Date Published: March 1, 2019
Publisher: Lippincott Williams & Wilkins
Author(s): Rebecca Rhead, Morten Skovdal, Albert Takaruza, Rufurwokuda Maswera, Constance Nyamukapa, Simon Gregson.
Research and intervention studies suggest that men face challenges in using HIV services in sub-Saharan Africa. To address these challenges, quantitative measurements are needed to establish the individual-level determinants of masculine norms and their implications for HIV prevention and treatment programmes.
Survey questions for four masculine norms identified in qualitative research were included in a general-population survey of 3116 men in east Zimbabwe, 2012–2013. Two sets of regression analyses were conducted in an structural equation modelling framework to examine: which sociodemographic characteristics were associated with high scores on each masculinity factor; and how high scores on these masculinity factors differed in their associations with sexual risk behaviour and use of HIV services.
Sociodemographic characteristics associated with high factor scores differed between masculine norms. In HIV-negative men, more men with scores exceeding one standard deviation above the mean (high scorers) for antifemininity than men with scores under one standard deviation below the mean (low scorers) took steps to avoid infection (61 versus 54%, P < 0.01). Fewer high than low scorers on social status reported a recent HIV test (69 versus 74%, P = 0.04). In HIV-positive men, more high scorers on sex drive had been diagnosed (85 versus 61%, P = 0.02), were on antiretroviral treatment (91 versus 62%, P = 0.04), and were in AIDS groups (77 versus 46% P = 0.03). HIV treatment, prevention programmes looking to engage men must consider the multidimensionality of masculine norms. The scale developed in this study is robust and can be used by other large multipurpose surveys to examine masculine social norms.
Masculine social norms have long been recognized as one of the primary factors shaping the patterns of sexual risk behaviour that drive generalized HIV epidemics in sub-Saharan Africa [1,2]. Masculinity is also considered to be a major influence on use of HIV prevention, testing and treatment services. Men, compared with women, have lower levels of HIV testing and receipt of results [3–6], are more likely to delay treatment initiation [7–9], and less likely to be retained in care [10,11], resulting in greater AIDS-related mortality amongst men [12–14].
Data for this study were taken from the Manicaland HIV/STD Prevention Project (Manicaland study) . The Manicaland study is an open-cohort general-population survey, which examines the dynamics of HIV transmission and its impact in eight sites in Manicaland province in eastern Zimbabwe (http://www.manicalandhivproject.org/). These sites represent four of the main socioeconomic strata in Manicaland: small towns, agricultural estates, roadside settlements and subsistence farming areas. Topics covered in individual interviews included socioeconomic characteristics, sexual behaviour, psychosocial characteristics and use of HIV testing and treatment services. Participants were also requested to provide a dried blood sample (DBS) for HIV sero-testing. All participants gave informed consent to participate and are free to withdraw from the study at any time. Data gathered from participants has been anonymized to ensure that they cannot be identified. Respondents’ names are not recorded but to permit subsequent linking of the data in the study database with laboratory results, each participant is assigned a study site number, a household number and a unique reference number. In this article, we analysed data from 3116 men who participated in round six (2012–2013) of the Manicaland study.
A better understanding of the multidimensional nature of masculinity, together with methods for measurement of its principal dimensions in general population surveys, is needed urgently to provide a basis for designing more effective interventions to end the major HIV epidemics in sub-Saharan African populations. Here we developed and piloted a new module of 16 survey questions to measure four different dimensions of masculine social norms. The results provide some of the first quantitative measurements of these norms, their individual-level determinants and their associations with key outcomes for HIV control. The findings provided support for our hypotheses that different masculine social norms are shaped by different individual characteristics and, also, that these different norms differ in their associations with HIV-related outcomes. Key findings for individual dimensions of masculinity include contrasting directions of effect of marriage on toughness (a negative association) and antifemininity and sex drive (positive associations); HIV-negative men with low sores for antifemininity being less likely than those with high scores to have taken steps to avoid HIV infection – despite their having similar patterns of sexual risk behaviour; and men with low scores for sex drive being less likely to have taken steps to avoid HIV (if HIV-negative), less likely to have had a recent HIV test, and less likely to have been diagnosed, to be on treatment and to be in an AIDS support group (if HIV-positive).
Authors’ contribution: R.R., M.S. and S.G. were involved in study concept and design, as well as the design of the analysis. C.N., R.M and A.T. acquired and curated the data. R.R. conducted the statistical analysis supervised by S.G. R.R., M.S. and S.G. interpreted the results and drafted the article.