May 6, 2013
The young men from Dar es Salaam, Tanzania, had heard it all.
They had been educated about safe sex and taught methods to prevent the dramatic spread of HIV ravaging their community. They were encouraged to reduce the ongoing physical and sexual violence against their sexual partners. They had data on the dangers of alcohol abuse. The instruction had come both from professionals and peers — presented in a variety of different ways — and yet the negative behaviors continued. They had heard it all, but nothing made them care enough to change
What did they want? An opportunity to make money, most of all. Training in business, so that if they got a chance to make money, they would know how to make more. But it takes money to make it, and these men were desperately poor.
So Suzanne Maman decided to give them $100 loans.
Affecting health-related behavior by providing small business start-up loans, known as microfinancing, was not unprecedented. Maman, associate professor of health behavior at Gillings School of Global Public Health, had heard of it, and she knew that Sheila Leatherman, research professor of health policy and management, had significant expertise in the area.
“I have been working in the nascent field of integrating microfinance and health for about ten years in Asia, Africa and Latin America,” Leatherman says. “Suzanne knew what I was doing as a Gillings Visiting Professor back in 2008 and wondered whether microfinance might be a possibility in her work with male youth groups in Tanzania.”
However, there was a catch. Most microfinancing in the service of health education had been done with women. If the men of Dar es Salaam were ignoring other health-care interventions, what made Maman think they would respond to this one?
“I sensed an opportunity,” she said. “Virtually all the young men with whom we had spoken were hungry for access to job opportunities and any type of business training.”
So she proposed to provide exactly that to 19 men. “One hundred dollars each,” Maman says. “They would use it to create their own small businesses, and we would provide counseling on starting a small business. But part of the deal was that the loans also would be combined with health education.”
Maman initially had hoped to target men in the 18- to 24-year-old range, but quickly found that opinions and habits of men that age were so ingrained that incentives likely would not change them. Instead the focus fell on a group of 15- to 19-year-olds. A Gillings Innovation grant (see www.sph.unc.edu/accelerate) and a grant from the National Institutes of Health provided support for a pilot study. The efforts would be centered on a local “camp.”
“Young men in their early teens to mid-20s from this part of Tanzania spend their time in ‘camps,’ which are something between social clubs and gangs,” Maman says. “Most don’t attend school or have access to stable income. Camps provide the men with an identity and a place to socialize with other young men.”
In addition, during research that led to the pilot program, Maman and colleagues found that 47 percent of the young men in the targeted age range said they had two or more sex partners in the past year; 47 percent of those had one or more concurrent sexual partnerships. Twenty-one percent also presented with at least one symptom of a sexually transmitted disease in the preceding four weeks, and 41 percent said they had perpetrated physical or sexual violence against a female partner. Their attitudes and behaviors regarding sex generally were learned from other men.
The pilot program focused on four groups of five young men. Each individual was given a loan of $100 and was responsible for paying back the money with interest at the end of the loan period.
Each received business skills training that included information about running a small business and managing money. Older men in the community who had been born into poverty – but had managed to establish successful businesses – were brought in as role models. The microfinance was combined with a peer-led HIV- and violence-prevention program. Leaders within the camps were recruited and trained to communicate with peers about behaviors that put themselves and their partners at risk for HIV and other sexually transmitted infections, and about strategies to resolve conflict with partners that did not involve violence.
The pilot ran in 2009. What kind of businesses did the young men start? Nothing extravagant. Some bought charcoal wholesale and resold it at a profit. Others performed bicycle repair, started a video rental business, sold secondhand clothing or fried fish. All but one repaid the money. Most importantly, the young men responded to the health behavior instruction. They retained a heightened awareness of negative sexual activity and reported a drop in high-risk sexual behaviors.
Maman’s study was published in 2010 in the journal Social Science and Medicine. (See tinyurl.com/maman-SSM-social-venues.) That work has led to a new $2.6 million grant from the National Institute of Mental Health to study a much larger sample of men.
“This study will involve about 2,800 young men in more than 50 camps,” Maman says. “It will include a baseline survey to assess behaviors, sexual activity and the frequency with which they commit physical or sexual violence against partners. We want to deter¬mine whether our combined microfinance and health leadership intervention produces a drop in incidence of sexually transmitted diseases, an increase in condom use, and a reduction of sexual and physical violence against their partners.”
The study will be done in collaboration with colleagues at Muhimbili University of Allied Sciences in Dar es Salaam.
Maman says she hopes this approach will provide young men with information and skills that enable them to build successful businesses and allow them to imagine a different kind of future for themselves.
“If men can envision a different way of life,” she says, “they may not engage in behaviors that put their futures at risk. Increasing men’s knowledge about sexually transmitted diseases and partner violence also will benefit the community’s women.”
If the larger project proves successful, Maman will have established the foundation for a microfinance-health behavior intervention that can be adapted in similar at-risk communities in other countries.
Researchers featured in this article:
Suzanne Maman, PhD, is associate professor of health behavior.
Sheila Leatherman, MSW, is research professor of health policy and management.
Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit sph.unc.edu/cph.