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\House, M.D.\ and Indirect Communication: A Close Textural Analysis
This dissertation utilizes indirect communication to analyze the television series, House, M.D. The work of Søren Kierkegaard and other indirect communication scholars was applied to this popular show, while the use of literary tropes of irony/sarcasm, metaphors, and deception were employed throughout the run of the series in order to indirectly bring up topics that were of interest to the general public. The methodology of close textural reading was made use of as I discuss the overhearing, inwardness, and double-reflection of indirect communication as it was seen in eight seasons of House.
Dissertation
Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa
Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.
We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.
We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men's fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men's expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family's health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner's results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.
Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men's and women's engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.
Journal Article
Conceptualizing Community Mobilization for HIV Prevention: Implications for HIV Prevention Programming in the African Context
Community mobilizing strategies are essential to health promotion and uptake of HIV prevention. However, there has been little conceptual work conducted to establish the core components of community mobilization, which are needed to guide HIV prevention programming and evaluation.
We aimed to identify the key domains of community mobilization (CM) essential to change health outcomes or behaviors, and to determine whether these hypothesized CM domains were relevant to a rural South African setting.
We studied social movements and community capacity, empowerment and development literatures, assessing common elements needed to operationalize HIV programs at a community level. After synthesizing these elements into six essential CM domains, we explored the salience of these CM domains qualitatively, through analysis of 10 key informant in-depth-interviews and seven focus groups in three villages in Bushbuckridge.
CM DOMAINS INCLUDE: 1) shared concerns, 2) critical consciousness, 3) organizational structures/networks, 4) leadership (individual and/or institutional), 5) collective activities/actions, and 6) social cohesion. Qualitative data indicated that the proposed domains tapped into theoretically consistent constructs comprising aspects of CM processes. Some domains, extracted from largely Western theory, required little adaptation for the South African context; others translated less effortlessly. For example, critical consciousness to collectively question and resolve community challenges functioned as expected. However, organizations/networks, while essential, operated differently than originally hypothesized - not through formal organizations, but through diffuse family networks.
To date, few community mobilizing efforts in HIV prevention have clearly defined the meaning and domains of CM prior to intervention design. We distilled six CM domains from the literature; all were pertinent to mobilization in rural South Africa. While some adaptation of specific domains is required, they provide an extremely valuable organizational tool to guide CM programming and evaluation of critically needed mobilizing initiatives in Southern Africa.
Journal Article
Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa
HIV and violence prevention programs increasingly seek to transform gender norms among participants, yet how to do so at the community level, and subsequent pathways to behavior change, remain poorly understood. We assessed shifts in endorsement of equitable gender norms, and intimate partner violence (IPV), during the three-year community-based trial of Tsima, an HIV 'treatment as prevention' intervention in rural South Africa. Cross-sectional household surveys were conducted with men and women ages 18-49 years, in 8 intervention and 7 control communities, at 2014-baseline (n = 1,149) and 2018-endline (n = 1,189). Endorsement of equitable gender norms was measured by the GEM Scale. Intent-to-treat analyses assessed intervention effects and change over time. Qualitative research with 59 community members and 38 staff examined the change process. Nearly two-thirds of men and half of women in intervention communities had heard of the intervention/seen the logo; half of these had attended a two-day workshop. Regression analyses showed a 15% improvement in GEM Scale score over time, irrespective of the intervention, among men (p<0.001) and women (p<0.001). Younger women (ages 18-29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53; p<0.05). Qualitative data suggest that gender norms shifts may be linked to increased media access (via satellite TV/smartphones) and consequent exposure to serial dramas modeling equitable relationships and negatively portraying violence. Tsima's couple communication/conflict resolution skills-building activities, eagerly received by intervention participants, appear to have further supported IPV reductions. There was a population-level shift towards greater endorsement of equitable gender norms between 2014-2018, potentially linked with rapid escalation in media access. There was also an intervention effect on reported IPV among young women, likely owing to improved couple communication. Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change.
Journal Article
Greater ambient air pollution exposure is associated with worse respiratory symptoms in men and women with HIV and chronic lung disease: a cohort study
Background
COPD and impairment in diffusing capacity for carbon monoxide (DLCO) are common comorbidities in people with HIV (PWH). HIV may increase susceptibility to inhaled toxins including air pollution. In PWH and people without HIV (PWoH), we investigated whether air pollution exposure was associated with within-group differences in lung function or respiratory symptoms, and whether these associations differed by HIV serostatus or the presence of underlying lung disease.
Methods
We analyzed cross-sectional data from the Multicenter AIDS Cohort Study (MACS) and the Women’s Interagency HIV Study (WIHS), including participants with pulmonary function tests and accompanying standardized respiratory questionnaires in 2017–2020. The participants were linked to fine particulate matter (PM
2.5
) and ozone exposure data. Associations between exposures and respiratory outcomes were quantified with regression models. Two subgroup analyses were conducted, restricting to individuals with COPD (FEV
1
/FVC ratio < 0.7) or impaired DLCO (< 80% predicted).
Results
338 MACS participants and 1073 WIHS participants were included. Overall, there were no significant associations between pollution exposures and either lung function or respiratory symptoms. In PWH with COPD, 1 µg/m
3
greater exposure to PM
2.5
was associated with worse St. George’s Respiratory Questionnaire (SGRQ) score (4.04 points; 95% CI 0.36–7.72) and worse modified Medical Research Council (mMRC) dyspnea score (0.28 points; 95% CI 0.02–0.53). In PWH with impaired DLCO, 1 µg/m
3
greater PM
2.5
exposure was associated with worse SGRQ (2.14 points, 95% CI 0.2–4.08) and mMRC (0.16 points, 95% CI 0.02–0.29). There were no significant associations between PM
2.5
and respiratory symptoms in PWoH with COPD or impaired DLCO. Ozone exposure was not associated with respiratory symptoms in PWH or PWoH.
Conclusions
PM
2.5
exposure may act synergistically with HIV infection to worsen respiratory symptoms in people with chronic lung disease. Further study is needed to determine if air pollution leads to decline in lung function in PWH.
Journal Article
Process elements contributing to community mobilization for HIV risk reduction and gender equality in rural South Africa
Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the 'One Man Can' intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a 'better life' and associated with behaviour change in the intervention's main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization-specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.
Journal Article
Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women
Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at
individual
and
community
levels and recent testing using a population-based sample (n = 1126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14–0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6–10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97–2.03; p = 0.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (p < 0.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately.
Journal Article
Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa
Introduction Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk. Methods Twenty two villages in the Agincourt Health and Socio‐Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory‐based, gender transformative, CM intervention or no intervention. Two cross‐sectional, population‐based surveys were conducted in 2012 (pre‐intervention, n = 600 women; n = 581 men) and 2014 (post‐intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent‐to‐treat (ITT) approach using survey regression cluster‐adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes. Results Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16). Conclusion Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly. Clinical Trials number ClinicalTrials.gov NCT02129530.
Journal Article