Experiences and perceived effects of participating in the Sisters For Life gender and HIV training intervention in Mahikeng municipality, North West province, South Africa

Muvhango, Lufuno
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Women in South Africa continue to be disproportionately infected by HIV. Biomedical interventions have demonstrated limited efficacy in preventing HIV among women. Intimate Partner Violence (IPV) is a major risk factor for HIV infection among women as it limits their ability to negotiate safer sex. Prevailing social norms continue to undermine behavioural interventions for the prevention of IPV and HIV when implemented alone. Evidence suggests the importance of addressing the underlying gender and economic inequalities as having the potential to effectively prevent HIV infection. However, there is a limited number of such interventions tested in South Africa. The study aims to explore the effects of gender norms and HIV training component of the IMAGE programme by exploring participants' experiences and perceived effects among women who participated in the SFL intervention. Method This is a qualitative inquiry undertaken in rural Mahikeng, South Africa. A total of seventeen in-depth interviews were conducted with a purposefully selected sample of 17 women aged between 18–50 years who participate in the SFL component of the IMAGE project between February – December 2016. Data was audio-recorded, transcribed and analysed thematically using word processing software. Ethics clearance was granted from the Human Research Ethics Committee, University of Witwatersrand: Clearance certificate number: M 161191.Findings Women described SFL as a valuable training that provides information that is relevant to their lived experiences. They appreciated its participatory activities and facilitators' skills. However, they expressed discomfort over discussing sensitive topics like domestic violence, sexuality and that training facilitation by male facilitators and short duration of the session and lack of referral system undermined SFL platform as a safe space for women to freely discuss such issues. SFL contributes to retention and adoption of HIV and IPV prevention messages and practices. Women were able to negotiate safer sex and use a condom, test for HIV also with their partners, disclose HIV status and access treatment. Unlike unmarried women, married women were less likely to report the use of condom; however, some of them were able to test for HIV together with their partners and this facilitated disclosure. Women became more aware of forms of IPV and some were able to act against IPV with varied level of success. Women experienced violence at the hands of their partners. Younger women (<35 years) were least successful in resolving IPV while older married women or cohabiting women who reportedly successfully addressed IPV with their partners. Problem-solving skills acquired form SFL as well as advice and support exchanged from loan groups were essential to address IPV.Women found gendered cultural messages and traditional practices to be the underlying cause of IPV experience among women. In addition to alcohol abuse, women attributed social norms and practices such as lobola, bride grooming and accompanying messages in wedding songs and idioms that condone male multiple partnerships and further groom women to tolerate violence as key factors that subjected women to IPV. Women condemned such messages and found them to be unfair and oppressive to women and that they were the main causes of violence within relationships. They further realized that women’s use of such messages and engaging in multiple sexual relationships increased the risks of violence from partners and they encouraged fellow women to refrain from such practices. Participation in the matched economic empowerment programme enabled women to meet needs, and was instrumental to improve financial decision making, shift roles to providers and leaders in the community. However, earning income had limited effect on women’s reported sexual decision making and women faced resistance by male partners and resulted in women being complicit with traditional gender roles. Women reported improved knowledge about sexuality and that it contributed to the adoption of healthy sexual practices. SFL provided accurate information about menstruation and sexuality and enabled women to adopt healthy sexual behaviours like refraining from dry sex and screening for cervical cancer. However, some of the SFL messages did not lead to a shift in attitudes towards gender norms nor changes in practices. Some women retained attitudes that blame sexual violence on women, and for engaging in transactional sex. They perceive that women should not participate in decision-making, that women should remain responsible for household chores. Conclusions and recommendations The study highlights SFL as an valuable, informative and transformative training that is responsive to women’s practical life situations However, it is important to ensure that participants are comfortable to discuss sensitive topics freely by ensuring training is delivered by female facilitators. In line with ethical standards, SFL should ensure accessible and well-coordinated referral system as part of the SFL programme to ensure that participants are provided with safe spaces and further support to address recall of painful events related to some of the topics discussed, HIV, disclosure and other challenges that they may be facing in their lives. The findings confirm that inequitable gender norms embedded in the social and cultural practices influence women’s exposure to HIV infection and IPV. The study contributes to the literature that explicates the limited efficacy of biomedical and behavioural interventions in preventing HIV and highlight that interventions to prevent IPV and HIV infection need to prioritize addressing social and gender norms. The study suggests that combining gender and HIV training to economic empowerment is essential for HIV prevention as both gender and economic inequalities contribute to and perpetuate violence against women. The study further suggests that older women are potential social norms change and HIV prevention brokers within their communities. Women’s reflections on how they contribute to enforcing inequitable gender norms as socializing agents for boys and young women (brides) and their ability to challenge and refrain from enforcing inequitable norms, suggest that women are placed at a unique and strategic position to lead social norm change. Limited shift in attitudes and practices are an indication of the difficulties involved in changing gender norms and highlight the need to strengthen SFL to improve women’s agency to challenge and act against gender norms. It further calls for structural interventions to consider involving men or partners to create an enabling environment to women address other areas of their lives that are undermined by male partners including gender roles and sexual decision-making
A research report submitted in partial fulfilment of the requirement for the degree of Master of Public Health, School of Public Health in the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2020