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While ample evidence from high-income country settings indicates the prevalence and risk factors for multiple mental ill-health symptoms in student populations, evidence from low- and middle-income higher education settings remains limited. We determined the frequency, associations, and structural pathways between mental health outcomes and possible risk factors among a sample of 1292 predominantly Black African and female students ages 18–30 years, enrolled at nine purposefully selected public universities and Technical Vocational Education and Training (TVET) campuses. We measured and created a mental ill-health latent outcome consisting of depressive symptoms, post-traumatic stress disorder (PTSD), and suicidal thoughts. We also measured traumatic exposures including childhood trauma, recent intimate partner violence (IPV), non-partner rape, and other life traumatic events. We used structural equation modelling to analyse data. We found that 50% of the surveyed students binge drank, 43% reported depressive symptoms, 9% reported PTSD symptoms, and 21% had suicidal thoughts. Students’ experiences of childhood trauma, food insecurity, other traumatic events, non-partner rape, and IPV impacted the mental ill-health latent. IPV experiences mediated the relationships between experiences of childhood trauma or other trauma and the mental ill-health latent, and the relationship between binge drinking and other life traumatic events. Non-partner rape mediated the relationship between food insecurity and the mental ill-health latent. Binge drinking directly impacted non-partner rape experience. The findings substantiate the need for campus-based mental health promotion, psychosocial services and treatments, and implementation of combined interventions that address the intersections of violence against women and mental health among students in South Africa.

Purpose Young people, not in formal employment or education, face exceedingly high levels of intimate partner violence (IPV). We evaluated whether Stepping Stones and Creating Futures, compared with a wait-list control, can reduce IPV and strengthen livelihoods. Methods A cluster randomized controlled trial with 34 clusters in urban informal settlements in eThekwini Municipality, South Africa. Participant inclusion criteria were aged 18–30 years, resident in the informal settlement, and not working or in education. A total of 676 women and 646 men were recruited from September 2015 to September 2016. At recruitment, participants were not blinded to study arm. Endline data were collected from March to October 2018 (24 months postenrollment). Analyses were by intention-to-treat and separate for men and women. No clusters withdrew; endline retention was 74.9% (n = 505) men and 80.6% (n = 545) women. Results At endline in the intervention arm, men's self-reported past year IPV perpetration was lower (physical IPV [adjusted odds ratio [aOR]: .71, 95% confidence interval [CI]: .51–.97], severe IPV [aOR: .70, 95% CI: .52–.94], and sexual IPV [aOR: .74, 95% CI: .54–1.03]). There was no difference in men's controlling behaviors (β = .06, 95% CI: −.51 to .63) or past month earnings (β = .21, 95% CI: −.42 to .83). For women, earnings were significantly higher in the intervention arm (β = .97, 95% CI: .43–1.51), but there were no differences for past year IPV experience (physical IPV [aOR: .92, 95% CI: .62–1.37]; sexual IPV [aOR: .90, 95% CI: .64–1.28], severe IPV [aOR: .93, 95% CI: .66–1.31]) or controlling behaviors (β = −.01, 95% CI: −.88 to .86). Conclusion Stepping Stones and Creating Futures is effective in reducing men's self-reported perpetration of IPV and strengthening women's livelihoods, but not women's experiences of IPV. Trial registration NCT03022370 . Registered January 13, 2017.

In this paper we examine men’s insights on how migration and minework affect their perceptions and performances of masculinity in the settings of minework and in their “real home” communities and explore the potential consequences of masculinity constructions for their own and their family’s health. This study used qualitative methodology. Findings are based on 13 in-depth interviews conducted over two phases of data collection with adult men who were either working or seeking work in the mines in North-West province, South Africa. Data suggest that for these men, migration to and working in the mines meant they must straddle the temporal space of work and the rural home space. For these men, the role of provider was an inescapable demand and, resulting from migration for work, their experience of fatherhood was solely centred on material provision with little or no emotional involvement with their children. Findings further illustrate the impact of minework on men’s health and livelihoods-resulting in some men reimagining and seeking to create alternative career paths for their children. There is pressing need for labour reforms on the employment conditions of low-paid mine workers to enable them to reinforce their livelihoods and secure better futures for their families. Gender-transformative interventions which aim to transform ideas of masculinity that emphasize providing rather than emotional involvement with children are also needed.

Background In order to reduce women’s exposure to violence and develop culturally appropriate interventions, it is important to gain an understanding of how men who use violence rationalize it. The present study sought to explore the perspectives of men who had used violence on their female partners, specifically their views on intimate partner violence (IPV), gender norms, manhood, their gender attitudes and to understand how these may drive male perpetrated IPV against women in the Central Region of Ghana. Methods This was a qualitative study involving purposively sampled adult men who had participated in a household-based survey in selected districts in the Central Region of Ghana and who had self-reported perpetration of IPV in the past 12 months. In-depth interviews were conducted with 17 men. Results Data revealed how a range of social, cultural, and religious factors ̶ stemming from patriarchy ̶ combined to inform the construction of a traditional masculinity. These factors included the notion that decision-making in the home is a man’s prerogative, there should be rigid and distinct gender roles, men’s perceptions of owning female partners and having the right to have sex with them whenever they desire, and the notion that wife beating is legitimate discipline. Findings suggest that it was through performing, or aspiring to achieve, this form of masculinity that men used varying forms of violence against their female partners. Moreover, data show that the men’s use of violence was a tactic for controlling women and emphasizing their authority and power over them. Conclusions Developers of interventions to prevent IPV need to recognize that there is a coherent configuration of aspirations, social norms and behaviours that is drawn on by some men to justify their use of IPV. Understanding the perspectives of men who have perpetrated IPV against women and their motivations for perpetration is essential for interventions to prevent IPV. This is discussed as drawing authority from ‘tradition’ and so engaging traditional and religious leaders, as well as men and women throughout the community, in activities to challenge this is likely to be particularly fruitful.

Background: Intimate partner violence (IPV) affects one in three women globally and undermines women’s human rights, social and economic development, and health, hence the need for integrated interventions involving communities in its prevention. Objective: This community-randomised controlled trial evaluated the Rural Response System (RRS) intervention, which uses Community Based Action Teams to prevent IPV by raising awareness and supporting survivors, compared to no intervention. Methods: Two districts of the Central Region of Ghana were randomly allocated to each arm. Data were collected by repeated, randomly sampled, household surveys, conducted at baseline (2000 women, 2126 men) and 24 months later (2198 women, 2328 men). The analysis used a difference in difference (DID) approach, adjusted for age and exposure to violence in childhood. Results: In intervention communities, women’s past year experience of sexual IPV reduced from 17.1% to 7.7% versus 9.3% to 8.0% in the control communities (DID = −9.3(95%CI; −17.5,−1.0), p = 0.030). The prevalence of past-year physical IPV among women in the intervention communities reduced from 16.5% to 8.3% versus 14.6% to 10.9% in the controls (DID = −4.2(−12,3.6), p = 0.289). The prevalence of severe IPV experienced by women reduced from 21.2% to 11.6% in intervention versus 17.3% to 11.4% in controls (DID = −3.7(−12.5,5.1), p = 0.408). The direction of impact of the intervention on violence perpetrated by men was more towards a reduction but changes were not statistically significant. Emotional IPV perpetration was significantly lower (DID = −15.0(−28.5, −1.7), p = 0.031). Women’s depression scores and reports of male partner controlling behaviour significantly also reduced in the intervention arm compared to those in the control arm (DID = −4.8(−8.0,−1.5), p = 0.005; DID = −2.7(−3.3,−1.0), p = 0.002, respectively). Conclusion: Our findings indicate that the RRS intervention reduced women’s experiences of IPV, depression, and partner controlling behaviour and some evidence of men’s reported reductions in the perpetration of IPV. The RRS intervention warrants careful scale-up in Ghana and further research.

Background Qualitative study of motivations to participate in research into violence and other sensitive issues can help interpretation of findings from community based quantitative surveys. It is equally important to conduct research that may enable a deeper understanding on what motivates people to participate in GBV studies. To date, not much research has been conducted to investigate the factors that influence non-enrolment and enrolment in GBV studies from the viewpoint of the real participants. The present study sought to explore people’s reasons for participating in a non-intervention GBV community-based survey in Gauteng province, South Africa. Methods Twenty-two qualitative in-depth interviews were conducted with adult black African men and women who had participated in a gender-based violence survey conducted in a low-income setting in South Africa. Results Some participants reported motives for survey participation which could be interpreted as altruistic. Their motives included a desire to contribute to advancement of knowledge and to share life experiences so that unknown others could learn from these experiences. Yet, some participants hoped their participation will result in personal benefit or that they may be helped with their socio-economic challenges. The analysis further revealed a complex relationship between altruism and self-interest motives for participating in the survey amongst some of the participants. Conclusion We conclude that it is difficult to discern which motive was primary or preceded the other. This is because such motives are not fixed, probably multiple and owing to their fluidity, may shift in people’s minds at different times and depending on the nature of the conversation. Moreover, there may be a shift in the weight given to different motives over time.

Understanding factors shaping attendance at behavioural interventions is critical for programmatic planning. Through the Stepping Stones and Creating Futures intervention trial amongst young (18-30) women and men to reduce intimate partner violence and strengthen livelihoods, we prospectively assessed factors associated with intervention attendance. Baseline data were collected between September 2015 and September 2016 among 677 women and 675 men. For women, in multinomial models, compared to high attenders, medium (

Background: Medical male circumcision (MMC) and traditional male circumcision (TMC) are reportedly having negative and positive outcomes in the Eastern Cape province. Researchers show contradictory remedies; some advocate for abolishment of TMC and others call for the integration of both methods. Aim: This study aimed to explore factors influencing the integration of TMC and MMC at different socio-ecological levels. Setting: The study was conducted at Ingquza Hill Local Municipality in the Eastern Cape province. Methods: An explorative qualitative study design, using in-depth interviews (IDIs) and focus group discussions (FGDs), was employed in this study. Purposive sampling was used to select the participants. A framework analysis approach was used to analyse the data, and the themes were developed in line with the socio-ecological model. Results: Four main themes emerged from the data as important in influencing the integration of TMC and MMC methods. These included: (1) individual factors, related to circumcision age eligibility and post-circumcision behaviour; (2) microsystem factors, related to alcohol and drug abuse, peer pressure, abuse of initiates, and family influence; (3) exosystem factors, related to financial gains associated with circumcision and the role of community forums; and (4) macrosystem factors, related to stigma and discrimination, and male youth dominance in circumcision practices. Conclusion: Male circumcision in this area is influenced by complex factors at multiple social levels. Interventions directed at all of these levels are urgently needed to facilitate integration of the TMC and MMC methods.

Participatory interventions with men and boys to transform masculinities are increasingly common to improve health and reduce intimate partner violence and HIV-related risk. Yet, despite this, there has been little consideration of how facilitators' own masculinities shape interventions. In this analysis of Stepping Stones and Creating Futures, a gender-transformative programme delivered to young men (aged 18-30 years) in urban informal settlements in Durban, South Africa we explore how facilitators' masculinities were employed to engender change in the masculinities of participants. We argue facilitators had to negotiate two tasks existing in some tension, the first, overt and the main aim of the programme: namely, challenging elements of the youthful masculinity at play in the lives of participants, such as exerting violent power over women. A second task was more covert: namely, establishing facilitators' credibility 'as men' in order to do this work with participants. Through strategies including clothes, mobile phones, jokes and storytelling, facilitators demonstrated to participants their 'successful' masculinity and could then engage with participants around emotions, non-violence and consistent condom use. This enabled facilitators and participants to undergo a limited processes of change, without 'compromising' their sense of masculinity, and without fundamentally challenging men's patriarchal privilege.

Supplemental Digital Content is Available in the Text., Background: Qualitative research emphasizes men's experiences of trauma increase HIV risk. We seek to understand associations between experience of traumatic events and HIV-risk behaviors among heterosexual men in 2 trials in urban informal settlements in South Africa. Methods: Cross-sectional surveys among men in Johannesburg and Durban, South Africa, enrolled in intervention trials. Adjusted logistic regression and structural equation modeling assessed associations between men's experiences of poverty and traumatic events, and HIV-risk behaviors (inconsistent condom use, transactional sex, and number of sex partners). We explored mediated pathways from trauma to HIV risk through mental health and alcohol, and gender attitudes. Results: Among 2394 men, in adjusted logistic regression, transactional sex and 4 or more sex partners were associated with witnessing the murder of a family member, witnessing a murder of a stranger, experiencing excessive pain, been kidnapped, and witnessing a rape. More consistent condom use was associated with witnessing the murder of a family member, being kidnapped, and witnessing a rape. In 3 separate structural equation modeling pathways were consistent, trauma directly increased transactional sex, and past year sexual partners, and increased consistent condom use. Risk was increased through mental health pathways, and gender inequitable attitudes and practices. Conclusion: Men's HIV-risk behaviors in this population emerge at the confluence of poverty, traumatic experiences, and gender inequalities. Effective HIV-prevention interventions needs to reduce men's experiences of poverty and trauma, transform gender norms, and reduce the mental health impact of trauma.

Although South Africa has the largest number of people on antiretroviral therapy (ART) in the world, many HIV clients drop out of care immediately after HIV diagnosis. This qualitative study explored the perceptions and experiences of newly diagnosed clients on the role support groups play in linking and retaining newly diagnosed clients in HIV care in Mbandazayo peri-urban location. The data were analysed using the thematic content analysis approach. Data revealed four mechanisms through which support groups appeared to link and retain newly diagnosed clients in the HIV care continuum. First, support groups were a formal link between newly diagnosed clients and health facilities. Second, support groups mitigated the effects of both felt and enacted stigma, thereby facilitating acceptance of HIV diagnosis among newly diagnosed clients. Third, support groups were an advocacy and networking tool for newly diagnosed clients to make their health related needs, challenges, and concerns known to local health clinics, thereby forging and maintaining a close relationship with their local health facilities. Last, support groups were spaces within the community where practical needs of newly diagnosed clients are met, which in turn help in retaining them within support groups, and facilitate their linkage and retention in the HIV continuum of care in Mbandazayo. Our findings suggest that HIV support groups are critical in enhancing linkages and retention of newly diagnosed clients in HIV care. With the introduction of universal test and treat (UTT) in South Africa, our findings suggest that support groups can play a significant role in retaining HIV care clients who are diagnosed and immediately enrolled on ART.Keywords: antiretroviral therapy, health system, linkage and retention, stigma, universal test and treat

Qualitative research suggests that men's inability to achieve dominant forms of masculinity may be related to HIV-risk behaviours and intimate partner violence (IPV) perpetration. Using clustered cross-sectional data, we assessed how young men's gender role conflict was associated with HIV-risk behaviours in urban informal settlements in KwaZulu-Natal, South Africa. Gender Role Conflict and Stress (GRC/S) was measured using a South African adaptation of the GRC/S scale comprising three sub-scales: subordination to women; restrictive emotionality; and success, power and competition. In random-effect models adjusting for socio-demographics, we tested the relationship with GRC/S sub-scales and sexual health behaviours (transactional sex, use of sex workers, ≥2 main partners and ≥2 casual/once off partners), and relationship practices (relationship satisfaction, relationship control, partnership type and perpetration of IPV). Overall, 449 young men (median age = 25, Q1, Q3 = 23-28) were included in the analysis. Higher GRC/S scores, denoting more GRC/S, were associated with increased relationship control and increased odds of having ≥2 casual or one-off partners and engaging in transactional sex. We found differences in associations between each sub-scale and sexual health and relationship practices, highlighting important implications for informing both theoretical understandings of masculinity and gender transformative efforts.

In this paper, we explore gender norms held by men and women that might contribute to male perpetration of intimate partner violence (IPV) in Ghana. This qualitative research was conducted at the pre-intervention stage of a cluster randomized controlled trial. Our intervention uses community-based action teams to change social norms on gender and violence. Focus group discussions and in-depth interviews were conducted within communities. We found that male perpetrated IPV is a common phenomenon within the study communities, yet it is complex and experienced differently depending on the context. A woman's non-compliance with gender norms provided context for the male partner to enforce societal conformity through IPV. Also, male partners' misbehavior (e.g. alcohol abuse) may exacerbate IPV. Whereas the former is socially acceptable, the latter may be contested. Victims may challenge/counteract IPV using varying tactics (e.g. threats), which were mainly directed toward male partners' immoral behavior. We conclude that there is a need to assess IPV with key considerations for female agency, as some victims may respond with violence. Moreover, some communities have the tendency to demonstrate more gender-equitable attitudes regarding male perpetration of IPV, as indicated by laws instituted by some traditional leaders to deter perpetrators. These are key learnings that can inform the design and delivery of various interventions that seek to address IPV.

Intimate partner violence (IPV) is a significant global public health problem. Understanding risk factors is crucial for developing prevention programmes. Yet, little evidence exists on population-based prevalence and risk factors for IPV in West Africa. Our objective was to measure both lifetime and past year prevalence of IPV and to determine factors associated with past year physical or sexual IPV experience. This population-based survey involved 2000 randomly selected women aged 18 to 49 years living in 40 localities within four districts of the Central Region of Ghana. Questionnaires were interviewer-administered from February to May 2016. Respondents were currently or ever-partnered, and resident in study area ≥12months preceding the survey. Data collected included: socio-demographics; sexual behavior; mental health and substance use; employment status; 12-month and lifetime experience of violence; household food insecurity; gender norms/attitudes; partner characteristics and childhood trauma. Logistic regression modelling was used to determine factors associated with sexual or physical IPV, adjusting for age and survey design. About 34% of respondents had experienced IPV in the past year, with 21.4% reporting sexual and or physical forms. Past year experience of emotional and economic IPV were 24.6% and 7.4% respectively. Senior high school education or higher was protective of IPV (AOR = 0.51[0.30–0.86]). Depression (AOR = 1.06[1.04–1.08], disability (AOR = 2.30[1.57–3.35]), witnessing abuse of mother (AOR = 2.1.98[1.44–2.72]), experience of childhood sexual abuse (AOR = 1.46[1.07–1.99]), having had multiple sexual partners in past year (AOR = 2.60[1.49–4.53]), control by male partner (AOR = 1.03[1.00–1.06]), male partner alcohol use in past year (AOR = 2.65[2.12–3.31]) and male partner infidelity (AOR = 2.31[1.72–3.09]) were significantly associated with increased odds of past year physical or sexual IPV experience. Male perpetrated IPV remains a significant public health issue in Ghana. Evidence-based interventions targeting women’s mental health, disabilities, exposure to violence in childhood, risky sexual behavior and unequal power in relationships will be critical in reducing IPV in this setting.

The concept of hegemonic masculinity has been used in gender studies since the early-1980s to explain men's power over women. Stressing the legitimating power of consent (rather than crude physical or political power to ensure submission), it has been used to explain men's health behaviours and the use of violence. Gender activists and others seeking to change men's relations with women have mobilised the concept of hegemonic masculinity in interventions, but the links between gender theory and activism have often not been explored. The translation of 'hegemonic masculinity' into interventions is little examined. We show how, in South Africa and Sweden, the concept has been used to inform theoretically-based gender interventions and to ensure that men are brought into broader social efforts to build gender equity. We discuss the practical translational challenges of using gender theory broadly, and hegemonic masculinity in particular, in a Swedish case study, of the intervention Machofabriken [The Macho Factory], and illustrate how the concept is brought to life in this activist work with men. The concept has considerable practical application in developing a sustainable praxis of theoretically grounded interventions that are more likely to have enduring effect, but evaluating broader societal change in hegemonic masculinity remains an enduring challenge.

Background Evidence-based interventions are essential in the prevention of violence against women (VAW). An understanding of risk factors for male perpetration of VAW using population-based research is crucial for developing such interventions. This study is a baseline assessment of a two-arm unmatched cluster randomised controlled trial (C-RCT), set up to assess the impact of a Rural Response System (RRS) intervention for preventing violence against women and girls in Ghana. This study aims at assessing past-year prevalence and risk factors for sexual or physical intimate partner violence (IPV) perpetration among men. Methods The population-based survey involved 2126 men aged 18 and above living in selected communities in 4 districts in the central region of Ghana. Logistic regression techniques were used to determine risk factors for sexual or physical IPV perpetration. All models adjusted for age of respondents and took into account the study design. Results Half of the men had perpetrated at least one form of violence against their intimate partners in their lifetime while 41% had perpetrated sexual or physical IPV. Majority (93%) of the men had been in relationships in the 12 months preceding the survey, and of these, 23% had perpetrated sexual or physical IPV. Childhood factors associated with sexual or physical IPV included witnessing abuse of mother (aOR:1.40(1.06±1.86)), and neglect (aOR:1.81(1.30±2.50)). Other major risk factors for IPV perpetration were: having multiple partners (aOR:1.76(1.36±2.26)), (involvement in transactional sex (aOR:1.76(1.36±2.26)), substance use (aOR:1.74(1.25±2.43)) and gender inequitable attitudes (aOR:0.94(0.91±0.97)). Conclusion Childhood violence experience and witnessing, risky behaviour (multiple partners, transactional sex, substance use), and gender inequitable attitudes are major risk factors for sexual or physical IPV perpetration. Perpetration of sexual or physical IPV tends to co-occur with non-partner violence and emotional IPV perpetration. Interventions targeting these factors are critical in reducing IPV.

Background Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions. Methods Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18–30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included. Discussion This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions. Trial registration NCT03022370. Registered 13 January 2017, retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4223-x) contains supplementary material, which is available to authorized users.

Strong research evidence has shown that medical male circumcision significantly reduces heterosexual HIV acquisition among men. However, its effectiveness is enhanced by behavioural factors such as condom use. Currently, little is known of unprotected sex associated with male circumcision (MC) among alcohol-drinking tavern-going men, or whether engagement in unprotected sex may differ between men who have been traditionally circumcised and those who have been medically circumcised. The study sought to determine the relative importance of alcohol consumption and MC as correlates of unprotected sex and to compare the risk of engaging in unprotected sex between traditionally circumcised and medically circumcised tavern-going men from two rural villages in North-West province, South Africa. Data from 314 adult men (≥18 years) were analysed. The men were recruited from four bars/taverns using systematic sampling. They responded to questions regarding their demographic characteristics, alcohol consumption, circumcision status and method (where applicable), and engagement in unprotected sex. Descriptive analyses and bivariate and multivariate logistic regression analyses were conducted. Age, education, relationship status, alcohol consumption and traditional male circumcision (TMC) were independently and significantly associated with unprotected sex. Specifically, probable alcohol dependence and traditional circumcision were independent risk factors for engaging in unprotected sex among tavern-going men. Traditionally circumcised men had a higher risk of engaging in unprotected sex than medically circumcised men. Interventions aimed at reducing alcohol consumption, encouraging protective behaviour among men who have undergone TMC, and increasing condom use are needed in bar/tavern settings. HIV prevention education must be urgently incorporated into TMC programmes.

Evidence shows the importance of working with men to reduce intimate partner violence and HIV-risk. Two claims dominate this work. The first is that interventions 'reconstruct' masculinities--these new formations of masculinity exist in opposition to existing ones and are healthier for men and less harmful for women. The second is that to be successful, such interventions need to address men's exclusion from the economy. Using a qualitative longitudinal cohort study of young men who participated in a gender transformative and livelihood strengthening intervention, as well as dyadic interviews with men's main female partners, we explore these claims. Data suggests men saw some improvements in livelihoods and relationships. However, challenging social contexts, including high rates of unemployment, peer networks and a dominant youth masculinity, limited change. Rather than reconstructing masculinity, a more subtle shift was seen with men moving away from 'harmful' aspects of a dominant youth masculinity towards a form of masculinity whereby male power is buttressed by economic provision and attempting to form and support 'households'. Working with men on their livelihoods at an instrumental level encouraged participation in the intervention. Beyond encouragement, men's improving livelihoods afforded men the opportunity to materially demonstrate the social changes - in the form of shifts in masculinity--they were seeking to enact.

Summary Background Although childhood trauma and violence against women are global public health issues, few population-based data from low-income and middle-income countries exist about the links between them. We present data from the UN Multi-country Study on Men and Violence in Asia and the Pacific, exploring the pathways between different forms of childhood trauma and violence against women. Methods In this multicountry study, we interviewed multistage representative samples of men and women, aged 18–49 years, in Asia and the Pacific, using standardised population-based household surveys. Men were interviewed in six countries, and women in four. Respondents were asked questions about their perpetration or experience of intimate partner violence or non-partner sexual violence, childhood trauma, and harsh parenting (smacking their children as a form of discipline). We used maximum likelihood multivariate logit models to explore associations between childhood trauma and violence against women, and fitted path models to explore associations between experience and perpetration of child maltreatment. Findings Between Jan 1, 2011, and Dec 1, 2012, 10 178 men and 3106 women completed interviews in this study, with between 815 and 1812 men per site and 477 and 1103 women per site. The proportion of men who experienced any childhood trauma varied between 59% (n=478, 95% CI 54·0–63·3; Indonesia rural site) and 92% (n=791, 89·4–93·8; Bougainville, Papua New Guinea). For women, the results ranged from 44% (n=272, 37·7–50·8; Sri Lanka) to 84% (n=725, 80·7–86·8; Bougainville, Papua New Guinea). For men, all forms of childhood trauma were associated with all forms of intimate partner violence perpetration. For women, all forms of childhood trauma were associated with physical intimate partner violence, and both physical and sexual intimate partner violence. There were significant, often gendered, pathways between men's and women's perpetration and experiences of childhood trauma, physical intimate partner violence, harsh parenting, and other factors. Interpretation The data point to both a co-occurrence and a cycle of abuse, with childhood trauma leading to violence against women and further child maltreatment, which in turn increases the risk of experience or perpetration of violence during adulthood. Efforts to prevent both forms of violence would benefit from a meaningful integrated approach. Interventions should promote positive parenting, address inequality and the normalisation of violence across the life course, and transform men's power over women and children. Funding Partners for Prevention. National studies were funded by the UN Population Fund in Bangladesh and China, UN Women in Cambodia and Indonesia, UN Develoment Programme in Papua New Guinea, and CARE in Sri Lanka.

Empirical research on ethical issues in HIV-prevention and gender-based violence research, critical for honing ethical and safety guidelines, is limited. In this paper we describe South African young people's motivations for participating in randomised controlled trial, the prevalence of negative occurrences, participation regrets and associated factors. This trial partly followed, but also deviated from, the WHO safety guidelines for research on violence against women. A total of 1085 women and 985 men provided information two years after the trial start. Most participated for HIV testing and to help their community. Fewer reported motivation by the financial incentive. Minor adverse events included upset from questions on childhood experiences and arguments at home with siblings. Just under 1 in 10 (8.1% women, 9.8% men) regretted participation. Factors were associated with this were keeping some questions secret from their partners, feeling sad about questions on childhood, quarrelling at home and, for women, being motivated by the incentive. Men who had been physically violent to a partner were twice as likely to regret participation. There were no recorded adverse effects from the deviations from the ethical guidelines. Participation regrets mostly stemmed from problems in participants' families preceding the research. There was no evidence that the research had been unsafe.

Background Studies of rape of women seldom distinguish between men’s participation in acts of single and multiple perpetrator rape. Multiple perpetrator rape (MPR) occurs globally with serious consequences for women. In South Africa it is a cultural practice with defined circumstances in which it commonly occurs. Prevention requires an understanding of whether it is a context specific intensification of single perpetrator rape, or a distinctly different practice of different men. This paper aims to address this question. Methods We conducted a cross-sectional household study with a multi-stage, randomly selected sample of 1686 men aged 18–49 who completed a questionnaire administered using an Audio-enhanced Personal Digital Assistant. We attempted to fit an ordered logistic regression model for factors associated with rape perpetration. Results 27.6 % of men had raped and 8.8 % had perpetrated multiple perpetrator rape (MPR). Thus 31.9 % of men who had ever raped had done so with other perpetrators. An ordered regression model was fitted, showing that the same associated factors, albeit at higher prevalence, are associated with SPR and MPR. Conclusions Multiple perpetrator rape appears as an intensified form of single perpetrator rape, rather than a different form of rape. Prevention approaches need to be mainstreamed among young men.

Sexual violence is a well-recognised global health problem, but there has been remarkably little research on men as perpetrators. The objectives of this paper are to describe the prevalence, patterns and factors associated with rape of an intimate partner and a woman who was not a partner with men aged 15-26 years in rural South Africa. The analysis presented here is of data collected during a baseline survey of participants in a cluster randomised controlled trial of an HIV behavioural intervention. A total of 1370 male volunteers were recruited from 70 rural South African villages. They completed a questionnaire asking about background, sexual practices and perpetration of rape and intimate partner violence. Among these men 16.3% had raped a non-partner, or participated in a form of gang rape; 8.4% had been sexually violent towards an intimate partner; and 79.1% had done neither. The mean age of first rape was 17 years. There was overlap between rape of a non-partner and partner, in that 44.3% of men who raped an intimate partner had also raped a non-partner, but overall the great majority of men who raped did not disclose both types of rape. The factors associated with rape of an intimate partner and non-partner had similarities and differences. After adjusting for the other variables, both forms of rape were strongly associated with ever having been physically violent to a partner, having had transactional sex with a casual partner and more sexual partners. Non-partner rape was also associated with peer-related variables, including gang membership and peer pressure to have sex, and also drug use. Non-partner rape was more common among wealthier and relatively more socially advantaged men. Both types of rape were associated with having more adverse childhood experiences. There was considerable overlap between rape-associated factors and known HIV risk factors, suggesting a need for further research on the interface of rape and HIV, and integrated prevention programming.

Intimate partner violence is a worldwide problem. South Africa has one of the highest rates of intimate partner violence and therefore requires effective and sustainable approaches to prevention and response. For abused women, the process of leaving an intimate partner is difficult and mired in an abundance of complex factors that influence decision making. This qualitative study explored women's experiences of leaving abusive homes and relationships and the critical factors that pushed them to leave. In-depth interviews were conducted with 11 adult women who had experienced partner abuse and were residents of a shelter in Gauteng Province, South Africa. All interviews were audio-taped with consent, translated where necessary and transcribed verbatim. Thematic analysis of interviews was carried out. Two themes emerged as being instrumental to leaving: 'a phase of change' and the 'process of leaving the abusive relationship'. Leaving an abusive relationship was found to be a complex process that did not necessarily imply the end of the relationship and it reflected women's changing attitudes over time. Awareness of shelters and social support was found to be critical in facilitating departure from abusive relationships.

Background Violence against women is often exacerbated by war, but most civilian research has investigated short term impact. We describe the conflict experiences of men and women from the general population of Bougainville Papua New Guinea, perceptions of the enduring impact of conflict, and the associations between these and the major health and development problems on the islands: mental ill-health and violence against women. Methods Fourteen years after the end of the decade long civil war, we conducted a household survey with a random sample of adult (n = 864) men and (n = 879) women living in Bougainville. The interviews were mostly conducted face-to-face, with very sensitive questions self-completed. Results Mental ill-health was highly prevalent, 37.8% of women and 32% of men had high levels of depressive symptomatology, 34.4% of men abused alcohol and 15.1% of women and 24.6% of men had high levels of PTSD symptoms. Among women, 23.3% had been raped in the year prior to the interview and 33.3% had experience physical or sexual partner violence. The prevalence of exposure to trauma during the civil war was very high and many of the men and women experienced lingering impact of conflict. Multiple logistic regression models showed that war trauma was associated with PTSD symptoms in women and PTSD symptoms, alcohol abuse and depressive symptoms in men. The perceived enduring impact of conflict was associated with depressive symptoms in men and women, problem drinking and suicidal thoughts in women and drug use in men. The perceived enduring conflict impact was associated with perpetration of past year rape and physical and/or sexual partner violence. Discussion The Bougainville civil war had a devastating impact on the population’s lives. Reversing this legacy is essential but requires addressing what is perceived as the enduring social, economic and psychological impact of the conflict and a major focus on prevention of violence against women.

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. Keywords : masculinity; HIV; violence; gender; multiple sexual partners; livelihoods; IPV; unemployment (Published: 8 April 2014) Citation : Glob Health Action 2014, 7 : 23676 - http://dx.doi.org/10.3402/gha.v7.23676 Cluster : This paper is part of the Cluster Gender and health . More papers from this cluster can be found here and here .

BACKGROUND: In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male-male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. METHODS AND FINDINGS: In a cross-sectional study conducted in 2008, men aged 18-49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male-male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26-12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22-7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24-7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17-10.9). CONCLUSIONS: In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male-female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male-male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Please see later in the article for the Editors' Summary. Language: en

Background: South African policy makers are reviewing legislation of prostitution, concerned that criminalisation hampers HIV prevention. They seek to understand the relationship between transactional sex, prostitution, and the nature of the involved men. Methods: 1645 randomly-selected adult South African men participated in a household study, disclosing whether they had sex with a woman in prostitution or had had a provider relationship (or sex), participation in crime and violence and completing psychological measures. These became outcomes in multivariable regression models, where the former were exposure variables. Results: 51% of men had had a provider relationship and expected sex in return, 3% had had sex with a woman in prostitution, 15% men had done both of these and 31% neither. Provider role men, and those who had just had sex with a woman in prostitution, were socially conservative and quite violent. Yet the men who had done both (75% of those having sex with a woman in prostitution) were significantly more misogynist, highly scoring on dimensions of psychopathy, more sexually and physically violent to women, and extensively engaged in crime. They had often bullied at school, suggesting that this instrumental, self-seeking masculinity was manifest in childhood. The men who had not engaged in sex for economic exchange expressed a much less violent, more law abiding and gender equitable masculinity; challenging assumptions about the inevitability of intersections of age, poverty, crime and misogyny. Conclusions: Provider role relationships (or sex) are normative for low income men, but not having sex with a woman in prostitution. Men who do the latter operate extensively outside the law and their violence poses a substantial threat to women. Those drafting legislation and policy on the sex industry in South Africa need to distinguish between these two groups to avoid criminalising the normal, and consider measures to protect women.

Background Sex motivated by economic exchange is a public health concern as a driver of the Sub-Saharan African HIV epidemic. We describe patterns of engagement in transactional sexual relationships and sex with women in prostitution of South African men, and suggest interpretations that advance our understanding of the phenomenon. Methods Cross-sectional study with a randomly-selected sample of 1645 sexually active men aged 18–49 years who completed interviews in a household study and were asked whether they had had sex with a woman in prostitution, or had had a relationship or sex they took to be motivated by the expectation of material gain (transactional sex). Results 18% of men had ever had sex with a woman in prostitution, 66% at least one type of transactional sexual relationship, only 30% of men had done neither. Most men had had a transactional relationship/sex with a main partner (58% of all men), 42% with a concurrent partner (or makhwapheni) and 44% with a once off partner, and there was almost no difference in reports of what was provided to women of different partner types. The majority of men distinguished the two types of sexual relationships and even among men who had once-off transactional sex and gave cash (n = 314), few (34%) reported that they had had sex with a ‘prostitute’. Transactional sex was more common among men aged 25–34 years, less educated men and low income earners rather than those with none or higher income. Having had sex with a woman in prostitution varied little between social and demographic categories, but was less common among the unwaged or very low earners. Conclusions The notion of ‘transactional sex’ developed through research with women does not translate easily to men. Many perceive expectations that they fulfil a provider role, with quid pro quo entitlement to sex. Men distinguished these circumstances of sex from having sex with a woman in prostitution. Whilst there may be similarities, when viewed relationally, these are quite distinct practices. Conflating them is sociologically inappropriate. Efforts to work with men to reduce transactional sex should focus on addressing sexual entitlement and promoting gender inequity.

Objective To explore how survey respondents perceived their experiences and the impact of participating in a survey, and to assess adverse consequences resulting from participation. Design Qualitative study involving purposefully selected participants who had participated in a household-based survey. Methods This qualitative study was nested within a survey that investigated the prevalence of gender-based violence perpetration and victimization with adult men and women in South Africa. 13 male- and 10 female-in-depth interviews were conducted with survey respondents. Results A majority of informants, without gender-differences, perceived the survey interview as a rare opportunity to share their adverse and or personal experiences in a 'safe' space. Gender-differences were noted in reporting perceptions of risks involved with survey participation. Some women remained fearful after completing the survey, that should breach of confidentiality or full survey content disclosure occur, they may be victimized by partners as a punishment for survey participation without men's approval. A number of informants generally discussed their survey participation with others. However, among women with interpersonal violence history or currently in abusive relationships, full survey content disclosure was done with fear; the partner responses were negative, and few women reported receiving threatening remarks but none reported being assaulted. In contrast no man reported adverse reaction by others. Informants with major life adversities reported that the survey had made them to relive the experiences causing them sadness and pain at the time. No informant perceived the survey as emotionally harmful or needed professional support because of survey questions. Rather the vast majority perceived benefit from survey participation. Conclusion Whilst no informant felt answering the survey questions had caused them emotional or physical harm, some were distressed and anxious, albeit temporarily. Research protocols need to put in place safeguards where appropriate so that this group receives support and protection.

Objective To investigate the associations between intimate partner violence, rape and HIV among South African men. Design Cross-sectional study involving a randomly-selected sample of men. Methods We tested hypotheses that perpetration of physical intimate partner violence and rape were associated with prevalent HIV infections in a cross-sectional household study of 1229 South African men aged 18–49. Violence perpetration was elicited in response to a questionnaire administered using an Audio-enhanced Personal Digital Assistant and blood samples were tested for HIV. A multivariable logistic regression model was built to identify factors associated with HIV. Results 18.3% of men had HIV. 29.6% (358/1211) of men disclosed rape perpetration, 5.2% (63/1208) rape in the past year and 30.7% (362/1180) of had been physically violent towards an intimate partner more than once. Overall rape perpetration was not associated with HIV. The model of factors associated with having HIV showed men under 25 years who had been physically violent towards partners were more likely to have HIV than men under 25 who had not (aOR 2.08 95% CI 1.07–4.06, p = 0.03). We failed to detect any association in older men. Conclusions Perpetration of physical IPV is associated with HIV sero-prevalence in young men, after adjusting for other risk factors. This contributes to our understanding of why women who experience violence have a higher HIV prevalence. Rape perpetration was not associated, but the HIV prevalence among men who had raped was very high. HIV prevention in young men must seek to change ideals of masculinity in which male partner violence is rooted.

Men's experience of sexual coercion is seldom the subject of research, yet it is commonly reported in all settings and increasingly evidence from South Africa points to the health risks associated with sexual coercion of men by men. Thirty-one in-depth interviews were conducted with heterosexual men aged 18-25 years who were volunteers in an HIV prevention behavioural intervention evaluation in the Eastern Cape. Men chosen included some who had reported coercion by men and women in their baseline structure interviews and some who had not. Sexual coercion by men involved abuse of trust and age-related power, temptation through material goods, as well as use of aggression. The narratives were notable for the anger that was caused by these assaults. In contrast, coercion by women was framed as 'temptation'. In some cases young men were tempted by much older women and those in a position of trust and the experience did not make them feel good. There are very substantial differences in the circumstances of coercion of young men by men and women. This needs to be taken into account in the growing trend to research coercion of men and present findings in a way that equates these two experiences.

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. Keywords : Men; HIV; masculinities; coping and adjustment; South Africa (Published: 1 October 2014) Citation : Glob Health Action 2014, 7 : 24631 - http://dx.doi.org/10.3402/gha.v7.24631