Measuring the impact of gender-focused interventions

1. Measuring the impact of gender-focused interventions Julie Pulerwitz, ScD Horizons Program/PATH

2. At Risk Due to Gender • Gender-related dynamics place both women and men at risk of negative health outcomes such as HIV/STI and violence • Women: power imbalances resulting in inability to negotiate condom use and mutual monogamy • Men: norms that encourage multiple partners

3. Addressing Gender in Programs • Increasingly HIV/STI and violence prevention interventions are seeking to change gender dynamics in relationships, posing challenges for evaluators • Few evaluations of programs, and fewer use evaluated measures to do so

4. Major Challenges of Intervention Research • Design Issues - How to attribute change • Many activities ongoing so difficult to attribute change to program • Control/comparison group not possible when program provides complete coverage • Instruments for Gender Focus • Many agree on importance but no consensus on definitions and how to operationalize • Gender is complex and multi-faceted

5. Examples Measuring Gender-related Dynamics and Designing Studies of Program Impact

6. Development of SRPS(Pulerwitz et al 2000, Sex Roles) • Sexual Relationship Power Scale (SRPS) to measure power in sexual relationships • Focus groups with women and theoretical framework to design items • 50 initial items administered to 388 mainly Latina women at reproductive health clinic in US • Key results with SRPS (23 items) • Highly reliable (alpha > .80) • Negatively associated with sexual and physical violence • Positively associated with education, condom use

7. Items in SRPS • 23 item SRPS with 2 subscales • Relationship Control • My partner always wants to know where I am. • My partner does what he wants, even if I don’t want him to. • My partner would get angry if I suggested condom use. • Decision-making Dominance • Who usually has more say about whether you have sex? • Who usually has more say about important decisions?

8. SRPS by % Consistent Condom Use* Percent *p < 0.01 - Mantel-Haenszel chi-square test for trend

9. Logistic Regression Model Predicting Consistent Condom Use (*p < 0.05) Controlling for socio-demographic and psycho-social variables. Other significant variables: Peer support for condom use.

10. Egs of use of the SRPS • School-based young men & women in inner-city NY (Bauman & Silver 2003, Albert Einstein College of Medicine) • Adult men & women at STI clinic in Boston (Pulerwitz et al 1999, unpublished manuscript) • Gang-affiliated young women in Texas (Excerpted from chapter by Amaro, Dai & Arevalo 2003; Study led by Valdez, U of Texas) • ANC clients in South Africa (Dunkle et al, Lancet May 2004) • Community-based youth in Thailand (ongoing) • OVC in Zimbabwe (ongoing UCSF study)

11. SRPS in “Stepping Stones” Study (Jewkes et al 2002, Medical Research Council, South Africa) • HIV intervention study in South Africa with Stepping Stones package - focused on gender inequalities and communication • Surveys at baseline and 3 months post intervention • Sample: 95 women and 107 men (pilot study), 94% response rate for women and 67% for men

12. Findings from Stepping Stones • SRPS items relevant and reliable (alpha > .80) for women, but less so for men • At baseline, less power associated with less condom use, physical and sexual violence for women • Post intervention, significant improvement in relationship power for women, especially among new condom users • Ongoing large intervention study

13. Lessons Learned about the SRPS • SRPS appears a useful measure for relationship power...for adults and youth, for different ethnicities and cultures. • Relationship Control subscale is sometimes more useful than Decision-making Dominance subscale. • SRPS is sometimes more useful for women than men.

14. Development of GEM Scale(Pulerwitz, Barker et al 2004, Horizons Report) • Gender Equitable Men (GEM) Scale to measure attitudes toward gender norms • Qualitative research with young men in Brazil (Barker 2000) and lit review to design items • 35 initial items tested with 749 men aged 15-60 in Rio de Janeiro (PROMUNDO, NOOS, and TA from Horizons) • At baseline, GEM Scale (24 items) associated with partner violence, education, and contraception use

15. Gender Norms Scale Domains • Home & child-care • Sexual relationship • Health & disease prevention • Violence • Homophobia & relations with other men

16. Items in GEM Scale • 24 item GEM Scale with 2 subscales (alpha > .80) • ‘Traditional’ Norms • Men are always ready to have sex. • There are times when a woman deserves to be beaten. • I would be outraged if my partner asked me to use a condom. • ‘Egalitarian’ Norms • A man and a woman should decide together what type of contraceptive to use.

17. Egs of use of GEM Scale • Intervention study with young men in India - CORO and Horizons/PROMUNDO • National survey with adults in Zambia - HCP • Intervention study with young men in Mexico - Salud y Genero • Intervention study with adult men in South Africa - MAP and Frontiers/Population Council

18. ‘Program H’ Intervention Study in Brazil(Instituto PROMUNDO, Horizons, and partners) Main objectives: • Determine the impact of different combination of gender-focused activities (group education, education plus community-based ‘lifestyle’ social marketing campaign) on attitudes toward gender norms, and HIV/STI and violence risk among young men Data collection: • Pre and post surveys with 3 groups (2 intervention, 1 control) followed over 1 year (n= 780 at baseline; over 75% response rate) • In-depth interviews with sub-sample and partners, for triangulation and validation from partners

19. Study Design 6 months 6 months Pre-test N = 258 Post-test 1 N = 230 Post-test 2 N = 217 INTERVENTION 1 6 months 6 months Pre-test N = 250 Post-test 1 N = 217 Post-test 2 N = 172 INTERVENTION 2 6 months 3 months Delayed intervention Pre-test N = 272 Post-test 1 N = 180 CONTROL

20. Change in GEM Items* Men need sex more than women do. Changing diapers, giving the kids a bath, and feeding the kids are the mother's responsibility. *p < .05 for individual items and full Scale; No significant change in control site

21. Association Between ‘Traditional’ Norms and STI Symptoms Over Time • At one year, young men that become more supportive of equitable norms report fewer STI symptoms: • 4.6* times more likely to report no STI symptoms in Intervention 1 site • 8.3* times more likely to report no STI symptoms in Intervention 2 site *p < 0.05 – logistic regression for correlated data; controlling for age, family income, and education

22. Lessons Learned about Research with the GEM Scale • Findings suggest GEM Scale a sensitive and cross-culturally relevant tool • Findings suggest change in attitudes towards gender norms possible via interventions, as well as subsequent changes in HIV/STI risk

23. ‘SDSI’ Intervention Study in Nicaragua(Puntos de Encuentro, Horizons, PATH, CIDS) • Communication for social change program to empower youth, promote gender equity, and reduce violence and HIV/STI risk

24. Intervention Activities • Weekly national edutainment telenovela (Sexto Sentido) • Daily call-in radio show to discuss show themes • Community-based activities • Coordination across organizational networks • Cast visits to schools • Youth training camps • IEC materials

25. Research Methodology • Longitudinal sample in three representative cities – Esteli, Leon, Juigalpa • Track change of individual people, not just group overall • Triangulation of results • Pre, mid-term and post surveys with 4567 male and female youth aged 13-24 at baseline (over 80% response rate at mid-term), in-depth interviews and focus group discussions, Participatory Action Research • Multivariate and multi-level analyses

26. Emerging Results • At baseline, HIV/STI risk behaviors substantial • 40% of sexually active had recent occasional partner • 69% did not use condoms consistently with occasional partners • At mid-term: • Exposure to activities associated with better outcomes • More support for gender equity (GEM items) over time • Communication with others about HIV prevention and sexual behavior increased • Increase in condom use among some groups • Longitudinal analysis ongoing

27. Conclusions: the Role of Gender Dynamics • Empirical support that both relationship power and inequitable gender norms are key factors in HIV/STI and violence risk. • Evidence that interventions can influence both relationship power and attitudes towards gender norms, and subsequent HIV risk behaviors.

28. Conclusions: Evaluation Issues • Evidence of measures and designs that capture impact of BCC and other interventions focused on gender dynamics. • Measuring impact challenging, but attempts ongoing and growing.