Men, Masculinities and Health Emerging Research and Program

Experiences from the Global South

Gary Barker, PhD, International Director Promundo

Brazil – USA – Rwanda – Burundi – Portugal www.promundo.org.br

Overview §  Why engage men in SRH,

MCH, HIV and other health issues?

§  What the International Men and Gender Equality Survey (IMAGES) tells us about men, health and gender equality

§  How findings are being used to develop interventions

PART 1: WHY ENGAGE MEN IN MCH, SRH, HIV?

Women exhibit more positive breastfeeding practices (Premberg, Hellstrom and Berg, 2008)

Women experience less pain in

labor and delivery (Plantin, 2007) Women attend more prenatal and

postpartum visits & more likely to have a skilled attendant (Mullany, Becker and Hindin, 2006)

When we engage men in MH…

Jorge  Lyra  Ricardo  Castro  

Benedito  Medrado  Ins5tuto  PAPAI/Gema-­‐UFPE  

Recife,  Brazil    

Invisibility of men in the current MCH, HIV and SRHR agendas

§ Men are over-represented in the 10 leading causes of death and chronic health problems worldwide § For 1970-2010, women had longer life expectancy that men “The tendency to underplay or misunderstand the role of gender, or to equate the gender dimensions of health solely with the specific health needs of women, has led to a failure to address the evidence of gendered determinants that affect and drive ill health for both men and women.” (Hawkes, Buse, Lancet, 2013, 381:1783-87)

Viewpoint

www.thelancet.com Vol 381 May 18, 2013 1783

Gender and global health: evidence, policy, and inconvenient truthsSarah Hawkes, Kent Buse

“Gender is probably the most restricting force in American life”

Gloria Steinem (American journalist, social activist and feminist), 2008

“But let me tell you, this gender thing is history.”

George HW Bush (former President of the United States of America)

Gender is missing from, misunderstood in, and only sometimes mainstreamed into global health policies and programmes. In this Viewpoint, we survey the evidence for the role of gender in health status, analyse responses to gender by key global health actors, and propose strategies for mainstreaming gender-related evidence into policies and programmes.

We use the WHO defi nition of gender: “socially con-structed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women”.1 When gender identity does not correspond with assigned sex, people might identify themselves as transgender.2 An individual’s experience of gender and gender relations can change according to context and situation.3 The term sex, by contrast, refers to biological characteristics that defi ne human beings as female or male.

The exact contributions that sex and gender make to health status are often hard to disentangle and quantify, and “biological infl uences and social infl uences do not operate independently”.4 Moreover, they often interact with other social deter minants of health.

We analysed the recent Global Burden of Disease (GBD) study 5 from a gender perspective. Data from this study are intended to help policy makers to set priorities and allocate resources according to population health needs. GBD methods have been critiqued, including from a gender perspective.6 Nonetheless, these datasets provide a stan dardised method to compare rates of morbidity and mortality risk across time and place.

All top ten contributors to global disability-adjusted life-years (DALY) have greater burdens on men than on women.5 Conditions common in childhood—lower respiratory infections, malaria, preterm birth—are more burdensome in boys than in girls, although diarrhoea a! ects them equally (appendix).

DALYs are recorded as absolute numbers rather than rates; thus, imbalances in demographics and population structure a! ect the overall DALY distribution between men and women, especially in some settings. India’s most recent census, in 2011, recorded 30 million more males than females aged more than 7 years;7 similarly,

Lancet 2013; 381: 1783–87

Institute for Global Health, University College London, UK (S Hawkes PhD) and UNAIDS, Geneva, Switzerland (K Buse PhD)

Correspondence to:Dr Sarah Hawkes, Institute of Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UKs.hawkes@ucl.ac.uk

more males than females were recorded across all age groups in the 2010 Chinese census.8 Sen 9 estimated that more than 100 million women are missing globally; however, women comprise 49"6% of the global popu-lation10 and have 45% of the overall DALY burden. Parity in life expectancy—used for the fi rst time in the GBD 2010—might overestimate the burden on men, but is justifi ed on the grounds that “there is no reason that society should have lower aspirations for health for males than females”.5 Higher DALY burdens in men were also recorded in earlier global DALY estimates based on a higher life expectancy for women than men.

GBD life expectancy tables for 1970–201011 show that, at all timepoints, women have a longer life expectancy than men, and that decreases in mortality were smaller in men than in females of all age groups. The smallest decrease in mortality rates during 1970–2010 was in young men aged 25–39 years, possibly because of injuries11—globally, road injuries kill three times more men than women.12

Drawing on the work of Lim and colleagues, who analysed the e! ects of 67 risk factors and clusters of risk factors for their disease burden and found the top 10 all to be more common in men,13 we review two high-burden risks (alcohol and unsafe sex) to show the role that gender norms have.

Alcohol-related health problems, including injuries, road tra# c accidents, cirrhosis, and other health issues, are third in the global risk rankings, and the highest ranked risk in eastern Europe, Latin America, and southern sub-Saharan Africa,13 behind tobacco and high blood pressure. Alcohol, like tobacco, has a substantially higher burden in men than in women—7"4% and 3%, respectively.13 Some of the disparity could be due to physiological di! erences in how women absorb and metabolise alcohol. However, much of the di! erence is derived from gender-determined patterns of exposure—men drink alcohol in greater quantities and more frequently than women.14

Alcohol consumption is a! ected by culturally driven gender norms of behaviour, portrayed and perceived as a positive aspect of masculinity.15 The e! ect is that women could be subjected to greater social opprobrium if they are seen to drink alcohol, particularly to excess. Patterns of alcohol consumption could be on the cusp of change in some societies. Data from European surveys show that boys report drinking alcohol more often and in higher quantities than girls, but that the reported frequency of drunkenness by girls and boys is about the same.16 These fi ndings refl ect complex social shifts that might be partly infl uenced by “greater

See Online for appendix

Other “Conflict” Settings: The case of Brazil’s Missing Men (IBGE, 2011): Effects of persistent, high rates of homicide and traffic

accidents (in millions)

Men and HIV testing and treatment:  

“Efforts  to  understand  men’s  health-­‐seeking  behaviour  are  poorly  understood  in  the  AIDS  epidemic,  and  encouraging  men  to  get  tested  and  into  treatment  is  a  major  challenge,  but  one  that  is  poorly  recognised.  Addressing  these  issues  effec5vely  means  moving  beyond  laying  blame,  and  star5ng  to  develop  interven5ons  to  encourage  uptake  of  preven5on,  tes5ng,  and  treatment  for  men—for  everyone’s  sake.” Expanding HIV care in Africa: making men matter. The Lancet Vol 374 July 25, 2009, Mills, Ford, Mugyenyi  

Growing evidence that engaging men and boys in health interventions shows impact

ü Those that make questioning what it means to be men or gender norms central to their intervention ü Those that have a longer duration ü  Those that have multiple components i.e. group education+ ü Equal evidence that mixed and single-sex groups (including couples groups) work ü Single most consistent intervention showing change: Group education with linkage to service provision

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S E X U A L V I O L E N C E R E S E A R C H I N I T I A T I V E

PART 2: WHAT’S UP WITH MEN: RESULTS FROM IMAGES

The International Men and Gender Equality Survey (IMAGES)

Coordinated by Promundo and ICRW

§  Multi-country study on men, gender equality, health and GBV, asking men and women about practices and attitudes

§  To date, >20,000 interviews in 9 countries completed

§  One of the most complete surveys of its kind that includes men’s and women’s assessments and includes a range of gender issues

§  Brazil, India, Croatia, Chile, Mexico, Rwanda, Bosnia, DRC, Mali

§  In process: Malawi, Mozambique, Nigeria §  “Sister” studies with Partners for Prevention:

China, Bangladesh, Indonesia, Cambodia, PNG, Sri Lanka

Funded by SIDA, NORAD, UNFPA, World Bank, UNDP, UN Women, Ford Foundation, MacArthur Foundation

(IMAGES)Initial Results from the International Men and Gender Equality Survey

Evolving Men

coordinated by the International Center for Research on Womenand Instituto Promundo

Ø  Use of physical and sexual violence against female partners Ø  Their participation in care work and MCH Ø  Couple communication about RH Ø  Having sought HIV testing Ø  Number of sexual partners Ø  Having paid for sex Ø  Rates of self-reported STI symptoms Ø  Condom use Ø  Substance/alcohol use In sum, how and to what extent boys and men

internalize prevailing inequitable social definitions of manhood and gender-related norms affects their health and that of their partners with direct linkages to GBV and many other key issues

Across the IMAGES sites, men’s attitudes about what it means to be men found to be correlated with:

Gender norms related to HIV testing: Results from the International Men and Gender Equality

Survey (IMAGES): Promundo and ICRW, 2011

37

reports of having a female partner who ever soughtan abortion are generally much lower, however(except in Brazil and Croatia).

Among those men who reported that a female partner had ever sought an abortion, high propor-tions (30 percent to 71 percent) say that they wereinvolved in the decision to terminate the pregnancy.Similarly, high proportions of women affirmed this(39 percent to 92 percent). This suggests that if theman is informed about the pregnancy, which isclearly not always the case, both women and menaffirm in relatively similar percentages that menparticipate to a fairly substantial degree in the decision to terminate a pregnancy.

While men tend to report high self-esteem, men alsoshow relatively high levels of negative feelings anddepression, with exceptions in Croatia and India.Men in Brazil, Chile and Mexico affirmed three itemsmeasuring positive self-esteem at levels consistently

Figure 20: Men’s and Women’s Reports of Having Ever Sought an HIV Test

Chile

Croatia

Brazil

India

Mexico

Men Women

% who report ever having been tested for HIV

3565

2730

2949

11

9

1337

Rwanda87

89

0 10 20 30 40 50 60 70 80 90 100

PART 1 PART 2 PART 3

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Alcohol Abuse Common among Men: Related to age, gender attitudes, education, work stress

A Missed Health Sector Opportunity: Engaging Men in MCH via Prenatal Visits

Evolv

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30

men’s participation in the care of children, andincluded in recommendations from the 48th Sessionof the Commission on the Status of Women (CSW) in 2004. Most countries – with the notable exceptionsof some Western European countries, Canada, Australia and New Zealand – continue to offer only a few days or a week at most of paid or unpaid pater-nity leave. This limited paternity leave continues toreinforce the notion that men are “helpers” when itcomes to the care of children, both perpetuatingunequal care work patterns and discouraging men’sinvolvement in their children’s lives. These trendspersist in spite of widely reported positive experi-ences in terms of men’s use of leave and women’sand men’s reported satisfaction as men take onincreased involvement in the care of children.

Among the countries included in the study, Braziland Chile have laws that provide men with five dayspaid leave (paid through national social securitytaxes), Mexico offers none (although Mexico City,not included in the survey, has a municipal provi-sion guaranteeing men 10 days paid paternity

leave), India has none (although national govern-ment employees have 15 days paid paternity leave)and Rwanda has none. Croatia offers paid paternityleave of up to three months and provides for someflexibility of transferring leave between mothersand fathers, although the results here affirm thatabout 37 percent of men take this leave but for farless than the allowed time.

Among men who took leave, the duration rangedfrom an average of 3.36 to 11.49 days of paid leaveand from an average of 3.8 to 10 days unpaid leave.Younger men are more likely to take leave in the caseof Chile and Croatia (although similar but statisti-cally insignificant differences were seen in India,Mexico and Rwanda). Men with higher educationallevels are more likely to take leave in the case ofIndia and Rwanda (with similar but statisticallyinsignificant differences seen in Brazil and Chile).Men who reported work-related stress were lesslikely to take leave in Brazil and India (with similarbut statistically insignificant trends seen in Chileand Croatia). Men with more gender-equitable atti-

Figure 12: Men’s and Women’s Reports of Men’s Accompaniment During Prenatal Visits During Most Recent Pregnancy

Men Women

0 10 20 30 40 50 60 70 80 90 100

% who say yes, man accompanied

Chile

Croatia

Brazil

India

Mexico

78

59

9280

8672

9275

9186

Which Men Support Gender Equality?

u Men with more stable sense of income

u Men in middle income countries and middle income households

u Men with some secondary education

u Across most countries, more support for gender equality at the “abstract,” more resistance when it comes to quotas for women

u Significant resistance to GBV laws across the countries surveyed

Men’s reports of use of IPV and women’s reports of victimization: Men will tell us about their use of violence

WHICH MEN ARE MORE LIKELY TO USE VIOLENCE AGAINST WOMEN (IPV)?

(IMAGES multivariate analysis)

MEN: §  With less equitable attitudes §  Who are economically stressed §  Who have been displaced (by conflict) §  Who witnessed violence by a man against their mother §  Who show higher rates of alcohol use

IMAGES global results – Factors Associated with Men’s Use of IPV

!"##

Table 11 Correlates of physical violence perpetration against a partner, presented as adjusted odds ratiosa

Demographic and Predictor Variables

Adjusted ORa

(n=7810)

95% Confidence Intervals

Age 18-28 (REF) 1.00 -- Age 29-39 1.56*** 1.35 - 1.80 Age 40-59 1.88*** 1.47 - 2.41 No schooling or primary (REF) 1.00 -- Secondary school 0.95 0.75 - 1.21 Post-secondary school 0.76+ 0.55 1.04 Low income (REF) 1.00 -- Mid-low income 1.11 0.93 - 1.33 Mid-high income 1.17** 1.04 - 1.31 Highest income 0.96 0.75 - 1.22 Employed 1.08 0.94 - 1.23 Witness of intra-parental violence 2.53*** 2.08 - 3.07 Permissive attitudes towards VAW 1.70*** 1.34 2.16

GEM Score (standardized) 0.89* 0.80 - 0.97 Has been involved in fights 2.38*** 1.91 2.97

+ p<0.10, * p<0.05, * * p<0.01, * ** p<0.001 (Bolded means significant P<.05) aAdjusted for all other variables presented in table

!"##

Figure 7 Visual representation of significant correlates of violence perpetration by country

Bosnia Brazil Chile Croatia DRC India Mexico Rwanda ALL

Country

Age

Education

Relative Income

Employment Witness of Intra-parental Violence ATT VAW GEM score Depressed NA NA NA Involved in Fights

Non-significant (p>.10)

Almost significant (0.05<p<.05)

Moderately Significant (0.01<p<0.05)

Very significant(p<.01)

Men reporting they would prevent violence against women

We also examined the ways in which men are willing to participate in the prevention of violence against

women in their community (

WHICH MEN DO MORE CAREGIVING? (IMAGES global multivariate analysis)

MEN: §  With more equitable attitudes § Who were taught to care for younger siblings § Men whose fathers did care work § With secondary education § Who were not exposed to violence as children § Who work fewer hours § Who are younger § Who took paternity leave (usually just a few days) § Whose partner (the child’s mother) also works

The Big Headlines from IMAGES

Ø Violence creates violence – most traumatic form is witnessing violence against mothers

Ø Caregiving creates caregiving: men who see their fathers caring twice as likely to do so

Ø Men’s educational attainment matters for almost every key gender outcome

Ø Younger generation taking up gender equality faster

Ø Men who buy into gender equality are happier and healthier - and their female partners are happier and healthier

(IMAGES)Initial Results from the International Men and Gender Equality Survey

Evolving Men

coordinated by the International Center for Research on Womenand Instituto Promundo

Contextual differences in IMAGES findings (example from Rwanda)

18Journeys of Transformation

Finally, the study also found that men who witnessed or were directly a!ected by the genocide had higher rates of reported use of violence against their female partners, as did men who reported witnessing violence by their fathers against their mothers in their household of origin. Taken together, these "ndings highlight the importance of understanding the roots of men’s attitudes and practices, and in particular the disempowerment felt by some men, particularly low income men, in Rwanda. #e "ndings a$rm the need to understand men’s perspectives on these issues while at the same time working to expand and improve our e!orts to empower women. #e data also a$rm the large gap between Rwandan policies on gender equality – which are very progressive – and the lived daily realities of women and men, as well as their attitudes toward these policies.

Table 1: Women’s and men’s income and women’s experiences of gender-based violence

Source: Slegh and Kimonyo 2010

PART 3: USING RESULTS TO DRIVE INTERVENTIONS

4 Emerging Areas of Large-Scale Interventions Coming from IMAGES

Ø MenCare: Promoting care work and men’s

Involvement in MCH via public health sector Ø Engaging men via women’s economic

empowerment and conditional cash transfers Ø Using the education sector to reach boys and girls

to change gender norms Ø Working with the peace and security sector to

build lasting, gender-equitable peace

The Context

About MenCare+

§  3-year collaboration between RutgersWPF, Promundo-US, Sonke and partners

§  Engaging men, ages 15-35, as caregiving partners in maternal and child health (MCH) and sexual and reproductive health and rights (SRHR)

§  Implementing in Brazil, Indonesia, Rwanda and South Africa

§  Objective is to scale up a combined MCH, SRH, GBV prevention approach with the health sector

CENTRAL COMPONENT: ENGAGING HEALTH SECTOR WORKERS TO ENGAGE

MEN AND COUPLES

•  Implemented in Nicaragua and Sri Lanka •  Pre-tested in 4 countries •  Full launch in October 2013 with IADB •  Impact Evaluation (RCT) in South Africa •  Great interest from Save the Children to develop

subsequent versions for parents with older children •  Being adapted in India, Guatemala, Senegal,

Honduras and Ecuador

Interventions on Men and WEE Journeys of Transformation: Pilot project in Rwanda to engage husbands of participants in savings associations. Evaluation found increase in: (1)  men’s support for women’s income

generation activities, (2)  couple communication, (3)  income, (4)  men’s care work Ø Starting RCT in Burundi Ø Study in Brazil to promote men’s

involvement in families via Bolsa Familia

Support: NORAD, CARE, UN Women, World Bank

Education Sector: Program H in schools ü Structured consciousness raising” about masculinity using a Paulo Freire approach ü Activism and community campaigns led by youth “resistors” ü Training of teachers via online training portal reaching 2000 teachers in 3 states in Brazil

Results of Program H: 22 countries

9 quasi-experimental evaluation studies found: § Reduction in violence-supportive attitudes; § Decrease in bullying behavior (Bosnia), sexual harassment (India), and physical violence against female partners (Brazil); § Increased condom use (Brazil, Chile, India); § Reduced disruptive classroom behavior (Brazil, Balkans); § All compared to no change or negative change in control groups

Living Peace: Trauma support, identity creation for men in partnership with women

Getting it into the public sector: Brazil’s Ministry of Health

Benefits of combined GBV prevention + health promotion + men’s caregiving +

promoting alternative identities §  Women’s lives get better – health,

well-being, income, reduced violence §  Children’s lives get better – health,

reduced violence, better developmental and education outcomes, girls empowered, boys more gender-equitable

§  Men’s lives get better – longer, healthier lives; more fulfilling relationships

Challenge is for health, education, poverty alleviation and peace and security sectors to take men’s involvement seriously