PRASIT: Using Strategic Behavioral Communication to Change Gender Norms in Cambodia
Programs focused on promoting gender equity and combating detrimental gender norms play a key role in HIV prevention. This case study (one of nine in a series) documents how the PRASIT program in Cambodia targets entertainment workers, their mainly middle class and male clients, and males who have sex with males using strategic behavior communication. Although the programs vary in their approaches, strategies employed by PRASIT have focused on community outreach, mass media campaigns, and peer education.
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PRASIT: Using Strategic Behavioral Communication to Change Gender Norms in Cambodia
By Kai Spratt and Nandita Kapadia Kundu
Rain is pattering relentlessly over a brightly lit stage set-up in an open field in the city of Kampong Cham, 124 kilometers northeast of Phnom Penh, Cambodia, but that does not deter the crowd of 500 young people gathered there. They watch with intense anticipation as Puu Kleng, a popular Cambodian-American rap artist, asks each of the 10 young male contestants on the stage to describe why he is a "real man." The excitement is palpable. This is the final act in a five-hour television reality show in which contestants competed in teams, tackled cooking challenges, and gave talent performances. Three of these young men will be chosen as finalists in the Kampong Cham Provincial "You're the Man" (YTM) contest. They will represent their province against contestants from six other provinces at the national YTM challenge in Phnom Penh. The winner will represent a new role model for men in Cambodia—a man who supports equality, respects women, and protects his health by resisting peer pressure to drink too much and visit entertainment workers (EWs).
The YTM reality show is part of three gender initiatives undertaken by the PRASIT program. The four-year PRASIT (which means effectiveness in Khmer) program, approaches HIV prevention for EWs through its SMARTgirl program, men who have sex with men (MSM) through the MStyle program, and middle-class men by challenging gender norms that increase the vulnerability of most-at-risk populations (MARPs) through YTM. (1) The program is funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID) and implemented by FHI.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
After peaking at 3.2 percent in 1997, Cambodia's HIV prevalence among men and women aged 15 to 49 had dropped to 0.9 percent; it is expected to decline to approximately 0.6 percent by 2012 (Ministry of Health [MOH] 2007). HIV in Cambodia has evolved from a generalized epidemic to one concentrated among MARPs: men who are clients of sex workers as well as their spouses; people who inject drugs; male, female, and transgender sex workers, and MSM.
Sex workers: State-sponsored HIV prevention programs targeting sex workers have been credited with reducing HIV prevalence among brothel-based sex workers from 43 percent in 1998 to 13 percent in 2006 (MOH 2007). Following the implementation of the 2008 Law on the Suppression of Trafficking and Sexual Exploitation (anti-trafficking law) that resulted in the closing of most brothels, some sex workers continue to work on the street or in parks or hotels; others have become EWs employed as waitresses and hostesses in karaoke bars, massage parlors, and beer gardens. Though many EWs do not sell sex or, even if they do have transactional sex, do not consider themselves to be sex workers, they are included among the high risk groups in the national strategic plan.
Men who have sex with men: Though HIV prevalence among Cambodian MSM varies between urban and rural areas, the most recent figures estimate a prevalence between 0.7 to 8.7 percent among urban MSM (van Griensven et al. 2009). Marriage and parenthood are almost universally expected of Cambodian men, so many MSM are married and have sex with their wives, as well as with girlfriends, female clients, and female sex workers, which places those women at risk (U.N. Development Programme [UNDP] 2009).
Transgender people: Most HIV prevention programs in Cambodia have targeted male-to-female transgender people who identify themselves as women. Because they radically transgress gender norms and do not try to "pass" as men in the community, transgender people suffer more discrimination and violence than MSM. Like other women, they are likely to have little power to negotiate safe sex (Earth 2006). Few, if any, HIV prevention programs work with the transgender community to address how female gender norms increase risk and vulnerability for HIV.
Gender Norms in Cambodia
The Khmer saying, "Men are gold, women are cloth," shows the lower value socially placed on women. It is widely believed that women can be worn, torn, and stained; men cannot (Amnesty International 2010). Cambodian gender roles reflect the country's hierarchical social structure. Norms for men require them to succeed in public life and allow them to make the decisions in sexual matters, whereas women must strive to be dutiful daughters, obedient wives, and sacrificing mothers. In general, girls receive less education than boys and therefore have fewer opportunities for employment in higherpaid jobs such as public sector management and administration, technical trades, and the transport industry. Women are poorly represented in government at all levels (Project Against Domestic Violence 2009). Female employment is relatively high but is concentrated in agriculture in the rural areas and low-paying urban jobs, such as the garment industry, which are highly vulnerable to economic downturns and unemployment. For poor women with little education, few marketable skills, and families to support, the sex and entertainment industries have been a source of employment.
The Policy Environment
Gender equity: Cambodia's Constitution of 1993 guarantees equal rights for men and women (Ministry of Women's Affairs 2009). The 2005 Law on the Prevention of Domestic Violence and Protection of Victims strengthens protection for women (though not for men and boys), but does not have penalty provisions. Gender-based violence (GBV) affects an estimated 22 percent of evermarried women aged 15 to 49 (National Institute of Public Health, National Institute of Statistics, and ORC Macro 2006). GBV is not discussed publicly, and survivors are often blamed for the violence. Thus, although laws promote the equality and empowerment of women, their implementation remains poor because of lack of guidance on how to implement the laws (The NGO Committee on CEDAW and the Cambodian Committee of Women Cambodia 2006). In addition, there is much to be done to address the attitudes and behaviors that underlie and condone GBV and the undervaluing of women (Ministry of Women's Affairs 2009).
MSM: There are no laws in Cambodia that prohibit homosexual relations, and discrimination based on sexual orientation is prohibited. In practice, however, stigma and discrimination against samesex sexual behavior is stigmatized, and legislation is needed to make discrimination against MSM unlawful in specified areas of public life such as employment, education, housing, and service provision (UNDP 2009). Some MSM have been subjected to GBV, extortion, and harassment by police and the general population.
Sex work: Neither the Cambodian Constitution nor any laws criminalize voluntary prostitution (Keo 2009). In March 2008, the Suppression of Human Trafficking and Commercial Sexual Exploitation Law was enacted in Cambodia to focus on nonvoluntary prostitution of adults and minors and to prohibit the financial profit of one person through the prostitution of another person. The law as currently interpreted allows a person to voluntarily provide sexual services in a private space (one that is not shared with others) without persecution—an unaffordable option for most sex workers (Keo 2009). Guidelines issued in October 2008 further advise that the employers of karaoke parlors, restaurants, and other entertainment venues will be in breach of the law if an EW leaves the workplace during working hours to provide sexual services to clients and then pays the employer part of the dividend from the sexual services.
Development of PRASIT Programs
After almost two decades of HIV prevention activities in Cambodia, public knowledge about HIV was high, but messages had become predictable and ineffective. FHI/Cambodia perceived a need to update and reposition HIV messages to reflect the rapidly changing Cambodian context. A 2007 study, Let's Go for a Walk, implemented by Population Services International and FHI/Cambodia, yielded two apparently contradictory findings that influenced FHI's strategy for new programming. The first was that decisions on engaging in transactional sex were typically made in male social groups, where intense peer pressure makes it difficult for men to resist their friends' urging to drink and then seek sex, following the socially endorsed idea that "men will be men." The second finding was that notions of Khmer masculinity include self-control: commitment to the family, controlling one's urges, and maintaining social harmony. This duality generates some amount of tension among men: how could they be real men but not engage in high-risk behaviors?
The 2008 anti-trafficking law also influenced FHI's strategy. As the brothels closed, the number of entertainment venues burgeoned, so that HIV programs had to find innovative ways to reach out to EWs, who were more mobile than brothel-based sex workers. In focus group discussions, EWs said that they wanted to be respected as working women who supported their families and pursued their goals. They wanted programs that portrayed EWs as important players in the HIV epidemic in Cambodia—not stupid, as the popular image portrayed them, but intelligent and able to avoid risky behavior.
FHI decided to refocus HIV prevention efforts for male, female, and transgender EWs and sex workers, and their clients, by challenging the gender norms that made these women and men vulnerable in the first place. In 2007, FHI began a major revision of its programs, its relationships with its partners, and its strategic approaches. Making these changes was not easy as many partners were comfortable with the way in which they had been working for more than a decade. Others were not comfortable addressing norms that some of their own staff embraced. In a number of cases, FHI had to find new partners to work with. The change of approach entailed a complete overhaul of FHI's monitoring framework and capacity building for nongovernmental organization (NGO) partner organizations. (2) In January 2009, FHI launched PRASIT with funding from USAID/Cambodia. FHI introduced what they call a "strategic behavior communication approach" which links HIV prevention with a "hip, fun, and healthy lifestyle." FHI developed branded materials for each of its client groups and employs branding to motivate clients' identifying with the product—the programs' positive messages and lifestyle choices.
PRASIT comprises three programs, each targeting a specific vulnerable population: the SMARTgirl initiative focuses on EWs; the MStyle program targets MSM; and YTM addresses the behavior and attitudes of the clients of EWs. Each of these three initiatives includes the following:
- A unique logo and positive role model that promotes an empowered brand identity which the target audience will want to emulate.
- A standard package of sexually transmitted infection (STI) and HIV prevention interventions, including peer outreach and education, condom provision and promotion, and systematic referral for STI and HIV and other sexual health services.
- A system of tokens with different colors and shapes to distinguish individuals who have been contacted for the first time from people who have had multiple contacts over quarterly periods. Referral slips are given to individuals and are used to track service uptake; when people seek services and produce the referral slip, they may be eligible for lotteries and prizes for the program.
- Clinical services targeting MARPs, which are implemented by three local NGOs in partnership with FHI.
SMARTgirl: The SMARTgirl brand promotes the EW as proactive in her work and personal life and able to act on the knowledge she has about her health to protect herself and pursue her dreams.
The objects of SMARTgirl are:
- Implementing targeted and branded behavior change approaches—through peer and outreach education, SMARTgirl clubs, special events, social mobilization, and advocacy—that emphasize risk reduction and promote safer sexual practices
- Promoting and increasing access to health information, products, and services among EWs
- Building a supportive environment for EW sexual health by mobilizing stakeholders such as entertainment establishment owners, police, health care providers, and others
- Building the capacity of implementing agencies to plan, implement, manage, and monitor the SMARTgirl program.
SMARTgirl is implemented in nine provinces and municipalities by five local and international NGOs working with 120 outreach workers and peer educators. EWs can choose to become SMARTgirl members. Peer leaders are trained by PRASIT partner organizations to deliver monthly communication sessions on a specific topic, which changes every three months, using standardized communications tools. Topics include health and lifestyle issues including family planning, reproductive health, HIV testing and counseling, and general health and beauty. The sessions take place in entertainment venues where owners have agreed to provide a space. SMARTgirl also supports drop-in centers, independent from the entertainment venues, where monthly group sessions using the same communication tools are held with club members, and where members can get health check-ups, health information, free hairdressing services, and makeup instructions.
In both venues, EWs receive colored tokens that distinguish club members from their contacts, as well as referral slips for services at health centers. The program also produces a quarterly magazine for club members that discusses beauty, health, and other topics of interest to young urban women. Recognizing that EWs may be male, female, or transgender, FHI harmonizes the quarterly SMARTgirl messages with those of MStyle, the MSM program, to ensure that the same messages are transmitted via several channels.
MStyle: The MStyle program projects the image of positive, knowledgeable MSM who know how to protect their sexual health. MStyle is a mirror image of the SMARTgirl initiative in terms of program design and strategies. Ten NGO partners implement MStyle clubs and drop-in centers in Phnom Penh and two provinces. Peer educators refer MSM to the drop-in centers, where they can gather to relax, get information about health and HIV, receive individual counseling, use the Internet, or participate in Saturday night karaoke sessions that help build the MSM community. As with SMARTgirl, educators deliver monthly talks on a particular topic that is changed every three months. Previous topics include risk assessment and referral; health-seeking in the absence of symptoms; alcohol and drug use; and reproductive health, condom use, and available services and hotlines.
To strengthen health messages, PRASIT workers also conduct monthly outreach to both SMARTgirl and MStyle members, so that each person receives an individual contact up to seven to eight times annually.
You're the Man: YTM focuses on the clients of EWs. This project, implemented in seven provinces, moves away from conventional HIV messaging and seeks to change negative male gender norms (such as those that push men to drink alcohol and have multiple sexual partners) by promoting those Khmer male cultural norms that stress responsibility, community, and restraint. The YTM program works through two complementary components—a reality TV show and an interpersonal communication outreach activity—to introduce men to protective strategies such as the following:
- Saying no to negative peer pressure
- Acting as a positive role model
- Buying, carrying, and using condoms
- Using STI and voluntary counseling and testing services when risk behaviors occur, and notifying partners accordingly
- Refusing unwanted sex
- Drinking alcohol in moderation
- Influencing friends to adopt these behaviors.
Reality show: In 2009, FHI and its partner The O People, a public sector media company, launched the YTM reality television show. The show aired on Channel 3, a national network, but not one of the top channels (these wanted to be paid for airing the show). Though the target audience was about 650,000, it is difficult to estimate the audience for Channel 3.
During its first year, the show brought together six male contestants who faced challenges that tested their ideas of manhood and their thinking. The show was meant to keep a light, humorous tone, while presenting serious issues for the viewers to mull over. Over the course of 12 weekly episodes, the contestants tackled problems that made them think about such issues as gender equality, self-control in the face of peer pressure, men's responsibilities in preventing HIV and other STIs, and men's duties to themselves and to their families, communities, and country (see Table 1). In episode 2, for example, the contestants were challenged to live in a village and do work traditionally assigned to women; in episode 11, the men lived in a pagoda and tried to bring spiritual balance into their lives. In each episode, judges evaluated the contestants' responses, and the men accumulated points to determine who would be chosen as "The Man" in the final episode. The winner would be awarded a motorcycle and a U.S.$3,000 cash prize.
In 2010, the format of YTM changed: the show sought to mobilize more men and take the reality television format to a new, more participatory level through a national challenge. In each of the seven provinces where PRASIT is implemented, 10 men took part in a live competition in an outdoor venue, with an audience watching; the show was then edited and aired approximately two weeks later. Contestants were given a set of challenges to complete within a time limit. The challenges were grouped as: 1) physical—stressing both bodily and mental strength, such as the ability to cooperate and take initiative, 2) mental—underscoring the idea that "real men" protect themselves and those around them, and know their HIV status, and 3) character—emphasizing that real men think for themselves and are good role models. A panel of judges scored each contestant and the best overall score determined who was "The Man."
The competitions were recorded on video, and one competition per week was aired as an episode of the YTM show. The top three contestants from each province competed for the YTM title in Phnom Penh in September 2010. The winning contestant was considered the man who best embodies the norms of a "real man." The winner received a substantial cash prize.
Interpersonal communication: Male peer educators in all seven provinces implement the interpersonal communication component. Outreach workers go to entertainment venues during the evening to promote the YTM television program, wearing YTM outfits and holding brief interactive sessions with different groups of men who are drinking or eating there. The interactive sessions take about 10 minutes and promote messages from the television show, which are changed every month.
What Worked Well
Strong program monitoring: PRASIT's monitoring systems track mapping, outreach, strategic behavior communications materials, referrals, and coordination so assessing the performance of each partner is fairly straightforward. The system has simple techniques for verifying data quality, incentives for returning referral slips, and a quarterly review process.
Referral slips: The referral slip strategy proved to be a useful tracking method. In 2008, when the anti-trafficking law went into effect, only 8,778 service referral slips were distributed to EWs. While sex workers had long received referral slips for STI services, in 2009, the year of PRASIT's launch, the number of service referrals distributed to EWs rose significantly to 55,192. In 2010, 86,135 were distributed. The number of HIV testing and counseling referral slips collected from EWs at voluntary counseling and testing sites rose from 1,883 in 2008 to 9,792 in 2010. FHI's previous program had reached only 3,818 MSM by the end of 2008; by October 2010, the MStyle program had reached 10,383. Monitoring data indicate that MStyle currently reaches 91 percent of the MSM estimated to be living in three target provinces.
Audience targeting: FHI commissioned a mixed method study in 2010 to assess how well the YTM audience liked the format and programming, understood the messages of each episode, and identified with the challenges the men faced. The study garnered a 17 percent response rate (341 of 1,990), but the majority of respondents did represent the target audience for the show: they were mostly urban (Phnom Penh) and educated. Most respondents (84 percent) were either university students or working in private sector, government, or NGO jobs. The study found that the show resonated with the viewers, who gained greater empathy for their mothers and wives, and who made the connection between "manly" behavior with peers and risk-taking.
Insufficient evaluation: There is much to learn from the PRASIT program. It is a truly unique opportunity to address gender norms on a large scale, using multiple communication approaches. The gender component is truly innovative in the PRASIT program. Unfortunately, funding did not include a comprehensive external evaluation. The YTM evaluation described previously was the only evaluation and with a small sample size. This postintervention evaluation (there was no baseline) of the first year of the YTM show suggested that many viewers were not clear about the purpose of the show. Without baseline data and a process evaluation, it will be difficult to measure any effect on gender norms or to what extent the branding strategy motivated the behavior changes the programs promote.
Limited timeframe: PRASIT has been under way for less than two years, and it is unlikely that changes in risk behaviors are occurring within large proportions of the MARPs that PRASIT is targeting. It would be possible, going forward, to track stages of change in gender-based attitudes or behaviors (using the Gender Equitable Men's Scale, for example) through a baseline and randomized cluster survey sampling approach, with the core audience—university students, for instance— informing how the program could be adapted as it is rolled out.
Absence of community linkages: A critical challenge to PRASIT is the dependency on mass media to change gender norms. Although the interpersonal communication activity was designed to reinforce the national challenge content, it is unlikely that the short communication sessions with entertainment establishment clients, most of whom have not seen the YTM show, will have any impact on risk behavior or gender norms because there is no follow-up with the men who were randomly exposed to the interpersonal communication messages. In cultures where the collective is emphasized over the individual, like Cambodia, changing group norms through dialogue among peers may have a greater impact on behavior change (Lapinksi and Rimal 2005); from a social norms perspective, individuals enact a behavior because they believe that people important to them expect them to do so (Rimal and Real 2005). Community activities to follow up the television show or the SMARTgirl and MStyle peer outreach and training activities are needed to stimulate ongoing discussions among men, women, boys, and girls about gender norms, their effect on HIV risk behavior and vulnerability, and how these norms can be changed in a culturally appropriate way. However, FHI has not been funded to do this kind of work at the community level, though other PEPFAR partner organizations do work with the general community. It might be more effective to have FHI carry out mass media campaigns in concert with other organizations undertaking community dialogue and mobilization projects so that the programs have unified messages and their approaches reinforce each other.
Narrow program focus for You're the Man: The target audience for YTM was the middle class. The question remains whether the majority of Cambodian men, who do not have white-collar jobs, good salaries, and disposable income, can identify in any way with the contestants chosen for the program. The focus on middle- and upper-class men results in missed opportunities to reach the majority of men who seek the services of EWs.
Unintentional effects: One impression that became apparent was the possible unintended consequence of the YTM and SMARTgirl programs reinforcing rather than challenging some gender norms. SMARTgirl messages presented EWs as beautiful, modern, and assertive, acknowledging the importance of beauty for Cambodian women, and EWs in particular. However, the focus on enhancing one's beauty also increases the likelihood that EWs will get more customers—several informants noted that "the most beautiful girls get the most clients"— and may reinforce the idea that beautiful women are more valuable. Content in the SMARTgirl magazine should help SMARTgirl members think about and question female gender norms, aspire beyond such low-paying jobs as hairdressing and make-up application, and provide information on things like life skills, savings, bank loans, home budgeting, and vocational and educational training.
Some recommendations are as follows:
- PRASIT is breaking new ground in Cambodia by stimulating examination of gender norms. While well-developed mass media programs have been shown to improve knowledge of HIV and short-term risk reduction behaviors, a paucity of rigorous evaluations on comprehensive programs limits our understanding of mass media's impact on the norms among social networks and longterm behavior change (Bertrand et al. 2006; Hutchinson, Mahlalela, and Yukich 2007).
- USAID should consider an overall program design that reinforces the PRASIT messages in the community and works within communities to address gender norms—such as GBV, which is common in Cambodia. Mass media campaigns can increase awareness about GBV, but violence is reduced only when communities decide that it is no longer acceptable and act to prevent it.
- The PRASIT program should prioritize a limited number of gender norms, and follow-up in communities to change those norms, to ensure more long-term impact than brief presentations conducted in entertainment venues.
- USAID might also consider funding well-designed external process evaluations that assess both qualitative and quantitative influences of the PRASIT program and others like it.
- Showing men doing women's work was entertaining and caused some men to appreciate women's responsibilities and contributions. It could be interesting to see how men react to women doing "men's work" in future YTM programs. It might be possible to conduct a companion program called "You're the Woman" or "You're the Couple" that models gender equity.
- There is an urgent need for more research and appropriate programming for non–gay-identified MSM, a much larger cohort than self-identified homosexual men, who are currently being missed by programs targeting MSM and by programs targeting male sex workers who have sex with men and with women.
PRASIT is a paradigm-shifting approach for working with at-risk populations within a challenging cultural and funding environment. No other programs in Cambodia have ever addressed male and female gender norms as a prevention strategy. FHI staff reported feeling that they had accomplished impressive changes in strategic planning and program implementation and monitoring in a short span of 18 months. PRASIT is a remarkable example for other programs in the Southeast Asia region (and beyond) on how to integrate gender strategies into program activities. With another two years of implementation, FHI is planning to conduct a midterm internal strategy review and assessment of results to date to inform implementation approaches and to refine the messages presented in the YTM program and in the MStyle and SMARTgirl tools, magazines, and outreach materials.
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Thanks to the FHI/Cambodia management team for engaging in frank and open discussions about their programs and responding to innumerable requests for information, reports and access to their staff, implementing partners, and program participants. Thanks also to USAID/Cambodia for permission to conduct the case study and the PEPFAR Gender Technical Working Group for their support and careful review of this case study.
Spratt, Kai, and Nandita Kapadia Kundu. 2011. PRASIT: Using Strategic Behavioral Communication to Change Gender Norms in Cambodia. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.