The influence of gender-equitable attitudes on sexual behaviour among unmarried adolescents in rural Tanzania: a longitudinal study

Patriarchal systems in Africa can perpetuate inequitable gender norms and power differentials that disadvantage women. This study aimed to examine the influence of community and individual gender-equitable attitudes on adolescents’ sexual health and risk behaviour in rural Tanzania, and whether the association of those attitudes differs between males and females. We conducted logistic regression using longitudinal data from a cluster randomised controlled trial in rural Tanzania to examine the association of gender-equitable attitudes with the sexual risk behaviour of 2017 adolescent males and females. High community-level gender-equitable attitudes were significantly associated with higher odds of HIV testing (OR = 1.31, 95% CI [1.00–1.72]) and lower odds of age-disparate partnerships (OR = 0.52, 95% CI [0.30–0.88]) for the pooled male and female sample. High individual-level (but not community) gender-equitable attitudes were associated with increased condom (OR = 2.07, 95% CI [1.07–4.00]) and contraceptive use (OR = 2.08, 95% CI [1.04–4.13]) for girls. Among sexually debuted adolescents, no significant associations were found between community or individual high gender-equitable attitudes and transactional sex, early sexual debut, HIV testing, concurrent sexual partners, or number of sexual partners. We found evidence of effect modification by sex for community-level attitudes and age-disparate sex (p = 0.005) and individual-level attitudes and condom use (p = 0.051). Efforts to incorporate gender transformative programming for whole communities may increase gender-equitable attitudes. PLAIN LANGUAGE STATEMENT: Gender norms that centre men and disadvantage women create gender inequality, which can lead to risky sexual behaviour. This study examined how both community and individual attitudes toward gender norms influenced risky sexual behaviour in adolescents, and whether that influence was different between males and females. We found that higher gender-equitable attitudes were linked to increased odds of HIV testing in the last 12 months, and decreased odds of engaging in a sexual relationship with a much older partner. Individual high gender-equitable attitudes among girls were also linked to higher odds of them using condoms and contraceptives. Gender-equitable attitudes did not seem to influence early sexual debut, engagement in transactional sex, having multiple sexual partners at the same time, or the number of sexual partners a participant had in the last 12 months. Based on these findings, programming designed to increase gender-equitable attitudes might be helpful in increasing HIV testing and condom and contraceptive use, but it needs to involve the entire community, not just individual boys and girls.