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Additional file 1.Supplementary Table 1. Meansures of fit for models one through three latent classes.

Background To date, whilst there have been many published studies exploring the links between masculinity and HIV, not much work has been done to explore how an HIV-positive diagnosis impacts men's sense of masculinity and contextualizing the masculinities as fluid and changing. Objective To explore how human immunodeficiency virus (HIV) impacts the lives of men and their constructions of masculinity through interviews with 18 men living with HIV. Design Qualitative study involving conveniently and purposively selected black South African adult men who lived with HIV. In-depth interviews were conducted with 18 men who resided in Johannesburg and Mthatha, South Africa. Results Our analysis suggests that the performance of risky masculinity may influence the acquisition of HIV. Yet, it also reveals that HIV can have a significant effect on men and their masculinities. Men's constructions of harmful notions of hegemonic masculinity pre-HIV diagnosis negatively affected their help-seeking behavior and coping and adjustment to living with HIV, post-diagnosis. The dominant discourse that men are strong and healthy visibly presented challenges for men when faced with an HIV-positive status. They interpreted HIV diagnosis as a loss, a sign of failure as a man, and evidence of an inability to retain control. Being sick undermined their ability to perform roles expected of them, and this led to feelings of powerlessness, worthlessness, and distress. Conclusions Interventions with men living with HIV need to provide safe spaces for men to critically explore gender and constructions of social identities and the pressures these place on men and implications for their health. With this approach, harmful constructions of masculinities may be challenged and mitigated, and this process may render men amenable to change., Background Although teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort. Objective Teenage girls, aged 15–18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status. Results Overall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21–0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05–2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07–0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58–0.83 and OR 0.78; 95% CI 0.64–0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07–6.25, and OR 2.21 95% CI 1.13–4.29). Conclusion Although some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented., The recent public outcry following a brutal gang rape of a young woman in India's national capital was a watershed moment in the world's largest democracy. It generated widespread public and political support for strengthening legal provisions to punish sex offenders. Although the legal response is a useful deterrent against such heinous crimes, women continue to suffer due to deeply rooted social prejudices that make them vulnerable to violence and discrimination in society. In this commentary, we aim to analyse the current developments with respect to gender violence in India within a background of the social position of women in Indian society. Using secondary data related to sex-selective abortions and crimes against women, and a critical review of the portrayal of women in Indian cinema, we reflect on the role of health workers, researchers and public health professionals in shaping a social response towards improving gender parity in our country., Background It is widely agreed upon that gender is a key aspect of sexuality however, questions remain on how gender exactly influences adolescents’ sexual health. Objective The aim of this research was to study correlations between gender equality attitudes and sexual behavior, sexual experiences and communication about sex among sexually active and non-sexually active adolescents in 2 Latin American countries. Design In 2011, a cross-sectional study was carried out among 5,913 adolescents aged 14–18 in 20 secondary schools in Cochabamba (Bolivia) and 6 secondary schools in Cuenca (Ecuador). Models were built using logistic regressions to assess the predictive value of attitudes toward gender equality on adolescents’ sexual behavior, on experiences and on communication. Results The analysis shows that sexually active adolescents who consider gender equality as important report higher current use of contraceptives within the couple. They are more likely to describe their last sexual intercourse as a positive experience and consider it easier to talk with their partner about sexuality than sexually experienced adolescents who are less positively inclined toward gender equality. These correlations remained consistent whether the respondent was a boy or a girl. Non-sexually active adolescents, who consider gender equality to be important, are more likely to think that sexual intercourse is a positive experience. They consider it less necessary to have sexual intercourse to maintain a relationship and find it easier to communicate with their girlfriend or boyfriend than sexually non-active adolescents who consider gender equality to be less important. Comparable results were found for boys and girls. Conclusions Our results suggest that gender equality attitudes have a positive impact on adolescents’ sexual and reproductive health (SRH) and wellbeing. Further research is necessary to better understand the relationship between gender attitudes and specific SRH outcomes such as unwanted teenage pregnancies and sexual pleasure among adolescents worldwide., Background Empowerment is essential for gender equity and health. The city of Malmö, Sweden, has formulated a development plan for gender equity integration (GEIDP). A ‘Policy Empowerment Index’ (PEI) was previously developed to assess the empowerment potential of policies. Objectives To pilot-evaluate the GEIDP’s potential for empowerment and to test the PEI for future policy evaluations. Design The GEIDP was analyzed and scored according to electronically retrieved evidence on constituent opinion, participation, capacity development, evaluation–adaptation, and impact. Results The plan’s PEI score was 64% (CI: 48–78) and was classified as ‘enabling’, ranging between ‘enabling’ and ‘supportive’. The plan’s strengths were: 1) constituent knowledge and concern; 2) peripheral implementation; 3) protection of vulnerable groups; and 4) evaluation/adaptation procedures. It scored average on: 1) policy agenda setting; 2) planning; 3) provisions for education; 4) network formation; 5) resource mobilization. The weakest point was regarding promotion of employment and entrepreneurship. Conclusions The PEI evaluation highlighted the plan’s potential of constituency empowerment and proposed how it could be augmented., Background Gender inequalities are important social determinants of health. We set out to critically review the literature relating to gender equity and sexual and reproductive health (SRH) in Eastern and Southern Africa with the aim of identifying priorities for action. Design During November 2011, we identified studies relating to SRH and gender equity through a comprehensive literature search. Results We found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Social and biological determinants combined to increase women's vulnerability to maternal mortality, HIV, and gender-based violence. Health systems significantly disadvantaged women in terms of access to care. Men fared worse in relation to HIV testing and care with social norms leading to men presenting later for treatment. Conclusions Gender inequity in SRH requires multiple complementary approaches to address the structural drivers of unequal health outcomes. These could include interventions that alter the structural environment in which ill-health is created. Interventions are required both within and beyond the health system., Background From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months – about 500 days – is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron–folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay., Background A substantial proportion of newly diagnosed HIV infections in sub-Saharan Africa occur within serodiscordant cohabiting heterosexual couples. Intimate partner violence is a major concern for couple-oriented HIV preventive approaches. This study aimed at estimating the prevalence and associated factors of intimate partner physical and sexual violence among HIV-infected and -uninfected women in Togo. We also described the severity and consequences of this violence as well as care-seeking behaviors of women exposed to intimate partner violence. Methods A cross-sectional survey was conducted between May and July 2011 within Sylvanus Olympio University Hospital in Lomé. HIV-infected women attending HIV care and uninfected women attending postnatal care and/or children immunization visits were interviewed. Intimate partner physical and sexual violence and controlling behaviors were assessed using an adapted version of the WHO Multi-country study on Women’s Health and Life Events questionnaire. Results Overall, 150 HIV-uninfected and 304 HIV-infected women accepted to be interviewed. The prevalence rates of lifetime physical and sexual violence among HIV-infected women were significantly higher than among uninfected women (63.1 vs. 39.3%, p, Background Men are overrepresented with regard to alcohol addiction and in terms of alcohol treatment worldwide. In Thailand, alcohol consumption continues to rise, but few of those afflicted with alcohol addiction attend alcohol treatment programs, even though there is universal care for all. No comprehensive studies have been done on men’s experiences with addiction and alcohol treatment programs in Thailand. Objective The aim of this study was to explore men’s experiences in terms of the ‘pros and cons of alcohol consumption’ in order to identify the barriers that exist for Thai men with regard to alcohol addiction and the decision to stop drinking. Design Purposive sampling was applied in the process of recruiting participants at an alcohol clinic in a hospital in Thailand. Thirteen men with alcohol addiction (aged 32–49 years) were willing to participate and were interviewed in thematic interviews. The analysis of the data was done with descriptive phenomenology. Results Through men’s descriptions, three clusters of experiences were found that were ‘mending the body’, ‘drinking as payoff and doping related to work’, and ‘alcohol becoming a best friend’ as ways of describing the development of addiction. Conclusions The results highlight the importance of addressing concepts of masculinity and related hegemonic ideas in order to decrease the influence of the barriers that exist for Thai men with alcohol addiction with regard to entering treatment and to stop drinking., Two in every three deaths among women are caused by non-communicable diseases (NCDs) – largely heart disease, stroke, cancer, diabetes and chronic respiratory diseases. The global discourse on health, however, largely views women in terms of their reproductive capacity, a persisting myth reflecting gender bias that shifts the focus away from NCDs, violence, and other injuries. Risk factors for NCDs are similar for men and women. Because fewer women actively smoke than men, and drink in less harmful ways, in most parts of the world, the impact of major NCD risk factors is far less in women than in men. In the area of diagnosis and treatment, gender bias can result in women being asked fewer questions, and receiving fewer examinations and fewer diagnostic tests for coronary heart disease and other NCDs compared with men with similar symptoms. In response to a UN meeting in September 2011, member states of WHO have agreed to a global goal to reduce avoidable NCD mortality by 25% by 2025 (‘25 by 25’). A set of voluntary targets and indictors have been agreed upon, although none of them are gender specific. Most require changes at the policy level that will ensure that women – and children – will also benefit. As the 2015 deadline for the Millennium Development Goals approaches, women and NCDs should be central to the sustainable human development agenda., Background Feminization of the HIV/AIDS epidemic has been a prominent phenomenon in sub-Saharan Africa. Inconsistent condom use among young people is one of the major risk factors in the continued propagation of the epidemic. Therefore, it is of importance to increase knowledge of gender aspects of condom use among young people. Objective To investigate whether gender differences regarding individual and social factors determine the association between condom efficacy and inconsistent condom use with a new sex partner, among Ugandan university students. Design In 2010, 1954 Ugandan students participated in a cross-sectional survey, conducted at Mbarara University of Science and Technology in southwestern Uganda. A self-administered questionnaire assessed socio-demographic factors, alcohol consumption, sexual behaviors (including condom use and condom efficacy), and peer norms. The data were stratified by sex and examined by multivariate logistic regression analysis. Results A total of 1,179 (60.3%) students reported having had their sexual debut. Of these, 231 (37.4%) males and 209 (49.2%) females reported inconsistent condom use with a new sex partner. Students with low condom efficacy had a higher risk of inconsistent condom use with a new sex partner, even after adjusting for the potential confounders. A synergistic effect was observed between being a female and low condom efficacy with inconsistent condom use. Conclusion The association between inconsistent condom use and low condom efficacy was found among both males and females, but females were found to be at a higher risk of inconsistent condom use compared to their male counterparts. Therefore, gender power relations should be addressed in policies and interventions aiming at increasing condom use among young people in sub-Saharan settings. Programs could be designed with intervention strategies that focus on interactive and participatory educational activities and youth-friendly counseling of young people, which in turn may improve their interpersonal communication and condom negotiation skills with their partners., Background Urban informal settlements remain sites of high HIV incidence and prevalence, as well as violence. Increasing attention is paid on how configurations of young men's masculinities shape these practices through exploring how men build respect and identity. In this paper, we explore how young Black South Africans in two urban informal settlements construct respect and a masculine identity. Methods Data are drawn from three focus groups and 19 in-depth interviews. Results We suggest that while young men aspire to a ‘traditional’ masculinity, prioritising economic power and control over the household, we suggest that a youth masculinity emerges which, in lieu of alternative ways to display power, prioritises violence and control over men's sexual partners, men seeking multiple sexual partners and men's violence to other men. This functions as a way of demonstrating masculinity and their position within a public gender order. Discussion We suggest there are three implications of the findings for working with men on violence and HIV-risk reduction. First, there exist a number of contradictions in men's discourses about masculinity that may provide spaces and opportunities for change. Second, it is important to work on multiple issues at once given the way violence, alcohol use, and sexual risk are interlinked in youth masculinity. Finally, engaging with men's exclusion from the capitalist system may provide an important way to reduce violence., Background Women experience poorer health than men despite their longer life expectancy, due to a higher prevalence of non-fatal chronic illnesses. This paper aims to explore whether the unequal gender distribution of roles and resources can account for inequalities in general self-rated health (SRH) by gender, across social classes, in a Southern European population. Methods Cross-sectional study of residents in Catalonia aged 25–64, using data from the 2006 population living conditions survey (n=5,817). Poisson regression models were used to calculate the fair/poor SRH prevalence ratio (PR) by gender and to estimate the contribution of variables assessing several dimensions of living conditions as the reduction in the PR after their inclusion in the model. Analyses were stratified by social class (non-manual and manual). Results SRH was poorer for women among both non-manual (PR 1.39, 95% CI 1.09–1.76) and manual social classes (PR 1.36, 95% CI 1.20–1.56). Adjustment for individual income alone eliminated the association between sex and SRH, especially among manual classes (PR 1.01, 95% CI 0.85–1.19; among non-manual 1.19, 0.92–1.54). The association was also reduced when adjusting by employment conditions among manual classes, and household material and economic situation, time in household chores and residential environment among non-manual classes. Discussion Gender inequalities in individual income appear to contribute largely to women's poorer health. Individual income may indicate the availability of economic resources, but also the history of access to the labour market and potentially the degree of independence and power within the household. Policies to facilitate women's labour market participation, to close the gender pay gap, or to raise non-contributory pensions may be helpful to improve women's health., Background Women subjected to intimate partner violence (IPV) experience different forms of abuse. Sexual violence is often under-reported because physically abused women, in particular, might see forced sex as an obligatory part of the sexual interplay. Accordingly, abused women have less sexual autonomy and experience unplanned pregnancies more often than other women. Objective To describe and analyse nine Swedish women's retrospective stories about IPV with a focus on power and coping strategies as intimate partners, particularly regarding experiences of sex, contraception, and becoming pregnant. Design Nine qualitative interviews were carried out with women who had been subjected to very severe violence in their intimate relationships and during at least one pregnancy. The stories were analysed using ‘Narrative method’ with the emphasis on the women's lived experiences. Results Despite the violence and many contradictory and ambivalent feelings, two of the women described having sex as desirable, reciprocal and as a respite from the rest of the relationship. The other seven women gave a negative and totally different picture, and they viewed sex either as obligatory or as a necessity to prevent or soothe aggression or referred to it as rape and as something that was physically forced upon them. The women's descriptions of their pregnancies ranged from being carefully planned and mostly wanted to completely unwelcome and including flawed contraceptive efforts with subsequent abortions. Conclusions Women subjected to IPV have diverse and complex experiences that have effects on all parts of the relationship. Intimacy might for some turn into force and rape, but for others sex does not necessarily exclude pleasure and desire and can be a haven of rest from an otherwise violent relationship. Accordingly, women may tell stories that differ from the ones expected as ‘the typical abuse story’, and this complexity needs to be recognized and dealt with when women seek healthcare, especially concerning contraceptives, abortions, and pregnancies., Background There is insufficient information regarding access and participation of immigrant women in Spain in sexual and reproductive health programs. Recent studies show their lower participation rate in gynecological cancer screening programs; however, little is known about the participation in other sexual and reproductive health programs by immigrant women living in rural areas with high population dispersion. Objectives The objective of this study is to explore the perceptions of midwives who provide these services regarding immigrant women's access and participation in sexual and reproductive health programs offered in a rural area. Design A qualitative study was performed, within a larger ethnographic study about rural primary care, with data collection based on in-depth interviews and field notes. Participants were the midwives in primary care serving 13 rural basic health zones (BHZ) of Segovia, a region of Spain with high population dispersion. An interview script was designed to collect information about midwives’ perceptions on immigrant women's access to and use of the healthcare services that they provide. Interviews were recorded and transcribed with participant informed consent. Data were analyzed based on the qualitative content analysis approach and triangulation of results with fieldwork notes. Results Midwives perceive that immigrants in general, and immigrant women in particular, underuse family planning services. This underutilization is associated with cultural differences and gender inequality. They also believe that the number of voluntary pregnancy interruptions among immigrant women is elevated and identify childbearing and childrearing-related tasks and the language barrier as obstacles to immigrant women accessing the available prenatal and postnatal healthcare services. Conclusions Immigrant women's underutilization of midwifery services may be linked to the greater number of unintended pregnancies, pregnancy terminations, and the delay in the first prenatal visit, as discerned by midwives. Future research should involve samples of immigrant women themselves, to provide a deeper understanding of the current knowledge, attitudes, and practices of the immigrant population regarding reproductive and sexual health to provide better health services., Background The literature shows how gender mandates contribute to differences in exposure and vulnerability to certain health risk factors. This paper presents the results of a study developed in the south of Spain, where research aimed at understanding men from a gender perspective is still limited. Objective The aim of this paper is to explore the lay perceptions and meanings ascribed to the idea of masculinity, identifying ways in which gender displays are related to health. Design The study is based on a mixed-methods data collection strategy typical of qualitative research. We performed a qualitative content analysis focused on manifest and latent content. Results Our analysis showed that the relationship between masculinity and health was mainly defined with regard to behavioural explanations with an evident performative meaning. With regard to issues such as driving, the use of recreational drugs, aggressive behaviour, sexuality, and body image, important connections were established between manhood acts and health outcomes. Different ways of understanding and performing the male identity also emerged from the results. The findings revealed the implications of these aspects in the processes of change in the identity codes of men and women. Conclusions The study provides insights into how the category ‘man’ is highly dependent on collective practices and performative acts. Consideration of how males perform manhood acts might be required in guidance on the development of programmes and policies aimed at addressing gender inequalities in health in a particular local context., Background Experiencing domestic violence is considered a chronic and stressful life event. A theoretical framework of coping strategies can be used to understand how women deal with domestic violence. Traditional values strongly influenced by religious teachings that interpret men as the leaders of women play an important role in the lives of Javanese women, where women are obliged to obey their husbands. Little is known about how sociocultural and psychosocial contexts influence the ways in which women cope with domestic violence. Objective Our study aimed to deepen our understanding of how rural Javanese women cope with domestic violence. Our objective was to explore how the sociocultural context influences coping dynamics of women survivors of domestic violence in rural Purworejo. Design A phenomenological approach was used to transform lived experiences into textual expressions of the coping dynamics of women survivors of domestic violence. Results Experiencing chronic violence ruined the women's personal lives because of the associated physical, mental, psychosocial, and financial impairments. These chronic stressors led women to access external and internal resources to form coping strategies. Both external and internal factors prompted conflicting impulses to seek support, that is, to escape versus remain in the relationship. This strong tension led to a coping strategy that implied a long-term process of moving between actively opposing the violence and surrendering or tolerating the situation, resembling an elastic band that stretches in and out. Conclusions Women survivors in Purworejo face a lack of institutional support and tend to have traditional beliefs that hamper their potential to stop the abuse. Although the women in this study were educated and economically independent, they still had difficulty mobilizing internal and external support to end the abuse, partly due to internalized gender norms., Background Traditional forms of masculinity strongly influence men's and women's wellbeing. Objective This study has two aims: (i) to explore notions of various forms of masculinities in young Nicaraguan men participating in programs addressing sexual health, reproductive health, and/or gender equality and (ii) to find out how these young men perceive their involvement in actions aimed at reducing violence against women (VAW). Design A qualitative grounded theory study. Data were collected through six focus groups and two in-depth interviews with altogether 62 young men. Results Our analysis showed that the informants experienced a process of change, labeled ‘Expanding your mind’, in which we identified four interrelated subcategories: The apprentice, The responsible/respectful man, The proactive peer educator, and ‘The feminist man’. The process showed how an increased awareness of gender inequities facilitated the emergence of values (respect and responsibility) and behavior (thoughtful action) that contributed to increase the informant's critical thinking and agency at individual, social, and political levels. The process was influenced by individual and external factors. Conclusions Multiple progressive masculinities can emerge from programs challenging patriarchy in this Latin American setting. The masculinities identified in this study show a range of attitudes and behaviors; however, all lean toward more equitable gender relations. The results suggest that learning about sexual and reproductive health does not directly imply developing more gender-equitable attitudes and behaviors or a greater willingness to prevent VAW. It is paramount that interventions to challenge machismo in this setting continue and are expanded to reach more young men., Background This study aims to explore young men’s understanding of intimate partner violence (IPV) in Ecuador, examining similarities and differences between how ordinary and activist young men conceptualize IPV against women. Methods We conducted individual interviews and focus group discussions (FGDs) with 35 young men – five FGDs and five interviews with ordinary young men, and 11 interviews with activists – and analysed the data generated using qualitative content analysis. Results Among the ordinary young men the theme ‘too much gender equality leads to IPV’ emerged, while among the activists the theme ‘gender inequality is the root of IPV’. Although both groups in our study rejected IPV, their positions differed, and we claim that this is relevant. While activists considered IPV as rooted in gender inequality, ordinary young men understood it as a response to the conflicts generated by increasing gender equality and women’s attempts to gain autonomy.