Impact of DREAMS Interventions on Attitudes towards Gender Norms among Adolescent Girls and Young Women: Findings from a Prospective Cohort in Kenya

"By quantitatively describing attitudes to gender norms, we hope to provide insight into areas where programming may be intensified or expanded to address the many factors that influence norms and related behaviours."

Adolescent girls and young women (AGYW) in sub-Saharan Africa remain at high, disproportionate risk of HIV infection, driven in part by structural factors and the overlapping vulnerabilities these factors create. Recognising these vulnerabilities, PEPFAR and private-sector partners launched the "DREAMS Partnership" in 2015 to support AGYW in leading "Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe" lives. One way DREAMS aims to reduce HIV incidence is by shifting gender norms, which can be defined as collective beliefs about the appropriate behaviours of men and women. This study evaluates the impact of DREAMS on attitudes towards gender norms among AGYW in two Kenyan settings.

The DREAMS core package aimed to empower AGYW to reduce their risk, strengthen families, mobilise communities for change, and reduce risk among sexual partners. Multiple DREAMS interventions - at both individual and contexual levels - seek to influence norms, including social asset building and violence reduction programmes for AGYW and their male peers, school-based programmes, and community strengthening efforts geared toward partners, parents, and caregivers.

Staggered rollout of DREAMS interventions began in 2016, with delivery led by implementing partners in each site. All interventions were being delivered by 2017. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-2018 and followed up to 2019.

 

Using an adapted version of the Gender Equitable Men (GEM) scale, the researchers estimated the association between self-reported invitation to DREAMS (in 2017-2018) and AGYWs' attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries.

The researchers estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health (SRH) decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95% confidence interval (CI):-2.5, +9.0). In Gem, they estimated a risk difference of +1.0 (89.6% vs 88.6%, 95% CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95% CI: -5.3, +6.5; Gem: 44.3% vs 48.2%, -3.9; 95% CI: -11.7, +3.0). The researchers found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms.

In Gem, equitable attitudes did increase over time, though this change was not attributable to DREAMS invitation. However, about half of AGYW in Gem agreed with inequitable statements around intimate partner violence (e.g., "It is okay for a man to hit his wife if she won't have sex with him"), suggesting a key area for focused interventions.

Thus, while there was some shift towards more equitable attitudes over time, the study found limited to no evidence for an effect of DREAMS. For the SRH decision-making norm dimension, high agreement with equitable statements prior to DREAMS may have left limited scope for improvement. This is especially the case in Nairobi, where equitable attitudes were prevalent from enrolment among both AGYW and young men.

In addition, because AGYWs' attitudes may be strongly influenced by those of their peers and caregivers, involving a broader range of participants may help reach key change agents or power-holders who can drive norms change. In that vein, DREAMS indeed included contextual interventions designed to reach adults and the male partners of young women. However, there was relatively lower awareness and uptake of DREAMS among these groups: Exposure to community-based interventions (mobilisation, social protection, and parenting/caregiver interventions) among adult men and women was low (<11%) in both sites. The key message going forward is that, "Though this study has focused on individual attitudes, norms are inherently relational and present at the intersection of individuals and their communities, resources, and institutions....Case studies have demonstrated that organised diffusion can be an important strategy for encouraging norms change, for example by facilitating information spread through peer groups..."

In conclusion, the "findings demonstrate some shifts in individual attitudes towards gender norms over time and highlight areas for more focused or inclusive programmes. It is essential for programmes to look beyond individual beneficiaries, including by increasing efforts to reach young men and other members of AGYW's communities....[I]t may take time for the interventions to lead to measurable change in norms. Investments in longer term evaluation efforts could therefore make valuable contributions to the evidence base."