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Building Healthy Masculinites: Supporting HIV+ Adolescents in Malawi

Through gender transformative support, HIV+ adolescents will build skills to foster healthy and safe relationships

Photo of Aine McGlynn

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What specific problem(s) are you trying to address?

The HIV epidemic among youth in Malawi is a health emergency. Young people account for 50% of new HIV infections. Alongside the physical health implications, people living with HIV (PLHIV) face the psychosocial burden of stigma and exclusion. Adolescence is a time when young people are starting to engage in romantic and sexual relationships and they must be provided with appropriate information, advice and support to encourage safe and happy relationships. Because of the fear of HIV, there are few support services of this kind for HIV+ teens. A lack of available gender transformative programming for HIV+ adolescent girls and boys can result in a lack of understanding and skills to discuss consent, safe sex and healthy relationships.

What are some of your unanswered questions about the problem(s) you are working to address?

Research, documentation and learning from young men’s lived experiences in relation to masculinity, power, gender and violence is notably absent from how we think about the support that young men need in a service delivery and care context. Though there is a great deal of data available about girls who experience gender based violence (GBV), the lack of data about adolescent boys’ relationship to GBV presents a challenge.

Explain Your Idea

The Dignitas International (DI) Teen Club is a support model designed to increase ART adherence amongst HIV+ teens through a peer-centered and skill-building curriculum meant to inform, empower and encourage healthy lives. Held once a month in 50 local health centers, Teen Club members see a clinician for a check-up and to receive their monthly ART medications. Members then come together as a group and participate in a range of activities that are facilitated by health care workers and community volunteers in collaboration with Teen Mentors and DI staff.

Using this existing platform, White Ribbon and DI will expand this service model to integrate HIV treatment and care with a focus on preventing gender-based violence. Based on local needs, assets and strengths, clinicians and Teen Club leaders will be trained to apply a gender-transformative approach to their work with Teen Club members. Strongly rooted in youth engagement approaches, the model will rely on a trauma-informed approach so as to recognize the lived reality in Malawi, that 1 in 5 girls and 1 in 7 boys has experienced sexual violence. The incorporation of a gender-transformative service model in Teen Clubs will support discussion on healthy masculinities, female empowerment, HIV prevention for discordant couples (including consensual and safer sex), explore attitudes on sexual behaviours and positive relationships, and foster behavior change related to sexual health, gender equality and violence prevention.

Name the three most important ways that your idea will address your identified problem(s).

Adherence to treatment will increase by working at the intersection of HIV care and gender-based violence prevention for HIV+ teens.

Addressing a gap in gender-transformational and HIV treatment programming will lead to the adoption and promotion of healthy masculinities, power-sharing and gender equitable relationships. A strength-based, youth-centered and agile methodology will reflect lived realities, needs and assets. Leadership capacity building will ensure teens can share their learnings to their HIV- peers.

Stronger relationships between service providers and teens will allow for constructive and safe conversations on sexual health, HIV prevention within discordant couples, gender norms/expectations and healthy masculinities.

How is your idea unique?

Applying a gender lens to improving HIV treatment and care is a novel way to address the psychosocial support needs of HIV+ teens, who are often excluded from discussions around safe and healthy sexual relationships. The use of the national health system infrastructure and DI’s existing Teen Clubs, is a cost-effective and culturally appropriate way to address the gap in gender transformational HIV treatment and prevention.
While sex education exists within the Malawian school curriculum, teaching generally does not speak to the complexity of sexuality, gender, and love - and less so within the context of an HIV+ status. This program will fill a gap in care for HIV+ adolescents and will have exponential impact. When teens build their capacity for empathy and their understanding of their role in ending GBV, that learning moves horizontally through their peer groups as well as vertically through their other relationships impacting individuals, families and whole communities.

What are some outstanding concerns or questions that you have regarding your idea?

- Overcoming resistance from parents/guardians, religious leaders, clinicians, as well as individual men and boys in the community to challenge toxic ideas of masculinity and discuss safer sex.
- Ensuring the end-product will be celebrated and heavily utilized by healthcare providers, and youth themselves.
- Ensuring that all stages of the design are human centered and informed by the users, and reflect the lived realities, needs and assets of key stakeholders.

Who are your end users?

There are ca. 2,200 HIV+ girls and 1,800 HIV+ boys ages 10-19 registered in 50 DI Teen Clubs in Malawi. Following a pilot phase of this project in 4 clubs in 4 districts, the goal is for all 4,000 HIV+ teens to participate in this programming. Health care providers and Teen Club Mentors will be trained in the delivery of this intervention. Innocencia, a Teen Club graduate and Peer Mentor says: “When I found out I was HIV+, it was hard for me to accept. But things started to turnaround after I joined Teen Club [...]. At Teen Club, I have many friends who are going through the same challenges as me. Because of Teen Club, I know I can make it. Now, I’m helping others have hope for their life.”

Where will your idea be implemented?

  • Malawi

What is the primary type of emergency setting where your innovation would operate?

  • Epidemic

Tell us more about the emergency setting that you intend to implement in

HIV is an ongoing epidemic in Malawi, with half of new infections among young people. This health emergency is compounded by the issue of sexual violence, which is linked to the spread of STIs, including HIV. 23% of females and 13% of males aged 13-17 reported experiencing sexual violence in the past 12 months. Harmful views on gender and a fragile health system necessitates the creation of peer-driven service models to engage youth on the intersection of HIV care and gender based violence.

What is your organization's name?

Dignitas International
White Ribbon

Tell us more about you.

Dignitas International is a medical and research organization dedicated to improving health care for people facing a high burden of disease and unequal access to services. We are committed to working with patients, health workers, researchers and policymakers to tackle the barriers to health care.

White Ribbon is working to end violence against women and girls, promote gender equity, healthy relationships and a new vision of masculinity. We work to examine the root causes of gender-based violence and create a cultural shift that helps bring us to a future without violence. White Ribbon provides gender-based violence prevention expertise and thought leadership in the following areas; awareness-raising, training, policy development.

Organizational Characteristics

  • International/global organization

What is the current scale of your proposed innovation?

  • Still in planning phase and does not exist yet

Experience in Implementation Country(ies)

  • Yes, for more than one year.

Expertise in Sector

  • Yes, for more than a year.

Organization Location

Dignitas - US (registered) Toronto (registered), Malawi (450 staff)
White Ribbon - Toronto (registered), 8 staff.

What is your organizational status?

  • Registered non-profit, charity, NGO, or community-based organization.

What is the maturity of your innovation?

  • Early Stage Innovation: exploring my innovation, refining, researching, and gathering inspiration.

Website

http://www.whiteribbon.ca
http://dignitasinternational.org/hiv/teen-club/

How has your idea changed based on feedback?

The feedback asked us to think about how this program could also be be beneficial to HIV- peers. We will incorporate a module that develops the capacity of Teen Club members to act as leaders in fostering healthy masculinity and gender equality within their wider peer groups.
The inclusion of and consultation with local GBV prevention efforts currently being undertaken has also been refined. As the majority of these efforts focus on girls and women, our program is innovative in its inclusion of men and boys in preventing GBV. As such, a key outcome will be to partner with local GBV initiatives to support the development of their male engagement plan.
Feedback received from current Teen Club members and Teen Club/DI staff indicate there is already awareness of GBV in Malawi. All youth surveyed connected personally to GBV. As such, our idea will now include a trauma-informed approach which will complement the strength-based, gender-transformative approach initially described.

Who will implement this idea?

This idea will be coordinated by DI staff in Malawi, including the Adolescent Coordinator and HIV Technical Advisor. Clinical staff participants are Ministry of Health employees, which embeds programming into the national infrastructure and encourages long term sustainability. Teen Club facilitators are volunteers from the area surrounding the clinic in which each Teen Club is based, further rooting this initiative in the wider community. White Ribbon program staff will be involved in the development and delivery of the training on the new gender transformative curriculum to Teen Club facilitators and clinicians. Teen Club participants themselves will implement peer outreach and engagement beyond the scope of the Teen Club sessions.

Using a human-centered design approach, you may uncover insights that lead to small or foundational changes to your organization’s existing strategy or processes in order to unlock the potential of your idea. How would your organization go about making such changes?

Both DI and White Ribbon are committed to responsive programming. We prioritize action learning and are prepared to be iterative in our approach based on what user feedback and evidence shows us. Prototyping, testing and iterating will be integrated into all stages of program design and implementation. An implementation committee, guided by an innovation mindset, will be created which represents the interests of all stakeholders, and which will be authorized by organizational leadership to take actions that reflect the local context and realities that the design process unearths. Gender transformative work must be guided by end users. This is inherently a process that is centred on the needs and learning capacities of the people involved.

What challenges do your end-users face? (1) What is the biggest challenge that your end-users face on a day-to-day, individual level? (2) What is the biggest systems-level challenge that affects your end-users?

HIV+ teens in Malawi face heightened risk of discrimination, isolation and often violence due to their status. This can result in impacts on mental wellness and a greater risk of these individuals being deterred from seeking treatment or dropping out of care. On a broader systems level, due to stigma, HIV+ teens are largely excluded from social services that provide appropriate information, advice and support to encourage safe and happy personal relationships. As a result, the building of healthy relationships and thinking about love, sex and family in this context is often a source of stress and anxiety for many of these teens. Our proposed initiative will work at the intersection of HIV treatment and care, and gender-based violence in order to tackle both the individual and systems-level

Tell us about your vision for this project: (1) share one sentence about the impact you would like to see from this project in five years and (2) what is the biggest question you need to answer to get there?

By 2022, capacity building on gender based violence prevention and reduction will be integrated into all Teen Clubs in Malawi with a total reach of over 4000 HIV+ teens, and Teen Club members will be empowered to engage in discussions related to GBV reduction in their wider social groups and communities.
Can the content of the gender transformative curriculum be translated into impact in the wider community outside of the intensive support mechanism provided through the Teen Club model?

What is it that most attracted you to Amplify instead of a more traditional funding model?

From a clinical perspective, in resource limited settings, patient choice and engagement is not often prioritized as there is such focus on delivering basic services. DI has built its medical programming on the belief in the inherent dignity of every human being and that the right to health belongs to everyone. The Amplify funding process allows us to put the people we serve at the centre of the model from which all planning, design and implementation emerges.

Do you intend to implement your Amplify idea in refugee camps / temporary settlements?

  • We aim to implement our Amplify idea in support of displaced populations, but not in a refugee camp / temporary settlement.

How long have you and your colleagues been working on this idea together?

  • Less than 6 months

How many of your organizations’s paid, full-time staff are currently based in the location where the beneficiaries of your proposed idea live?

  • Over 50 paid, full-time staff

Is your organization registered in the country you intend to implement your idea in?

  • We are registered in all countries where we plan to implement.

My organization's operational budget for 2016 was:

  • Above $1,000,000 USD

What do you need the most support with for your innovation?

  • Program/Service Design

14 comments

Join the conversation:

Comment
Photo of OpenIDEO
Team

Hi Aine McGlynn and Team, We’re excited to share feedback and questions with you from a set of experts that are supporting this Challenge. We encourage you to think about this feedback as you continue to improve your idea, whether that’s refining it or adding more context. You are welcome to respond in the comments section and/or to incorporate feedback into the text of your idea. Your idea and all associated comments will all be reviewed during the final review process, but all critical information should be in the body of your contribution somewhere.

- You clearly capture how your idea aims to challenge normative masculinities and work with young men directly. Great job!
- We're curious to know more about how you will engage stakeholders in the design of your idea. Will young women be invited to the Teen Club? How will the gendered power dynamics in that space be negotiated and managed?
- One of our experts recommends to make it clear that Teen Clubs already exist around clinics in Malawi and you are working within an existing health system and adding something to the current curriculum, not starting completely from scratch.
- Tell us more about your relationships with these communities. Do you have local implementing partners you are currently working with?
- Some provoking questions to ask yourself: will isolating boys + men in discussions about masculinity be problematic? Other than gender, what are some other cultural norms to consider in the development of your idea (for example: religion, etc.) and how do you intend to mitigate these challenges?
- What kind of curriculum/approach will you use to train leaders and to lead discussions? Will technologies, be accessible to girls and boys alike?
- We're curious to know about your thoughts on the viability of your plan operating a Teen Club requires ongoing support and resource intensive. It might be interesting to see how these clubs could be self-sustaining. For example: could they operate a business? Provide a service for fee? Might be something to explore!
- One of our experts writes, "I know something similar has been done in Teen Clubs in Botswana and South Africa. Have you looked at their experiences and how its worked or not worked? How does the existing Teen Club structure help with reaching out to these boys? What about the girls? Will they also have separate meetings?"

In case you missed it, check out this Storytelling Toolkit (http://ideo.to/OZznV4) for inspiration on crafting strong and compelling stories as well as the recorded Office Hour (http://ideo.to/Gf1Cs6). Storytelling is an incredibly useful tool to articulate an idea and make it come to life for those reading it. Don’t forget - the last day to make changes to your contribution on the OpenIDEO platform is October 26 at 11:30PM PST.

Have questions? Email us at amplify@ideo.org

We look forward to reading more, and thank you for the important work that you are doing!

Photo of Aine McGlynn
Team

Thanks team! Yes, we will be inclusive of existing GBV initiatives already existent in Malawi - particularly the The Malawi Network on Gender Based Violence. We would hope to work with them to assess their capacity for engaging men and boys and build their capacity in that area.

We think that girls can be particularly well-engaged in program design and evaluation and that they too can gain a great deal from learning about healthy masculinity, healthy relationships and how men can be effective allies in gender equality. A 2015 USAID and Healthy Policy Project literature review of GBV in Malawi noted that 30 percent of males and 39 percent of females agreed with the statement “women sometimes deserve to be beaten.” As such, both men and women can benefit from understanding where to draw the line on violence, and how to do so effectively.

White Ribbon's methodology has been well-honed after 25 years and we find it very effective to separate men and boys and women and girls in the context of these conversations. Often in the women's groups, revelations of past abuse comes to light and the gendered nature of the space provides them the safety to express these things. Equally amongst young men, disclosures of past trauma or past use of violence often emerge in a gendered group. We also have experience of working with faith leaders on how they can help support men from adopting positive masculinities and eschewing anti-social behaviours often associated with "toxic masculinity" .

Photo of OpenIDEO
Team

Hi Aine McGlynn and team!

An important reminder, Refinement Phase closes this Thursday, October 26 at 11:30pm PST.

We can only consider complete submissions, so please make sure that you have reviewed the Feedback and Refinement Phase Checklists and answered all of the questions on the platform. Note that we added one more multiple choice question to the end of the form.

If you're having trouble figuring out how to edit your idea, please refer to this guidance: https://docs.google.com/document/u/1/d/e/2PACX-1vQUuV2N-wO8Oy8MysMAza3CbKUA1ZcMenollZjPh4FA0fGgIDcVXwWtEe6CLh36_Wik5AypEHixreFH/pub

Best of luck!

Photo of Tasha
Team

Adding on to the Teen Club program to bring further information to participants for safe and healthy relationships is a great idea. Expansion in this format makes sense with the already existing aims of Teen Club, and will hopefully cause safer and healthier sexual relationships.

Photo of DANIELA BELEN Garone
Team

Adolescence present a unique challenge as rapidly changing physiological and psychological maturity influence attitudes towards care and health seeking behaviors, and intersect with issues around livelihood security, disrupted family structure, and fear of stigma.
An estimated 2.1 million adolescents globally are living with HIV (ALHIV). Despite remarkable progress in antiretroviral therapy (ART) scale up – only a third has access to HIV treatment and care. Adherence and virological suppression remain a great challenge among ALHIV on ART
Adolescent needs a differentiated model of care, not a modified adult care model.
prevention strategies among adolescents hasnt prove all effective.
The proposal address some of the existing challenges through a model that put patients at the center of their care. The Teen Club model also work with teachers and care givers as well as health staff. The model is well implemented since 2011 and taken to scale. Building from its successes and learning from the implementation challenges, the Teen model of care can evolve into:
- integrate HIV negative adolescents and build peer-to-peer or HIV positive to negative relationships to enhance HIV prevention strategies, including promoting HIV self-testing by peers.
- Include interventions to address and prevent sexual violence among adolescents. Some models of self-defense has been pilot in malawi, the team can learn from them
- Increase the sport component in the club activities
- link the program with academical institutions like Colleges in zomba and other districts to liaise adolescent with scholarship and professional development
- Ensure to include the advocacy component in the proposal

ALL THE BEST, this is an amazing proposal!!!

Daniela

Photo of william
Team

Through Gender Transformation Support HIV+ adolescents will build skills to foster health and safe relationships, This is such great idea that would have greater impact in Malawian boys/men to right information on gender base violence since these boys/men does not have enough information about this, that's why we are having a lot of gender based violence issues here in Malawi,so this will be good start and this welcome idea.
(1)I like this proposal because will help boys/men to have enough information on gender based violence hence will help to empower Girls and Women in Malawi.
(2)I individually i am interested in this idea because this will help equal participation in all activities that are happening in our country as well as in our communities.
(3)Further more this will help both boys/men and girls/women to have uninformed choice when doing things and help girls/women to have self-esteem.
NOTE= I strongly believe that boys/men can play a positive role to prevent violence against girls/women why because knowledge is power in each and every human being.

Photo of Aine McGlynn
Team

Hi William - thanks so much for this feedback. We also believe that boys and men can play a really important role in violence prevention. Really looking forward to the next round of this grant process so that we can incorporate these great new suggestions!

Photo of Alinafe Chibwana
Team

Thanks for this great concept Alyx and team. I have gone through this and these are my thoughts:
1. In responding more about the emergency setting that we want to implement, we need to provide data on magnitude of GBV in Malawi. We may use this general data to justify our implementation in teen clubs since we have not done any study exploring GBV among adolescents though we know some are HIV positive because of GBV.
2. Networking and collaboration with other partners working in GBV should be featured in the proposal.
3. Interventions specifically on GBV briefly can be mentioned in the concept including management of cases and linkage.
4. I suggest to include empowerment of older teens as youth champions at facility and community level. In addition, these may impact the lives of other boys and young men as they participate in community dialogue, youth corners, drop in centres and other support clubs.
As such we need to expand also on who are our end users apart from over 2000 HIV + adolescents because some of these in the community are HIV negative but may benefit a lot
5. I suggest also to include Health Advisory Committees in health centers to assist in advocacy since chiefs participate in these meetings.
6. Outstanding concern: There is also GBV against boys and young men by older women for example with money and cases are there although are under reported. Can we feature this within GBV for boys to be protected from such?

Photo of Aine McGlynn
Team

These are really insightful comments Alinafe. We're so grateful for your feedback. I'm looking forward to incorporating them into the proposal for the next round of evaluation. I'm particularly intrigued by the insight that the program would also benefit HIV negative youth. You're so right!

Photo of James Nyirongo
Team

This is a wonderful proposal and i like the following sections
1. The proposal aims to address lack of gender transformative programming with boys and young men
2. Integration of HIV treatment service with prevention of gender based violence
Some sections have to be improved are
1.The end user should not be limited to only adolescents living with HIV but also youth without HIV in communities, facility youth friendly clubs and youth drop in centers
2.Consider collaboration with local partners already working in GBV involvement and support
3.I suggest we should start with few pilot teen club sites/youth friendly sites not all 50 clinics
4.Consider empowering older adolescents to reach out fellow peers in other youth forums like drop in centres and youth friendly clubs

Photo of Aine McGlynn
Team

Thanks James. This feedback is really helpful, and will help us make the program even stronger. Do you have any suggestions as to which local GBV partners would be a good fit to partner with?

Photo of ethel manda
Team

This is such a great idea that would make a huge impact because once the boy-child has adequate knowledge and information it is certain to have shared accountability, especially in relationships as mentioned in your idea

Photo of Aine McGlynn
Team

Thanks for the feedback Ethel! We think it's a great idea too :)

Photo of Ashley Tillman
Team

Hi Aine, Great to have you in the Challenge!

Wanted to send a friendly reminder to have your Idea finalized and published by September 17 at 11:30PM PT! To be considered please make sure you answer all the questions.

And check out our Anatomy of an Amplify Idea visualization: http://ideo.pn/amplify-anatomy + some tips on adding visual goodness to your idea: http://bit.ly/vi-sual