et al. (2015). Changing gender nrms and reducing intimate partner vilence: Results frm a quasi-experimental interventin study with yung men in Ethipia. American Jurnal f Public Health, 105(1), The prgramme The prgramme invlved cmmunity engagement (CE) and grup educatin (GE) activities. 21

22 CE activities invlved entire cmmunities and included distributin f mnthly newsletters and leaflets (apprximately 15,000), music and drama skits reaching 8700 peple, mnthly cmmunity wrkshp meetings, and distributin f mre than 1000 cndms. They tk place ver six mnths. GE activities included rle plays, grup discussins, and persnal reflectin. They tk place ver fur mnths. Baseline and endline surveys were cnducted amng participants. Participants in the GE + CE interventin were twice as likely as thse in the cmparisn grup t shw increased supprt fr gender-equitable nrms. The percentage f GE + CE participants wh reprted IPV tward their partner in the preceding 6 mnths decreased frm 53% t 38% between baseline and end line. The percentage in the CE-nly grup decreased frm 60% t 37%. Changes were negligible in the cmparisn grup. Dyle, K. et al. (2014). Transfrming gender rles in dmestic and caregiving wrk: preliminary findings frm engaging fathers in maternal, newbrn, and child health in Rwanda. Gender & Develpment, 22(3), The prgramme MenCare is a glbal initiative t engage men in prmting family well-being and gender equality as equitable, caring, and nn-vilent partners and caregivers, and is active in mre than 25 cuntries. It includes campaign and prgramme activities that use fatherhd, and the prenatal perid in particular, as an entry-pint t invlve men in transfrming gender dynamics, and redistributing the burden f care wrk. MenCare+ is implemented in fur f Rwanda s 30 districts. The prgramme, knwn as Bandebereh ( rle mdel ) in Kinyarwanda, aimed t engage mre than 60,000 cmmunity members in campaigns r grup educatin by the end f Grups fr yung men, yung wmen, and cuples were facilitated at the cmmunity level by a netwrk f 112 cmmunity vlunteers. These grups aimed t increase gender-equitable attitudes, cntraceptin use, participatin in sexual and reprductive health (SRH) and maternal, newbrn and child health services, and t reduce intimate partner vilence. 22

23 The preliminary results frm father grups in Rwanda reveal that gender transfrmative prgrammes, which engage men in deliberate questining f gender nrms, can increase men s invlvement in ways that shift the burden f care wrk and address unequal pwer relatins. Yuth educatinal initiatives Lundgren, R. et al. (2013). Whse turn t d the dishes? Transfrming gender attitudes and behaviurs amng very yung adlescents in Nepal. Gender & Develpment, 21(1), Di: / The prgramme The Chices prgramme, designed and implemented by Save the Children, sught t enable very yung adlescents (VYAs) bys and girls aged years ld t transfrm their thinking abut gender nrms; and t recgnise gendered differences and inequality. The curriculum encurages children t explre expressins f psitive gender rles/within their husehlds, and within their cmmunities. It adpts activities that encurage behaviur based n an understanding and acceptance f gender equality. Chices was pilted in 12 child clubs in the Bhawanipur and Pkharvinda Village Develpment Cmmittees (VDCs) in the Siraha district f Nepal. A ttal f 309 children (48 per cent f whm were girls) participated in Chices. A further 294 children were used as a cntrl grup in the evaluatin. The evaluatin f Chices set ut t measure whether participatin in the prgramme resulted in a statistically significant change t bys and girls attitudes t gender issues, and whether this led in turn t a change in behaviur and practices. The evaluatin used bth quantitative and qualitative data. Yung peple in the experimental grup were interviewed befre and after participating in Chices. Results suggest that participatin in Chices led t mre equitable gender attitudes and behaviur. Statistically significant changes were bserved in the pre- and pst-test scres f the experimental grup, while n differences were seen in the cntrl grup. Gender attitudes: the attitudes f bys and girls were significantly mre equitable after participating in Chices. 23

24 Gender rles: bys and girls wh participated in Chices were mre likely t cnsider a brad range f husehld rles such as washing dishes r sweeping the flr as gender neutral, tasks that shuld be perfrmed by bth bys and girls. Phtvice: the images f gendered behaviur captured by Chices participants differed markedly frm thse f the cntrl grup. Participants phtgraphed cmmunity members acting in nn-traditinal rles (e.g. men and bys cking, washing dishes, r helping wmen and girls with husehld chres); whereas mst phts frm the cntrl grup reflected difference-based gender steretypes. Gender inequality: after Chices, the experimental grup rejected the idea f rigid steretypical gender nrms, which they had supprted prir t the interventin. While parents did nt participate directly in Chices, the results f the parent fcus grups suggest that the prgramme encuraged parent-child cmmunicatin, and expsed parents t new ideas and ways f behaving thrugh their children. Qualitative data supprt this cnclusin. Path. (n.d.) Evaluatin summary: Changing gender nrms amng yung men, and reducing vilence, in Chngqing, China. Washingtn, DC: Path. The prgramme The prgramme fcused n prmting gender equity amng yung men, with the aim f reducing harmful behaviurs (e.g., partner vilence and sexual harassment) and supprting the equitable treatment f girls and wmen. The main interventin audience was male vcatinal schl students and factry wrkers between the ages f 15 and 24. Fr the student-fcused cmpnent, teachers were trained t cnduct educatin sessins during their nging classes. In factries, staff were trained t facilitate sessins with grups f male wrkers. The eight sessins cvered tpics related t gender, sexuality, relatinships, and vilence. The interventin perid was abut six mnths in length. Baseline and endline evaluatin data were cllected using bth quantitative and qualitative methdlgies. 606 students cmpleted the baseline survey and 496 cmpleted the endline survey. 549 factry wrkers cmpleted the baseline survey, 466 cmpleted the endline survey and 219 cmpleted bth the baseline and endline surveys. Supprt fr (in)equitable gender nrms was measured using a versin f the Gender Equitable Men (GEM) Scale specifically adapted fr the Chinese cntext. 24