Results of a Field Test

Transcription

1 Interactive Workshops to Promote Gender Equity and Family Planning in Rural Communities of Tanzania Results of a Field Test December 2012

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3 Interactive Workshops to Promote Gender Equity and Family Planning in Rural Communities of Tanzania: Results of a Field Test December 2012 By Sidney Ruth Schuler, Geeta Nanda, Rachel Lenzi, Mario Chen, and Sam Field This publication is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) through USAID, under the terms of Agreement No. GPO-A The contents are the responsibility of C-Change, managed by FHI 360, and do not necessarily reflect the views of USAID or the United States Government.

4 Recommended Citation Schuler, S. R., G. Nanda, M. Chen, L. F. R. Rodriguez, and R. Lenzi Interactive Workshops to Promote Gender Equity and Family Planning in Rural Communities of Tanzania: Results of a Field Test. Washington, DC: C-Change/FHI 360. C-Change is a USAID-funded project implemented by FHI 360 and its partners: CARE; Internews; Ohio University; IDEO; Center for Media Studies, India; New Concept, India; Soul City, South Africa; Social Surveys, South Africa; and Straight Talk, Uganda. Contact Information: C-Change FHI Connecticut Avenue NW Washington DC Phone: (202) Fax: (202)

5 Acknowledgments C-Change is grateful to Fredrick Nyagah, who collaborated in the development of the facilitators manual and trained the facilitators. We thank Marie Stopes, and in particular, Heidi Brown, director of programs, and Innocent Augustino, senior researcher; Sikitiko Kapile, director, Mary Rusimbi, senior researcher, and Rose Mangilima, survey supervisor, all of PEMConsult East Africa Ltd; and Eric Van Praag, FHI 360 senior regional technical advisor in Dares-Salaam. This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A The contents are the responsibility of the C-Change project, managed by FHI 360, and do not necessarily reflect the views of USAID or the United States Government.

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7 CONTENTS SUMMARY... 1 INTRODUCTION... 2 BACKGROUND... 2 IMPLEMENTING PARTNERS... 3 SETTING... 4 METHODS... 4 Interventions...4 Research Sites...5 CBM and Workshop Participant Selection...6 Study Design...7 Data Analysis...8 RESULTS... 8 Service Statistics...8 Cognitive Interviews...13 Participation in Workshop...13 Survey Coverage...13 Participant Characteristics...13 Gender Equity Scores...14 Knowledge of Modern Contraceptive Methods...16 Contraceptive Use...18 DISCUSSION Gender Attitudes...19 Knowledge of Modern Contraceptive Methods...19 Contraceptive Use...19 STUDY LIMITATIONS CONCLUSIONS REFERENCES Appendix 1. Percentages of Women Reporting Equitable Responses on the GAFPE Scale Appendix 2. Percentages of Men Reporting Equitable Responses on the GAFPE Scale... 26

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9 SUMMARY In rural Tanzania, gender norms contribute to high fertility and closely spaced births by discouraging contraceptive use and constraining women from making decisions regarding the timing of their pregnancies and the size of their families. Community workshops for men, women, and couples were conducted in two rural communities in Tanzania to test the hypothesis that the promotion of gender equity in the context of reproductive health will contribute to gender-equitable attitudes and strengthen the practice of family planning. The communities were randomly assigned to intervention and control groups. Pre/post surveys were conducted. Data analysis consisted of tests based on comparisons of odds ratios estimated with mixed effect logistic models to account for community-level randomization and repeated measures per participant. Analyses showed statistically significant effects of the intervention on two of the three outcomes examined: gender attitudes and contraceptive knowledge. The results suggest that it is possible to influence both inequitable gender norms and reproductive health knowledge and behaviors in a short span of time (in this case in less than two months) using appropriately designed communications interventions that engage communities in rethinking the inequitable gender norms that act as barriers to health. 1

10 INTRODUCTION This report describes an intervention study conducted in by Marie Stopes Tanzania (MST) and FHI 360 s Communication for Change Project (C-Change) to test the hypothesis that community mobilization strategies in this case, interactive community-level workshops and community-based mobilizers that incorporate gender issues have a greater impact on adoption of family planning than strategies that attempt to expand access to family planning without addressing gender issues. The project described here worked with married couples and focused on the intersection of gender norms and family planning. Ethical review of the project was provided by the National Institute for Medical Research Tanzania and the Protection of Human Subject Committee at FHI 360. The evaluation was designed by FHI 360 and implemented by PEMConsult East Africa, Ltd., an independent research firm based in Dar-es- Salaam. BACKGROUND In many parts of the world, gender norms contribute to high fertility and closely spaced births by discouraging contraceptive use, constrain women from making decisions regarding the timing of their pregnancies and the size of their families, and distance men, who have more decision-making power, from reliable family planning information and services. For example, gender norms influence: The number and type of sexual partners that women and men are expected to have The situations in which couples are likely to have sex Who has the power to determine when to have sex Who decides whether to use condoms and other contraceptive methods The role of violence (or its threat) in forcing women into sex Increasingly, health and development interventions are designed to: 1. Mitigate gender inequities and social structures that deprive women of access to opportunities, and violate their rights to access the necessary resources to ensure their welfare and that of their families. 2. Change concepts of masculinity that are associated with behaviors such as men s use of violence as a means of controlling women and girls. 3. Address gender norms that disadvantage women at various phases in their life cycle. However, few published studies document the impact of interventions intended to alter gender attitudes related to health, and even fewer analyze the effects of changing gender norms or attitudes on the use of contraception in less developed countries (Boender at al 2004; Rottach 2

11 et al 2009; Shattuck et al. 2011). Here we present findings from a study testing a short-duration intervention designed specifically to influence the inequitable gender norms that constrain the practice of family planning. The project was inspired in part by the work of Promundo, based in Brazil, which has shown success in reducing HIV and AIDS risk behaviors in several countries by holding interactive discussion sessions with groups of young men in which the men are encouraged to examine and question prevailing stereotypes and norms of masculinity (Barker et al 2004, 2006; Pulerwitz et al 2006). This project worked with married couples and focused on the intersection of gender norms and family planning. The hypothesis of this study is that the promotion of gender equity in the context of reproductive health will contribute to gender equitable attitudes and an uptake of family planning. A minimum level of access to contraceptive methods is required to test this hypothesis. For this reason, the mobile clinic services and community outreach programs of MST provide a unique platform for implementation of the present study in rural Tanzania. IMPLEMENTING PARTNERS The C-Change project of FHI 360 is a USAID supported project to improve the effectiveness and sustainability of social and behavior change communication as an integral part of development efforts in the health, environment, and civil society sectors. C-Change works with global, regional, and local partners to implement programs that use communication to change behaviors and social norms; conduct operational research to improve the effectiveness of its programming in the immediate- and long-term; and provide evidence of the impact of communication interventions. One approach C-Change uses to improve health and well-being is implementing programs that address gender norms. Marie Stopes Tanzania (MST) has been operating in Tanzania since 1989, delivering high quality sexual and reproductive health (SRH) services. MST currently has 14 static clinics and 14 outreach teams delivering a full range of short-term, long-term, and permanent family planning methods in more than 95 percent of districts across the country. In 2010, MST delivered sexual and reproductive health care and primary health care services to more than 300,000 clients. This included 32,000 tubal ligations, 23,000 contraceptive implants, and 26,000 inter-uterine contraceptive devices (IUCD). MST works in various ways with community-based mobilizers (CBMs) who have been trained by the Ministry of Health (MOH) to generate demand for family planning (FP) in their communities and to make reproductive health referrals to government facilities and MST mobile services. PEMconsult East Africa Ltd., a Tanzania-based research firm, was established in 2002 and is led by independent consultants who cooperate with a range of public sector enterprises and NGOs. 3

12 SETTING The project was implemented in 36 rural sites where MST currently provides FP outreach services and FP methods; 18 each from two districts: Geita in Mwanza Region and Biharamulo in Kagera Region in the Lake Zone of Tanzania. In 2010, Tanzania had a total fertility rate of 5.4 births per woman, only a slight decrease from 5.7 births per woman in Forty-five percent of births occur less than three years after a previous birth, with the most need for spacing seen in the Lake and Western Zones (mean number of months spacing is only 30 in both zones). While contraceptive prevalence among married women has increased significantly in recent years, use of modern methods in mainland rural areas remains at 25 percent, compared to nearly 35 percent in mainland urban areas; in the Lake Zone only 12 percent of married women reported using a modern method. Across Tanzania, 25.3 percent of married women have unmet need for FP, and 33 percent of women in the Lake Zone have unmet need. Results from a recent qualitative study (Schuler, Rottach, and Mukiri 2011) suggest that gender inequality is an important contributor to unmet need for FP among women. METHODS Interventions The community mobilization strategy tested in this study is comprised of a series of six interactive workshop sessions on gender and family planning. The workshop sessions were designed to be held about one week apart, sessions 1 and 2 with men and women in separate groups and 3 and 4 with men and women combined into one group for a total of six workshops. The manual used to guide the workshops incorporates games, role-plays, and other exercises meant to raise awareness of gender inequality and the gender issues that function as barriers to FP, and to encourage gender-equitable attitudes and openness to FP. The manual is available on the C-Change website C-Change staff and consultants developed it specifically for this project and a similar project in Guatemala. The manual adapted material from a number of sources, including Stepping Stones, the EngenderHealth Men as Partners manual, and the Population Council s Sakhi Saheli manual (Welbourn 2007, EngenderHealth and Promundo 2008, Sakhi Saheli 2008). The facilitators also distributed information sheets on contraceptive methods. The topics of the four workshops were: 1. Setting the Stage and Exploring the Concept of Gender 2. Strengthening Demand for Family Planning and Encouraging Responsible Parenthood 3. Sexuality and Communication about Sex and Family Planning 4. Communication between Men and Women on Sex and Contraception 4

13 For example, in one workshop a role-play session was designed to strengthen women s ability to negotiate contraceptive use with their male partners. The facilitator asked three women to volunteer to be women and three to volunteer as their male partners. They were paired together and another volunteer was asked to be a baby for the third pair. Each pair was given minutes to create a small play about sex, fear of pregnancy, and FP, using one of three scenarios. One was the following: Role-play 3: A man proposes sex but the wife says the baby is in the room. The man asks why she always wants to sleep with the baby, who is already three years old. As the man tries to convince the wife to loosen her skirt, the baby starts crying and the husband threatens to find another woman to have sex with him. The wife gives in, reasoning loudly that it is better she accepts than have him go to another woman. The women then performed their plays in front of the group. After each play, the facilitator asked the rest of the group to briefly discuss the following questions: Research Sites Is this dialogue realistic? Who is in control? Does the man seem to care whether his partner gets pregnant? Can the woman understand whether he wants her to get pregnant? Does the woman seem to care whether she gets pregnant? Can the man understand whether she wants to get pregnant? Is there a risk of an unplanned pregnancy? Do they have a good relationship? What would make this situation better? Marie Stopes first selected a district in each of two regions of the country where contraceptive prevalence was comparatively low and their mobile clinics were active. Staff visited each district to explain the project to local MOH officials and asked them to propose 20 communities to participate in the project. MST then used a Research Randomizer to randomly assign six of these to each of three groups two intervention groups (Groups I and II) and one control group (Group III). The workshops in Group II were delayed until after the completion of the interventions in the first intervention group (Group I) so that it could serve as a control group for the survey portion of the evaluation. In Groups I and II, surveys were undertaken to measure changes in gender attitudes among workshop participants. Changes among participants in Group I were compared with future participants in Group II, where changes might be attributed to the Hawthorne effect 5

14 or to extraneous factors. The simultaneous recruitment of participants in the Group II communities was a strategy to minimize selection bias. In this way, participants would not be compared with groups of people who might have been unwilling to attend the workshops (Table 1). In Group III, only service statistics were collected. CBM and Workshop Participant Selection Before beginning the CBM and participant recruitment process, MST sent letters requesting community participation in the baseline study to regional medical officers, regional reproductive and child health coordinators, district executive directors, district medical officers and reproductive and child health coordinators, and local government authorities at the community level in Biharamulo District in Kagera Region and Geita District in Mwanza Region. In each of the 24 sites of Groups I and II, local MOH officials selected two CBMs (one male and one female 48 CBMs in total) to facilitate the interactive workshop sessions. Each selected CBM participated in a 10-day training with an expert trainer focusing on general FP knowledge, gender norms, and instruction on facilitation of the interactive workshop sessions using the manual developed by C-Change. MST collaborated with local government health workers and the selected CBMs in each community to recruit workshop participants. A community meeting was held at each site to recruit participants. Drama groups were used to attract people to attend. At the community meetings, MST provided information to the community on the nature of the study, procedures to be followed, and any anticipated risks and benefits to eligible participants. Table 1: Implementation Timeline Dec 2011 Jan 2012 Feb 2012 Mar 2012 Apr 2012 May 2012 Group I Participant Recruitment Baseline Survey Facilitator Training Workshops Mobile Clinic Visit Endline Survey Group II Participant Recruitment Baseline Survey Facilitator Training Workshops Mobile Clinic Visit Endline Survey Control Group Mobile Clinic Visit 6

15 Study Design The outcomes of interest for the study included: 1. Changes in uptake of FP services/products 2. Changes in gender attitudes and attitudes toward FP 3. Changes in knowledge of FP Additionally, the study compared relationships among these three outcomes. The study was designed so that outcomes could be compared across three data sources: 1. Survey Data Baseline and endline surveys were held in both the intervention groups to measure changes in gender attitudes among the participants in the interactive discussions. The surveys were conducted in both Group I sites and Group II sites before and after the workshops were held in Intervention Group I (but before they had been held in Group II) to compare changes among participants who had completed the workshops and persons who had signed up to participate but had not yet completed the workshops. While the study was originally designed such that the baseline and endline surveys would occur in Group I sites and Group II sites simultaneously, due to unexpected problems with the data collection teams, the team was unable to conduct the baseline survey in the Group II sites until March 2012, just before the endline survey was conducted in the Group I sites. Since the endline survey had to be completed in the Group II sites before the workshops could begin (to preserve the group as a comparison group for the survey), the endline survey was conducted in April 2012, thus the interval between the baseline and endline surveys in Group I was four months, while the interval in Group II was only one month. Gender attitudes were measured using the Gender and Family Planning Equity (GAFPE) Scale, which was developed for this study and for a similar study in Guatemala. The GAFPE Scale (shown in Appendices 1 and 2) contains 20 items. Three items are drawn from the Gender Equitable Men (GEM) Scale (Pulerwitz and Barker 2008), and the rest were designed to reflect gender norms that influence family planning in the two countries. Only a few items were too country-specific to be used in both settings. Statements reflecting norms and practices related to sexuality and family planning that were either equitable or inequitable were read to participants, who were asked whether they agreed, partially agreed, or disagreed with each statement. One point was given for each response that indicated an equitable attitude (as opposed to an inequitable or partially equitable attitude). After all responses were tallied, points were summed to create a continuous gender equity score for each individual, at baseline and at follow-up. The individuals 7

16 who expressed the most gender-equitable attitudes thus accumulated the greatest number of points. Cognitive interviews were conducted in several of the intervention sites with 14 men and 19 women who did not participate in the interventions in order to qualitatively assess their understanding of the scale items. 2. Service Statistics Evaluation of the interventions effects on contraceptive adoption was conducted by comparing the numbers of contraceptive adopters in Group I to the number of adopters in Group II and also to the sites in the control group. Uptake was compared from mobile clinics conducted in the previous year, mobile clinics held just after the Group I interventions, and mobile clinics held just after the Group II interventions. Data Analysis SPSS v.21 and SAS v.9.3 were used to analyze the survey data. Variables measuring gender attitudes and contraceptive knowledge and use were compared within Group I and Group II, and levels of change were compared between the groups. Tests of significance were conducted using mixed effect models accounting for community-level randomization and repeated measures per participant. A linear mixed model was used for assessing changes in GAFPE and a logistic mixed model for contraceptive knowledge and use as these were measured dichotomously. The analysis for contraceptive use included nonpregnant women only. RESULTS Service Statistics The study collected monthly counts of contraceptive service utilization for mobile and stationary clinics that span the pre- and post-treatment time periods (January 2011 May 2012). Time series plots by service type are shown in Figures 1 3 for mobile clinics and 4 5 for the stationary clinics. 1 The data from the stationary clinic showed evidence of strong ceiling effects, where the exact count of service utilization was observed in a single clinic for multiple, consecutive months. Developing and implementing the appropriate statistical methodology that could account for such effects was time and cost prohibitive. This report, therefore, focuses exclusively on the data from the mobile clinics. Data from these types of clinic involved long-acting contraceptive methods: bilateral tubal ligation (BTL), IUCD, and implants. The 1 The actual location of the sample points have been randomly scattered so that data points for months in which two or more clinics have the same observed service utilization do not stack on top of each other. 8

17 observed monthly rate of sterilization service utilization was too low to estimate treatment impacts. Figure 1: Service Use: Bilateral Tubal Ligation Figure 2: Service Use: Implants 9

18 Figure 3: Service Use: Intrauterine Contraceptive Devices Figure 4: Service Use: Daily Contraceptive Pills 10

19 Figure 5: Service Use: Depo-Provera Injections For these analyses, the observed time series were divided into pre- and post-treatment time periods, with the post-treatment time period beginning on January 1, A visual inspection of Figures 1 3 reveal a strong seasonal pattern of service utilization, with the service utilization appearing to peak between December and February across all types of services. To account for seasonality, data were discarded from June through August and the comparison was based across pre- and post-treatment time periods using data from four months (February 2011, May 2011, March 2012, and May 2012). The main treatment comparison involves the growth/decline in service utilization for the months of February 2011 (pretreatment) and March 2012 (post-treatment). Descriptive statistics for service utilization during these months are shown in Table 2. 11

20 Table 2: Descriptive Statistics for Service Use by Month, Year, and Treatment Group Pretreatment Post-treatment February May March May Mean Std N Mean Std N Mean Std N Mean Std N Tubal ligation Intervention II Intervention I Control IUCD Intervention II Intervention I Control Implants Intervention II Intervention I Control To control for secular trends, the mean change observed in the two treatment groups was compared to the mean change observed in the control group. Unfortunately, data for the month of March during the pretreatment time period were not available. Estimates are, therefore, based on a linear mixed model, with the rate of service utilization in March 2011 being interpolated from a linear trend estimated using the February and May 2011 data. Figures 1 3 show model estimated trends in the service utilization rates as solid arrows. The model also included a random intercept to adjust for between site variance in the mean level of service utilization across the entire study window. The estimates of treatment impacts shown in Table 3 are based on linear combinations of estimated model parameters. Table 3: Comparisons of March Service Use Across Time Period and Treatment Group Treatment Group Comparison BTL# IUCD Implants Intervention I March 2011 March (1.25) 3.00(0.68)*** (3.74)*** Intervention II March 2011 March (1.25)*** 2.58(0.68)*** (3.74)*** Control March 2011 March (1.25) 1.17(0.68) (3.74)*** # Standard errors parentheses Control vs. Intervention I -3.08(1.77) 1.83(0.96) 5.06(5.28) Control vs. Intervention II -6.19(1.77)*** 1.42(0.96) -4.83(5.28) 12

21 In both treatment groups, the mean level of BTL service utilization was lower in March 2012 than it was in March 2011, while this decline was not observed in the control group. This indicates that treatment is negatively associated with BTL service utilization, although this effect is only statistically significant for Intervention II (last row of table). For the remaining services, IUCD and implants, none of the treatment and control comparisons were statistically significant, suggesting that the treatment was not broadly associated with increased service utilizations among the sites in which it was implemented. Cognitive Interviews Results from cognitive interviews done to test comprehension of selected items in the GAFPE Scale found no notable problems. Participation in Workshop A total of 199 men and 233 women participated in at least one of the workshops in Group I, including 193 married couples; in Group I the workshops were completed in February A total of 178 men and 269 women participated in at least one of the workshops in Group II, including 138 married couples; in Group II the workshops were completed in May The remainder of the participants were married, but not to other participants. With a few exceptions, the participants were ages 35 and under. Most had one or more children. Two mobile clinics were held in each group of sites. Table 4: Participant Totals Men Women Total Group I Group II Total Survey Coverage Since the focus of this study is the assessment of changes, analysis of the data was restricted to participants who completed both baseline and follow-up interviews. A total of 764 interviews were completed in the baseline survey. Of these, 369 were re-interviewed in the follow-up survey. To qualify for the follow-up survey in the intervention sites, the potential respondent had to have been interviewed in the baseline survey and participated in at least one of the workshops. Participant Characteristics As shown in Table 5, the mean age of participants was about 28 for both Group I and Group II. Slightly more than half the respondents in Group I and just over 60 percent among Group II reported that they had three or more living children. About 90 percent of participants were Christian in both groups. The remainder said they were Muslim or nonreligious. Group II had a 13

22 slightly higher number of children than Group I, 3.5 compared with 3.1. There was a slightly higher proportion with no education in Group I than in Group II 12.7 percent versus 7.1 percent. Table 5: Selected Characteristics of Survey Participants at Baseline, by Group Group I (n=229) Group II (n=140) Mean age Age groups Less than age 20 (16) 7.0% (6) 4.3% Ages (51) 22.3% (39) Ages (134) 58.5% (67) 47.9% Ages 35+ (28) 12.2% (28) 20.0%) Gender Female (125) 54.6% (84) 60.0% Male (104) 45.4% (56) 40.0% Religion Muslim (11) 4.8% (9) 6.4% Christian (209) 91.3% (126) 90.0% None (9) 3.9% (5) 3.6% Education None (29)12.7% (10) 7.1% Primary (partial or complete) (168) 73.3% (114) 81.5% Partial secondary (10) 4.4% (7) 5.0% Complete secondary or some university (22) 9.6% (9) 6.4% Mean number of children Number of living children None (21) 9.2% (13) 9.3% One (44) 19.2% (20) 14.3% Two (46) 20.1% (22) 15.7% Three or more (118) 51.5% (85) 60.7% Gender Equity Scores Group II gained more equity points between the two surveys than Group I on only one item for men and one for women, and the differences in these gains were small. Among the women, the greatest gains in equity points among Group I were on the items: Having sex using contraception is more exciting because you do not have to worry about pregnancy (25.9 points); If your church says you should use only natural family planning methods, you should follow that (24.8 points); My husband would be justifiably angry if I asked him to use a 14

23 condom (21.2 points); and If a woman cannot use an FP method without side effects, her partner should use a method (16.8 points). Among men in Group I, the greatest gains were on: Having sex using contraception is more exciting because you don t have to worry about pregnancy (26.1 points); If a woman does not want to get pregnant and is not using contraceptives, her partner should do so (25.1 points); If a woman cannot use an FP method without side effects, her partner should use one (22.4 points); and If your church says you should use only natural family planning methods, you should follow that (18.8 points). Tables 6 and 7 present the results of the linear mixed model analysis for the comparison of changes in equity scores. The differences in the levels of change in gender equity scores between the two groups are highly significant, both for men and for women. The models adjust for education, age, and number of living children, factors known to be significant predictors of contraceptive use. Table 6: Linear Mixed Model Estimates of Intervention Effect on Equity Scores, Women Women (n=209) Estimates 95% CI P-value Education 1 vs [0.61,2.05] < vs [0.47,2.18] Age 1 vs [-0.53,1.51] vs [-1.28,0.98] vs [-0.97,1.98] Number of living children 1 vs [-0.14,1.36] vs [-0.00,1.79] Group I: FU-Baseline 2.73 [2.15,3.31] <0.001 Group II: FU-Baseline 0.81 [0.10,1.52] Difference in Difference 1.92 [1.01,2.83] <

24 Table 7: Linear Mixed Model Estimates of Intervention Effect on Equity Scores, Men Men (n=160) Estimates 95% CI P-value Education 1 vs [0.46,4.76] vs [0.74,5.13] Age 1 vs [-5.29,0.78] vs [-4.68,1.15] vs [-4.74,1.26] Number of living children 1 vs [-1.09,0.75] vs [-0.68,1.23] Group I: FU-Baseline 2.95 [2.15,3.75] <0.001 Group II: FU-Baseline 0.59 [-0.50,1.68] Difference in Difference 2.36 [1.01,3.71] Differences in the level of change positive and negative equity points were calculated by subtracting the mean scores of Group II from those of Group I. Negative numbers indicate that Group I had fewer equity points than Group II or that Group II scores dropped by fewer points than Group I between baseline and follow up. Positive numbers show gains in equity points for Group I, relative to Group II. Knowledge of Modern Contraceptive Methods Knowledge of contraceptive methods was higher in Group II, where more than 55 percent of men and women knew of eight or more contraceptive methods, than Group I, where only about a third of women and less than 40 percent of men knew of eight or more methods (Table 8). Levels of knowledge of modern contraceptive methods increased among women and men in both groups in the follow-up survey, perhaps in part reflecting a Hawthorne effect (i.e., some respondents may have learned the names of contraceptive methods from the survey itself), but increases in Group I were considerably greater than those in Group II. In Group I, the percentage of women and men knowing eight or more modern FP methods increased by 52.8 and 45.2 percentage points, respectively, while in Group II the percentages increased by 17.9 and 16 points. 16

25 Table 8: Changes in Knowledge of Modern Contraceptive Methods, by Group and Gender Tanzania Women Men % knowing 8 or more modern FP methods Intervention (n =125) Control (n =84) Intervention (n =104) Control (n =56) Baseline Follow-up Tables 9 and 10 show comparisons of odds ratios estimated with mixed effect logistic models. The differences in the levels of change in contraceptive knowledge between the two groups are highly significant for both men and women. Table 9: Mixed Logistic Models of Treatment Effect on FP Knowledge, Men Men (N=160) OR 95% CI P-value Education 1 vs [0.12,12.71] vs [0.09,10.36] Age 1 vs [0.08,18.80] vs [0.19,40.10] vs [0.57,147.25] Number of living children 1 vs [0.40,2.13] vs [0.27,1.60] Group I: FU-Baseline [5.53,26.07] <0.001 Group II: FU-Baseline 2.30 [0.92,5.74] Difference in Difference 5.22 [1.58,17.26]

26 Table 10: Mixed Logistic Models of Treatment Effect on FP Knowledge, Women Women (N=209) OR 95% CI P-value Education 1 vs [1.44,6.57] vs [0.78,4.82] Age 1 vs [0.79,6.58] vs [0.73,7.69] vs [0.78,18.36] Number of living children 1 vs [0.65,3.07] vs [0.63,4.10] Group I: FU-Baseline [9.28,43.66] <0.001 Group II: FU-Baseline 2.51 [1.18,5.31] Difference in Difference 8.03 [2.75,23.45] <0.001 Contraceptive Use Modern contraceptive use was defined as currently using one of the following methods: the pill, injectables, implants, condoms, spermicides, IUCDs, or male or female sterilization. Baseline levels of modern contraceptive use were 47.3 percent in Group I and 34.5 percent in Group II (Table 11). In the follow-up survey, the rates increased in both groups. The increase was 6.5 points in Group I and 6.9 points in Group II. These analyses excluded women who were pregnant at baseline or at follow-up. When the increase in modern contraceptive use was compared between the groups, the difference was not statistically significant (Table 12). Table 11: Percent Currently Using Modern Contraceptive Methods Group I (N=91) Group II (N=58) Baseline Follow-up

27 Table 12: Mixed Logistic Model Estimates of Intervention Effect on Current FP Use Among Couples* Tanzania (N=148) OR 95% CI P-value Education 1 vs [0.58,4.54] vs [0.34,3.91] Age 1 vs [1.45,68.16] vs [0.60,33.79] vs [0.38,59.35] Number of living children 1 vs [0.39,3.34] vs [0.32,4.00] Group I: FU-Baseline 1.41 [0.69,2.85] Group II: FU-Baseline 1.47 [0.59,3.68] Difference in Difference 0.96 [0.30,3.06] * Restricted to nonpregnant women DISCUSSION Gender Attitudes In aggregate, baseline scores were higher for men and women in Group II and, in this case, both men s and women s scores in Group I surpassed those of Group II. The same pattern was found on most of the individual items. There were significant differences relating to greater increases in the equitability of gender attitudes among both men and women in Group I. The greatest gains in the women s GAFPE scores in Group I were on items that had to do with women s rights to protect themselves against pregnancy with their male partner s cooperation, an important theme in the workshops. Among the men who attended the workshops, the greatest gains were on the themes of male responsibility and respect for their partners (also important workshop themes) and resisting church control over decisions about contraception. Knowledge of Modern Contraceptive Methods The gains in knowledge of contraception were more than double the baseline levels for both the men and the women who took part in the workshops. There were also modest gains among men and women in Group II, probably reflecting a Hawthorne effect. Contraceptive Use There was no evidence that the interventions influenced contraceptive use. 19

28 STUDY LIMITATIONS The potential for this intervention study to yield positive results regarding contraceptive use was limited by the short time between the interventions and follow-up survey, and the relatively small size of the sample. Also of concern is the sizeable percentage of the baseline samples lost to follow up (dropouts). The most notable differences were: among participants, there were fewer people with no education than among the dropouts (12.7 percent in Group I, 21.1 percent among the dropouts; 7.1 percent among participants in Group II, 22.6 percent among the dropouts). Men in Group II had slightly higher GAFPE scores than dropouts (14.6 percent compared with 13.9 percent), and both men and women in Group II had higher levels of contraceptive knowledge than the male and female dropouts (58.3 percent of Group II women knew eight or more modern methods compared to 50.7 percent of dropouts; 55.4 percent of Group II men knew eight or more compared to 44 percent of dropouts). More dramatically, 39.4 percent of men in Group I and only 19.5 percent of the dropouts knew eight or more methods. Participants in Group I also had higher levels of modern contraceptive use (47.3 percent compared with 34.3 percent). Thus it is possible that individuals who were more interested in FP and likely to use modern contraceptives were less likely to drop out of the intervention and the follow-up survey. As this study looks at changes in both groups, the differences between the participants and the dropouts are unlikely to have much effect on the results. However, these findings should be taken into account in recruitment efforts if this intervention is replicated. CONCLUSIONS Notwithstanding the above limitations of the study, overall the findings confirm the hypothesis that the promotion of gender equity in the context of reproductive health will contribute to gender-equitable attitudes. The workshops had a significant effect on both men s and women s gender attitudes. While the effect of the interactive workshops on contraceptive uptake was not discernible, the effect on knowledge of contraceptive methods was large and statistically significant. The randomized design of the study, the use of phased interventions to minimize selection bias, and the statistical methods that control for the cluster effect (caused by randomly assigning communities rather than individuals to the intervention and control groups) all contribute to the robustness of the results. The results are all the more impressive given the brevity of the intervention only four workshop sessions per individual over the period of a month which contributes to its scalability. The widely promoted Promundo Program H model for reducing inequitable gender attitudes and HIV risk behaviors among young men, as implemented in Brazil and India, entailed weekly sessions over a period of six months, and stipends to ensure continued participation (Barker et al. 2004; Pulerwitz et al. 2006). 20

29 REFERENCES Barker G., M. Nascimento, J. Pulerwitz, C. Ricardo, M. Segundo, and R. Verma Engaging young men in violence prevention: Reflections from Latin America and India. In Combating Gender Violence in and Around Schools, ed. F. Leach and C. Mitchell. Trowbridge, UK: Cromwell Press. Barker G., M. Nascimento, M. Segundo, and J. Pulerwitz How do we know if men have changed? Promoting and measuring attitude change with young men. In Gender Equality and Men, ed. S. Buxton. Oxford: Oxfam. Boender C., D. Santana, et al The so-what? report: A look at whether integrating a gender focus into programs makes a difference to outcomes. Inter-Agency Gender Working Group Task Force Report. Washington, DC: Population Reference Bureau. EngenderHealth and Promundo Engaging boys and men in gender transformation: the group education manual. New York: The ACQUIRE Project. Hausmann R., L. Tyson, and S. Zahidi The global gender gap report Geneva: World Economic Forum. Netzer S., and L. Mallas Incremento en el acceso a la planificación familiar entre grupos de indígenas en Guatemala. Iniciativa de la Política de la Salud. USAID. Pulerwitz J. and G. Barker Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale. Men and Masculinities 10: Pulerwitz J., G. Barker, M. Segundo, and M. Nascimento Promoting more genderequitable norms and behaviors among young men as an HIV/AIDS prevention strategy. Horizons Report. Washington, DC: Population Council. Rottach E., S. Schuler, and K. Hardee Gender perspectives improve reproductive health outcomes: New evidence. Washington, DC: Population Reference Bureau. Sakhi Saheli Promoting gender equity and empowering young women, a training manual. New York: Population Council. Schuler S., E. Rottach, and P. Mukiri Gender norms and family planning decision-making in Tanzania: A qualitative study. Journal of Public Health in Africa (e25): Shattuck D., B. Kerner, K. Gilles, M. Hartmann, T. Ng ombe, and G. Guest Encouraging contraceptive uptake by motivating men to communicate about family planning: The Malawi Male Motivator Project. American Journal of Public Health 101(6):

30 Verma R., V. Mahendra, J. Pulerwitz, G. Barker, J. Van Dam, and S. Flessenkaemper From research to action: Addressing masculinity and gender norms. Indian Journal of Social Work 1: Special Issue. Verma R., J. Pulerwitz, V. Mahendra, S. Khandekar, G. Barker, P., Fulpagare, and S. Singh Challenging and changing gender attitudes among young men in Mumbai, India. Reproductive Health Matters 14(28):1 10. Verma R., J. Pulerwitz, V. Mahendra, S. Khandekar, A. Singh, S. Das, S. Mehra, A. Nura, and G. Barker Promoting gender equity as a strategy to reduce HIV risk and gender-based violence among young men in India. Horizons Final Report. Washington, DC: Population Council. Welbourn A Stepping stones: A training package on HIV/AIDS, communication and relationship skills. Oxford: Strategies for Hope. World Health Organization Engaging men and boys in changing gender-based inequity in health: Evidence from programme interventions. Geneva: World Health Organization. 22

31 Appendix 1. Percentages of Women Reporting Equitable Responses on the GAFPE Scale GAFPE Scale Statements Group I Group II Diff You don t talk about sex, you just do it! Contraceptive use makes it easier for a woman to have more than one sexual partner. My husband would justifiably be angry if I asked him to use a condom. In my opinion, a woman can suggest using condoms like a man can. It is man's responsibility to make sure his wife will not get pregnant if she does not want to. It is the responsibility of both the woman and her partner to avoid pregnancy. A man should not have sex without knowing if his partner wants to get pregnant. If a woman does not want to get pregnant and is not using contraceptives, her partner should do so. Baseline (n=187) Follow up (n=187) Difference between follow up and baseline Baseline (n=149) Follow up (n=149) Difference between follow up and baseline Tx1 diff Tx2 diff

32 GAFPE Scale Statements Group I Group II Diff Having sex without using contraception is more exciting because the woman can get pregnant. Baseline (n=187) Follow up (n=187) Difference between follow up and baseline Baseline (n=149) Follow up (n=149) Difference between follow up and baseline Tx1 diff Tx2 diff Having sex using contraception is more exciting because you do not have to worry about pregnancy. The man is the one with the power to impregnate, so he should decide whether to use contraceptives. It is the husband who should decide how many children to have, since he is the one who has to support them. A couple should decide together if they want to have children, and how many children they want. If a man gets a woman pregnant, the child is the responsibility of both

33 GAFPE Scale Statements Group I Group II Diff The woman has the right to decide to use contraceptives because she is the one who will get pregnant. A man and a woman should decide together what contraceptive method they will use. The woman can decide what type of contraceptive to use because she is the one who will use it. If a woman experiences side effects from using an FP method, her husband or partner should help her find a method that suits her better. If a woman cannot use an FP method without side effects, her partner should use a method. If your church says you should use only natural methods of family planning, you should follow that. Baseline (n=187) Follow up (n=187) Difference between follow up and baseline Baseline (n=149) Follow up (n=149) Difference between follow up and baseline Tx1 diff Tx2 diff

34 Appendix 2. Percentages of Men Reporting Equitable Responses on the GAFPE Scale GAFPE Scale Statements Group I Group II Diff You don t talk about sex, you just do it! Contraceptive use makes it easier for a woman to have more than one sexual partner. I would get mad if my wife asked me to use condoms. In my opinion, a woman can suggest using condoms like a man can. It is man's responsibility to make sure his wife will not get pregnant if she does not want to. It is the responsibility of both the woman and her partner to avoid pregnancy. A man should not have sex without knowing if his partner wants to get pregnant. If a woman does not want to get pregnant and is not using contraceptives, her partner should do so. Baseline (n=141) Follow up (n=141) Difference between follow up and baseline Baseline (n=126) Follow up (n=126) Difference between follow up and baseline Tx1 diff Tx2 diff

35 GAFPE Scale Statements Group I Group II Diff Having sex without using contraceptives is more exciting because a woman can get pregnant. Baseline (n=141) Follow up (n=141) Difference between follow up and baseline Baseline (n=126) Follow up (n=126) Difference between follow up and baseline Tx1 diff Tx2 diff Having sex using contraception is more exciting because you do not have to worry about pregnancy. The man is the one with the power to impregnate, so he should decide whether to use contraceptives. It is the husband who should decide how many children to have, since he is the one who has to support them. A couple should decide together if they want to have children, and how many children they want If a man gets a woman pregnant, the child is the responsibility of both

36 GAFPE Scale Statements Group I Group II Diff The woman has the right to decide to use contraceptives because she is the one who will get pregnant. A man and a woman should decide together what contraceptive method they will use. The woman can decide what type of contraceptive to use because she is the one who will use it. If a woman experiences side effects from using an FP method, her husband or partner should help her find a method that suits her better. If a woman cannot use an FP method without side effects, her partner should use a method. If your church says you should use only natural methods of family planning, you should follow that. Baseline (n=141) Follow up (n=141) Difference between follow up and baseline Baseline (n=126) Follow up (n=126) Difference between follow up and baseline Tx1 diff Tx2 diff