Adolescent Girls and Their Family Members' Attitudes Around Gendered Power Inequity and Associations with Future Aspirations in Karnataka, India.

Intergenerational differences in inequitable gender attitudes may influence developmental outcomes, including education. In rural Karnataka, India, we examined the extent of intergenerational (adolescent girls [AGs] vs. older generation family members) dis/agreement to attitudes around gendered power inequities, including gender roles and violence against women (VAW). Unadjusted and adjusted logistic regression examined associations between intergenerational dis/agreement to attitude statements and AGs' future educational and career aspirations. Of 2,457 AGs, 90.9% had a matched family member (55% mothers). While traditional gender roles were promoted intergenerationally, more AGs supported VAW than family members. In adjusted models, discordant promotion of traditional gender roles and concordant disapproval of VAW were associated with greater aspirations. Results highlight the need for family-level programming promoting positive modeling of gender-equitable attitudes.

Community health workers augment the cascade of TB detection to care in urban slums of two metro cities in India.

BACKGROUND: Tuberculosis Health Action Learning Initiative (THALI) funded by USAID is a person-centered initiative, supporting vulnerable urban populations to gain access to TB services. THALI trained and placed 112 Community health workers (CHWs) to detect and support individuals with TB symptoms or disease within urban slums in two cities, Hyderabad and Bengaluru, covering a population of about 3 million. METHODS: CHWs visited the slums once in a fortnight. They conducted TB awareness activities. They referred individuals with TB symptoms for sputum testing to nearest public sector laboratories. They visited those testing TB positive, once a fortnight in the intensive phase, and once a month thereafter. They supported TB patients and families with counselling, contact screening and social scheme linkages. They complemented the shortfall in urban TB government field staff numbers and their capacity to engage with TB patients. Data on CHWs' patient referral for TB diagnosis and treatment support activities was entered into a database and analyzed to examine CHWs' role in the cascade of TB care. We compared achievements of six monthly referral cohorts from September 2016 to February 2019. RESULTS: Overall, 31 617 (approximately 1%) of slum population were identified as TB symptomatic and referred for diagnosis. Among the referred persons, 23 976 (76%) underwent testing of which 3841 (16%) were TB positive. Overall, 3812 (99%) were initiated on treatment and 2760 (72%) agreed for regular follow up by the CHWs. Fifty-seven percent of 2952 referred were tested in the first cohort, against 86% of 8315 in the last cohort. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100 000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100 000 persons. The treatment success rate was 87.1% among 193 in the first cohort vs 91.3% among 677 in the last cohort. CONCLUSIONS: CHWs in urban slums augment TB detection to care cascade. Their performance and TB treatment outcomes improve over time. It would be important to examine the cost per TB case detected and successfully treated.

'I have the confidence to ask': thickening agency among adolescent girls in Karnataka, South India.

Gender norms serve to normalise gender inequalities and constrain girls' agency. This paper examines how girls' agency, along a continuum, is influenced by the interplay between constraining and enabling influences in the girls' environments. We analyse data from a qualitative study nested within a cluster randomised evaluation of Samata, a multi-layered programme supporting adolescent girls to stay in school and delay marriage in Karnataka, South India. Specifically, we compare agency among 22 girls from intervention communities and 9 girls in control communities using data from the final round of interviews in a qualitative cohort. Using the concept of 'thin' and 'thick' agency on a continuum, we identified shocks like mothers' death or illness, poverty stress, gender norms and poor school performance as thinning influences. Good school examination results; norms in support of education; established educational aspirations; supportive parents, siblings and teachers; and strategic government and Samata resources enabled thicker agency. The intervention programme's effect increased in parallel to the gradient from thin to thicker agency among girls in progressively supportive family contexts. Engagement with the programme was however selective; families adhering to harmful gender norms were not receptive to outreach. In line with diffusion theory, late adopters required additional peer encouragement to change norms.

Changes in Family-Level Attitudes and Norms and Association with Secondary School Completion and Child Marriage Among Adolescent Girls: Results from an Exploratory Study Nested Within a Cluster-Randomised Controlled Trial in India.

We evaluated the impact of Samata, a 3-year multilayered intervention among scheduled caste/scheduled tribe (SC/ST) adolescent girls in rural northern Karnataka, on family-level (parents or guardian) attitudes and direct and indirect norms related to child marriage and girl's education. Endline data from 1840 family members were used to assess the effect of Samata on attitudes and norms related to schooling and child marriage, while data from 4097 family members (including 2257 family members at baseline) were used to understand the shifts in attitudes and norms over the period 2014-2017. Overall, we found that the programme had little impact on family-level attitudes and norms. However, there were shifts in some attitudes, norms and perceived sanctions between baseline (when girls were aged 13-14 years) and endline (when girls were aged 15-16 years), with some becoming more progressive (e.g. direct norms related to child marriage) and others more restrictive (e.g. norms around girls completing secondary education and norms related to child marriage and educational drop-out, blaming girls for eve teasing and limiting girls' mobility so as to protect family honour). Moreover, non-progressive norms related to marriage and education were strongly associated with child marriage and secondary school non-completion among adolescent girls in this rural setting. Norms hypothesised to be important for marriage and schooling outcomes were indeed associated with these outcomes, but the intervention was not able to significantly shift these norms. In part, this may have been due to the intervention focusing much of its initial efforts on working with girls alone rather than family members, the relevant reference group. Future interventions that seek to affect norms should conduct formative research to clarify the specific norms affecting the outcome(s) of interest; likewise, programme planners should ensure that all activities engage those most influential in enforcing the norm(s) from the beginning. ClinicalTrials.gov registration number: NCT01996241.

Media, nationalism, and the body: Exploring masculinities, male partner violence, and HIV vulnerability among female sex workers in northern Karnataka, India.

Public health and media discourses on men and HIV prevention in India have largely focused on changing knowledge, attitudes and risk behaviour pertaining to condom use and safe sex. Little attempt has been made towards intervening in areas such as masculinity, dominant gender norms and intimate partner violence (IPV) that have been shown to have a direct link to HIV prevalence. In this paper, drawing on findings from an ethnographic study in northern Karnataka (India), we show how socio-political and communicative contexts influence and perpetuate violent behaviours by men in intimate relationships with female sex workers (FSW). We argue that constructions of masculinity, the stereotypes of which are reinforced through contemporary media, and movies, are intricately linked with processes of nationalism and play out in forms of chauvinism among working-class men. Violence, celebrated through various patriarchal discourses, legitimises and reinforces gender ideals that govern the private lives of men and their female intimate partners. This study provides a complex and nuanced understanding of structural factors that lead to IPV against FSWs and offers implications for HIV intervention planning in the region and beyond.

Effectiveness of a multilevel intervention to reduce violence and increase condom use in intimate partnerships among female sex workers: cluster randomised controlled trial in Karnataka, India.

INTRODUCTION: Samvedana Plus is a multilevel intervention working with sex workers, their intimate partners (IPs) and communities to reduce intimate partner violence (IPV) and to increase condom use within intimate relationships of sex workers in Northern Karnataka, India. METHODS: A cluster randomised controlled trial in 47 villages. Female sex workers with IPs in the last 6 months were eligible for baseline (2014), midline (2016) and endline (2017) surveys. 24 villages were randomised to Samvedana Plus and 23 to a wait-list control. Primary outcomes among sex workers included experience of physical and/or sexual IPV or severe physical/sexual IPV in the last 6 months and consistent condom use with their IP in past 30 days. Analyses adjusted for clustering and baseline cluster-level means of outcomes. RESULT: Baseline (n=620) imbalance was observed with respect to age (33.9 vs 35.2) and IPV (31.4% vs 45.0%). No differences in physical/sexual IPV (8.1% vs 9.0%), severe physical/sexual IPV (6.9% vs 8.7%) or consistent condom use with IPs (62.5% vs 57.3%) were observed by trial arm at end line (n=547). Samvedana Plus was associated with decreased acceptance of IPV (adjusted OR (AOR)=0.62, 95% CI 0.40 to 0.94, p=0.025), increased awareness of self-protection strategies (AOR=1.73, 95% CI=1.04-2.89, p=0.035) and solidarity of sex workers around issues of IPV (AOR=1.69, 95% CI=1.02-2.82, p=0.042). We observed an increase in IPV between baseline (25.9%) and midline (63.5%) among women in Samvedana Plus villages but lower in comparison villages (41.8%-44.3%) and a sharp decrease at end line in both arms (~8%). CONCLUSION: We found no evidence that Samvedana Plus reduced IPV or increased condom use, but it may impact acceptance of IPV, increase knowledge of self-protection strategies and increase sex worker solidarity. Inconsistencies in reported IPV undermined the ability of the trial to assess effectiveness. TRIAL REGISTRATION NUMBER: NCT02807259.

The Samata intervention to increase secondary school completion and reduce child marriage among adolescent girls: results from a cluster-randomised control trial in India.

BACKGROUND: Secondary education and delayed marriage provide long-term socio-economic and health benefits to adolescent girls. We tested whether a structural and norms-based intervention, which worked with adolescent girls, their families, communities, and secondary schools to address poverty, schooling quality and gender norms, could reduce secondary school drop-out and child marriage among scheduled-caste/scheduled-tribe (SC/ST) adolescent girls in rural settings of southern India. METHODS: 80 of 121 villages in Vijayapura and Bagalkote districts, Karnataka State, were randomly selected (control = 40; intervention = 40). All 12-13 year-old SC/ST girls in final year of primary school (standard 7th) were enrolled and followed for 3 years (2014-2017) until the end of secondary school (standard 10th). Primary trial outcomes were proportion of girls who completed secondary school and were married, by trial end-line (15-16 years). Analyses were intention-to-treat and used individual-level girl data. RESULTS: 92.6% (2275/2457) girls at baseline and 72.8% (1788/2457) at end-line were interviewed. At end-line, one-fourth had not completed secondary school (control = 24.9%; intervention = 25.4%), and one in ten reported being married (control = 9.6%; intervention = 10.1%). These were lower than expected based on district-level data available before the trial, with no difference between these, or other schooling or sexual and reproductive outcomes, by trial arm. There was a small but significant increase in secondary school entry (adjusted odds ratio AOR = 3.58, 95% confidence interval CI = 1.36-9.44) and completion (AOR=1.54, 95%CI = 1.02-2.34) in Vijayapura district. The sensitivity and attrition analyses did not impact the overall result indicating that attrition of girls at end-line was random without much bearing on overall result. CONCLUSIONS: Samata intervention had no overall impact, however, it added value in one of the two implementation districts- increasing secondary school entry and completion. Lower than expected school drop-out and child marriage rates at end-line reflect strong secular changes, likely due to large-scale government initiatives to keep girls in school and delay marriage. Although government programmes may be sufficient to reach most girls in these settings, a substantial proportion of SC/ST girls remain at-risk of early marriage and school drop-out, and require targeted programming. Addressing multiple forms of clustered disadvantage among hardest to reach will be key to ensuring India "leaves no-one behind" and achieves its gender, health and education Sustainable Development Goal aspirations. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT01996241.

What determines violence among female sex workers in an intimate partner relationship? Findings from North Karnataka, south India.

BACKGROUND: Like other women in India, female sex workers (FSWs) frequently experience violence from their intimate partners (IPs)-a reality that increases their risk of acquiring HIV or other sexually transmitted infections. Less is known about the nature of these intimate relationships or what aspect of the relationship increases the risk of IP violence (IPV). We measured the prevalence and determinants of IPV on FSWs in the context of north Karnataka, India, characterized by high HIV-prevalence and extreme poverty. METHODS: Overall 620 FSWs with an IP participated in a baseline survey conducted for an on-going cluster-randomised controlled trial aiming to evaluate the impact of a multi-level intervention on IPV reduction. We characterize the nature of intimate relationships and explored determinants of severe physical and/or sexual IP violence using univariable and multivariable analyses. RESULTS: The median age of participants was 35 years with 10 years of duration in an intimate relationship. Though most relationships originated from a sex work encounter, 84% stated that IPs did not know they were currently practicing sex work. In past 6 months, the experience of emotional violence was 49% (95%CI:45.2-53.2), physical 33% (95%CI:29.5-37.1) and sexual violence 7% (95%CI:4.8-8.9), while 24% (95%CI:21.0-27.9) FSWs experienced recent severe physical and/or sexual violence from IPs. Factors associated with recent IPV included experience of physical and/or sexual violence from their clients in last 6 months (AOR 2.20; 95%CI: 1.29-3.75), sexual intercourse in the past 1 month when their IP was under the influence of alcohol (AOR 2.30; 95%CI: 1.47-3.59) and providing financial support to their IP (AOR 2.07; 95%CI: 1.28-3.34). CONCLUSIONS: The association between increased risk of violence and provision of financial support to an IP is indicative of gendered power dynamics as men remain dominant irrespective of their financial dependency on FSWs. Interventions are needed that address inequitable gender norms which makes FSWs tolerate violence even though she is not financially dependent on IP. Higher likelihood of violence in presence of alcohol use and FSWs' previous experience of workplace violence linked to IPV call for strengthening the crisis management systems within community-based organisations that can address all forms of violence and associated risk factors. TRIAL REGISTRATION: Clinical Trials NCT02807259.

Education, poverty and "purity" in the context of adolescent girls' secondary school retention and dropout: A qualitative study from Karnataka, southern India.

BACKGROUND: Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation. METHODS: Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses. RESULTS: Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating. CONCLUSIONS: In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication.

A community-based qualitative study on the experience and understandings of intimate partner violence and HIV vulnerability from the perspectives of female sex workers and male intimate partners in North Karnataka state, India.

BACKGROUND: Research has increasingly documented the important role that violence by clients and the police play in exacerbating HIV vulnerability for women in sex work. However few studies have examined violence in the intimate relationships of women in sex work, or drawn on community partnerships to explore the social dynamics involved. A community-based participatory research study was undertaken by community and academic partners leading intimate partner violence (IPV) and HIV prevention programs in Bagalkot district, Karnataka state, India. The purpose was to explore the experience and understandings of intimate partner violence and HIV/AIDS among women in sex work and their intimate partners in Bagalkot that would inform both theory and practice. METHODS: A community-based, interpretive qualitative methodology was used. Data was collected between July and October 2014 through in-depth interviews with 38 participants, including 10 couples, 13 individual female sex workers, and 5 individual male intimate partners. Purposive sampling was done to maximize variation on socio-demographic characteristics. Thematic content analysis was conducted through coding and categorization for each interview question in NVivo 10.0, followed by collaborative analysis to answer the research questions. RESULTS: The results showed that an array of interrelated, multi-level factors underlay the widespread acceptance and perpetuation of violence and lack of condom use in participants' intimate relationships. These included individual expectations that justified violence and reflected societal gender norms, compounded by stigma, legal and economic constraints relating to sex work. The results demonstrate that structural vulnerability to IPV and HIV must be addressed not only on the individual and relationship levels to resolve relevant triggers of violence and lack of condom use, but also the societal-level to address gender norms and socio-economic constraints among women in sex work and their partners. CONCLUSION: The study contributes to a better understanding on the interplay of individual agency and structural forces at a time when researchers and program planners are increasingly pondering how best to address complex and intersecting social and health issues. Ongoing research should assess the generalizability of the results and the effectiveness of structural interventions aiming to reduce IPV and HIV vulnerability in other contexts.

Understanding the Relationship Between Female Sex Workers and Their Intimate Partners: Lessons and Initial Findings From Participatory Research in North Karnataka, South India.

While traditional HIV prevention programs with female sex workers (FSWs) in Karnataka, India, have focused on reducing HIV transmission between FSWs and clients through increased condom use, these programs have not fully addressed the transmission risk between FSWs and their nonpaying intimate partners (IPs). Condom use is infrequent and violence is recurrent in these relationships: Furthermore, there is little evidence on the precise nature of FSW-IP relationships. Our study addresses this knowledge gap to inform HIV programs targeted at FSWs. A series of workshops, using participatory tools, was held to explore FSW-IP relationships; 31 FSWs and 37 IPs participated. Three aspects of FSW-IP relationships were examined: how FSWs and IPs understand and interpret their relationships, factors influencing condom use, and the role of violence and its consequences. FSWs wish to be perceived as their IPs' wives, while IPs expect their FSW partners to accept their dominance in the relationship. Nonuse of condoms signals fidelity and elevates the status of the relationship almost to that of marriage, which helps FSWs enter the category of "good" (married) women. Tolerating and accepting violence in these relationships is normative, as in other marital relationships; IPs justify violence as necessary to establish and maintain their power within the relationship. Both FSWs and IPs value their relationships despite the high degree of risk posed by low condom use and high levels of violence. Implications for program design include addressing current norms around masculinity and gender roles, and improving communication within relationships.

Correlates of school dropout and absenteeism among adolescent girls from marginalized community in north Karnataka, south India.

Secondary education among lower caste adolescent girls living in rural Karnataka, South India, is characterized by high rates of school drop-out and absenteeism. A cross-sectional baseline survey (N=2275) was conducted in 2014 as part of a cluster-randomized control trial among adolescent girls (13-14 year) and their families from marginalized communities in two districts of north Karnataka. Bivariate and multivariate logistic regression models were used. Overall, 8.7% girls reported secondary school dropout and 8.1% reported frequent absenteeism (past month). In adjusted analyses, economic factors (household poverty; girls' work-related migration), social norms and practices (child marriage; value of girls' education), and school-related factors (poor learning environment and bullying/harassment at school) were associated with an increased odds of school dropout and absenteeism. Interventions aiming to increase secondary school retention among marginalized girls may require a multi-level approach, with synergistic components that address social, structural and economic determinants of school absenteeism and dropout.

Pursuing Authenticity From Process to Outcome in a Community-Based Participatory Research Study of Intimate Partner Violence and HIV Vulnerability in North Karnataka, India.

Community-based participatory research has been seen to hold great promise by researchers aiming to bridge research and action in global health programs and practice. However, there is still much debate around whether achieving authenticity in terms of in-depth collaboration between community and academic partners is possible while pursuing academic expectations for quality. This article describes the community-based methodology for a qualitative study to explore intimate partner violence and HIV/AIDS among women in sex work, or female sex workers, and their male partners in Karnataka, South India. Developed through collaborative processes, the study methodology followed an interpretive approach to qualitative inquiry, with three key components including long-term partnerships, knowledge exchange, and orientation toward action. We then discuss lessons learned on how to pursue authenticity in terms of truly collaborative processes with inherent value that also contribute to, rather than hinder, the instrumental goal of enhancing the quality and relevance of the research outcomes.

Supporting adolescent girls to stay in school, reduce child marriage and reduce entry into sex work as HIV risk prevention in north Karnataka, India: protocol for a cluster randomised controlled trial.

BACKGROUND: Low caste adolescent girls living in rural northern Karnataka are at increased risk of school drop-out, child marriage, and entry into sex-work, which enhances their vulnerability to HIV, early pregnancy and adverse maternal and child health outcomes. This protocol describes the evaluation of Samata, a comprehensive, multi-level intervention designed to address these structural drivers of HIV risk and vulnerability. METHODS/DESIGN: The Samata study is a cluster randomised controlled trial that will be conducted in eighty village clusters (40 intervention; 40 control) in Bijapur and Bagalkot districts in northern Karnataka. The intervention seeks to reach low caste girls and their families; adolescent boys; village communities; high school teachers and school governing committees; and local government officials. All low caste (scheduled caste/tribe) adolescent girls attending 7th standard (final year of primary school) will be recruited into the study in two consecutive waves, one year apart. Girls (n = 2100), their families (n = 2100) and school teachers (n = 650) will be interviewed at baseline and at endline. The study is designed to assess the impact of the intervention on four primary outcomes: the proportion of low caste girls who (i) enter into secondary school; (ii) complete secondary school; (iii) marry before age 15; and (iv) engage in sex before age 15. Observers assessing the outcomes will be blinded to group assignment. The primary outcome will be an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at follow-up. We will also conduct survival analyses for the following secondary outcomes: marriage, sexual debut, pregnancy and entry into sex work. Complementary monitoring and evaluation, qualitative and economic research will be used to explore and describe intervention implementation, the pathways through which change occurs, and the cost-effectiveness of the intervention. DISCUSSION: This is an innovative trial of a comprehensive intervention to improve the quality of life and reduce HIV vulnerability among marginalised girls in northern Karnataka. The findings will be of interest to programme implementers, policy makers and evaluation researchers working in the development, education, and sexual and reproductive health fields. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01996241 . 16th November 2013.