Gaining Traction: Promising Shifts in Gender Norms and Intimate Partner Violence in the Context of a Community-based HIV Prevention Trial in South Africa

"Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change."

Experience shows that gender inequities must be addressed for HIV and intimate partner violence (IPV) prevention efforts to be successful. Researchers have articulated a need to better understand how to effect meaningful changes in gender norms/social expectations about men's and women's appropriate roles, rights, and responsibilities at the community and societal levels, outside of group-based activities. Drawing on cross-sectional household surveys and qualitative research, this paper investigates whether and how gender norms and IPV changed during a 3-year community mobilisation intervention to address social barriers to HIV service use in Mpumalanga province, South Africa.

The study described in this paper was part of a community randomised controlled trial (RCT) to test the effects of Tsima ("working together"), a 3-year intervention by Sonke Gender Justice to increase HIV testing, linkage to and retention in care, and treatment among men and women ages 18-49 by addressing key social barriers to service uptake, including inequitable gender attitudes and norms. (For more on this initiative and research, see Related Summaries, below.) Led by a team of 18 trained community mobilisers and volunteer Community Action Team (CAT) members, activities comprised 2-day workshops (with about 10-30 male and female participants), community-based activities (e.g., street theatre and murals), young women's groups, support groups for people living with HIV (PLHIV), and engagement of village leadership and other stakeholders. The focus was on intentionally integrating critical reflection and testimonials about inequitable gender norms and relationship violence, as well as on learning and role-playing healthier couple communication and conflict resolution skills (e.g., supporting HIV status disclosure and talking more openly with partners about safer sex).

Quantitative data come from 2 cross-sectional surveys: a baseline survey conducted among 1,149 individuals (566 men; 583 women) in the 15 study communities (8 intervention and 7 control) pre-intervention from July-November 2014; and an endline survey conducted among 1,189 individuals (541 men; 648 women) from July-December 2018. Qualitative methods included in-depth interviews (IDIs) with 23 intervention staff (community mobilisers and CAT members) and 59 community members, as well as 2 focus group discussions (FGDs) with 11 community mobilisers. The IDIs and FDGs were conducted at 2 time points: in the final year (2018) of the 3-year intervention; and in 2019, after preliminary endline survey data analyses were complete.

Robust participation in Tsima was reported at endline among both men and women, whereas exposure to the intervention was low in control communities. Notably, not assessing the same participants over time makes it more difficult to link changes to the intervention.

The study found a roughly 17% increase in endorsement of equitable gender norms among men between baseline and endline, which was experienced similarly across intervention and control communities. Among women, similar to men, there was about a 13% increase in endorsement of equitable gender norms between baseline and endline, which again was experienced similarly across intervention and control communities.

In terms of IPV:

• Among younger men, reported IPV perpetration decreased over time (i.e., between baseline and endline) in both intervention and control communities. For example, physical IPV perpetration declined from about 40% to 25% in both trial arms. Among older men, there was no association between IPV with time or the intervention.
• Among younger women, there was a significant intervention effect (i.e., change over time in intervention vs. control) on reductions in reported experiences of IPV (adjusted odds ratio (aOR) 0.48; 95% confidence interval (CI): 0.23, 0.98; p<0.05). (In unweighted analyses, this aOR was similar at 0.50, but was not statistically significant (95% CI: 0.22, 1.14). Thus, this finding should be interpreted with caution.)
• For older women, reported experience of IPV significantly increased over time, irrespective of the intervention (showing a general community-based trend). (In unweighted analyses, there was a significant intervention effect on reductions in reported experiences of IPV (aOR 0.29; 95% CI: 0.09, 0.93; p<0.05)).
• Qualitative findings around IPV behaviour spoke to the positive effects of the intervention on reducing IPV in relationships, reflecting the survey results demonstrating reduced violence for younger women due to the intervention. Tsima participants and intervention staff consistently described how Tsima led to a reduction in IPV - largely by promoting critical reflection around violence against women and building skills around healthier couple communication and conflict resolution.

According to the researchers, "The most plausible reason that emerged for the broad shifts in gender norms (and the lack of evidence that these shifts were due to intervention activities), was rapidly-increasing access to TV programming (via satellite dish) and smartphones across the study area, starting since the 2014 baseline survey. Nearly all qualitative study participants described such increased access," which was later confirmed in local and national statistics. For example, when asked how the increase they had reported in media access may have caused changes in gender norms/relationships between men and women, most FGD participants described how serial dramas ("soapies") and talk shows portray couples communicating equitably and resolving conflicts, and mostly depict IPV in a negative light. Most shows mentioned were South African/African-based. That said, in the qualitative findings, respondents "described how messaging/modeling on TV, while a consistent presence in people's lives, remained 'distant' - and how facilitation and direct engagement in Tsima helped men and women translate these messages into new patterns of interaction in their relationships."

Again, in terms of IVP findings, it could be that the increasing media exposure described above directly impacts younger men's IPV behaviour, even without an intervention present. Alternatively, perhaps younger men underreported IPV perpetration because of new community norms and/or media messaging contrary to such behaviour.

Implications of the findings of the study are outlined, including the need to:

• Attend more closely to the (often rapidly changing) social contexts in which interventions are carried out, including the "digital transformation" underway across the African continent, and how these shifts could be harnessed by public health initiatives to promote healthier behaviours.
• Scale up facilitated discussion that fosters critical reflection around gender, power, and IPV, as well as skill-building around shared decision-making and conflict resolution in relationships. Both women and men in the study described their eagerness for this guidance, and willingness to engage constructively, often together as a couple, to achieve more equitable and violence-free relationships.

In conclusion: "These findings echo previous experience from gender-transformative interventions that while community mobilization-only and mass media interventions can produce changes in individual and collective attitudes, critical reflection and skill-building around gender equity and violence prevention, usually imparted in smaller and more intensive groups, is often required to support notable change in related behaviors..."