Erin Stern

The relational dynamics of hegemonic masculinity among South African men and women in the context of HIV.

In South Africa, the frequent positioning of mens sexual behaviours as a prime driver of the HIV epidemic has generated much interest in mens sexuality. However, the relational nature of dominant male norms that exacerbate the risk of HIV transmission is inadequately understood. This study used sexual biographies to explore how men and women negotiate gendered norms and how this affects their sexual and reproductive health (SRH). A total of 50 sexual-history interviews and 10 focus group discussions were conducted with men, and 25 sexual-history interviews with women, with participants sampled from three age categories (ages 18–24, 25–55 and 55+years), a range of cultural and racial backgrounds and urban and rural sites across five provinces in South Africa. The narratives illustrate that men and womens SRH is largely dependent on the type and quality of their relationships. Mens sexuality was regularly depicted as being detached from intimacy and uncontrollable, which was premised as being opposite from and/or superior to womens sexuality and could justify mens high-risk sexual behaviours. Yet many participants also supported gender equitable relationships and endorsed accountable and healthy SRH behaviours. The narratives reveal that HIV-risky dominant male norms should be addressed relationally for the sake of better SRH outcomes.

Health care provider perspectives on pregnancy and parenting in HIV-positive individuals in South Africa

BackgroundWithin the health system, limited attention is given to supporting the fertility and parenting desires on HIV-positive people. In this study, we explore health care providers’ knowledge and perspectives on safer conception and alternate parenting strategies for HIV-positive people.MethodsBetween November 2007 and January 2008, in-depth interviews were conducted with 28 health care workers involved in providing HIV and/or antiretroviral services at public sector clinics in Cape Town, South Africa. Views on sexual and reproductive health services, pregnancy, childbearing and parenting in HIV-positive men and women were explored using a semi-structured interview guide. Data were analyzed using a thematic approach.ResultsProviders recognized the sexual and reproductive rights of HIV-positive individuals, but struggled with the tension between supporting these rights and concerns about spreading infection. Limited knowledge of safer conception methods constrained their ability to counsel and support clients in realizing fertility desires. Providers believed that parenting alternatives that do not maintain biological and cultural linkage are unlikely to be acceptable options.ConclusionsHealth care provider training and support is critical to providing comprehensive sexual and reproductive health care and meeting the fertility desires of HIV-positive people.

A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries

BackgroundLow-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs.MethodsWe searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review.ResultsBoth quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment.ConclusionIn LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers’ access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.

Sexual and reproductive health perceptions and practices as revealed in the sexual history narratives of South African men living in a time of HIV/AIDS

Abstract The frequent positioning of mens sexual risk-taking as driving the HIV/AIDS epidemic in South Africa has triggered interest in mens sexual and reproductive health (SRH) perceptions, attitudes, and practices. Much research, however, presents men as a homogenous group, and focuses on the quantifiable aspects of male sexual behaviors, providing an inadequate basis for understanding mens SRH needs and addressing the gendered aspects of HIV prevention. This study used sexual history narratives to yield more nuanced and contextualized understandings of male sexuality as it relates to SRH. Fifty sexual life history individual interviews and 10 focus-group discussions (FGDs) with men, as well as 25 sexual life history interviews with women, were conducted with participants purposively sampled from three age categories: (18–24, 25–55, and 55+ years), a wide range of cultural and racial backgrounds, and in urban and rural sites across 5 provinces in South Africa. Interviews and FGDs elicited stories of participants early knowledge of sex and sexual experimentation and then explored sexual relationships and experiences in adulthood—including engagement with HIV risks and SRH management. The data were analyzed using a thematic approach. Many male participants conformed to dominant norms of masculinity associated with a high risk of sexually transmitted infections including HIV, such as having regular unprotected sex, reluctance to test for HIV, and poor SRH-seeking behaviors. Yet, the narrative accounts reveal instances of men taking steps to protect their own SRH and that of their partners, and the complex ways in which hegemonic gender norms influence men and womens SRH. Ultimately, the study points to the value of sexual biographies for gaining a deeper understanding of male sexuality, and the social structures, meanings, and experiences that underlie it. Such insights are critical to more effectively engaging men in HIV prevention efforts.

South African women's conceptualisations of and responses to sexual coercion in relation to hegemonic masculinities.

Despite the documented relationship between hegemonic norms of masculinities and South African men’s use of sexual violence, less is known about how women’s engagement with norms of masculinity influences their agency in sexually coercive experiences. This study applied a narrative approach to assess how women’s understandings of hegemonic male norms affected their perceptions of and responses to sexually coercive experiences. Twenty-five sexual history narrative interviews were conducted with women across five South African provinces representing a range of ages, language and sociocultural backgrounds. Interviews elicited stories of first experiences of sex and the range of sexual relationships through adulthood. Data were analysed using principles of thematic and narrative analysis. Coercive sexual experiences informed many women’s normative ideas about men’s sexuality including being impulsive, controlling and aggressive. This could underpin women’s limited ability to exercise agency and their increased vulnerability to sexual abuse. Some women reported levels of trust and respect in subsequent relationships, which typically involved deconstructing norms of men’s use of coercion and moving beyond self-blame and guilt. The findings highlight the need to appreciate the fluid and situated nature of women’s agency from a relational perspective in terms of how women condone and challenge gender norms that support men’s use of sexual violence in their relationships.

The Use of Sexual History Narratives to Assess Processes of Hegemonic Masculinity among South African Men in the Context of HIV/AIDS

Connell’s concept of hegemonic masculinities has been invaluable for prevention efforts that seek to promote a shift in hegemonic male norms driving the HIV epidemic. However, inadequate attention has been given to the internal processes of hegemony, which limits the comprehension of how to engage men in HIV prevention efforts. A narrative approach, which privileges the diversity in men’s lived experiences, could address such concerns. Fifty sexual history interviews were conducted with men sampled from three age categories: (eighteen to twenty-four, twenty-five to fifty-four and fifty-five plus), a range of cultural and racial backgrounds, and in urban and rural sites across five provinces in South Africa. For the purpose of this article, narrative analysis was conducted on three cases that provide a platform for understanding how men both conform to and resist gender norms that influence their sexual and reproductive health. Implications of the narratives for gender transformative HIV prevention efforts are discussed.

Experiences and conceptualizations of sexual debut from the narratives of South African men and women in the context of HIV/AIDS

Given the pivotal role of first sex in the development of sexual and reproductive health (SRH) practices, there is a need for more contextualised and nuanced understandings of young peoples early sexual debut experiences. This study used sexual history narratives to investigate how South African men and women experience and attribute meaning to their sexual debut, and their SRH practices. In light of the gendered disparities among young peoples SRH awareness and risk, differences between men and womens narratives of sexual debut were assessed. Fifty sexual history interviews were conducted with men and 25 sexual history interviews with women, with participants purposively sampled from three age categories, a range of cultural and racial backgrounds and urban and rural sites across five provinces. Narrative interviews were designed to elicit stories around participants’ early knowledge of sex and sexual experimentation, their range of sexual relationships and SRH practices. The data were analysed using a thematic approach. Participants generally reflected on their early sexual experiences with feelings of inadequacy and disappointment. While men appeared to hold greater decision-making power than women at sexual debut, descriptions of mens early sexual experiences were often characterised by respect, intimacy and vulnerability. Many men attributed the timing of their sexual debut to peer pressure, which typically generated higher social status and rarely included consideration of the need to practice safer sex. Several women felt pressured by their partner to sexually debut, which could have informed their perceptions of men being sexually controlling and aggressive. The study demonstrates the value of a narrative approach for generating insights on young peoples sexual debut experiences and SRH practices, and the underlying gendered norms and expectations that shape these. The findings indicate the need for gender transformative HIV interventions to take into the diversity of young peoples SRH needs and social realities.

Gender differences in South African men and women's access to and evaluation of informal sources of sexual and reproductive health (SRH) information

While much research has documented unsatisfactory sexual and reproductive health (SRH) awareness among young people in South Africa, understanding of gender differences in access to and evaluation of SRH information is limited. This paper concerned itself with men and womens informal sources and content of SRH, and gendered divergences around accessibility, evaluation, and impact of such information. Fifty sexual history narrative interviews and twenty-five narrative interviews with women were conducted with participants purposively sampled from a range of ages, cultural and racial backgrounds, and in urban and rural sites across five provinces in South Africa. Data were analysed using thematic analysis. While young women were more likely to learn about SRH information from family members, they also reported greater regulation concerning their sexuality. This could enhance stigma surrounding womens sexuality and hinder open communication. Men predominantly learned about sex through pornography and peers, which was reported to encourage sexual prowess to the neglect of practising safer sex. Lack of adequate SRH instruction for young people as revealed through the narratives had significant and often negative implications for men and womens early safer sex behaviours. In response to these insights, recommendations are offered to strengthen informal sources of SRH awareness.

Conceptions of Agency and Constraint for HIV-Positive Patients and Healthcare Workers to Support Long-Term Engagement With Antiretroviral Therapy Care in Khayelitsha, South Africa

In the context of the optimism around antiretroviral therapy (ART) as prevention of HIV/AIDS, addressing the barriers to long-term ART adherence is critical. This is particularly important given the tendency to individualise or use a blame discourse when exploring why HIV-infected patients “fail” to adequately adhere to ART, and not sufficiently exploring contextual reasons for poor adherence that may require varying solutions. This study took place at three clinics and one hospital in Khayelitsha, South Africa, to document the contextual factors that challenged ART adherence in this community. Interviews were conducted with 20 HIV-infected patients who had defaulted on their ART and were subsequently admitted to Khayelitsha hospital for clinical complications, and 9 ART service providers including doctors, nurses and HIV counsellors. Interviews assessed the reasons patients defaulted on ART and explored ways this could be prevented. Data from both groups were analysed collectively using thematic analysis. While the interviews revealed a landscape of environmental risks threatening adherence to ART, all patients managed to overcome the identified barriers at some point in their treatment phase, indicating the fluidity of patients’ needs and decision making. Patients reported that distrustful relationships with service providers could inhibit their understanding of ART and/or interrupt their follow-up at clinics. Patients described their rationale and agency underlying non-adherence, such as testing their bodies’ physical limits without ART medication. The study speaks to the need to appreciate contextual social and structural barriers related to ART adherence, and how these are negotiated differently by specific sub-groups, to support an appropriate response. It is imperative to not solely emphasise loss to follow-up but also assess patients’ subjective trajectory of their ART journey, decision making and agency with adhering to ART, their relations with healthcare workers, and how these dynamics are intertwined with broader constraints in health systems.

The Relationship Between Hegemonic Norms of Masculinity and Men’s Conceptualization of Sexually Coercive Acts by Women in South Africa

While sexual abuse against women and girls in South Africa has generated much deserved attention, the awareness of men’s experiences of sexual coercion is limited, and often restricted to a homosexual context. This article illuminates men’s experiences of pressurized sex in a heterosexual context, which were revealed in a broader men’s sexual health study. Fifty sexual history narrative interviews were conducted with men purposively sampled from three age categories: (18-24, 25-54, and 55+), a wide range of cultural and racial backgrounds, and in urban and rural sites across five provinces in South Africa. Narrative interviews began with accounts of early knowledge of sex and sexual experimentation and explored the range of sexual relationships and experiences through adulthood. The narratives privileged the diversity of men’s conceptualizations of and the impact of reportedly sexually coercive experiences by women. Many men described feeling unready for their first sexual experiences but pressured to do so by their peers and female partners, who were often older. There were also some instances of sexual coercion by women against men, some of which would constitute a criminal offense in South Africa. Due to the pressure for men to always be responsive to women’s sexual desires, these experiences were often not framed as sexual coercion. Nevertheless, for many of these men, such experiences were uncomfortable and unrewarding. Men’s negative responses to such experiences appeared to be linked to the fact that they did not fit social stereotypes of masculine sexuality as being initiative and dominant. Such coercive experiences could influence men’s sexual risk-taking, including their use of sexual coercion against women. Research on sexual abuse should not be limited to male against male sexual abuse, but needs to explore the meanings and experiences associated with reported coercion against men by women to more comprehensively prevent and respond to sexual violence.