Promoting Healthy Relationships and HIV/STI Prevention for Young Men: Positive Findings from an Intervention Study in Brazil

This research update from Population Council/Horizons reviews a Horizons and Instituto PROMUNDO study that posits: 1) that young men can change their behaviour and develop positive attitudes through participation in group educational activities that encourage reflection about what it means to be a man, and 2) that reinforcing these messages on the community level will have additional positive impacts on these young men. The study looks at promoting social norms in favour of greater gender equity and attempts to measure changes in gender norms and their effect on HIV/sexually transmitted infection (STI) protective and risk behaviours.

The study, set in Rio de Janeiro, Brazil, follows 3 groups of young men aged 14 - 25: "One intervention component was interactive group education sessions for young men led by adult male facilitators. The other was a community-wide ‘lifestyle’ social marketing campaign to promote condom use, using gender-equitable messages that also reinforce the messages promoted in the group education sessions. One arm of the study, based in Maré, focused on group education only, while the second arm based, in Bangu, received an intervention that combines group education with the community-wide lifestyle campaign. In the third community, Morro dos Macacos, a delayed intervention served as a control. To assess program impact, the researchers developed and used the Gender-Equitable Men (GEM) Scale, which includes 17 items that measure “traditional” attitudes about gender roles related to HIV/AIDS and pregnancy prevention, violence, sexual relationships, domestic chores and caregiving, and homosexuality. Informants also provided information on HIV-related risk, such as STI symptoms, condom use, and number of sexual partners."

The intervention is called "Program H". It "focuses on helping young men question traditional norms related to manhood and on promoting the abilities of young men to discuss and reflect on the 'costs' of traditional masculinity and the advantages of more gender-equitable behaviors. Intervention activities include two main components: (1) a field-tested curriculum that includes a manual and an educational video for promoting attitude and behavior change among men, and (2) a lifestyle social marketing campaign for promoting changes in community or social norms about what it means to be a man. The curriculum includes an overview and framework for thinking about these issues, a 20-minute cartoon video, and 70 activities that were developed and pre-tested with groups of young men 15to 24 years old. The activities are organized under five themes: Sexuality and Reproductive Health, Fatherhood and Caregiving, From Violence to Peaceful Coexistence, Reasons and Emotions (including communication skills, substance abuse, and mental health), and Preventing and Living with HIV/AIDS. The activities in the manual are designed to be carried out in a brainstorming exercises, discussion sessions, and individual reflections. Eighteen exercises (plus video) in total were conducted with the young men during once-a-week sessions for about two hours each over approximately a six-month period. Adult men facilitated the exercises to serve as more gender-equitable role models for the young men.

The lifestyle social marketing campaign was developed by working with men to identify their preferred sources of information and cultural outlets in the community, and to craft messages - in the form of radio spots, billboards, posters, postcards and dance - to make it ‘cool and hip’ to be a more 'gender-equitable' man. This campaign encourages young men to reflect about how they act as men and enjoins them to respect their partners, to avoid using violence against women and to practice safer sex. The campaign has been called 'Hora H', or 'In the Heat of the Moment.' The phrase was developed by young men who frequently heard their peers say, ‘Everybody knows that you should use a condom, but in the heat of the moment ….'".

Baseline data are included in the document, followed by findings at 6 months and one year in the two intervention and single delayed intervention groups:

1. "Young men in the intervention sites reported greater support for more equitable gender norms." As scored on the GEM scale, the intervention sites showed less support for traditional gender norms over time, while the delayed site showed no significant changes over the first 6 months.
   
2. "There were significant improvements in key HIV/STI risk and prevention outcomes, with greater changes often taking place among the young men in the site with the combined group education and community activities." Reported STI symptoms decreased, and condom use with regular partners increased, at the 2 intervention sites, with a greater decrease at the site with the combined intervention. At the delayed intervention site, there was no decrease in STI symptoms and no increase in reported condom use. "In all three sites, there was no significant increase in condom use with casual partners. The percentage of sexually experienced informants at both intervention sites who reported having two or more partners over the last month decreased slightly, but not significantly. In contrast, the percentage of sexually experienced respondents in the control site with multiple partners increased slightly."
   
3. "Agreement with more equitable gender norms was associated with changes in HIV/STI risk outcomes." Preliminary analyses indicate that improvements on the gender norm scale were associated with changes in HIV/STI risk outcomes.

The study suggests that educational interventions focused on positive, less traditional roles for men can successfully influence young men's attitudes about gender roles. The findings also suggest that a behaviour change intervention focused on gender dynamics can decrease HIV/STI risk. The discussion notes that the change was often greater for young men exposed to the combination of group education activities using interpersonal communication and the community-based lifestyle social marketing campaign reinforcing gender equity messages on the community level.