Working with young men to promote gender equality: An experience in Brazil and Latin America
BACKGROUND PROGRAM H
The Program H Initiative was developed by Instituto Promundo, located in Rio de Janeiro, Brazil, and other collaborating Latin American organizations. Program H is theoretically based and has been empirically shown to positively influence safer sexual behaviors (including increased condom use in those sexually active, reducing gender based violence), fewer unplanned pregnancies, improved partner negotiation skills, and increased utilization of health services in several Latin American and Caribbean countries. Program H focuses on helping young men to reflect upon and question the traditional norms of what defines "manhood."
The Program H Initiative targets these norms through a focus on gender-equitable norms and behaviors, as defined by four principles: 1) Relationships are based on respect, equality, and intimacy rather than sexual conquest; 2) A perspective on fatherhood where men should take financial and caregiving responsibility; 3) An assumption of some responsibility for their own and their partners' reproductive health and disease prevention issues; and 4) Opposition towards partner violence.
Program H and this initiative consist of two components: 1) A validated curriculum that includes a manual series and 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 related to what it means to be a man. Additionally, a culturally relevant validated evaluation model (the GEM Scale - Gender Equitable Attitudes in Men Scale) for measuring changes in attitudes and social norms around manhood has been developed to measure outcomes of the initiative.
The health behavior change model used to develop the Program H intervention is based on theories of gender socialization and empirical research about what leads to changes in individual attitudes about what it means to be a man. The Program H model is a tested and validated set of interventions that work at two levels: 1) promoting attitude and behavior change among individual young men, and 2) promoting changes in social or community norms that influence these individual attitudes and behaviors.
Research with adolescent boys internationally suggests that viewing women as sexual objects, using coercion to obtain sex, and viewing sex from a performance-oriented perspective often begins in adolescence and may continue into adulthood (Jejeebhoy, 1996; Bledsoe & Cohen, 1993). If on the other hand, boys learn to be respectful of their partners and to practice safer sexual activity, they will often continue this behavior into adulthood. For example, a study in the US found that adolescent males who used condoms during their first sexual relations were more likely to use condoms consistently thereafter (Sonenstein, Pleck & Ku, 1995). An analysis of data from the National Survey on Adolescent Males in the US found that beliefs about manhood emerged as the strongest predictor of risk-taking behaviors; so young men who adhered to traditional views of manhood were more likely to report substance use, violence and delinquency, and unsafe sexual practices (Courtenay, 1998). Likewise, research with a random sample of 750 men ages 15-60 and Brazil found that traditional beliefs about manhood were highly correlated to condom use and violence against partners (Barker & Pulerwitz, 2003).
A constellation of traditional beliefs and views about masculinity - sometimes called "machismo" - has been reported in a wide variety of settings. These include beliefs that men have more sexual urges than women, that men have the right to decide when and where to have sex, that sexual and reproductive health issues are women's concerns, that men have the right to outside partners or relationships while women do not and that child care or parenting is primarily a woman's issue (Marsiglio, 1988). These traditional beliefs sustain and support the behaviors of men who have internalized such norms, and in turn, act on them, by for example, not using condoms, not seeking health services, relegating reproductive health issues to women and not taking an active role in caring for children they father. These are the beliefs that continue into adulthood if not reversed otherwise in younger years.
What follows from this finding is that we need to work on changing community norms and to help individual men reflect and question these traditional norms to promote behavior change. This requires reaching beyond the clinic setting to the myriad of places where young men and adult men are socialized like their families, social institutions (schools, for example), and their peer groups, (Archer, 1984; Archer, 1994; Kindler, 1995; Erikson, 1968; Ross, 1994). Research has shown that even in communities where traditional norms prevail, it is possible for individual young men to act in more gender-equitable ways. For example, extensive qualitative research with more gender-equitable young men in low income settings in Chicago and in Rio de Janeiro identified three key factors that contributed to their more gender-equitable behaviors (Barker, 1998, 2000a & 2001). 1) Having an important relationship or multiple relationships with someone who modeled alternative ways of being a man, or alternative gender roles was extremely important; 2) Belonging to an alternative peer group that reinforced a more gender-equitable version of masculinity emerged as important. For instance, some of the young men interviewed were part of an on-going peer group that was non-gang-involved and also sought to project and support more respectful ways of interacting with women; and 3) Having reflected about the costs or consequences of traditional views about manhood. For example, more than half of the young men reported witnessing a man using violence against a woman in their home and perceived the impact of this violence on the family. In such cases, some of the young men were able to talk about how male violence affected their family and how they wanted to avoid this in their own relationships, and thus perceive the costs or negative consequences of such versions of manhood.
Directly corresponding to these factors, three programmatic implications emerge from this research in terms of promoting more gender-equitable attitudes and behaviors among young men, including: 1) Offering young men opportunities to interact with gender-equitable role models in their own community setting; 2) Promoting these more gender-equitable attitudes in small group settings as well as in the greater community; and 3) The need for group and individual activities that promote reflections about life histories and help young men perceive the costs of some traditional versions of masculinity.
THE INTERVENTION MODEL
The Program H initiative thus seeks to incorporate these findings into an intervention model that consists of two components: the curriculum component and the social marketing component. Each will be discussed in turn.
The Program H initiative was developed in 1999, with four Latin American non-governmental organizations (NGOs) that had significant experience in promoting sexual rights and reproductive rights with men: Promundo, ECOS (in São Paulo, Brazil), Instituto PAPAI (Recife, Brazil) and Salud y Género (Mexico).
The activities in the manuals are designed to be carried out in a same-sex group setting, and generally with men as facilitators who can and should also serve as more gender-equitable role models for the young men. The activities consist of role plays, brainstorming exercises, discussion sessions and individual reflections about how men are socialized, positive and negative aspects of this socialization, and the benefits of changing certain behaviors. The themes in the manuals were selected based on a review of literature on the health and development of boys, and a survey of programs worldwide working with young men, in collaboration with the World Health Organization (Barker, 2000).
The manuals reinforce each other and make appropriate links between specific activities and themes. The manuals are printed in Portuguese, Spanish and English, and are currently widely used in Latin America by NGOs and by ministries of health. The themes of the manuals are as follows: 1) Sexual and Reproductive Health; 2) Violence and Violence Prevention (including gender-based violence prevention); 3) Reasons and Emotions, which focuses on mental health issues and young men, particularly communication skills, dialogue, emotional intelligence and substance use; 4) Fatherhood and caregiving, which encourages young men to reconsider their roles in caregiving in the family, including caregiving to children they have or may have; 5) HIV/AIDS: Prevention and caregiving, which includes a series of activities about condom use; couple communication; STI prevention in general; basic information about HIV/AIDS; issues involved in counseling and testing; and issues involved in caregiving for partners, family members or friends who may be living with HIV/AIDS.
The manuals are accompanied by a no-words cartoon video that presents the story of a young man from early childhood through adolescence to early adulthood. Scenes include witnessing violence in his home, interactions with his male peer group, social pressures to behave in certain ways to be seen as a "real man," his first unprotected sexual experience, having an STI and facing an unplanned pregnancy. The video was developed in workshop processes with young men in diverse settings in Latin America and the Caribbean. By being a cartoon video, it quickly engages young men and transfers easily across cultures. The video uses a pencil, which erases certain behaviors or thoughts, as a metaphor for gender socialization and the indirect and direct ways boys are encouraged to act. In discussion following the video, young men discuss how they were socialized or raised to act as men, and ways they can question some negative aspects of that socialization.
These manuals and the video were field-tested with 271 young men ages 15-24 with five organizations in eight sites in Latin America. The following positive outcomes were cited during the field tests: Participating in male-only groups allowed for emotional exchange; Increasing empathy and attention to being caring and caregiving; Questioning machismo; Reflecting about fatherhood; Telling their male friends about the groups; Recognizing the cycle of violence; and Changing their style of male-to-male interaction.
In addition to the curriculum, PROMUNDO and its partner organizations have also developed what they call a "lifestyle social marketing" process for promoting a more gender-equitable lifestyle among men in a given cultural setting. This involves working with men themselves to identify their preferred sources of information, identify young men's cultural outlets in the community and craft messages - in the form of radio spots, billboards, posters, postcards, dances, etc. – to make it "cool and hip" to be a more gender-equitable man. PROMUNDO has partnered with SSL International (makers of Durex condoms) to incorporate these ideas into lifestyle social marketing campaigns.
Promundo has carried out a two-year impact evaluation study to measure the impact of the manuals and video in a population of 750 young men ages 15-24 in Rio de Janeiro, Brazil. This study, supported by the U.S. Agency for International Development, included developing an attitude scale, called the GEM Scale – Gender Equitable Behaviors in Men – that created 24 scale questions to assess men's attitudes about gender and manhood. Steps in the construction of the scale included:
(1) Identifying and defining the characteristics of "more gender-equitable" men in a given cultural setting; (2) Identifying the domains or aspects of how manhood is defined in the setting, for example norms or values related to male-female roles, household roles, sexuality, parenting, and homophobia, to name some; and (3) Testing the attitude questions and assessing their correlation with key behavioral variables, including condom use and use of physical violence against women.
Results confirm that Program H interventions have a positive impact on attitudes related to gender, and that the GEM Scale is a relevant and valid model for measuring this change. Pre-testing with the scale found that it is reliable and valid (when tested with a random sample of 750 men ages 15-59 in Brazil) for assessing men's individual and collective attitudes about gender roles. In field-testing of the GEM Scale, the researchers also confirmed that the scale is highly correlated with key outcome behavioral variables – most importantly, condom use and use of domestic violence. Given the short time-line of many interventions with men, it is often unrealistic to expect behavior change in the short run and difficult to measure such change. The GEM Scale thus provides a more sensitive evaluation instrument for measuring attitude changes that suggest a movement or change in the direction of gender equity on the part of men. The instrument also provides a useful assessment tool for baseline research to identify areas or attitudes that need to discussed or addressed with men in a given setting.
 Marcos Nascimento is a psychologist with master degree in Public Health. He coordinates the Gender and Health Program at Instituto Promundo, a NGO based in Rio de Janeiro, Brazil.