Cluster Randomized Controlled Trial Evaluation of a Gender Equity and Family Planning Intervention for Married Men and Couples in Rural India

"...appears to be an effective approach to engage men in family planning, improve marital contraceptive communication and use, and reduce male perpetration of sexual IPV."

More than one in five of the estimated 153 million women with unmet need for family planning (FP) reside in India. Given men's role in controlling contraception and, relatedly, the need to improve gender equity (GE) in this context (as demonstrated by disproportionate burden of intimate partner violence (IPV) in the country), there has been an increasing focus on engaging men in FP interventions. This cluster randomised controlled trial (RCT) was conducted to evaluate the impact of CHARM [Counseling Husbands to Achieve Reproductive health and Marital equity] on marital contraceptive use and incident pregnancy - and, secondarily, on contraceptive communication and men's IPV attitudes and perpetration - in rural areas of Thane district, Maharashtra, India.

The intervention involved three gender-, culture-, and contextually-tailored GE+FP counseling sessions delivered over a 3-month period by trained male village healthcare providers to married men, alone (sessions 1 and 2) and with their wives (session 3). A desk-sized CHARM flipchart was used by village health providers to provide men and couples with pictorial information on FP options, barriers to FP use (including GE-related issues), the importance of healthy and shared FP decision-making, and how to engage in respectful marital communication and interactions (inclusive of no spousal violence in the men's sessions). At each contact, village health providers offered free condoms and oral contraceptive pills; the latter required women to visit the provider.

The CHARM intervention was developed based on a theoretical framework that included Social Cognitive Theory (SCT) and Theory of Gender and Power (TGP):

• SCT posits that behaviour change (in this case, contraceptive use) is more likely if an individual perceives positive outcomes for engaging in the behaviour (e.g., beliefs that spacing births through contraception will produce healthier children), feels capable of engaging in and controlling the behaviour (i.e., self-efficacy to use contraception), and has an environment supportive of the behaviour (e.g., access to FP services). Hence, SCT would support use of FP education and skills-building with improved access to contraceptives.
• TGP posits that gender-based power dynamics inherent to many heterosexual dyadic relationships due to societally reinforced social norms can facilitate male control over sexual and reproductive decision-making, including contraceptive use, and that some men may even use violence to control their female partners. Hence, counseling that can affect GE and FP normative beliefs among men, particularly if the counseling was delivered by a respected male, could be useful in improving contraceptive use in the context of safer and healthier relationships.

CHARM included Government of India FP information, education, and counseling (IEC) materials used in the public health system to provide basic FP knowledge and positive outcome expectancies, as well as contraceptives. Additional elements focused on GE and social norms were then created for the CHARM curriculum based on the above-described theoretical framework and findings from formative research. The latter involved qualitative data collection from rural couples, mothers-in-law, and providers serving rural couples.

Findings from this formative research demonstrated the need for FP education to dispel ongoing myths related to health consequences of spacing contraceptives and GE social norm change approaches related to expectations of pregnancy early in marriage, son preference, lack of male responsibility in FP, and greater male or in-law relative to female control of FP decision-making. Once the model and curriculum were developed, review and feedback were obtained from rural health practitioners and FP experts for finalisation and pilot-testing. CHARM providers were allopathic (n = 9) and non-allopathic (n = 13) (mostly male) village healthcare providers trained over three days on FP counseling, GE and IPV issues, and CHARM implementation.

A 2-armed cluster RCT was conducted with young married couples (n = 1,081 couples), who were were majority (68.0%) tribal, from 50 geographic clusters (25 clusters randomised to CHARM and a control condition, respectively) in rural Maharashtra, India.

A significant time-by-treatment effect on contraceptive use was seen in intent-to-treat analyses (p = 0.02), and marginally significant differences by treatment group were seen for contraceptive use at 9- and 18-month follow-ups. (See Table 3 in the paper.) Further examination of the time by treatment effect revealed that contraceptive use in the intervention group increased significantly from baseline at both 9-month (adjusted odds ratio (AOR) = 2.13, 95% confidence interval (CI) = 1.53, 2.95) and 18-month (AOR = 2.61, 95% CI = 1.88, 3.61) follow-ups, while the control group increased at 18-month follow-up (AOR = 1.51, 95% CI = 1.12, 2.04), but less than that seen in the intervention group. Dose analyses further revealed that contraceptive use doubled by 18-month follow-up among those participating in male-only sessions (AOR = 1.96, 95% CI = 1.18, 3.27) and in male and couple sessions (AOR = 2.00, 95% CI = 1.26, 3.17), relative to those receiving no intervention sessions. No significant effect on pregnancy was seen.

Dose analyses further reveal that couple sessions were required to improve contraceptive communication, highlighting the importance of couple sessions, despite the greater difficulty in achieving couple versus male-only session participation: Most men recruited from CHARM communities (91.3%) received at least one CHARM intervention session; 52.5% received the couples' session with their wife.

Examples of gender-specific findings:

• Women from the CHARM condition, relative to controls, were more likely to report contraceptive communication at 9-month follow-up (AOR = 1.77, p = 0.04) and modern contraceptive use at 9- and 18-month follow-ups (AORs = 1.57-1.58, p = 0.05), and they were less likely to report sexual IPV at 18-month follow-up (AOR = 0.48, p = 0.01).
• Men in the CHARM condition were less likely than those in the control clusters to report attitudes accepting of sexual IPV at 9-month (AOR = 0.64, p = 0.03) and 18-month (AOR = 0.51, p = 0.004) follow-up, and attitudes accepting of physical IPV at 18-month follow-up (AOR = 0.64, p = 0.02).
• Men who received CHARM and participated in a response-to-programme survey (n = 347) largely (more than 93%) reported comprehensive FP content coverage and positive response to the programme, but only half of participants reported receipt of contraceptives, almost exclusively in the form of condoms. Most (81.6%) found the men's sessions very useful, but only 58.5% found the couple session useful.

In short, the study findings document the effectiveness of CHARM in engaging husbands and improving marital contraceptive communication and use among young couples in rural Maharashtra, India. The study also demonstrated effects of CHARM on reduction in men's perpetration of sexual IPV and attitudes toward acceptability of IPV, likely due to inclusion of GE counseling.

Reflecting on the experience, the researchers suggest that CHARM "may further benefit from more expanded choices for contraceptives and better reach to women for use of more effective contraceptives, given that the current model did not affect highly effective contraceptive use or incident pregnancy."

In conclusion: "This low intensity intervention, able to be delivered by existing rural medical providers, including non-allopathic private providers, offers a potentially sustainable approach to improve spacing contraceptive use among young couples in rural India and possibly elsewhere....The evidence-based CHARM intervention, which capitalizes on the country's existing rural health infrastructure inclusive of the numerous and accessible private providers, may offer an important means to accelerate improvements in family planning uptake...