{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T12:49:08Z","timestamp":1779194948331,"version":"3.51.4"},"update-to":[{"DOI":"10.12688\/gatesopenres.15127.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,5,27]],"date-time":"2025-05-27T00:00:00Z","timestamp":1748304000000}}],"reference-count":65,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2025,5,27]],"date-time":"2025-05-27T00:00:00Z","timestamp":1748304000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"publisher","award":["R01MH114562\u201301"],"award-info":[{"award-number":["R01MH114562\u201301"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"publisher"}]},{"name":"UK Medical Research Council and Foreign, Commonwealth and Development Office","award":["MR\/R015600\/1"],"award-info":[{"award-number":["MR\/R015600\/1"]}]}],"content-domain":{"domain":["gatesopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Gates Open Res"],"abstract":"<ns3:p>\n                    Background Gender norms against adolescent girls and young women (AGYW)\u2019s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption. Methods General-population survey participants in Manicaland, Zimbabwe (ages\u226515, N=9803) reported agreement\/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW\u2019s perceiving negative gender norms and condom HIV prevention cascades. Results 57% of men and 70% of women disagreed that \u2018If I have a teenage daughter and she has sex before marriage, I would be ok with this\u2019; and 41% of men and 57% of women disagreed that \u2018If I have a teenage daughter, I would tell her about condoms\u2019. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39%\n                    <ns3:italic>vs.<\/ns3:italic>\n                    68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1%\n                    <ns3:italic>vs.<\/ns3:italic>\n                    6.9%; aOR=0.57, 95%CI, 0.08-2.66). Conclusions Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.\n                  <\/ns3:p>","DOI":"10.12688\/gatesopenres.15127.2","type":"journal-article","created":{"date-parts":[[2025,5,27]],"date-time":"2025-05-27T11:25:07Z","timestamp":1748345107000},"page":"22","update-policy":"https:\/\/doi.org\/10.12688\/gatesopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Gender Norms and Structural Barriers to Use of HIV Prevention in Unmarried and Married Young Women in Manicaland, Zimbabwe: An HIV Prevention Cascade Analysis"],"prefix":"10.12688","volume":"8","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2707-0714","authenticated-orcid":false,"given":"Simon","family":"Gregson","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Louisa","family":"Moorhouse","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rufurwokuda","family":"Maswera","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tawanda","family":"Dadirai","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Phyllis","family":"Mandizvidza","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morten","family":"Skovdal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Constance","family":"Nyamukapa","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2025,5,27]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"287-305","DOI":"10.1002\/psp.552","article-title":"Bringing norms back in: a theoretical and empirical discussion of their importance for understanding demographic behaviour.","volume":"16","author":"A Liefbroer","year":"2010","journal-title":"Popul Space Place."},{"key":"ref-2","article-title":"Where are the Ancestors? 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status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/gatesopenres.16463.r36328, Lucy Chimoyi, Implementation Research, The Aurum Institute, Johannesburg, Gauteng, 19 Jul 2024, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/gatesopenresearch.org\/articles\/8-22\/v1#referee-response-36328","order":0,"name":"referee-response-36328","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Simon Gregson<\/b>; \n<i>Posted: 06 Apr 2025<\/i>; We thank the reviewer for the very helpful comments and suggestions for improvements to the manuscript. We have updated the manuscript now in the ways described in the responses to each comment listed below:&nbsp;   \n<u>Introduction:<\/u>  The last paragraph of the introduction is providing methods, results, and some interpretation of some of these findings. Something I find unusual. Usually, the last paragraph focusses on the gap and what was done by the authors to address this important gap. My suggestion is to move some of the information in this paragraph to the appropriate sections. &nbsp;  \n<u>Response:<\/u> This approach is often used in social science articles similar in length and nature to the current paper. However, as both reviewers have suggested we change it here, we have replaced the last paragraph of the Introduction with a shorter list of objectives. &nbsp;  \n<u>Methods:<\/u>  Study settings: why were these particular 8 communities selected? &nbsp;  \n<u>Response:<\/u> The 8 communities were selected to reflect the main socio-economic population strata found in Zimbabwe. We have clarified this now in the text in the \u2018Study setting and survey procedures\u2019 sub-section of the Methods section.   The paragraph beginning with \u201cFollowing these procedures\u2026.\u201d Is reporting some findings which should be moved to the Results Section. &nbsp;  \n<u>Response:<\/u> These details have been moved now to the Results section.   In the methods, authors mention the survey period as between July 2018 and December 2019 and also introduced data between 1998-2013 which included 6\/8 communities. Authors have not explained how they established the calculated risk difference for the two communities not included in the previous survey. Did they consider estimating the parameters using available data from published peer-review articles or grey literature? Or is this a limitation? &nbsp;  \n<u>Response:<\/u> The risk difference between the communities included in the current and previous surveys could not be calculated because no representative general population data on HIV incidence exist for the two new communities. We have noted this limitation now in the Discussion.&nbsp;&nbsp; &nbsp;   \n<u>Results:<\/u>   The explanation for hyperinflation is not necessary in the results section. &nbsp;  \n<u>Response:<\/u> The reference to hyperinflation has been removed from the Results section.&nbsp;   Ensure that the tables and graphs are self-explanatory. Write in full (footnotes) all acronyms as some are not universally known such as CGP. &nbsp;  \n<u>Response:<\/u> We have reviewed the footnotes for all tables and graphs in the paper and in the extended data and have elaborated the acronyms to make them self-explanatory.   \n<u>Discussion:<\/u>  The first paragraph summarized the findings of the paper without providing a background interpretation. This interpretation can be done in the subsequent paragraphs in the discussion.  \u2022&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; \n<u>Response:<\/u> We agree with the reviewer and this is indeed the approach that we have taken in the&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Discussion.  Can the authors clarify the experienced stigma in their discussion? Reference to this form of stigma is missing from the results. This was mentioned on page 16 from this sentence &quot;\n<i>HIV stigma, experienced or perceived by unmarried AGYW@Risk, was also associated with their lacking motivation to use condoms41 and may be reinforcing these effects.\u201d<\/i> &nbsp;  \n<u>Response:<\/u> The reviewer is quite correct, the results in this paper are just for perceived stigma. We have removed the mention of experienced stigma now from the text on page 16.","URL":"https:\/\/gatesopenresearch.org\/articles\/8-22\/v2#referee-comment-3776","order":1,"name":"referee-comment-3776","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/gatesopenres.16463.r36677, Maxime Inghels, University of Lincoln, Lincoln, 23 Jul 2024, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/gatesopenresearch.org\/articles\/8-22\/v1#referee-response-36677","order":2,"name":"referee-response-36677","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Simon Gregson<\/b>; \n<i>Posted: 06 Apr 2025<\/i>; We thank the reviewer for the very helpful comments and suggestions for improvements to the manuscript. We have updated the manuscript now in the ways described in the responses to each comment listed below:&nbsp;  \n<u>Abstract<\/u>  The method mentions a logistic regression model to measure associations between AGYW\u2019s perception of negative gender norms and HIV prevention cascades involving condom use, but the related results are not presented in the results section of the abstract. &nbsp;  \n<u>Response:<\/u> The results section of the Abstract includes results from these logistic regression analyses. For example, the p-values given for the comparisons of condom use according to whether or not friends use condoms are results from these analyses. The journal\u2019s abstract word limit restricts the detail we can provide here; but, to make this more apparent, we have edited the text and replaced the p-values with odds ratios (with 95% confidence intervals). There wasn\u2019t enough space in the Abstract to include results from the logistic regression analyses investigating socio-demographic variations in community views on AGYW\u2019s use of condoms so we have removed mention of this from the Methods section.   Since the results presented can refer to different populations (e.g., men, women, AGYW, unmarried AGYW at risk, married AGYW at risk), the sample size of each population should be presented or at least the ratio with numbers associated with each percentage should be added. &nbsp;  \n<u>Response:<\/u> We agree with the reviewer that including more information on sample sizes for the different parts of the analysis would be helpful. Unfortunately, this isn\u2019t feasible given the journal\u2019s 300 word limit for the abstract.   \n<u>Introduction<\/u>  The explanation of the context is clear and well-written. My only comment is about the summary of the findings at the end of the section, which is a bit unusual to me. &nbsp;  \n<u>Response:<\/u> Please see our response to the similar comment by Reviewer 1.   \n<u>Results: <\/u>  \u201cEighty-six point three percent (95% CI, 80.1%\u201381.2%) of unmarried AGYW at risk\u201d \u2013 the percentage does not fall within the confidence interval. &nbsp;  \n<u>Response:<\/u> The upper bound of the confidence interval should have been \u201891.2%\u2019 and has been corrected in the text.   As the authors consider multiple populations, which can sometimes be hard to follow, I would encourage them to add the headcount fraction associated with each percentage presented in the text. &nbsp;  \n<u>Response:<\/u> In most cases, the numerators and denominators are shown in the Tables in \u2018Extended data\u2019 but we agree with the reviewer that it would be easier for the readers if they are shown in the text and so we have done this now. In the remaining cases, these details are provided in Tables in the paper; so, to avoid over-cluttering the text, we have not repeated them there. &nbsp;   Sub-section title p12: \u201cHIV-negative AGYW@Risk\u2019s perceptions of the influence of gender norms and other structural factors on their decisions to use condoms by marital status.\u201d I would drop the term \u201cHIV-negative\u201d as it is misleading since all the AGYW populations considered in the study are HIV-negative. &nbsp;  \n<u>Response:<\/u> \u2018HIV-negative\u2019 has been dropped now from this sub-section title.    \n<u>Discretionary General Comments: <\/u>  I would encourage the author to refer to the UNAIDS terminology guidelines, particularly for the use of \u201cexposed\u201d instead of \u201cat risk\u201d population (see: UNAIDS Terminology Guidelines). &nbsp;  \n<u>Response:<\/u> We have referred to the UNAIDS terminology guidelines. However, given the focus of this particular scientific paper, we believe it is important to be as precise as possible about the meanings of the variables that are being used. Therefore we prefer to retain the current use of \u2018at risk\u2019 populations.","URL":"https:\/\/gatesopenresearch.org\/articles\/8-22\/v2#referee-comment-3777","order":3,"name":"referee-comment-3777","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/gatesopenres.17714.r39670, Ashley L. Buchanan, Claire Pearsall, Department of Pharmacy Practice and Clinical Research, University of Rhode Island College of Pharmacy, Kingston, Rhode Island, 29 Aug 2025, version 2, indexed","URL":"https:\/\/gatesopenresearch.org\/articles\/8-22\/v2#referee-response-39670","order":4,"name":"referee-response-39670","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by the Bill and Melinda Gates Foundation [INV-009999], the National Institute of Mental Health [R01MH114562\u201301], and the Medical Research Council Centre for Global Infectious Disease Analysis [MR\/R015600\/1 to SG, LM, and CN], which is jointly funded by the UK Medical Research Council and Foreign, Commonwealth and Development Office. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}