Shifting Gender Norms to Improve HIV Service Uptake: Qualitative Findings from a Large-scale Community Mobilization Intervention in Rural South Africa

"Findings from this study shed light on how community mobilization efforts can shift key inequitable gender norms linked to HIV service uptake, and positively effect engagement in HIV services."

Gender norms that reproduce and support power hierarchies between men and women are prevalent in South Africa and contribute to HIV risk in this setting, where the burden of HIV is high. Community mobilisation strategies, which seek to bring communities together to spark dialogue and collective action to achieve a shared goal, have demonstrated promise in altering inequitable and harmful gender norms, including those that contribute to HIV risk. Tsima ("Working together") was a community mobilisation intervention that sought to improve both men's and women's engagement in HIV testing, care, and treatment by addressing social barriers that deter service uptake. Conducted during the Tsima community mobilisation trial (see Related Summaries, below), this qualitative study sought to assess whether and how relevant gender norms were shifting and to understand whether and how shifting norms were impacting HIV service uptake.

As described at Related Summaries, below, the Tsima intervention was implemented in the Bushbuckridge subdistrict of rural Mpumalanga province in northeast South Africa from 2015 to 2018. Adapted from Sonke Gender Justice's One Man Can campaign, Tsima's community mobilisation model was grounded in social science theory and validated in the study community. Activities, which were led by community mobilisers and Community Action Team (CAT) members, included: conducting 2-day workshops, door-to-door outreach, digital stories screenings, young women's groups, community mural creation, and soccer and other events; engaging local leadership; and fostering community cohesion to support people living with HIV. Throughout all activities, Tsima aimed to change gender norms that discourage engagement in care and to reinforce communication skills to support healthy partnerships.

Data for this paper come from 55 qualitative in-depth interviews (IDIs) conducted in early- to mid-2018 among 25 intervention community members (48% women) and 30 key informants (70% women), including community mobilisers, CAT members, and community opinion leaders. Data were analysed using an inductive-deductive approach.

The researchers identified three avenues for gender norms change which, when coupled with other strategies, were described as supporting HIV service uptake:

1. Challenging norms related to men's toughness and avoidance of help-seeking - Participants described their perception that, prior to Tsima, many men in their community did not test for HIV because they wanted to feel and be seen as strong and invulnerable. Activities that challenged these norms, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), was found to have eased men's fears of a positive diagnosis and facilitated HIV service uptake. Mobilisers and CAT members pointed to intervention activities (e.g., "Act like a Man, Act like a Woman") that offered an opportunity for men to come together in a space where they could confidentially and critically reflect about how gendered expectations might negatively impact their health behaviour and, ultimately, their health and wellbeing.
2. Challenging norms about male control over women in relationships - Participants described how women's experience and/or fear of intimate partner violence (IPV) prevented them from testing for HIV, disclosing a positive HIV status to their partners, and engaging in care and treatment. Participants described how Tsima facilitated critical reflection about norms supporting men's coercive control and emphasised establishing healthy relationships grounded in trust, honesty, respect, collaboration, and strong communication. Mobilisers also noted how Tsima’s emphasis on healthy relationships and skills-building around healthy communication encouraged couple support around HIV service uptake.
3. Challenging norms around women being solely responsible for the family's health - Participants asserted that because of Tsima, more men were proactively testing for HIV instead of assuming their status was the same as their partner's. They attributed this change to Tsima workshops that challenged the perception that women inherently value and prioritise health more than men, as well as education about sero-discordance within couples (i.e., when one partner is living with HIV and the other is not).

Although inequitable gender norms were described as shifting because of Tsima, contributing to improved HIV service engagement for many community members, participants also noted several structural barriers that continued to prevent men (more so than women, in part due to norms) from accessing HIV services. These barriers included long wait times at health facilities, inconvenient facility hours, and concerns that clinic staff (most of whom were women) did not maintain patient confidentiality. Because these structural issues were frequently raised in community consultations, intervention staff and volunteers advocated to supplement standard clinic-based testing with community-based testing events in partnership with local healthcare services as part of the Tsima intervention.

The researchers stress that, while the gender norms Tsima sought to address are common in many settings, it is important to distinguish specific relevant norms in a given locale in order to tailor programmes appropriately. The findings "also highlight the promise of the Tsima strategy of pairing intervention messages and activities that challenge these norms with those that provide concrete and up-to-date information related to HIV care and treatment and skills around equitable couple communication and conflict resolution...[These] strategies...should be coupled with approaches that address facility-level barriers to service uptake."