Program H aims to prevent and reduce the prevalence of HIV/STIs by questioning male gender norms. There is a strong link between gender attitudes toward sexuality and HIV risk behaviours, such as non-condom use.
Program H seeks to engage young men and their communities in critical reflections about rigid norms related to manhood. It includes group educational activities, community campaigns and an innovative evaluation model for assessing the programme’s impact on gender-related attitudes.
Program H was developed and validated in Latin America and the Caribbean in 1999 by four Latin American NGOs: Instituto Promundo (Rio de Janeiro, Brazil), ECOS (São Paulo, Brazil), Instituto PAPAI (Recife, Brazil) and Salud y Género (Mexico). This case study focuses on implementation of Program H as a 12-month quasi-experimental study in Rio de Janeiro in 2002.
Pre- and post-implementation surveys from this study indicated a significant positive change in men’s attitudes toward women, increased condom use and reduced reported STI symptoms in the two intervention sites, and no change in the control site. Qualitative in-depth interviews with young men and women also indicated increased caring and respect in participants’ relationships, as well as more health-protective behaviours.
Around the world many young men aged 15 to 24 are at high risk of HIV and other sexually-transmitted infections (STIs), and are victims and perpetrators of sexual coercion and violence. Moreover, young men are less likely than young women to seek health services, making it more difficult to reach them with information and other assistance. Many institutions, such as UNAIDS, have called for more effective and innovative strategies to incorporate men—particularly young men—into HIV/STI and violence prevention initiatives.
Since 1993 more cases of AIDS in Brazil are attributed to heterosexual transmission than homosexual transmission. Among adult males (13 years and over), 17 per cent of AIDS cases were due to heterosexual sex from 1980 to 1995, compared to 35 per cent in 2000 and over 46 per cent in 2007. This increase has brought with it an alarming rise in the percentage of women affected by HIV. There is evidence that women are less likely to use condoms when having sex with casual partners than men, adding to concerns that many women do not see themselves as being at risk of becoming infected with HIV.
It has also become increasingly clear that young people are bearing the brunt of the epidemic and that poor people and those with a low level of education are at a higher risk of becoming infected.
There is growing evidence that early socialisation that promotes inequitable gender roles as the norm encourages risky behaviours among young men and women. Thus, addressing gender norms is increasingly recognised as a key strategy to increase condom use and prevent the spread of HIV infection.
Common examples of gender norms for men include that they should have multiple partners and maintain control over their female partners. Women are often taught to be submissive and often do not have the power to negotiate safer sex with their male partners. Gender inequity in relationships—where males have greater power than females—can also lead to sexual coercion and physical violence, circumstances under which HIV-protective behaviours are impossible to initiate and maintain.
However, promoting social norms in favour of greater gender equity is challenging. Moreover, few interventions to promote gender-equitable behaviour among young men have been evaluated and relatively little is known about how best to measure changes in gender norms and the effect of such changes on HIV/STI protective and risk behaviours.
To address these gaps, the Horizons Program and Instituto Promundo (a Brazilian NGO), with support from USAID, Durex, the John D. and Catherine T. MacArthur Foundation and JohnSnowBrasil, and with technical support from Salud y Género, ECOS, and Instituto Papai, forged a partnership known as the H Alliance to examine the effectiveness of interventions designed to improve young men’s attitudes toward gender norms and to reduce HIV/STI risk.
The initial research for Program H began in 1999, led by Instituto Promundo. This involved ‘mapping’ masculinity to better understand how men and women view what it means to be male. A range of existing literature, studies and surveys from Latin America and elsewhere were reviewed. This confirmed that boys and young men in Latin America are frequently socialised around a constellation of gender norms related to sexual and reproductive health and risk, sexuality, homophobia, fatherhood, use or acceptability of violence against women, and participation in domestic chores. While there is variation by setting, family and individual, extensive qualitative and ethnographic research indicates that there is remarkable consistency in the norms into which boys and young men are socialised across the region. Styles of interaction in intimate relationships are often ‘rehearsed’ during adolescence and continue into adult relationships.
Traditional masculinity embraces the belief that:
- Men have more sexual urges than women
- Men have the right to decide when and where to have sex
- Men should initiate sexual activity early in life
- Unsafe or risky sex is more enjoyable than safer sex
- Sexual and reproductive health issues are women's concerns
- Men have the right to outside partners or relationships while women do not
- Childcare or parenting is primarily a woman's issue
- Women should be submissive and accept their partners’ sexual requests
In the process of interviewing men in Latin America, researchers identified individuals who questioned the prevailing views about manhood. Through in-depth interviews with these ‘more gender-equitable men’, the team sought to understand how it was that these particular men came to question the dominant paradigms. These men generally showed a high degree of self-reflection in the interviews, some awareness of the personal benefits of embracing gender equality, and usually had others around them - family members, a valued peer or peer group, or an adult male - who modelled gender-equitable attitudes and behaviours. These men sometimes also had seen or experienced gender violence - violence against a mother or sister when they were children, or perhaps had used violence against a female partner themselves. The resulting emotional pain to themselves and others had caused them to oppose or question such violence.
These research findings provided the conceptual framework for Program H (‘H’ for homens, or men, in Portuguese, and hombres in Spanish). Specifically, this formative research reinforced the need to:
- Work at the level of individual attitude and behaviour change by engaging young men in a critical reflection on the costs of traditional versions of masculinity
- Work at the level of social or community norms, including among parents, service providers, community and religious leaders, the mass media, and others that influence or model these individual attitudes and behaviours
The programme focuses on young men rather than older men, since they potentially hold more flexible views about gender and are just beginning their sexual lives or starting to develop intimate partnerships.
Program H seeks to encourage young men to:
- Seek relationships with women based on equality and intimacy, rather than sexual conquest. This includes believing that men and women have equal rights and that women have as much sexual desire and ‘right’ to sexual agency as do men
- Seek to be involved fathers (for those who are fathers) or to be involved in caregiving
- Assume some responsibility for reproductive health and disease-prevention issues. This includes taking the initiative to discuss reproductive-health concerns with their partner, using condoms, or assisting their partner in acquiring or using a contraceptive method
- Oppose violence against women
Based on the research findings and direct experience of working with men in various parts of the Americas region, three strategies were developed to promote more gender-equitable attitudes and behaviours among young men:
- Offering young men opportunities to interact with gender-equitable role models in their own community setting
- Promoting these more gender-equitable attitudes in small group settings and in the greater community
- 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 activities were selected to address each of the characteristics mentioned below, all with a gender-focus. Here, ‘gender-equitable’ men:
- Are respectful to women, show concern about the feelings and opinions of their sexual partners and seek relationships based on equality and intimacy, rather than on sexual conquest
- Believe men and women have equal rights
- Assume, or share with their partners, responsibility for reproductive health and disease prevention issues
- Are, or seek to be, domestic partners and fathers, who are responsible for at least some of the household chores and childcare
- Are opposed to violence against women in their intimate relationships
- Are not homophobic
Changing behaviours to reflect positive gender roles has both short- and long-term benefits. In the short term, young people can choose to avoid risky behaviours that may lead to disease or death, as well as sexual coercion and physical violence. In the longer term, changing machismo attitudes can lead to stronger and more rewarding relationships and more life choices for future generations. It is critical, however, to change these gender norms during the teenage years so it does not become established behaviour in adulthood.
The key barriers to the target men adopting the desired behaviours include a long cultural tradition that reinforces machismo, the lure of sexual gratification, and peer pressure ('Everyone is doing it'), reinforced by entertainment media's representation of machismo values.
The Transtheoretical (Stages of Change) Model underpins Program H, because the target audience must be moved through early stages of indecision. The programme begins with knowledge objectives, eventually resulting in a shift of basic beliefs about gender equity, thereby leading to behaviour changes.
The programme also drew on the ecological model and its guidance regarding the importance of addressing key issues from multiple levels, from the individual to the greater society. Hence, the interventions include the promotion of individual reflection, a peer and interpersonal group education component and a broader community-based component.
Program H focuses on helping young men question traditional norms related to manhood and on promoting their abilities to discuss and reflect on the ‘costs’ of inequitable gender-related views and advantages of more gender-equitable behaviours. It involves two main components:
- A validated curriculum that includes a manual and educational video for promoting attitude and behaviour change among men
- A lifestyle campaign for promoting changes in community or social norms about what it means to be a man
The curriculum was developed in 1999 by four Latin American NGOs (coordinated by Instituto Promundo) and was designed based on qualitative research with the study population. It includes a 20-minute cartoon video and 70 activities developed and pre-tested with groups of young men aged 15 to 24. The activities in the manual were designed to be carried out in a same-sex group setting and consist of role plays, brainstorming exercises, discussion sessions and individual reflection. Activities are organised under five themes:
- Sexual and reproductive health
- Fatherhood and caregiving
- From violence to peaceful coexistence
- Reasons and emotions (including communication skills, substance abuse and mental health)
- Preventing and living with HIV/AIDS
The cartoon video used during the sessions, called ‘Once Upon a Boy’, tells the story of a young man from early childhood, through adolescence, to early adulthood. The story highlights different experiences in the young man’s life, including witnessing violence in his home, interactions with male peer groups, his first sexual experience, contracting a STI, and facing an unplanned pregnancy. Like the educational activities, the video was widely ﬁeld-tested in Latin America and the Caribbean and its content was based on previous qualitative research with young men in the region.
In 2001, Promundo, JohnSnowBrazil and Durex developed a behaviour change communication campaign to promote a more gender-equitable lifestyle and reinforce messages learned in the group education sessions. The campaign was called ‘Hora H’, or ‘In the Heat of the Moment’.
The Hora H brand was conceived and developed by Durex in conjunction with peer promoters’ – young men recruited from the community – to help develop and implement the campaign. These men identified preferred sources of information and cultural outlets in the community. They also crafted intervention messages about how ‘cool and hip’ it was to be a more gender-equitable man. The phrase was developed by young men who frequently heard their peers say, ‘Everybody knows you shouldn’t hit your girlfriend, but in the heat of the moment...’ or ‘Everybody knows that you should use a condom, but in the heat of the moment you might forget or not have access to a one’.
Condom use and negotiation are presented in the campaign as important elements of creating a more gender-equitable lifestyle. While condoms were widely available in the Brazilian market, youth participating in the programme stated that none were targeted specifically at young people and they were perceived as being unaffordable. Taking cues from graffiti artists, branded condoms were sold in packs of three with a fun, colourful youth magazine, developed by the young men themselves. A different packaging format was used to distinguish the brand from the competitors. Even the instructions for use were rewritten in a language that was better suited to the target audience. These new condoms were strategically distributed to common cultural outlets for young men, including bars, community dances and parties. Distribution was also secured in retail outlets such as music and clothing stores in addition to traditional pharmacies and drug stores.
An advertising campaign was created with posters depicting young people from the community, which was highly successful because the public could relate to them more than they would with celebrities or models. The poster campaign was supplemented with community based radio programming and fairs, together with point-of-sale material to communicate “An attitude with a difference - Real men use Hora H”.
Drawing on the operational definition of a ‘gender-equitable man’, and on an extensive literature review, a scale to measure the impact of the intervention on attitudes toward gender norms – called the Gender-equitable Men (GEM) Scale – was developed and validated in 2001 by Insituto Promundo and Institut NOOS, with technical assistance from the Horizons Program.
The GEM Scale was initially tested with a community-based sample of 742 men aged 15 to 60 (including 23 young men aged 15 to 24), in both low- and middle-income neighbourhoods in Rio de Janeiro. Less equitable (or more ‘traditional’ attitudes) were reported by men from varied socioeconomic backgrounds and in both low- and middle-income neighbourhoods. Men with lower educational levels tended to hold more inequitable views on gender roles and what it means to be a man. A strong association was found between GEM Scale scores and key health-related outcomes, such as partner violence and contraceptive use. As hypothesised, more equitable attitudes were associated with less reported partner violence and higher reported contraceptive use.
The GEM Scale includes 17 items on 5 key areas related to gender norms:
- Sexual relationships
- Reproductive health and disease prevention
- Domestic chores and childcare
- Homophobia and relationships with other men
In 2002, Promundo and the Horizons Program piloted Program H in Rio de Janeiro, Brazil. This quasi-experimental study compared the impact of different combinations of programme activities to identify which are particularly useful for achieving desirable changes in attitudes and behaviours. Three groups of young men aged 14 to 25 (at baseline, n=780) were followed over time and were based in three different but fairly homogeneous low-income communities. Young men from these three favelas do not tend to interact with each other, so there was minimal risk of ‘contamination’.
Programme activities were implemented in the pilot communities as follows:
- Maré: Focused on group education only
- Bangu: Combined group education with the community-wide lifestyle campaign
- Morro dos Macacos: Delayed intervention (reduced hours of group education) followed a control period of no intervention
The study team considered a six-month period long enough to expect an impact from the intervention, yet short enough that it was not too much of a burden on the young men to complete, nor on future organisations that may be interested in implementing it. A Technical Advisory Group, comprised of the founding members of the Program H Alliance and Population Council, selected six months’ worth of activities (18 in total) from the curriculum that were seen as most relevant for promoting gender equity and HIV prevention and were most successful in engaging young men during the field-tests.
Five adult men were selected to facilitate the group activities, which were conducted with young men during once-a-week sessions for two hours each, for a total of 28 hours. Each of them had prior experience working with groups of youth from low-income communities on gender and health issues. The facilitators had previously worked with Promundo and were selected in part because of their gender-sensitive and equitable perspectives. Facilitators were additionally trained by programme staff for a total of 24 hours. As part of their training, they had to participate in the educational activities they would later facilitate. This way they reflected on their own attitudes toward the issues.
During implementation, the coordinator of Promundo’s Gender and Health Program led regular (usually weekly) meetings with workshop facilitators to discuss their progress and how the young men were reacting to the programme.
Promundo worked with local community groups, resident associations, local schools and a community radio station to recruit young men to participate in the intervention and secure space for the educational workshops. Participants were paid a small stipend (equivalent to US$7 per month) to reimburse them for transportation expenses and for their time.
At each workshop, the facilitators took attendance. Young men who did not attend were contacted and reminded of the next sessions via phone, messages left with resident associations, schools or other participants, or home visits. While almost 30 per cent attended all or most of the sessions in Bangu and Mare, more than half of the group participated in less than half of them. The most common reason for missing a session was work-related. The team also found it more difficult to recruit older youth (aged 20 to 24), since they were working, searching for work or prioritised professional training courses.
Although participants were initially shy and uncomfortable with the structure of activities, as the groups progressed they became increasingly comfortable with contributing personal stories and opinions. However, in some sessions there were conflicts (even physical) between participants because of the themes they were discussing, such as homophobia. Facilitators had to be trained and prepared to resolve these, and to use these moments to promote further discussion in subsequent sessions.
The lifestyle social marketing campaign was launched only in Bangu to determine if it would lead to improved outcomes in support of the group education. Working in conjunction with Promundo, Durex played a crucial part in the management of the programme through the provision of condoms and its technical expertise.
Peer promoters were trained in selling and marketing the brand within their community, giving them the opportunity to enter the formal job market and to learn negotiation skills, earning them a commission and with profits channelled back into providing additional promotional activity.
An ‘Hora H Kit’ containing lifestyle promotional materials, display stand, training manual and Hora H condoms, allowed easy replication in new settings. The use of condoms was promoted through sketches, informative leaflets, posters and discussion groups on how to use and negotiate the use of condoms. The price was affordable and the product quality unsurpassed. Consumer feedback quickly established that the Hora H condom was the best quality condom available in Brazil.
Quantitative data collection
Surveys were administered to a cohort in each site prior to any intervention activities (258 in Bangu, 250 in Maré, 272 in Morro dos Macacos), then again six months (230 in Bangu, 212 in Maré, 180 in Morro dos Macacos) and one year (217 in Bangu and 190 in Maré) after the interventions began implementing.
- At six months, agreement with inequitable gender norms items significantly decreased in both intervention sites, with 10 out of 17 items improving in Bangu and 13 out of 17 items improving in Maré. These positive changes were maintained at the one-year follow-up in both intervention sites. In Morro dos Macacos responses to only one of 17 items significantly improved
- At both intervention sites, condom use at last sex with a primary partner increased and reported STI symptoms over the prior three months decreased. These improvements were maintained, and in fact greater, at one-year follow-up. In Morro dos Macacos, there was no significant increase in condom use or decrease in reported STI symptoms at six months
- There was a slight reduction at six months and at one year in the proportion of participants in both intervention groups who reported having two or more sexual partners over the last month last month, and a slight increase in the control group
Qualitative data collection
In-depth interviews were conducted upon conclusion of the intervention activities with a sub-sample of young men in ongoing primary relationships and their female sexual partners. The primary goal was to explore their reactions to the programme, particularly the impact of the programme on their relationships.
- The young men discussed how the workshops helped them to question their attitudes: “I learned to talk more with my girlfriend. Now I worry more about her… it’s important to know what the other person wants, listen to them. Before [the workshops], I just worried about myself.”
- Some young men reported that they changed their general views about women and had come to see women as having the same sexual agency as men
- Some men reported having a new willingness to wait to engage in sexual activity with partners and paying more attention to other aspects of the relationship outside of the sexual component: “Used to be when I went out with a girl, if we didn’t have sex within two weeks of going out, I would leave her. But now [after the workshops], I think differently. I want to construct something [a relationship] with her.”
- Young men reported, and their female partners confirmed, that they engaged in more open communication around sexual risk reduction and paid greater attention to their overall health needs, specifically to HIV testing
Process evaluation and costing
Facilitators of the educational sessions kept records after each session on the group dynamics, challenges and successes, and attendance of the group education. This was intended for the facilitators to provide a qualitative assessment of what was discussed and what they thought of the group workshops.
The costs of implementing the different components of the programme were also tracked to permit a costing analysis. The total costs in Bangu and Maré were US$35,856.87 and US$21,060.28, respectively. The cost-per-output of the intervention, or the cost per youth reached, is US$138.98 for Bangu and US$84.24 for Maré.
Therefore, it is almost twice as much to reach young men in a combined programme. However, this analysis focuses on the costs of reaching the young men who participated in the group education in both arms of the study (approximately 500). It does not take into account the many other young men and community members that were reached by the community-based lifestyle campaign. Therefore, the reach was likely greater than what this analysis conveys.
Promoting ‘male-friendly’ health services was added to the programme as a third component in Bangu. This element involves training health professionals to provide services for young men and adapting health service delivery programmes so that they are more appealing to young men. In Rio, Promundo is working with six public health units with support from the PAHO and WHO. Program H is still running in Rio and in other major cities throughout Brazil.
Following the evaluation of Program H in Rio de Janeiro, the study and intervention has inspired ongoing adaptations in other countries. The Horizons Program, in collaboration with local partners and Instituto Promundo, has funded and led the adaptation and replication of the GEM Scale, as well as the adaptation and piloting of a group education intervention in Mumbai, India. The MacArthur Foundation is now funding a full-scale evaluation of the intervention in India, and a pilot in Mexico, which is being implemented by Horizons/Population Council and Promundo, with local partners CORO, an Indian NGO, and Salud y Genero. Durex is also supporting the development and testing of a lifestyle social marketing campaign in Mumbai, which is being conducted by CORO, Horizons and Promundo. Promundo is working with partner organisations in several countries in sub-Saharan Africa (Ethiopia, Mozambique and Namibia) to adapt these processes and approaches for specific settings in Africa.
The methodology has also been adapted for use in the Balkans, Peru, Tanzania and Vietnam, and has been used as the basis for trainings and technical support in Asia (India, Nepal and Thailand), Central America (Nicaragua, Costa Rica and Panama) and in the United States and Canada.
Building on their success in educating young men about the social and health costs of machismo culture, in 2005 the Program H partners and World Education launched Program M (M for Mulheres and Mujeres, the words for women in Portuguese and Spanish) to empower young women to take control of their sexual and reproductive health. It includes educational and campaign strategies that engage young women in critical reflections about life choices, health and sexuality. Using similar intervention design strategies to Program H, Program M was built on research that explored women’s concepts of empowerment and the key facilitators that contribute to their feelings of autonomy and self worth. The Program M curriculum was originally field-tested in Brazil, Jamaica, Mexico and Nicaragua and has since been adapted for use in India and Tanzania.
Programmes working with men to promote gender equality should rely on the voices of men and women at the community level to develop realistic indicators or outcome-measures. The alternative voices of men who show greater equality should inform programme development. These young men should also be engaged at all levels of programme development.
Evaluation must include both individual men, who can be encouraged to question and reflect about traditional views, and the community, where norms are promoted.
“Young men don’t learn behaviours in isolation. Social norms play an important role, and from the study we learned that individual reflection can help change their views, which is a first step in changing what is appropriate and expected behaviour for men.” Dr. Gary Barker, Director of Instituto Promundo
Attitude questions applied through a questionnaire, as well as qualitative research, should be combined, so that we understand how change takes place and can more closely listen to the voices and realities of the women and men involved.
The positive changes in attitudes towards gender norms were equally great for young men exposed to the combination of group education activities and the community-based lifestyle campaign, and the group participating in education activities alone. This finding underscores that the group education was likely most successful in addressing gender-related attitudes, and an interactive and interpersonal process may be needed to influence often deep-seated and complex gender-related norms.
Improvements in HIV/STI-related outcomes were often greater for young men exposed to the combined intervention. This finding highlights the importance of combining both interpersonal communication and reinforcing gender equity and HIV risk reduction messages at the community level. In addition, exposing the young men to similar messages outside of the small group setting will likely increase the probability of sustained change over a longer period of time.
Qualitative data indicates that young men were resistant to the idea of mutual monogamy in relationships, so interventions regarding this issue with this population may take substantially longer to be effective.
Qualitative findings emphasise the complexity of measuring and influencing attitudes towards gender norms. Young men and young women sometimes have inconsistent views, holding gender-equitable views about one issue, but not another. Young men also show different behaviours with different partners, reflecting the complexity and interactive nature of relationship styles. The issues of tolerance towards homosexuality and the desire for men to have multiple sexual partners, proved to be among the most difficult areas to challenge.
With special thanks to Peter Roach (Head of Social Marketing, Durex), who contributed to the content and development of this case study.