Date Published: April 4, 2018
Publisher: Public Library of Science
Author(s): Kate Doyle, Ruti G. Levtov, Gary Barker, Gautam G. Bastian, Jeffrey B. Bingenheimer, Shamsi Kazimbaya, Anicet Nzabonimpa, Julie Pulerwitz, Felix Sayinzoga, Vandana Sharma, Dominick Shattuck, Jacobus P. van Wouwe.
Rigorous evidence of the effectiveness of male engagement interventions, particularly on how these interventions impact relationship power dynamics and women’s decision-making, remains limited. This study assessed the impact of the Bandebereho gender-transformative couples’ intervention on impact on multiple behavioral and health-related outcomes influenced by gender norms and power relations.
We conducted a multi-site randomised controlled trial in four Rwandan districts with expectant/current fathers and their partners, who were randomised to the intervention (n = 575 couples) or control group (n = 624 couples). Primary outcomes include women’s experience of physical and sexual IPV, women’s attendance and men’s accompaniment at ANC, modern contraceptive use, and partner support during pregnancy. At 21-months post-baseline, 1123 men and 1162 partners were included in intention to treat analysis. Generalized estimating equations with robust standard errors were used to fit the models.
The Bandebereho intervention led to substantial improvements in multiple reported outcomes. Compared to the control group, women in the intervention group reported: less past-year physical (OR 0.37, p<0.001) and sexual IPV (OR 0.34, p<0.001); and greater attendance (IRR 1.09, p<0.001) and male accompaniment at antenatal care (IRR 1.50, p<0.001); and women and men in the intervention group reported: less child physical punishment (women: OR 0.56, p = 0.001; men: OR 0.66, p = 0.005); greater modern contraceptive use (women: OR 1.53, p = 0.004; men: OR 1.65, p = 0.001); higher levels of men’s participation in childcare and household tasks (women: beta 0.39, p<0.001; men: beta 0.33, p<0.001); and less dominance of men in decision-making. Our study strengthens the existing evidence on male engagement approaches; together with earlier studies our findings suggest that culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched gender inequalities and a range of health-related behavioral outcomes. ClinicalTrials.gov NCT02694627
Interest and investment in interventions engaging men in reproductive and maternal health and violence prevention in low- and middle-income countries has grown tremendously since the 1990s . Male engagement interventions have evolved from seeking to involve men to overcome specific barriers, such as women’s limited decision-making power or access to health care, to be increasingly gender-transformative, engaging men and their partners to challenge the inequitable gender and power dynamics that give rise to such barriers [2,3]. However, rigorous evidence of the effectiveness of such interventions, particularly from low- and middle-income countries (LMIC), remains limited [3–5]. In addition, there is a need to measure how these interventions impact relationship power dynamics and women’s decision-making, to ensure male engagement approaches do not undermine women’s autonomy . We undertook a randomized controlled trial (RCT) in Rwanda to assess the effectiveness of the Bandebereho (meaning “role model” in Kinyarwanda) couples’ intervention, a gender-transformative program for men and couples to promote men’s engagement in reproductive and maternal health, caregiving, and healthier couple relations. This study evaluates the intervention’s impact on multiple behavioral and health-related outcomes influenced by gender norms and power relations, which were addressed by the intervention.
We conducted a two-arm multi-site randomized controlled trial to assess the impact of the Bandebereho couples’ intervention on our outcomes of interest. Couples were recruited from local communities in Karongi, Musanze, Nyaruguru and Rwamagana districts in Rwanda from February 19 to March 17, 2015, and followed over a period of 21 months for this study. Men were interviewed at three time points: baseline, 9 months post-baseline, and 21 months post-baseline; due to funding constraints, women were interviewed at only two time-points, at 9 and 21 months post-baseline. In order to highlight the longer-term effects of the intervention, this paper presents the findings from 21 months post-baseline. The Rwanda Men’s Resource Center, a local non-governmental organization implementing the intervention, selected the sites in collaboration with district authorities.
Table 3 presents the baseline characteristics of men by intervention and control groups. Independent samples t-tests and chi-squared tests of association, as appropriate, showed no statistically significant differences in baseline characteristics between the intervention and control group respondents. Men reported a mean age of 28.7 and their partners’ mean age of 26.6 years. More than 60% of men had only primary education or less, and less than a third reported always being able to afford basic items. Nearly all men were employed, with the majority of those self-employed. Three quarters had biological children, and about two thirds were expecting a child. Women were not surveyed at baseline.
The Bandebereho intervention led to substantial improvements in multiple reported outcomes, including women’s experience of physical and sexual IPV, women’s ANC attendance, men’s accompaniment at ANC, modern contraceptive use, and partner support during pregnancy. Importantly, the intervention also led to reductions in men’s dominance in household decision-making and improvements in the household division of labor. Notably, our findings at 21-months are similar to those at 9 months (not reported here), suggesting sustained effects over time. Our study strengthens the existing evidence on male engagement approaches; together with earlier studies our findings suggest that culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched inequalities and a range of health-related behavioral outcomes.
Our study demonstrates that a gender-transformative intervention can positively impact a range of health and gender-related behavioral outcomes. Our study builds on existing evidence of male engagement interventions and makes unique contributions to measuring the impact of male engagement on household power dynamics. While our findings show substantial positive effects, high rates of inequality and violence persist: about one in three women in the intervention group reported experiencing IPV in the past 12 months, the vast majority of parents used physical punishment, and men still dominated household decisions. Further research should examine whether these rates can be lowered if the intervention is implemented over longer time periods or with additional components. Future research could also directly measure health outcomes and use health facility or biomarker data to corroborate self-reported behavior change, and examine the effect of the intervention if implemented over longer time periods, when implemented with greater numbers and in other settings, or when delivered through the public sector. Nevertheless, the findings highlight the promise of the Bandebereho intervention, designed and adapted to fit the particular cultural context. Targeting the transition into fatherhood and parenting, and supporting couples with skills to make their relationships stronger and more equitable, had important effects on the intervention outcomes.