Gender Norms, Masculine Gender-Role Strain, and HIV Risk Behaviors Among Men in Rural South Africa

Introduction: Studies suggest strong links between inequitable gender norms and men’s HIV risk behaviors in South Africa, where one-fifth of adults are HIV-positive. Masculine gender-role strain (MGRS), the psychological strain men experience from trying to live up to expectations of themselves as men, had not previously been measured or applied in HIV prevention research in the African setting. The aims of this mixed-methods study among men in Mpumalanga province were to evaluate measures of gender norms and MGRS, examine relationships between these constructs and key HIV risk behaviors, and qualitatively explore men’s experience of MGRS. Methods: Quantitative data came from community surveys with 581 men ages 18 to 35. We conducted factor analyses to assess the factor structure, validity, and reliability of the Gender Equitable Men’s scale (GEMS) and Gender Role Conflict/Stress (GRC/S) scale. We then used logistic regression to examine the impact of inequitable gender norms and MGRS on three HIV risk behaviors. Finally, we conducted qualitative interviews with 18 men and analyzed data using both narrative and coding procedures. Results: The unidimensional GEMS and multidimensional GRC/S scale were valid and reliable. Prevalence of sexual partner concurrency in the previous last 12 months was 38.0%, 13.4% of men reported perpetrating intimate partner violence (IPV) in that period, and 19.9% abused alcohol. In multivariate analyses, more inequitable gender norms and higher MGRS were each significantly associated with an increased odds of concurrency, IPV perpetration, and alcohol abuse. Qualitative findings supported the salience of MGRS in men’s lives. Men experienced all three theoretical sub-types of MGRS. Most common was discrepancy strain from unemployment; twothirds of men were unmarried and unable to establish their own households and become providers. Some men also experienced trauma strain from intense peer pressure to sexually exploit women. Finally, participants described dysfunction strain from restricting emotions and abusing alcohol, which contributed to family violence. Conclusion: Social constructions of masculinity shape HIV risk in Mpumalanga. We underscore recent calls to scale up gender transformative programs and recommend exploring complementary strategies to reduce the three sub-types of MGRS grounded in a local understanding of male vulnerabilities.Doctor of Philosoph