Can a Gender Equity and Family Planning Intervention for Men Change Men's Gender Ideology?: Results from the CHARM Cluster Randomized Controlled Trial in Rural India

"Given the role of husbands' gender ideology in women's contraceptive use, the CHARM intervention represents a promising approach for challenging root causes of women's unmet need for contraception."

Research in India and other global contexts has demonstrated that unmet need for family planning (FP) is often caused by gender-related attitudes that emphasise men's control over contraceptive decision-making. Research indicates that contraceptive use is subject to gender and power dynamics, particularly in places like India, where restrictive gender norms emphasise male decision-making. The concepts of gender ideology and power dynamics within heterosexual relationships are embedded within The Theory of Gender and Power (TGP), which informs the intervention and analyses in this study. The study assesses the effect of CHARM [Counseling Husbands to Achieve Reproductive health and Marital equity], a gender equity (GE) and FP counseling intervention for husbands in rural India, on men's gender ideology.

CHARM (which is described in further detail at Related Summaries, below) is a relatively brief intervention compared to other gender-transformative interventions that have been evaluated; it can be difficult to engage men, especially working men, in time-intensive interventions. The intervention involved 3 gender-, culture-, and contextually tailored FP+GE counseling sessions delivered over 3 months by trained allopathic (n=9) and non-allopathic (n=13) male village healthcare providers (VHPs) to married men (sessions 1 and 2) and couples (session 3) in a clinical setting, or if required, near or in the participant's home. VHPs used a desk-sized CHARM flipchart to provide men and couples with pictorial information on FP options, barriers to FP use (including GE-related issues such as son preference), the importance of healthy and shared FP decision-making, and strategies for engaging in respectful marital communication and interactions (inclusive of no spousal violence in the men's sessions).

As explored in the paper (see especially Table 1), the portion of the CHARM intervention related to GE was informed by TGP, which identifies 3 social structures that characterise the gendered relationships between men and women: (i) the sexual division of labour, (ii) the sexual division of power, and (iii) the structure of cathexis, which imposes the differential behavioural norms for men and women and holds that men should be dominant and women should be deferential to men's authority. Taken together, these 3 structures shape the gender-power dynamics within romantic relationships.

The researchers used a 2-armed cluster randomised control (RCT) trial design and collected survey data from husbands (n=1,081), with 469 receiving the CHARM intervention and 612 in the control group, at baseline, 9 months, and 18 months. (Men in the control condition were simply notified of available public health FP services, and their wives were referred to government health system FP services.) The study used 2 primary outcome variables, measured at each time point: (i) gender ideology, which was measured was treated as a continuous variable and measured using the Gender Equitable Men (GEM) scale; and (ii) Equitable Attitudes towards Household Decision Making, which was treated as a dichotomous variable and used items from the Demographic and Health Surveys (DHS). To assess differences on these outcomes, the researchers used generalised linear mixed models (GLMMs).

Main findings include:

• Analyses of simple main effects while adjusting for socio-demographic factors at each time point for gender ideology showed that, while there were no significant differences in mean GEM score at baseline between men in the intervention and control groups, at 9-month follow-up, men in the intervention group had a higher mean GEM score (mean difference: 0.88, standard deviation (SD): 0.50), representing greater support for GE, but this difference was non-significant (p=0.08). There were no significant differences in mean GEM score at 18-month follow-up (mean difference: -0.06, SD: 0.50, p=0.90).
• Analyses of simple main effects for each time point indicated that, while there were no significant differences between treatment groups on equitable attitudes towards household decision-making at baseline, men in the intervention group were significantly more likely to report equitable attitudes towards household decision-making at 9-month follow-up than men in the control group (adjusted odds ratio (AOR): 1.83, 95% confidence interval (CI): 1.29-2.60). By 18-month follow-up, these significant effects were lost (AOR: 1.04, 95% CI: 0.73-1.49).
• For equitable attitudes towards household decision-making at 9-month follow-up adjusting for control variables, men who only attended male sessions had 1.94 times the odds of having equitable attitudes compared to men who received no sessions (95% CI: 1.19-3.17), and men who attended the male and couple sessions had 1.76 times the odds of having equitable attitudes compared to men with no sessions (95% CI: 1.17-2.64). Again, effects were lost by 18-month follow-up.

Reflecting on the findings, the researchers suggest that future iterations of CHARM (e.g., see Related Summaries, below) may need to adjust certain strategies for increased impact. For example, the marginally non-significant impact on men's gender ideology (p=0.08) could be due to the fact that CHARM focused more on power dynamics within the household dyad; future versions of this intervention could incorporate elements on gender roles more generally. In addition, the fact that men who only attended the male sessions were the most likely to have equitable attitudes towards household decision-making could be explained by different delivery or interpretation of that content in the presence of women, or the fact that men who were willing to go to couples sessions differed in some systematic way from men who only attended the male sessions. Future implementation could consider and assess whether these dynamics were factors contributing to this finding.

Furthermore, the fact that the intervention effects were not sustained "represents a key question for the field related to how to make long-term impact....[I]intervention implementers need to be thoroughly connected to communities and community organizations so they can continue to engage on the topics after the actual intervention period. Reminders or refreshers for program participants may be sufficient to carry the short-term impacts into longer term change." The researchers propose that "a community-wide media campaign could serve this reinforcement purpose, or the facilitator may need to visit the man again to review what was discussed....[T]o further community-level change in gender norms - in addition to the men's own changes - implementation could include a fourth session that incorporates mother-in-laws or other key influencers in men's lives so that the process of change is supported by members of his social network."

In conclusion, the evidence presented in this paper and the findings from other studies referenced herein "demonstrate that gender-transformative programming could be successfully implemented to positively impact a key determinant of family planning outcomes: gender-power dynamics."