South African men's perceptions of breast cancer: impact of gender norms on health care accessibility.

Women in low- and middle-income countries (LMICs) often present to the health care system at advanced stages of breast cancer (BC), leading to poor outcomes. A lack of BC awareness and affordability issues are proposed as contributors to the delayed presentation. In many areas of the world, however, women lack the autonomy to deal with their health needs due to restrictive gender norms. The role of gender norms has been relatively underexplored in the BC literature in LMICs and little is known about what men know about BC and how they are involved in women's access to care. To better understand these factors, we conducted a qualitative descriptive study in South Africa. We interviewed 20 low-income Black men with current woman partners who had not experienced BC. Interviewees had limited knowledge and held specific misconceptions about BC symptoms and treatment. Cancer is not commonly discussed within their community and multiple barriers prevent them from reaching care. Interviewees described themselves as having a facilitative role in their partner's access to health care, facets of which could inadvertently prevent their partners from autonomously seeking care. The findings point to the need to better consider the role of the male partner in BC awareness efforts in LMICs to facilitate prevention, earlier diagnosis and treatment.

Women in undeveloped countries are often not diagnosed with breast cancer until the disease is already very severe. Some of the reasons for this include the women's lack of awareness about breast cancer and difficulty affording the costs of health care or the costs of transportation to a hospital or clinic. In many areas of the world, women also do not have the freedom to respond to their own health needs without having a male family member involved. However, we do not know very much about how men may be involved in women's health care. To better understand this, we conducted a research study in which we talked to 20 South African men about what they knew about breast cancer and how they are involved in their partner's health care decisions. Through talking to them, we found out that many did not know about breast cancer or had inaccurate information about it. The men reported that people in their community do not often talk about cancer. The men described themselves as having a positive influence on their partner's health care decisions, but some of the things they reported doing might stop their partners from being able to receive health care independently. Overall, we think that campaigns to raise awareness of breast cancer should consider how women's partners may be involved in their health care.

Gendered syndemic of intimate partner violence, alcohol misuse, and HIV risk among peri-urban, heterosexual men in South Africa.

Men whose sexual behaviors place them at risk of HIV often exhibit a "cluster" of behaviors, including alcohol misuse and violence against women. Called the "Substance Abuse, Violence and AIDS (SAVA) syndemic," this intersecting set of issues is poorly understood among heterosexual men in sub-Saharan Africa. We aim to determine cross-sectional associations between men's use of alcohol, violence, and HIV risk behaviors using a gendered syndemics lens. We conducted a baseline survey with men in an informal, peri-urban settlement near Johannesburg (Jan-Aug 2016). Audio-assisted, self-completed questionnaires measured an index of risky sex (inconsistent condom use, multiple partnerships, transactional sex), recent violence against women (Multicountry Study instrument), alcohol misuse (Alcohol Use Disorders Tool), and gender attitudes (Gender Equitable Men's Scale). We used logistic regression to test for syndemic interaction on multiplicative and additive scales and structural equation modeling to test assumptions around serially causal epidemics. Of 2454 men, 91.8% reported one or more types of risky sex. A majority of participants reported one or more SAVA conditions (1783, 71.6%). After controlling for socio-demographics, higher scores on the risky sex index were independently predicted by men's recent violence use, problem drinking, and inequitable gender views. Those men reporting all three SAVA conditions had more than 12-fold greater odds of risky sex compared to counterparts reporting no syndemic conditions. Each two-way interaction of alcohol use, gender inequitable views, and IPV perpetration was associated with a relative increase in risky sex on either a multiplicative or additive scale. A structural equation model illustrated that gender norms predict violence, which in turn predict alcohol misuse, increasing both IPV perpetration and risky sex. These data are consistent with a syndemic model of HIV risk among heterosexual men. Targeting intersections between syndemic conditions may help prevent HIV among heterosexual men in peri-urban African settings.

HIV non-testing, perpetration of violence against women, and sexual risk-behaviour: A cross-sectional analysis of South African peri-urban township men.

Despite HIV testing having improved globally, men remain disproportionately less likely to test for HIV. While violence against women (VAW) and HIV risk have a strong association among women, few studies explore men around VAW perpetration, risky-sexual behaviour, and HIV testing. Males aged 18-42 years were recruited from a peri-urban settlement near Johannesburg, South Africa. Data were from an endline of a trial. We used logistic regression to assess odds of non-HIV testing using STATA 13. At endline, 1508 men participated in the study. Of these nearly one-third (31.6%, n = 475) had not tested for HIV in the past year. HIV non-testing was significantly lower among men who were single, older, did not complete high school and were less food secure. VAW perpetration retained a significant association with HIV non-testing after controlling for socio-demographics (AOR = 0.73, 95%CI = 0.58-0.93). In multivariate models, HIV non-testing was also associated with inconsistent condom use (AOR = 0.64, 95%CI = 0.48-0.85), problem drinking (AOR = 0.72, 95%CI = 0.55-0.94) and reporting of all four risky sexual behaviours (AOR = 0.70, 95%CI = 0.49-1.01). Data suggests that one-third of men who never test for HIV in this setting may represent a high-risk group. Future campaigns could consider behaviour change around non-violence, relationship quality, and gender norms alongside HIV testing.

Correction to: Effectiveness of a multi-level intervention to reduce men's perpetration of intimate partner violence: a cluster randomised controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

Effectiveness of a multi-level intervention to reduce men's perpetration of intimate partner violence: a cluster randomised controlled trial.

BACKGROUND: Men's perpetration of intimate partner violence (IPV) limits gains in health and wellbeing for populations globally. Largely informal, rapidly expanding peri-urban settlements, with limited basic services such as electricity, have high prevalence rates of IPV. Evidence on how to reduce men's perpetration, change social norms and patriarchal attitudes within these settings is limited. Our cluster randomised controlled trial aimed to determine the effectiveness of the Sonke CHANGE intervention in reducing use of sexual and/or physical IPV and severity of perpetration by men aged 18-40 years over 2 years. METHODOLOGY: The theory-based intervention delivered activities to bolster community action, including door-to-door discussions, workshops, drawing on the CHANGE curriculum, and deploying community action teams over 18 months. In 2016 and 2018, we collected data from a cohort of men, recruited from 18 clusters; nine were randomised to receive the intervention, while the nine control clusters received no intervention. A self-administered questionnaire, using audio-computer assisted software, asked about sociodemographics, gender attitudes, mental health, and the use and severity of IPV. We conducted an intention-to-treat analysis at the cluster level comparing the expected risk to observed risk of using IPV while controlling for baseline characteristics. A secondary analysis used latent classes (LCA) of men to see whether there were differential effects of the intervention for subgroups of men. RESULTS: Of 2406 men recruited, 1458 (63%) were followed to 2 years. Overall, we saw a reduction in men's reports of physical, sexual and severe IPV from baseline to endpoint (40.2% to 25.4%, 31.8% to 15.8%, and 33.4% to 18.2%, respectively). Intention-to-treat analysis showed no measurable differences between intervention and control clusters for primary IPV outcomes. Difference in the cluster-level proportion of physical IPV perpetration was 0.002 (95% confidence interval [CI] - 0.07 to 0.08). Similarly, differences between arms for sexual IPV was 0.01 (95% CI - 0.04 to 0.06), while severe IPV followed a similar pattern (Diff = 0.01; 95% CI - 0.05 to 0.07). A secondary analysis using LCA suggests that among the men living in intervention communities, there was a greater reduction in IPV among less violent and more law abiding men than among more highly violent men, although the differences did not reach statistical significance. CONCLUSION: The intervention, when implemented in a peri-urban settlement, had limited effect in reducing IPV perpetrated by male residents. Further analysis showed it was unable to transform entrenched gender attitudes and use of IPV by those men who use the most violence, but the intervention showed promise for men who use violence less. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02823288. Registered on 30 June 2016.

Process evaluation of a community mobilization intervention for preventing men's partner violence use in peri-urban South Africa.

Intimate partner violence (IPV) is experienced by one-third of women globally, yet few programs attempt to shift men's IPV perpetration. Community mobilization is a potential strategy for reducing men's IPV perpetration, but this has rarely been examined globally. We conducted a mixed-methods process evaluation alongside a trial testing community mobilization in peri-urban South Africa. We used in-depth interviews (n=114), participant observation (160 h), and monitoring and evaluation data to assess program delivery. Qualitative data (verbatim transcripts and observation notes) were managed in Dedoose using thematic coding and quantitative data were descriptively analyzed using Stata13. We learned that outreach elements of community mobilization were implemented with high fidelity, but that critical reflection and local advocacy were difficult to achieve. The context of a peri-urban settlement (characterized by poor infrastructure, migrancy, low education, social marginalization, and high levels of violence) severely limited intervention delivery, as did lack of institutional support for staff and activist volunteers. That community mobilization was poorly implemented may explain null trial findings; in the larger trial, the intervention failed to measurably reduce men's IPV perpetration. Designing community mobilization for resource-constrained settings may require additional financial, infrastructural, organizational, or political support to effectively engage community members and reduce IPV.

Pathways From Food Insecurity to Intimate Partner Violence Perpetration Among Peri-Urban Men in South Africa.

INTRODUCTION: Although poverty is sometimes seen as a driver of intimate partner violence victimization, less is known about how it intersects with men's violence perpetration. Food insecurity is a sensitive marker of poverty that may have unique mechanisms leading to men's intimate partner violence perpetration given its association with gender roles and men "providing for the family." METHODS: Using cluster-based sampling, the team conducted an audio-assisted questionnaire in 2016 among men living in a peri-urban settlement near Johannesburg, South Africa. The aim was to examine the relationship between men's food insecurity and their use of past-year intimate partner violence, and to explore the pathways linking these two conditions. RESULTS: Among 2,006 currently partnered men, nearly half (48.4%) perpetrated intimate partner violence and more than half (61.4%) were food insecure. Food insecurity was associated with doubled odds of intimate partner violence (OR=2.15, 95% CI=1.73, 2.66). This association persisted after controlling for sociodemographics, relationship characteristics, and neighborhood clustering. In a structural equation model, food insecurity retained a direct relationship with men's violence perpetration and worked through indirect pathways of mental health and relationship quality. CONCLUSIONS: Addressing men's perpetration of intimate partner violence may require examination of broader structural challenges, such as food insecurity. Future interventions should consider livelihood strategies alongside relationship and mental health approaches.

Effect of Childhood Poverty and Trauma on Adult Depressive Symptoms Among Young Men in Peri-Urban South African Settlements.

PURPOSE: Depressive disorders contribute to health declines among young men, but little is known about how childhood trauma alongside poverty alters depressive symptoms in young adulthood. These life-course dynamics are particularly under-researched in African settings. METHODS: We assessed how childhood trauma and poverty were associated with depressive symptomology among young men (aged 18-30 years). Data were collected through community-based surveys in two peri-urban, South African settlements. Validated measures assessed childhood abuse, depressive symptomology, and food insecurity. Markers of childhood poverty and young adult socioeconomic predictors were also assessed. RESULTS: A total of 2,427 young men reported low levels of income, food security, and education. One-third of the sample (39.2%) reported symptoms consistent with probable depression. The majority (76.9%) reported one or more forms of childhood abuse, which was predicted by childhood hunger. Compared with counterparts without childhood trauma, those with physical, sexual, or psychological childhood abuse had a higher risk of later depressive symptoms (adjusted odds ratio [AOR]=2.37,2.42,2.39, respectively). A fully saturated linear mixed model showed each form of childhood trauma predicted increased depressive symptomology in adulthood, with the combination of physical, sexual, and psychological abuse strongly predicting increased depressive symptoms (coef=6.78, 95%CI=5.78-8.17). In all models, childhood poverty and adult poverty independently predicted young adult depressive symptoms. CONCLUSION: Household poverty may be a key reason that children experience abuse and, in turn, common mental disorders in young adulthood. Structural interventions for food security, employment, and parenting are essential to break the intergenerational nexus of poverty, trauma, and health in peri-urban settings.

A cluster randomised controlled trial to determine the effect of community mobilisation and advocacy on men's use of violence in periurban South Africa: study protocol.

OBJECTIVE: This paper describes the design and methods of a cluster randomised controlled trial (C-RCT) to determine the effectiveness of a community mobilisation intervention that is designed to reduce the perpetration of violence against women (VAW). METHODS AND ANALYSIS: A C-RCT of nine intervention and nine control clusters is being carried out in a periurban, semiformal settlement near Johannesburg, South Africa, between 2016 and 2018. A community mobilisation and advocacy intervention, called Sonke CHANGE is being implemented over 18 months. It comprises local advocacy and group activities to engage community members to challenge harmful gender norms and reduce VAW. The intervention is hypothesised to improve equitable masculinities, reduce alcohol use and ultimately, to reduce VAW. Intervention effectiveness will be determined through an audio computer-assisted self-interview questionnaire with behavioural measures among 2600 men aged between 18 and 40 years at baseline, 12 months and 24 months. The primary trial outcome is men's use of physical and/or sexual VAW. Secondary outcomes include harmful alcohol use, gender attitudes, controlling behaviours, transactional sex and social cohesion. The main analysis will be intention-to-treat based on the randomisation of clusters. A qualitative process evaluation is being conducted alongside the C-RCT. Implementers and men participating in the intervention will be interviewed longitudinally over the period of intervention implementation and observations of the workshops and other intervention activities are being carried out. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of the Witwatersrand Human Research Ethics Committee and procedures comply with ethical recommendations of the United Nations Multi-Country Study on Men and Violence. Dissemination of research findings will take place with local stakeholders and through peer-reviewed publications, with data available on request or after 5 years of trial completion. TRIAL REGISTRATION NUMBER: NCT02823288; Pre-result.

On the advancement of therapeutic penality: therapeutic authority, personality science and the therapeutic community.

In this article I examine the advancement of therapeutic penality in the UK, a penal philosophy that reimagines prison policy, practices and environments utilising psychological knowledge. Adopting a historical approach, I show how modern therapeutic penality is linked to the emergence of personality science in the nineteenth century and the development of the democratic therapeutic community (DTC) model in the twentieth century. I outline how at the turn of the twenty-first century a catalytic event generated a moral panic that led the British government to mobilise psychological knowledge and technologies in an attempt to manage dangerous people with severe personality disorder. Tracing subsequent developments, I argue psychological ways of talking, thinking and acting have obtained unparalleled salience in domains of penality and, in turn, radically transformed the conditions of imprisonment.