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

3. 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

4. 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

5. 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

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

7. 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

8. 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 dont 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?

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

10. 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.

11. 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& Silver 2003, Albert Einstein College of Medicine) Adult men & women at STI clinic in Boston (Pulerwitz et al 1999, unpublished manuscript) Gang-affiliated young women in Texas (Excerpted from chapter by Amaro, Dai & Arevalo 2003; Study led by Valdez, U of Texas) ANC clients in South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)

12. 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

13. 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

14. 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.

15. 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

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

17. 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.

18. 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

19. 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

20. Study Design Pre-test N = 258 Post-test 1 N = 230 Post-test 2 N = 217 6 months Pre-test N = 250 Post-test 1 N = 217 Post-test 2 N = 172 6 months INTERVENTION 1 INTERVENTION 2 CONTROL Pre-test N = 272 Post-test 1 N = 180 Delayed intervention 6 months3 months

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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.

29. 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.