Gender Perspectives Improve Reproductive Health Outcomes: New Evidence

Gender Perspectives
Improve Reproductive Health Outcomes:
new evidence

This publication was prepared with support from the
BRIDGE Project (No. GPO-A-00-03-00004-00), funded by
the U.S. Agency for International Development (USAID),
and implemented by the Population Reference Bureau
(PRB) on behalf of the Interagency Gender Working Group
(IGWG), a network comprising USAID Cooperating Agencies
(CAs), non-governmental organizations (NGOs), and the
USAID Bureau for Global Health.
The examples provided in this publication include experiences
of organizations beyond USAID. This publication does not
provide official USAID guidance but rather presents exam-ples
of innovative approaches for integrating gender into
reproductive health and HIV programs that may be helpful
in responding to the Agency requirements for incorporating
gender considerations in program planning. For official
USAID guidance on gender considerations, readers should
refer to USAID’s Automated Directive System (ADS).
Copyright December 2009, Population Reference Bureau.
All rights reserved.

Gender Perspectives
Improve Reproductive Health Outcomes:
new evidence
By
Elisabeth Rottach
Sidney Ruth Schuler
Academy for Educational Development
Karen Hardee
Population Action International
December 2009
Prepared with support from the Interagency Gender Working Group,
USAID, and Population Action International

Acknowledgments
This publication would not have been possible without the
work of the original Interagency Gender Working Group
(IGWG) Task Force on Evidence that Gender Integration
Makes a Difference to Reproductive Health Outcomes. The
Task Force produced the 2004 “So What?” Report, whose
authors included Carol Boender, Diana Santana, Diana
Santillan, Margaret E. Greene, and two of the current authors,
Karen Hardee and Sidney Schuler.
Special thanks also to USAID’s Michal Avni and Patty
Alleman, gender advisors in the Office of Population and
Reproductive Health of the Global Health Bureau, for their
support and commitment to this publication, and to Diana
Prieto, gender advisor in USAID’s Office of HIV/AIDS for her
invaluable review and suggestions. This publication also bene-fitted
greatly from the comments of various external reviewers,
including Dr. 'Peju Olukoya of the World Health Organization’s
(WHO) Department of Gender, Women, and Health. Thanks
also to other reviewers from WHO, including: Shelly Abdool,
Heli Bathija, Venkatraman Chandra-Mouli, Isabelle de Zoysa,
Elise Johansen, Claudia Morrissey, Annie Portella, and Kirsten
Vogelson.
The authors are grateful to Charlotte Feldman-Jacobs and
Marissa Yeakey of the Population Reference Bureau (PRB) for
their editing, support, and encouragement in moving this
important resource to its successful end.
Elisabeth Rottach, Sidney Schuler, and Karen Hardee
ii Gender Perspectives Improve Reproductive Health Outcomes: New Evidence

Table of Contents iii
Table of Contents
Executive Summary.................................................................................1
1. Introduction........................................................................................4
2. Reducing Unintended Pregnancies.....................................................12
Case Study: Women’s Empowerment Model to Train
Midwives and Doctors....................................................................18
Case Study: PROCOSI Gender-Sensitive Reproductive
Health Program..............................................................................20
3. Improving Maternal Health................................................................22
Case Study: Involving Men in Maternity Care...............................25
Case Study: Social Mobilization or Government Services.............27
4. Reducing HIV/AIDS and Other STIs.....................................................30
Case Study: Tuelimishane (“Let’s Educate Each Other”)..............38
Case Study: Stepping Stones..........................................................40
Case Study: Program H..................................................................42
5. Harmful Practices: Barriers to Reproductive Health.............................44
Case Study: Delaying Age at Marriage in Rural Maharashtra........52
Case Study: Tostan Community-Based Education Program..........54
Case Study: Intervention with Microfinance for AIDS
and Gender Equity (IMAGE)..........................................................56
6. Meeting the Needs of Youth...............................................................58
Case Study: Ishraq (“Enlightenment”)..........................................62
Case Study: First-time Parents.......................................................64
7. Conclusions......................................................................................66
Appendix ..............................................................................................70
References............................................................................................84
Glossary................................................................................................93

iv Gender Perspectives Improve Reproductive Health Outcomes: New Evidence

Executive Summary 1
Executive Summary
In 2004, the Interagency Gender Working
Group (IGWG) published The “So What?”
Report: A Look at Whether Integrating a Gender
Focus into Programs Makes a Difference to
Outcomes. The 2004 report presented evidence
of the value of integrating gender into programs
for promoting positive reproductive health (RH)
and gender outcomes. The purpose of this new
2009 review is to assemble the latest data and
update the evidence as to what difference it
makes when a gender perspective is incorporat-ed
into RH programs.
The review focuses on five components of
reproductive health programs, including inter-ventions
related to:
n Unintended pregnancy;
n Maternal health;
n HIV/AIDS and other STIs;
n Harmful practices, including early marriage,
female genital mutilation/cutting, and gen-der-
based violence; and
n Youth.
The authors examined gender-related barri-ers
to each component of reproductive health
and the strategies undertaken by programs to
address the barriers. Out of nearly 200 inter-ventions
reviewed, 40 are included here as
examples of programs that integrate gender to
improve reproductive health outcomes.
The interventions selected for inclusion
were limited to those that have been evalu-ated—
meaning they established criteria for
assessment that were related to the goals of
the intervention and followed an evaluation
design—and that used accommodating or trans-formative
approaches. The results of these pro-grams
suggest that the field is evolving toward a
deeper understanding of what gender equality
entails and a stronger commitment to pursue
this equality in reproductive health programs.
Reducing Unintended Pregnancies
Several of the projects to reduce unintended
pregnancy countered the traditional practice of
aiming family planning (FP) services at women
only; they encouraged husbands and other
males to take more responsibility in this area.
The strategies included enlistment of men who
hold power, such as community or religious
leaders, to support FP; influencing husbands to
encourage their wives to use FP services; and
providing a male-controlled contraceptive
method. Other projects encouraged joint deci-sionmaking,
shared responsibility in FP, and
the institutionalization of gender into RH ser-vices.
Addressing the balance of power between
health-care service providers and female cli-ents,
quality of care initiatives aimed to sensi-tize
providers about the role of gender in their
practice.
Many of these programs took place in set-tings
where women have little autonomy in their
daily lives and little assertiveness in their rela-tionships.
By using a gender perspective, unin-tended
pregnancy can be addressed not only
through programs targeting women, but also by
targeting men, leaders, and decisionmakers.
Improving Maternal Health
A common feature of all the projects to
improve maternal health was their recognition
that decisions about ante- and post-natal care
typically are not made by young pregnant
women and new mothers, but more often by
husbands or mothers-in-law. Particularly suc-cessful
gender transformative approaches
sought to create a supportive environment to
improve women’s use of services by reaching
out to husbands and mothers-in-law, in addi-tion
to women. Several projects reached out to
couples through counseling and information.

Through educational materials and couples’
counseling, health facilities broadened their
reach to include husbands as well as pregnant
women, addressing the particular roles that
both partners can play in improving maternal
health. Other projects aimed to improve the
quality of antenatal care services and to change
attitudes and practices among service providers
with an emphasis on women’s rights to a basic
standard of care and to be treated respectfully
as clients.
Reducing HIV/AIDS and Other STIs
Evaluations of a number of interventions to
reduce HIV/AIDS and STIs provide strong evi-dence
that addressing gender norms, promoting
policies and programs to extend equality in
legal rights, and expanding services for women
and men can result in improved HIV/AIDS and
gender outcomes. Some of the interventions
are designed for groups that are particularly
vulnerable to HIV/STIs; some attempt to reach
clients through reproductive health services,
members of particular demographic groups, or
those who are in need of care and treatment
for HIV.
A common feature of successful programs
was to stimulate dialogue on the relationship
between gender norms and sexual behavior.
These messages were communicated through a
variety of channels, such as peer groups, work-shops,
or mass media. Some programs used
peer educators to deliver the messages, while
others used health professionals, HIV/AIDS spe-cialists,
or spokespersons and celebrities.
Another approach to addressing HIV/AIDS was
to include a gender perspective in promoting
the use of health services. Sensitizing service
providers to the gender components of risky
behaviors and health-care seeking patterns
helped to improve quality of care.
These interventions demonstrated that
strategies that incorporate gender in order to
reduce HIV/AIDS and other STIs are becoming
increasingly sophisticated in their approach to
addressing gender dynamics. Many programs
also focused on helping men identify and begin
to question their gender roles, both the advan-tages
conferred to them and the risks to which
these roles expose them.
Harmful Practices:
Barriers to Reproductive Health
Harmful practices, including early marriage,
early childbearing, female genital mutilation/
cutting, and gender-based violence, play a sub-stantial
2 Gender Perspectives Improve Reproductive Health Outcomes: New Evidence
role in undermining reproductive
health, especially among young women. The
harmful practices interventions reviewed were
broad in focus, but shared common features.
All employed gender transformative elements
and sought to influence attitudes and behaviors
of a range of community stakeholders, includ-ing
women, men, parents, leaders, and entire
communities.
Linking social vulnerability and limited life
options with vulnerability, life-skills education
projects with unmarried adolescent girls aimed
to increase their self-esteem and literacy.
Interventions were often partnered with educa-tional
modules on topics such as rights, prob-lem-
solving, hygiene, and women’s health.
Behavior change communication messages
were disseminated through multiple channels,
including community meetings, performances,
and mass media activities.
Meeting the Needs of Youth
The interventions addressing youth focused on
gender norms, providing information, and
building skills related to sexual and reproduc-tive
health (SRH). The themes of gender atti-tudes,
partnerships, life skills, and participation
of youth were common throughout many inter-ventions.
Several sought to improve adolescent repro-ductive
health by promoting gender equitable
norms. The interventions themselves often com-prised
life skills education and training, such as
skills to provide opportunities for out-of-school
youth. Other programs aimed to reach youth
with RH information and services, empowering
them to address their own needs. Some pro-grams
sought support of communities for the
activities, through village committees made up
of a broad group of stakeholders. These commit-tees
helped define and support the recruitment
and program activities. Some used interven-tions
at multiple community levels for policy,
youth-friendly services, behavior change com-munication,
and livelihood skills training.

Conclusions
In the past five years there has been a clear
increase in the evidence that integrating gender
does improve reproductive health outcomes.
Today, women and men are reaping the bene-fits
of gender-integrated programming that uses
a gender-transformative approach and stronger
evaluations are measuring the effects. This new
review makes an important contribution to the
growing body of literature on gender-based
approaches to policy and programming. The
evidence presented here suggests that incorpo-rating
gender strategies contributes to reducing
unintended pregnancy, improving maternal
health, reducing HIV/AIDS and other STIs,
eliminating harmful practices, and meeting the
needs of youth – all broadly included under the
term “reproductive health.”
In addition, this report generated several
new findings:
n Gender-integrated strategies are stronger
and better evaluated than they were five
years ago;
n Incorporating a gender strategy leads to a
better understanding of RH issues;
n Formative research is critical;
n Programs that integrate gender can benefit
from working at multiple levels; and
n Projects that integrate gender need to focus
on costs, scale-up, and identifying policy
and systemic changes required to “main-stream”
gender.
The way forward, focusing on well-evaluated
projects that address policy, systems, and cost
issues, scaling up gender integration, and
addressing sustainability of equitable gender
relations over time, will make important contri-butions
to the health and lives of women, men,
and families around the world.
Executive Summary 3

1Introduction
International initiatives to achieve reproduc-tive
health (RH) outcomes—such as reducing
unintended pregnancy, stopping the spread of
HIV/AIDS, and improving maternal health—are
increasingly recognizing that these outcomes
are affected by gender, or the roles that are
commonly assumed to apply to women and
men (see the gender definition in the box
below). This includes the roles that affect inti-mate
and sexual relationships.
Governments worldwide are working to
achieve the Millennium Development Goals,
including Goal 3: to promote gender equality
and empower women. Most international donor
agencies have embraced the idea that RH poli-cies
and programs should support women’s
empowerment and gender equity, and have
included this in their goals and strategies. For
example, the United States Agency for
International Development (USAID) has long
required that gender issues—both the potential
effect of gender on proposed objectives and the
impact of results on gender relations—be
addressed within its projects, including health
programs. USAID provides guidance on gender
through its Automatic Directive System (ADS).1
Since 1997, the Interagency Gender Working
Group (IGWG), funded by USAID, has supported
development of evidence-based materials and
training for the implementation of programs that
integrate gender into RH programs. The U.S.
President’s Emergency Plan for AIDS Relief
(PEPFAR), which is a key component of the
Global Health Initiative, has provided technical
assistance and guidance for the integration of
gender into HIV prevention, treatment, and care
programs, including the implementation of five
PEPFAR gender strategies.2
The United Nations (UN) and the World
Health Organization (WHO) have encouraged
“gender mainstreaming” for the last decade.3
The Global Fund to Fight AIDS, Tuberculosis,
and Malaria is developing a gender strategy that
promotes increased attention to gender in
country grants and within the organization
itself.4 The World Bank adopted a gender and
development mainstreaming strategy in 2001
and issued a revised Operational Policy and
Bank Procedures statement in 2003.5 More
recently, through the Gender Action Plan, it
created a guiding framework to advance wom-en’s
economic empowerment in order to pro-mote
shared growth and MDG3.6 Many other
bilateral and multilateral organizations also
support policies and programs that promote
gender equality.
UNFPA’s State of the World Population 2008
Report states that “Gender equality is a human
right. In all cultures there are pressures
towards and against women’s empowerment
and gender equality.” The 2008 report goes on
1 The ADS 200 and 300 series specify requirements for
mandatory integration of gender considerations into plan-ning,
programs implementation, and evaluation. The latest
version can be found at www.usaid.gov/policy/ads.
2 The five gender strategies include: 1) increasing gender
equity; 2) addressing male norms and behavior; 3) reduc-ing
violence and sexual coercion; 4) increasing income
generation for women and girls; and 5) increasing women’s
legal protection and property rights.
3 UN, 2002, 2008; WHO, 2002, 2007.
4 OSI and PAI are currently undertaking an analysis of evi-dence
from gender programming to support implementa-tion
of the Global Fund’s Gender Strategy.
5 World Bank, 2003.
6 World Bank, 2006.
Gender refers to the different roles men and women play
in society, and to the relative power they wield. While
gender is expressed differently in different societies, in
no society do men and women perform equal roles or
hold equal positions of power.
Riley, 1997: 1

Are interventions more strongly focused on transforming
inequitable gender relations? Are interventions that incorporate
gender evaluated using more rigorous approaches?
Introduction 5
to advocate culturally sensitive approaches in
pursuing international development goals.7
Consistent with this perspective, the authors
have based this IGWG report on the premise
that RH policies and programs should support
social and culturally competent approaches in
favor of women’s empowerment and gender
equality, as a contextual factor influencing mul-tiple
RH outcomes, and in pursuit of advancing
human rights.
Many international organizations and gov-ernments
have increasingly focused on results
and impact of programs and have sought to
make investments that rest on evidence that
gendered approaches actually improve out-comes.
Until 2004, when the IGWG published
The “So What?” Report: A Look at Whether
Integrating a Gender Focus Into Programs
Makes a Difference to Outcomes, such evi-dence
had not been brought together in a sys-tematic
fashion. The purpose of this 2009
review is to assemble the latest data and
update the evidence as to what difference it
makes when a gender perspective is incorpo-rated
into RH programs.
Background
The 2004 “So What?” report used the term
“reproductive health” in its broadest sense, as
defined at the 1994 International Conference
on Population and Development (ICPD), to
cover interventions to reduce unintended preg-nancy
and abortion; reduce maternal morbidity
and mortality; and to combat the spread of STI/
HIV/AIDS. Interventions to improve quality of
care were also assessed. Out of 400 interven-tions
that were reviewed, 25 were found to
have either accommodated gender differences
or to have transformed gender norms to pro-mote
equality. The report presented evidence
of the value of integrating gender into pro-grams,
for promoting both positive RH and gen-der
outcomes. The report recommended: 1)
stronger integration of gender in designing pro-gram
interventions; and 2) more rigorous eval-uations
of interventions that integrate gender.8
Objective
The current review, also supported by the
IGWG,9 looks at new projects and research
findings with the objective of determining
whether progress has been made in the inter-vening
years both in gender and RH program-ming
and in its evaluation.
None of the interventions reviewed in the
2004 report are included here. In addition to
assessing whether RH outcomes are enhanced
with the integration of gender, the authors of
this review explore the following two questions
in this newer set of gendered programs:
n Are the interventions more strongly focused
on transforming inequitable gender relations
rather than accommodating them?
n Are interventions that incorporate gender
evaluated using more rigorous approaches?
Intended Audience
This document is intended primarily for gender
and health experts who design, implement,
manage, and evaluate programs in developing
countries. The findings on the effect of inte-grating
gender are intended also for donors,
policymakers, civil society, and advocacy
groups to make the case for gender integration
in health programs.
Methods
The authors identified documents for this
review through online literature searches and
by contacting key informants in the interna-tional
reproductive health field. This report
uses both published and unpublished docu-ments
found in English, primarily evaluation
reports, project summaries, and published jour-
7 UNFPA 2008.
8 Boender et al., 2004: 3.
9 Population Action International funded co-author Karen
Hardee’s time for this review.

nal articles. Databases of reproductive health,
development, and academic literature were
searched extensively.10 The authors also
searched peer-review journals (e.g., Studies in
Family Planning, Reproductive Health
Matters, International Family Planning
Perspectives, Population and Development
Review, Violence Against Women, and The
Lancet) and organization websites, such as
Population Council, International Center for
Research on Women (ICRW), the Interagency
Youth Working Group, and the American Public
Health Association (APHA).
To extend the reach of the review beyond
what is available online, experts and practitio-ners
from organizations worldwide were con-tacted
to locate additional program evaluation
documents and identify other organizations
and people involved in gender and reproductive
health programs. Nearly 100 individuals span-ning
40 organizations were contacted to
request information about relevant interven-tions
or suggest additional key informants.
After completing the literature search, the
authors reviewed approximately 200 project
documents that have been published since the
year 2000. This year was selected as the start of
the search range in order to capture the most
recent publications and minimize overlap with
the previous “So What?” review; search results
were filtered to exclude any publications
reviewed at that time. The documents cover a
range of reproductive health interventions,
cross-sectoral development and life skills pro-grams
with reproductive health components,
and pilot and operations research projects.
Criteria for Inclusion in the Review
Interventions selected for this update had to
meet the following criteria:11
1. Does the intervention integrate gender?
2. Has the intervention been evaluated?
3. Does the intervention have measured repro-ductive
health outcomes?
Forty studies from developing countries
were found to meet all three criteria.12 Only
programs that used accommodating or transfor-mative
approaches were included in this
review. (See Appendix A.1 on page 71 for a
table of the 40 projects, including their objec-tives,
strategies, and reproductive health and
gender outcomes.)
Types of Gender Integration
Strategies
The IGWG has developed a continuum of the
ways that gender is approached in projects (see
Figure 1 below, the Gender Integration
Continuum). This continuum13 categorizes
approaches by how they treat gender norms
and inequities in the design, implementation,
and evaluation of programs or policy.
The term “gender blind” refers to the
absence of any proactive consideration of the
larger gender environment and specific gender
roles affecting program/policy beneficiaries.
Gender blind programs/policies give no prior
consideration for how gender norms and
unequal power relations affect the achievement
of objectives, or how objectives impact on gen-der.
In contrast, “gender aware” programs/poli-cies
deliberately examine and address the
anticipated gender-related outcomes during
both design and implementation. An important
10 The complete list of databases searched includes:
POPLINE, the Development Experience Clearinghouse,
Expanded Academic, Interagency Youth Working Group,
HRH Global Resource Center, PubMed, and the WHO
Reproductive Health Library. All databases were searched
with equal rigor and the same set of search terms.
11 These are the same criteria that were used in the 2004
report.
12 A significant number of the final 40 projects were funded
in whole or in part by USAID, who has also funded this
review and publication. USAID projects frequently require
evidence of program impact through structured evalua-tions.
As a result, many USAID programs met the evalua-tion
requirements for inclusion in this review as they were
able to demonstrate the impact of their gender programs.
13 This framework draws from a range of efforts that have
used a continuum of approaches to understanding gender,
especially as they relate to HIV/AIDS. See Geeta Rao
Gupta, “Gender, Sexuality and HIV/AIDS: The What, The
Why and The How” (Plenary Address at the XIII
International AIDS Conference), Durban, South Africa:
2000; Geeta Rao Gupta, Daniel Whelan, and Keera
Allendorf, “Integrating Gender into HIV/AIDS Programs:
Review Paper for Expert Consultation, 3–5 June 2002,”
Geneva: World Health Organization, 2002; and WHO/
ICRW, “Guidelines for Integrating Gender into HIV/AIDS
Programmes,” forthcoming.

FIGURE 1.1. The Gender Integration Continuum14
prerequisite for all gender-integrated interven-tions
is to be gender aware.
In the graphic above, the circle depicts a
specific program environment. Since programs
are expected to take gender into consideration,
the term “gender aware” is enclosed in an
unbroken line, while the “gender blind” box is
defined by a dotted, weak line. Awareness of
the gender context is often a result of a pre-program/
policy gender analysis. “Gender
aware” contexts allow program staff to con-sciously
address gender constraints and oppor-tunities,
and plan their gender objectives.
Programs/policies may have multiple compo-nents
that fall at various points along the con-tinuum,
which is why multiple arrows exist.
The IGWG emphasizes the following two
gender integration principles:
n First, under no circumstances should pro-grams/
policies adopt an exploitative
approach since one of the fundamental
principles of development is to “do no
harm.”
n Second, the overall objective of gender
integration is to move toward gender trans-formative
programs/policies, thus gradually
challenging existing gender inequities and
promoting positive changes in gender roles,
norms, and power dynamics.
Gender exploitative approaches, on the left
of the continuum, take advantage of rigid gen-der
norms and existing imbalances in power to
achieve the health program objectives. While
using a gender exploitative approach may seem
expeditious in the short run, it is unlikely to be
sustainable and can, in the long run, result in
harmful consequences and undermine the pro-gram’s
intended objective.
Gender accommodating approaches, in the
middle of the continuum, acknowledge the role
of gender norms and inequities and seek to
develop actions that adjust to and often com-pensate
for them. While such projects do not
actively seek to change the norms and inequi-ties,
they strive to limit any harmful impact on
gender relations. A gender accommodating
approach may be considered a missed opportu-nity
because it does not deliberately contribute
to increased gender equity, nor does it address
the underlying structures and norms that per-petuate
gender inequities. In situations where
gender inequities are deeply entrenched and
pervasive in a society, however, gender accom-modating
approaches often provide a sensible
first step to gender integration. As unequal
power dynamics and rigid gender norms are
Introduction 7
14 While this gender continuum framework has been adopted
by the IGWG and applied to USAID’s work, other organiza-tions
may use different gender frameworks; see, for exam-ple,
the World Health Organization gender strategy at
http://www.who.int/gender/mainstreaming/strategy/en/
index.html

recognized and addressed through programs, a
gradual shift toward challenging such inequities
may take place.
Gender transformative approaches, at the
right end of the continuum, actively strive to
examine, question, and change rigid gender
norms and imbalance of power as a means of
reaching health as well as gender-equity objec-tives.
Gender transformative approaches
encourage critical awareness among men and
women of gender roles and norms; promote the
position of women; challenge the distribution
of resources and allocation of duties between
men and women; and/or address the power
relationships between women and others in the
community, such as service providers or tradi-tional
leaders.
[T]he field is evolving toward a deeper understanding of
what gender equality entails and a stronger commitment
to pursue this equality in health programs.
A particular project may not fall neatly
under one type of approach, and may include,
for example, both accommodating and transfor-mative
elements. Also, while the continuum
focuses on gender integration goals in the
design/planning phase, it can also be used to
monitor and evaluate gender and health out-comes,
with the understanding that sometimes
programs result in unintended consequences.
For instance, an accommodating approach may
contribute to a transformative outcome, even if
that was not the explicit objective. Conversely,
a transformative approach may produce a reac-tion
that, at least temporarily, exacerbates gen-der
inequities. Monitoring and evaluating
gender outcomes against the continuum allows
for revision of interventions where needed.
Accommodating or
Transformative?
In some cases a particular intervention strategy
may be accommodating in one context and
transformative in another, depending on the
nature of the intervention and how it is imple-mented.
For example, a project may work with
male power holders such as local religious lead-ers
to try to enlist them in encouraging (or to
stop opposing) contraceptive use among
women. This could be seen as an accommoda-tion
to the gender status quo in which males
holding power act as gatekeepers. It could also
be seen as transformative if the leaders are
explicitly engaged to question or change their
traditional role in regard to family planning
communication.
Transformative strategies may experience
greater challenges to implementation in that
they explicitly address the structural underpin-nings
of gender inequality in social systems,
and therefore are likely to encounter resis-tance.
For the same reason, however, they have
the potential to bring about long-term and
more sustainable benefits for women and men.
Programs and policies may transform gen-der
relations through:
n Encouraging critical awareness of gender
roles and norms;
n Empowering women and/or engaging men,
thus achieving gender equality and health
equity objectives; or
n Examining, questioning, and changing the
imbalance of power, distribution of resourc-es,
and allocation of duties between women
and men.
A majority of the interventions in this
review employ transformative approaches. This
suggests that the field is evolving toward a
deeper understanding of what gender equality
entails and a stronger commitment to pursuing
equality in health programs.

Intervention Evaluations
The interventions selected for inclusion in this
report were limited to those that have been
evaluated – those that established criteria for
assessment that were related to the goals of the
intervention and followed an evaluation design.
The evaluations are of varying quality and thor-oughness,
employing methods ranging from
randomized-control trials (RCT) to post-test-only
designs, a few of which used qualitative
methods exclusively (see Table 1.1).15
Countries Represented
Twenty-five countries were represented in the
interventions to improve reproductive health
outcomes by integrating gender. Most interven-tions
were located in Africa (10), followed by
Asia and Latin America and the Caribbean (6
each), the Near East (2) and Other (1). Some
countries had multiple interventions. Two
countries, India and South Africa, were home
to the most interventions (eight and seven
interventions, respectively).
Reproductive Health Outcomes
The outcomes highlighted in this report cover a
range of indices in reproductive health and
family planning, as well as broader indicators
such as age at marriage and knowledge about
sexual and reproductive health, as well as indi-cators
of gender outcomes (see Tables 1.3 and
1.4). The authors have limited this review to
programs with measured reproductive health
outcomes, although broader indicators and gen-der
outcomes are included when available.
Organization of the Report
This report is divided into seven chapters: an
introduction; four chapters corresponding to
reproductive health issues (unintended preg-nancies;
maternal health; HIV/AIDS and other
sexually transmitted infections (STIs); and
harmful practices); a chapter on meeting the
needs of youth (due to the large number of pro-grams
targeted to this vulnerable and demo-graphically
important group, as well as the
Table 1.1
Table 1.2
special strategies needed to reach youth); and,
finally, a conclusion. Each chapter contains at
least two detailed case studies, highlighting
particularly noteworthy projects with strong
evaluations and transformative approaches.
Noteworthy projects that had less information
available were included in the summary within
each chapter.
Of the 40 programs that met the criteria for
inclusion, 18 are cross-cutting interventions,
addressing two or more RH issues. In these
cases, the programs are categorized in the
chapter on the RH issue they most directly
address. In addition, many of the interventions
included in this report related to working with
Introduction 9
15 See the Glossary, page 93, for definitions of evaluation and
research methodology terms.
Methodologies Used in Evaluation of Gender Integrated
Interventions
Methodology Number of studies
Quantitative (primarily) 37
Experimental design 5
Quasi-experimental design 17
Non-experimental design 15
Qualitative (exclusively) 3
Countries Included in the Analysis of Outcomes Related to
Gender-integrated Interventions
Africa (10) Asia (6) LAC (6) Near East (2) Other (1)
Ethiopia (3) Afghanistan Bolivia Egypt (2) Georgia
Ghana Bangladesh Brazil Jordan
Guinea Cambodia Ecuador
Kenya (2) India (8) El Salvador
Liberia Nepal Nicaragua
South Africa (7) Philippines Peru
Tanzania (2)
Senegal
Sudan
Uganda
Note: some programs and evaluations were conducted in multiple countries. Some
programs were implemented in multiple countries without all countries being included
in the evaluations. Only countries that had evaluations are included in this table.

Table 1.3
Number of Interventions Reporting Selected* Reproductive Health Outcomes**
Reproductive Health Issue Outcomes Number of Interventions
Reducing Unintended Pregnancy
Greater contraceptive knowledge 11
Greater contraceptive use 11
Greater awareness of fertility 2
Increase in communication and joint decision-making with partner about contraception 2
Improved provider clinical skills and knowledge of FP methods and STI detection/treatment 1
Increase in use of skilled pregnancy care 3
Reduced case fatality rate 1
Increase in screening of pregnant women for Syphilis 1
Increase in women’s emergency obstetric care needs being met 1
Greater knowledge of warnings signs in pregnancy 1
Increase in awareness of prenatal care 1
Greater knowledge of HIV/AIDS transmission and prevention 7
Greater condom use:
At last sex 3
With primary partner 4
Increase in visits to centers that provide HIV/AIDS and STI services 5
Lower reported STI symptoms 2
Greater knowledge of STI symptoms 1
Increased exclusive breastfeeding 1
Greater receipt & ingestion of nevirapine 1
Greater CD4 testing 1
Eliminating Harmful Practices
Decrease in belief that IPV/SV is justified under some circumstances 3
Greater knowledge of IPV/SV resources 2
Decrease in incidence of violence 3
Increased community action and protest against harmful practices 2
Attitudes toward IPV/SV 4
Decrease in risk of IPV/SV 1
Decrease in controlling behavior by intimate partner 1
Increased uptake of RH services 1
Greater knowledge of harmful consequences of FGM/C and advantages of not cutting girls 3
Decrease in belief that FGM/C is necessary 2
Increase in number of men who marry uncircumcised girls 1
Decrease in FGM/C incidence 2
Increase in age at marriage 1
Increase in interval between marriage and first birth 1
Greater knowledge of risks of early childbearing 1
Fewer adolescent pregnancies 1
Fewer adolescent marriages 1
Greater sexual and reproductive health knowledge 4
Increase in decision-making ability related to:
Condom use 2
Sex 1
Increase in age at sexual debut 1
*Additional RH outcomes were measured beyond those listed here. Please see the program reports for additional information.
**Interventions addressing more than one reproductive health outcome are listed more than once.

Introduction 11
men. These interventions are included under
each of the main chapters because the construc-tive
engagement of men and boys is an integral
part of integrating gender into programs.
Each chapter begins with a summary of the
issues surrounding the reproductive health out-come
discussed in the section. Next, summa-ries
of interventions and studies are presented,
highlighting each project’s gender approach as
well as evaluation design. At the end of each
chapter, readers will find expanded case studies
that highlight selected interventions, including
their gender integration strategies and evalua-tions.
Information on costs has been included
where available. Some of the program areas
had more intervention examples than others
and the amount of detail on each of the meth-odologies
and approaches of the interventions
is limited by the quality of description found in
reports and communications.
The 2004 “So What?” report, reflecting the
state of the field at the time, did not have sepa-rate
chapters on harmful practices or youth.
Interventions in these areas certainly existed,
but most had not been evaluated, or had not
been evaluated extensively enough to be
included in the review. Also, the 2004 report
had a separate chapter on gender in quality of
care initiatives. Quality of care has increasingly
been incorporated as a standard component of
RH programming; therefore, quality of care ini-tiatives
are not highlighted separately here.
Table 1.4
Number of Interventions Reporting Selected* Gender
Outcomes**
Gender Outcomes Number of Interventions
Increased partner communication about
reproductive health or family planning 11
Increased equitable gender attitudes and beliefs 9
Women's increased self-confidence, self-esteem
or self-determination 5
Women's increased participation in the community
and development of social networks 3
Higher scores on an empowerment scale for women 3
Increased support (emotional, instrumental, family
planning, or general support) from partners or community 2
Increased life and social skills 2
Women's increased decision-making power 1
Higher formal educational participation for women or girls 1
Women's increased mobility 1
Improved gender relations within the community 1
Women more articulate in discussing IPV/SV and RH 1
Decreased tolerance for kidnapping of girls 1
*Additional gender outcomes were measured beyond those listed here. Please see the
program reports for additional information.
**Interventions addressing more than one gender outcome are listed more than once.

Reducing Unintended
Pregnancies
Unintended pregnancy is a critical issue
throughout the world. Data from 53 coun-tries
indicate that one in seven married and
one in 13 never-married women have an unmet
need for contraception16 and are thus at risk of
unintended pregnancy. Unmet need is highest
in sub-Saharan Africa, where one in four mar-ried
women have an unmet need for contracep-tion.
In the regions of Latin America and the
Caribbean, North Africa, West and Central
Asia, and South and Southeast Asia, unmet
need is lower, but still significant.17
Numerous gender-related barriers that con-tribute
to unintended pregnancy have been
identified, some at the institutional and policy
level, and others at the levels of the family and
community. Fertility control has often been
seen as women’s domain, and women are often
construed as targets of family planning (FP)
programs rather than beneficiaries of reproduc-tive
health care. As a result, programs have
been slow to engage men and address gender-based
inequities. Men’s power over women in
the household also has implications for contra-ceptive
use and reducing unintended pregnan-cies.
Women are often in a weak position in
negotiating the timing and circumstances of
sexual intercourse.18 The perception that
women are responsible for FP may mean that
women without their own sources of income
are unable to use family planning services
unless they are free of charge.19 Women are
often blamed for unplanned pregnancies20 even
though men often play important roles in regu-lating
2
women’s access to RH services through
control of finances, women’s mobility, means of
transportation, and health care decisions.21
Women in some settings would rather undergo
abortions than risk repeated conflicts with
their husbands over contraceptive use.22
Women are disadvantaged by unequal power
relations outside the home as well as within it.
Gender power imbalances in client-provider
relationships often are exacerbated by dispari-ties
in social status and education, which are
likely to be greater when the client is female
and the provider is male.23 This may encourage
providers to behave in an authoritarian fashion
that often results in compliance and passivity
from their clients.24 Regardless of the sex of the
provider, female clients often fail to ask ques-tions
or voice concerns that may affect the suc-cess
of their family planning use.25
Additionally, gender norms may discourage
16 Women who prefer to space or limit births but are not
using any form of contraception are considered to have
unmet need for family planning.
17 Sedgh et al., 2007. Based on data from Demographic and
Health Surveys (DHS).
18 Schuler et al., 1994.
19 Schuler et al., 2002b.
20 Hoang et al., 2002.
21 Robey et al., 1998; Goldberg and Toros, 1994.
22 Biddlecom and Fapohunda, 1998; Schuler et al., 1994.
23 Upadhyay, 2001.
24 DiMatteo, 1994; Schuler et al., 1994.
25 Schuler et al., 1985; Schuler and Hossain, 1998.
Program Country
Male Motivation Campaign Guinea
Together for a Happy Family Jordan
Cultivating Men’s Interest in Family Planning El Salvador
Reproductive Health Awareness Philippines
PRACHAR India
REWARD Nepal
CASE STUDY: Women’s Empowerment Model to Afghanistan
Train Midwives and Doctors
CASE STUDY: PROCOSI Gender-Sensitive Bolivia
Reproductive Health Program

Table 2.1
Reducing Unintended Pregnancies 13
women, especially young women, from appear-ing
to know or acquiring knowledge about sex-ual
matters or suggesting contraceptive use.26
At the same time, the social construction of
masculinity may contribute to male risk–taking
in the form of unprotected sex and expecta-tions
to prove sexual potency.27
Interventions
Several of the projects reviewed both for this
chapter and for the chapter on maternal mor-tality
and morbidity countered the traditional
practice of aiming FP services at women only;
they encouraged husbands and other males to
take more responsibility in this area. The strat-egies
included enlistment of people who hold
power—for example, religious leaders and, in
one case, the royal family—to support FP;
influencing husbands to encourage their wives
to use FP services; and providing a male-con-trolled
contraceptive method. Other projects
encouraged joint decisionmaking and shared
responsibility in FP and the institutionalization
of gender into RH services.
The two projects selected as case studies
reduce unintended pregnancy through a gen-der-
transformative approach. They are the
Women’s Empowerment Model to Train
Midwives and Doctors and the PROCOSI
Gender-Sensitive Reproductive Health
Program (see pp. x and x). The Women’s
Empowerment Model was used to train mid-wives
and doctors on clinical skills in family
planning, particularly IUD insertion, and to
increase family planning knowledge in
Afghanistan. The PROCOSI gender-sensitive
program adopted a long-term perspective and
worked with a large number of institutions in
Bolivia to integrate gender into reproductive
health services.
Of the other six interventions that met the
criteria for this review, the first four described
here aimed to meet the RH goal of reducing
unintended pregnancy through constructive
engagement of men. Their approaches range
from accommodating to transformative, and
sometimes encompass elements of both.
Table 2.1 lists the key gender strategies
used to reduce unintended pregnancy in the
projects reviewed.
Male Motivation Campaign28
Country: Guinea
Implementing organizations: Johns Hopkins University
Center for Communication Programs (JHU/CCP) and the
Guinean Ministry of Health
Through constructive engagement of men, this
intervention sought to increase knowledge and
use of quality health care services and the
adoption of positive health practices in Guinea.
The first phase of this campaign consisted of
advocacy with religious leaders—a strategy that
falls somewhere between gender accommodat-ing
and transformative. In the context of a
patrilineal and male-dominated society in
Guinea, the program accommodated existing
power structures by reaching out to male reli-gious
leaders, knowing that empowering reli-gious
leaders would help to ensure social
support for family planning. In the second
phase, the project utilized multimedia interven-tions
to educate married men about FP and
persuade them to talk with their wives and
encourage them to use FP services. Engaging
community men and those in positions of lead-ership
has the potential to transform gender
relations to a greater equity by expanding lim-
26 Bezmalinovic et al., 1997; Population Council, 2000.
27 UNFPA, 2008.
28 Blake and Babalola, 2002.
Strategies Used in Programs to Reduce Unintended
Pregnancy
Improving male partners’ accurate knowledge about RH and FP; and
Encouraging male partners to take more responsibility for FP
Encouraging joint decision-making and shared responsibility for FP
Institutionalization of gender into NGO RH services, including accreditation
Advocacy with religious leaders and policymakers
Integration with non-health development activities (water and sanitation)
Use of established male networks to diffuse information, refer to services,
and expand method choice
Empowering female providers
Increasing gender awareness and sensitivity of health providers
Empowering women and girls

ited traditional male roles to include knowledge
of, and engagement in, FP/RH. In addition to
the two primary audiences, the campaign also
addressed women of reproductive age and ser-vice
providers. The project covered a relatively
large population; for example, about 30,000
people attended community mobilization
events surrounding 30 rural health centers.
The evaluation of the Male Motivation
Campaign in Guinea had two components: a
panel study with religious leaders and a popula-tion-
based study with men and women of
reproductive age. In the first component, 98
religious leaders were interviewed at two points
in time. In the second component, a sample of
1,045 men and women who were interviewed
in the 1999 Guinea Demographic and Health
Survey were re-interviewed. Following the
intervention, involvement in advocating for
modern family planning methods became more
widespread among religious leaders and fewer
believed that FP methods were prohibited by
Islam. Multiple regression analysis controlling
for confounding effects of prior ideation showed
that campaign exposure was associated with
considerable and significant change in an “ide-ation
index” measuring awareness of and
approval of FP; discussion of FP with spouse,
friends, or relatives; and spousal approval of FP.
Actual use of contraception, however, did not
increase significantly among women and stag-nated
among men.
Together for a Happy Family29
Country: Jordan
Implementing organizations: Johns Hopkins Bloomberg
School of Public Health Center for Communication Programs
(JHU/CCP) in collaboration with the Jordanian National
Population Committee
This project engaged men by encouraging cou-ple
communication and joint decision-making.
The project worked with religious leaders and
the royal family in Jordan, where many people
were unaware that Islam permits use of modern
FP methods. In Jordan, husbands’ opposition to
family planning, preferences for large families,
perceived religious prohibitions, and health
concerns all limit the use of modern FP meth-ods.
For a two-year period beginning in March
1998, national-level, multi-media behavior
change communication messages were used to
enlist men in making informed decisions with
their wives to use family planning. The premise
of the project was that highly-respected people
would be able to influence men effectively.
Project researchers, with staff from the
Jordanian Department of Statistics, compared
the project’s 1996 knowledge, attitudes, and
practices (KAP) survey results with findings
from the 2001 Men’s Involvement in
Reproductive Health Survey (MIRHS) following
the campaign. The analysis showed improved
knowledge and substantially more positive atti-tudes
among both men and women regarding
specific modern FP methods. The majority of
both men and women reported in 2001 that
they decided together on the number of chil-dren
they planned to have, compared with
about one-third who said they decided together
in 1996. Similarly, in 2001 nearly 80 percent of
MIRHS respondents said that husbands and
wives share responsibility for avoiding
unwanted pregnancies. Survey respondents
were given a list of topics from which they
were to rank issues discussed and actions taken
as a result of exposure to the campaign.
Respondents ranked discussing issues with
spouses and sharing decision-making as the top
actions taken. They also included treating sons
and daughters equitably and adopting a FP
method. Comparison of the 1996 and 2001 sur-veys
showed a decrease in ideal family size
from 4.3 to 3.8. While it is not possible to attri-bute
these changes entirely to the “Together for
a Happy Family” campaign, the magnitude of
the changes is notable.
Cultivating Men’s Interest in Family Planning 30
Country: El Salvador (rural)
Implementing organizations: The Institute for Reproductive
Health (IRH) of Georgetown University, the El Salvadoran
Ministry of Health, and Project Concern International, with its
local El Salvador affiliate PROCOSAL (Programas
Comunitarias para El Salvador)
This was a pilot project carried out in 13 small
villages in rural El Salvador. The objective was
to integrate family planning—specifically
increasing male involvement in family planning
29 JHUCCP, 2003.
30 Lundgren et al., 2005.

and use—into a water and sanitation program.
It sought to facilitate couple communication
and joint decision-making regarding family
planning. The initiative also aimed to integrate
women into water committees which had previ-ously
been monopolized by men. Results of
interviews with men and women defined as
having unmet need indicated that some men
were unwilling to use modern contraceptive
methods, or to have their wives use them, both
because of concern about side effects and
because they worried that their wives might be
unfaithful. The researchers found that the prac-tice
of periodic abstinence was common, but
that most people could not correctly identify
their fertile days.31 The project sought to use
networks established around issues men cared
about and in which they were already involved.
These networks were used to diffuse informa-tion,
facilitate referrals, and expand method
choice (with an emphasis on the Standard Days
Method™ or SDM). The project creatively used
a metaphor to promote family planning: fertile
cycles of the land were equated with the fertile
cycles of women. Moreover, the incorporation
of men into FP decisionmaking was construed
as a natural parallel to including women in
decisionmaking in development efforts. Thus,
gender-equity strategies from a project in the
environmental sector were imported into a FP
initiative, furthering the objective of reducing
unintended pregnancy as well as promoting
gender equality.
The evaluation of this project employed
community-based surveys of individuals of
reproductive age prior to the start (January
2001) and at the end of the project (September
2002). Logistic regression analyses showed sub-stantial
differences in knowledge, attitudes, and
behavior after the FP intervention.
Communication between partners also
increased. The differences between participants
and non-participants were small, suggesting a
community-level effect. The researchers attri-bute
the program’s success to the way the
intervention was integrated into an already
successful water and sanitation project
equipped with its own outreach infrastructure
for involving many men and women in the
community.32
Reproductive Health Awareness (RHA)33
Country: Philippines
Implementing organizations: KAANIB in the Philippines;
evaluation conducted in collaboration with FRONTIERS/
Population Council, the Institute for Reproductive Health
(IRH, Georgetown University), and the Research Institute for
Mindanao Culture (RIMCU at Xavier University).
In this male engagement intervention, KAANIB
worked with small farmers and agrarian reform
beneficiaries and implemented the RHA inter-vention
through its trained volunteer couple
members. The RHA project sought to promote
constructive engagement of men in reproduc-tive
health by improving awareness, knowledge,
health-seeking behavior, and couples communi-cation
on RH. The project used a couples
approach, but emphasized husbands’ needs and
involvement in RH. The volunteer couples were
trained on four topics: fertility and body aware-ness;
family planning; RTI/STI and HIV/AIDS;
and couples communication on RH. These top-ics
had been identified as gaps in knowledge
during a 1997 baseline survey of male involve-ment
conducted by the FRONTIERS Project
and IRH/Georgetown.
The evaluation included a pre- and post-test
nonequivalent control group design. At pre-test
(prior to the RHA intervention), 210 couples
who were members of KAANIB and 249 couples
from the comparison areas were interviewed.
At post-test, 183 of the original 210 couples in
KAANIB areas were found and interviewed, as
well as 217 couples in the comparison areas. In
the intervention area, significant positive
changes were found in supportive attitudes by
husbands toward RH, and in husband-wife
communication, as reported by husbands and
their partners. Knowledge and awareness about
anatomy and physiology, fertility, family plan-ning
methods, and STI increased significantly
among women but not among men. No changes
were found in family planning use. Statistically
significant improvements were found among
men in the program area regarding communi-cation
with spouses on the fertile period and
use of family planning. The intervention dem-onstrated
the feasibility of using couples as RH
educators in the community.
33 Palabrica-Costello, 2001.

PRACHAR34
Country: India
Implementing organizations: Pathfinder International with 30
local NGOs in Bihar, India.
The PRACHAR project aimed to raise aware-ness
about FP and the healthy timing and spac-ing
of pregnancy among young people and
community leaders. The project worked with
married and unmarried young people, both
male and female, as well as with mothers-in-law
and other family members of young couples
and respected community elders and commu-nity
leaders. The three-year project that began
in 200135 worked in 452 villages and provided
information on RH/FP issues to over 90,000
adolescents and young adults and over 100,000
parents and other adults in the communities.
Educational messages regarding the risks and
disadvantages of early marriage and childbear-ing,
and the benefits of delaying and spacing
births, were tailored for these different audi-ences.
The project also provided contraceptives
and worked with community-based practitio-ners
to increase their skills in providing basic
maternal and child health and RH/FP services.
The transformative approach focused on
empowering girls and women, increasing men’s
knowledge and sensitization to FP, and on open
communication between partners on issues
related to childbearing, family size, and use of
contraception. The PRACHAR project’s evalua-tion
relied on project monitoring data and pre-/
post surveys in intervention and control areas
to assess impact. Key RH results included:
n The percentage of the population (all
respondents) who said they believed that
contraception is both necessary and safe
increased from 38 percent to 81 percent.
Among unmarried adolescents, this figure
n The percentage of recently married couples
using contraceptives to delay their first
child more than tripled, from five percent to
20 percent, and the interval between mar-riage
and first birth increased from 21
months to 24 months.
n The percentage of recently married contra-ceptive
adopters who began using contra-ception
within the first three months of the
consummation of marriage increased dra-matically,
from less than one percent to 21
percent.
n The percentage of first-time parents who used
contraception to space their second child
34 Information from Wilder et al.. 2005. See also, E.E. Daniel
et al., 2008.
35 This section relates to data from Phases I and II of the
PRACHAR project. As this publication goes to press, the
project is currently in Phase III.

REWARD36
Country: Nepal
Implementing organizations: The Centre for Development and
Population Activities (CEDPA), The Nepal Red Cross Society
(NRCS), and the Centre for Research on Environmental
Health and Population Activities (CREHPA).
The NRCS, in collaboration with CREHPA,
implemented the REWARD (Reaching and
Enabling Women to Act on Reproductive
Health Decisions) Project to strengthen wom-en's
capabilities for informed decisionmaking
to prevent unintended pregnancy and improve
reproductive health in three districts of Nepal.
The project worked with Village Development
Committees and supported a network of more
than 700 community-based staff and volunteers
engaged in delivering reproductive health infor-mation
and methods (pills, condoms, and
Depo-Provera) at the community level. It aimed
both to provide services and referrals and to
create an enabling environment to strengthen
women's informed RH decisionmaking. Two
components of this strategy were educational
sessions to increase gender awareness among
program managers and service providers, and
encouragement of women’s participation at all
levels of the NRCS. The project also created
women-only community action groups (CAGs)
that met monthly to discuss reproductive
health issues. At the program’s peak, there
were 495 active CAGs with nearly 10,000
members.
After the REWARD project in Nepal was
phased out in 2002, CEDPA conducted an eval-uation
that included two components: 1) an
assessment of project performance based on
secondary data; and 2) a population-based sam-ple
survey in one district (security concerns
prevented a more extensive survey).
Comparison of baseline and endline data sug-gested
increases in contraceptive prevalence
and “couple years of protection” (CYP);
increased popularity of reversible contracep-tives
such as DMPA, condoms, and pills; and
increased use of maternal and child care ser-vices
during the course of the project.
36 CEDPA, 2004; and CREHPA, 2002.

REDUCING UNINTENDED PREGANCIES CASE STUDY
Intervention:
Women’s Empowerment Model to Train Midwives and Doctors
Country: Afghanistan
Type of Intervention: Health provider training
Implementing Organizations: Family Health Alliance (FHA)
Gender-Related Barriers to RH
Women in Afghanistan are among the least
empowered groups in the world. Afghan
women often lack agency to make the most
basic decisions, including those regarding
reproductive health and family planning.
Additionally, the country has one of the
highest maternal mortality rates in the
world.37 This is a direct result of the patriar-chal
structures prevalent across
Afghanistan, and the ensuing constraints
placed on women’s lives. The restrictions
limit women’s educational and economic
opportunities, as well as their access to
reproductive health care. In addition, years
of conflict and instability have devastated
Afghanistan’s health care facilities and
health professional capacities, further
impacting women’s health.
Objective
This intervention (implemented 2005 –
2007) sought to address maternal mortality
in Afghanistan by preventing unwanted
pregnancies and promoting birth spacing
through the expansion of family planning
services.
Strategy
FHA sought to improve RH outcomes by
training female midwives and doctors using
the Women’s Empowerment Model. This
training program focused on clinical skills
in family planning, particularly IUD inser-tion,
and increasing family planning knowl-edge.
The project sought to reduce
infections, enhance detection and treatment
of STIs, and improve their approach in edu-cating
clients in HIV/AIDS/STI prevention.
FHA trained 47 female family planning ser-vice
providers from more than 10 prov-inces.
The rationale for using a women’s
empowerment approach was that this
model would lead to increased communica-tion
and changes in gender norms and
decision-making power. Additionally,
empowered women health providers could
become more valued members of the
healthcare system and be better able to
meet their clients’ healthcare needs.
The program used five empowerment
strategies:
1. Role modeling. The project recruited pro-fessional
Muslim women trainers from Iran.
2. Developing critical thinking skills.
Trainers focused on the status of Afghan
women and compared them with other
women in the region.
3. Individual consultations. The project
encouraged one-on-one meetings between
trainers and trainees to discuss barriers to
trainees completing the program (e.g.
obtaining husbands’ permission).
4. Fostering teamwork and personal
responsibility. Trainees were involved in
problem-solving tasks during the program.
5. Overcoming fatalism. The project pro-moted
women as agents of change and a
culture of “it can be done.”
Evaluation Design:
Single sample pretest-posttest
The program was evaluated using pre- and
post-tests of trainees’ knowledge and clini-cal
skills.
Findings showed a significant increase,
from 53 percent to 89 percent, in trainee
knowledge of family planning methods,
counseling strategies, and STIs and HIV/
AIDS. Clinical skills tests showed an aver-age
score of 86 percent in the areas of
infection prevention procedures, correct
use of medical instruments, counseling
strategies, IUD insertion and removal, and
detection and treatment of STIs.
Gender Outcomes
Results showed that trainees demonstrated
increased understanding of the importance
of applying women's empowerment strate-
37 UNICEF and CDC, 2002.

Figure 2.1
Results of Clinical Assessment: Kabul and Mazar Combined
n=47
gies when interacting with their family plan-ning
clients.
Limitations
While this intervention demonstrated the
improvements in healthcare providers’ skills
that can happen when careful attention is
paid to the cultural barriers that they face,
this was also a missed opportunity for
understanding how gender integration
affects gender outcomes in addition to
health outcomes. An evaluation design that
included, for example, a woman’s empower-ment
scale to measure gender attitudes,
would have been a complement to the
knowledge and clinical assessments, provid-ing
richer data and a clearer understanding
of the empowerment process.
Conclusions
The results indicate that a women’s empow-erment
training model can effectively help
female health providers to develop high lev-els
of competency in clinical skills and
greater knowledge of family planning meth-ods,
counseling strategies, and STIs and
HIV/AIDS. Trainees also developed a greater
appreciation of women’s empowerment
strategies that could be used with family
planning clients.
18
16
14
12
10
8
6
4
2
References
Family Health Alliance. Clinical Family
Planning/ Reproductive Health Training
Program in Afghanistan, 2007. Accessed
online Dec. 1, 2009 at www.familyhealthal-liance.
org/programs.php.
Taraneh R. Salke, Lessons from the Field:
Using a Women's Empowerment Model to
Train Midwives and Doctors in Afghanistan.
Presentation at 2007 APHA Conference.
Washington, DC: FHA, 2007.
0
75% or
Below
76-80% 81-85% 86-90% 91-95% 96-100%
Number of People
Percent Correct
Note: Results indicate percent of questions answered correctly after health provider trainings.
Source: T. R. Salke, 2007.

Reducing Unintended Pregnancies Case Study
Intervention:
PROCOSI Gender-Sensitive Reproductive Health Program
Country: Bolivia
Type of Intervention: Reproductive health service delivery
Implementing Organizations: PROCOSI (Programa de Coordinación en Salud Integral)
Cost: Average cost of intervention only: $23,148
Bolivia has a long history of discrimination
against women, evident in many national
health and well-being indicators where
women suffer from higher rates of poverty,
illiteracy, unemployment, domestic violence,
and lower rates of political participation.
Healthcare clinics often overlook the inequi-ties
between women’s and men’s lives,
including power, decision-making capacity,
and access to resources, as well as varying
communication patterns. These inequities
limit women’s ability to access and use
reproductive health services.
Objective
The objective of this project was to assess the
effects and cost of incorporating a gender per-spective
into existing RH service programs.
Strategy
PROCOSI is a network of 24 Bolivian NGOs
that coordinates and implements health pro-grams
throughout the country. The
“Incorporating Gender Program” was imple-mented
from 2001 – 2003 by 17 of the
PROCOSI partner NGOs. First, all PROCOSI
organizations were invited to participate in
the program. Next, PROCOSI adapted a
framework developed by International
Planned Parenthood Federation (IPPF)38 to
operationalize a gender perspective. The
framework evaluated seven organizational
areas through 71 indicators. The organiza-tional
areas included: institutional policies
and practices; practices of providers; client
satisfaction; client comfort; use of gendered
language; information, communication and
training; and monitoring and evaluation.
PROCOSI trained evaluation teams
from each of the 17 organizations. The
teams completed baseline evaluations and
analyzed the results. Each team then partici-pated
in two workshops to decide which
areas the organization should improve
upon. An action plan was developed for
each selected indicator and then imple-mented
over a 15-month period. All partici-pating
organizations received a package of
Married, Non-Pregnant Women With Unmet Family Planning Needs
SURVEY
Unmet need for: Pre (N=707) Post (N=830)
Limiting with desire to use* 10.6 7.1
Spacing with desire to use* 6.1 3.8
Limiting and spacing* 25.5 20.8
Limiting and spacing with desire to use* 16.7 10.9
* Significant statistical difference between periods with a confidence level of 95 percent
Source: E. Palenque, et al., Effects and Costs of Implementing a Gender-Sensitive Reproductive
Health Program, 2004.
print materials and videos related to gender,
reproductive health, and family planning for
distribution to clients and providers.
Evaluation Design:
Mixed-methods, pretest-posttest
Household surveys of health service users
and their partners were administered pre-and
post-intervention. Nine organizations
from the participating 17 were initially
selected, from which 10 clinics were chosen
for evaluation. IPPF provided technical
assistance to conduct the baseline and end-line
studies. The evaluation included: 1) exit
interviews with clients after their visits to
the clinics, before and after the gender
interventions; 2) follow-up interviews with
the same women in their households three
months after the exit interviews; 3) a survey
with a sample of the women’s partners; 4)
analysis of service statistics; 5) a cost anal-ysis
to estimate the costs of incorporating a
gender perspective into service delivery; and
6) monthly visits to each clinic to qualita-tively
assess changes in the organization.
Student’s T and Chi square tests were used
to test significance.
Results showed significant decreases in
unmet need for family planning when all
sites were aggregated. Unmet need for teta-nus
vaccination among pregnant women
% %
and for contraceptive services among non-pregnant
women were used as proxy indica-tors
to assess the impact of the
interventions on users’ health. There were
no significant changes in meeting unmet
needs related to tetanus vaccines for preg-nant
women.
There were significant changes in out-comes
related to quality of care, including
more comfortable interactions with the
health provider and changes in provider
practices, such as mentioning SRH issues.
There was a significant increase in the pro-portion
of women who reported that provid-ers
asked them questions or gave them
specific information to actively explore their
health needs, on topics such as cervical or
breast cancer, STIs/HIV/AIDS, sexuality, and
domestic and sexual violence. There were
also significant increases in screening for
FP needs. The proportion of women
screened on the above topics, however,
remained below half at endline.
Gender Outcomes
The evaluation measured changes in partner
communication, couple decisionmaking, and
attitudes toward gender roles and gender-based
violence. Findings showed modest
changes. There were no significant changes
38 IPPF, Manual to Evaluate Quality of Care
from a Gender Perspective, 2000.
Table 2.2

Table 2.3
Table 2.4
with regard to women’s perceptions of their
partners’ attempts to control them; however,
there was a significant decrease in the pro-portion
of men who said they always
decided what their partner had to do, for-bade
her from wearing certain kinds of
clothes, and did not allow her to speak in
social gatherings.
In both surveys, but particularly at end-line,
the majority of women said they could
speak easily to their husbands regarding FP
methods, when to have children, sexual
relations, STIs, and family health.
With regard to perceptions of gender
roles, significant changes in women’s
responses toward more gender-equitable views
were found in two indicators: it is not correct
for a woman to initiate sexual relations, and
women’s work should be mainly at home. One
indicator—women’s work should be mainly in
the home—was significant for men.
The proportion of women who believed
that there are circumstances in which men
have the right to beat their partners
decreased significantly from 4.4 to 1.8 per-cent.
No significant changes were found
among men.
Replication
As a follow-up to the above intervention, in
2005 FRONTIERS collaborated with
PROCOSI to test the feasibility and costs of
a certification system for verifying that its
member organizations provided gender-sen-sitive
reproductive health services. Service-delivery
facilities were required to comply
with 80 percent of 65 pre-established stan-dards
on quality of care and gender. The
categories included institutional policies and
practices, provider practices, personnel
knowledge of reproductive health, client
comfort, use of gendered language, infor-mation,
education, communication and
training, client satisfaction, and monitoring
and evaluation.
The certification process was imple-mented
in three steps: an initial diagnostic
assessment; development and implementa-tion
of workplans; and finally an external
evaluation to issue the two-year certification.
The initial diagnostic assessment showed
that the NGO facilities complied with an aver-age
of 14 percent of the gender- and quality-related
standards. At the endline assessment,
the facilities met 94 percent of the standards.
Average costs for improvements
across the seven facilities were lower than
the case study intervention, averaging
$4,004, compared to $23,148. Excluding
staff time, the average cost was $2,039,
with the majority of expenses due to meet-ings,
workshops, and infrastructure
improvements in the three facilities that
required infrastructure changes.
Limitations
The high cost of the intervention poses a
considerable challenge to replicating or scal-ing
up this intervention. As the follow-on
project by FRONTIERS and PROCOSI dem-onstrated,
a more cost-effective approach to
operationalizing a gender perspective may
be to develop a certification system with
teams from the NGOs implementing all
training activities, infrastructure changes,
procedures, and revisions of statutes with
their own resources. Under this approach,
14 out of 15 organizations were able to
meet 80 percent of the standards, costing,
on average, $19,144 less than the incorpo-rating
gender program.
Conclusions
PROCOSI'S gender program produced a
number of positive RH outcomes, including
a decrease in unmet need for contraception,
improved client satisfaction and quality of
care, increased staff awareness of SRH, and
positive changes in behavior among male
and female staff.
The intervention produced moderate
but important gender outcomes, including
women’s increased confidence in their
capacity to discuss SRH and awareness of
their rights to use contraceptive methods.
Among partners, a decrease in tolerance of
gender-based violence was found.
References
E. Palenque, L. Monano, R. Vernon, F.
Gonzales, P. Riveros, and J. Bratt. Effects
and Costs of Implementing a Gender-
Sensitive Reproductive Health Program.
Frontiers Final Report. (Washington, DC:
Population Council, 2004).
E. Palenque, P. Riveros Hamel, and R.
Vernon. Consolidating a Gender Perspective
in the PROCOSI Network. Frontiers Final
Report. (Washington, DC: Population
Council, 2007).
Women’s Perceptions of Characteristics of Their Interaction with
Health Providers (significant outcomes)
Variable Pre-survey (%) Post-survey (%)
N= 1,060 N= 1,062
Felt uncomfortable during the interaction 8.3 5.8
Called by her name 72.7 86.8
Provider used visual aids in his/her interactions 16.8 32.6
Provider informed her she had right to ask questions 20.3 47.8
Had time to ask questions 77.8 83.3
Asked questions 73.6 80.1
Source: Palenque et al., 2004.
Affirmative Answers on Variables Related to Gender Roles
Variable Pre-survey (%) Post-survey (%)
Women
It is not correct for a woman to initiate sexual relations 56.3% 52.0%
Women’s work should be mainly in the home 46.0% 27.5%
In certain circumstances men have the right to beat
their partner 4.4% 1.8%
Men
Women’s work should be mainly in the home 42.5% 28.3%

According to the 2006 Lancet Maternal
Survival Series, “The risk of a woman dying
as a result of pregnancy or childbirth during her
lifetime is about one in six in the poorest parts
of the world, compared with about one in
30,000 in Northern Europe.”39 This disparity
highlights the enormous difficulty of meeting the
fifth Millennium Development Goal—reducing
maternal mortality by 75 percent between 1990
and 2015. Most maternal deaths occur during
labor, delivery, and the immediate postpartum
period, with the main medical cause of maternal
deaths being obstetric hemorrhage.
The social, economic, and political causes
are many and include gender inequality.40
Gender-related barriers amplify the physiologi-cal
dangers associated with motherhood. For
example, women’s lack of decision-making
power may deny them access to health care
and negatively affect maternal health out-comes.
41 Women’s limited access to education
can impede their understanding of basic health
care concepts such as danger signs in preg-nancy.
In many settings, women’s limited
mobility outside the home may make them
uncomfortable in institutional settings, such as
clinics and hospitals, and interfere with their
communication with health care providers.
Men are often the primary wage earners; as
a result, their health may be valued more than
women’s,42 and families may be reluctant to
use resources for pregnancy-related care.
Pregnant women may be reluctant to consume
extra calories or seek care when danger signs
arise,43 or may be scolded by husbands or
mothers-in-law for doing so.44 Men are often
primary decisionmakers about their wives’
health care, yet they are often ignorant about
their wives’ health before, after, and even dur-ing
labor and delivery.45
In some societies, gender norms require
that women demonstrate their strength by suf-fering
3
22
Gender Perspectives Improve Reproductive Health Outcomes: New Evidence
through labor and childbirth with little
or no assistance.46 Physicians and other obstet-ric
service providers may discourage or forbid
family members from being present or provid-ing
support during labor47 despite the many
studies that have demonstrated the beneficial
impact of labor companions on clinical out-comes.
48 These types of gender-related barriers
to maternal health come from the personal,
family, and community levels, and together cre-ate
significant barriers to women’s ability to
access services.
39 Ronsmans and Graham, 2006; accessed online Dec. 1,
2009 at www.womendeliver.org/pdf/Maternal_Lancet_
series.pdf
40 Sen, Ostlin, and George, 2007.
41 See Atkinson and Farias, 1995; Nachbar, 1997; Vissandjee
et al., 1997; World Health Organization, 1995; Roth and
Mbizvo, 2001.
42 Schuler et al., 2002.
43 Hoang et al., 2002.
44 Raju and Leonard, 2000.
45 Raju and Leonard, 2000.
46 Bradby, 1999; Sargent, 1998.
47 Jessop et al., 2000: 54; Boender et al., 2004:32.
48 Zhang et al., 1996; Hodnett, 2001; Sosa et al., 1980.
Program Country
FEMME Project Peru
Men in Maternity Project India
CASE STUDY: South Africa
Involving Men in Maternity Care
CASE STUDY: India
Social Mobilization or Government Services

Strategies Used in Programs to Improve Maternal Health
Improving use of MH services by improving accurate RH knowledge and
changing attitudes of mothers-in-law, husbands
Testing models to encourage husbands’ participation in wives’ antenatal and
postpartum care
Providing couples counseling and information and encouraging men to
attend services
Training health providers to understand women’s right to basic standard
of care
IImmpprroovviinngg MMaatteerrnnaall HHeeaalltthh 2233
Interventions
Four projects met the review’s criteria and
incorporated gender approaches in interven-tions
to reduce maternal mortality and morbid-ity
(see table. 3.1 for gender strategies). Of
these four, two were chosen as case studies
because of their successful gender transforma-tive
approaches (see pages 25 and 27). The
Project in India sought to create a supportive
environment to improve women’s use of ser-vices
by reaching out to husbands and moth-ers-
in-law, in addition to women. In South
Africa, the Involving Men in Maternity Care
Project followed two broad strategies: improv-ing
antenatal care services and reaching out to
couples through counseling and information.
A common feature of all four projects was
their recognition that decisions about ante- and
postnatal care typically are not made by young
pregnant women and new mothers, but more
often by husbands or mothers-in-law. These
projects, therefore, focus on men or older
women as well as young women. The strategy
of involving men in maternity care may be seen
as either gender-accommodating, in building on
men’s roles as gatekeepers, or gender-transfor-mative
insofar as it encourages men to expand
their traditional gender roles.
These projects also sought to change atti-tudes
and practices among service providers,
drawing on some of the longstanding work
developed under earlier quality of care initia-tives.
This emphasis on women’s rights to a
basic standard of care, and to be treated
respectfully as clients, makes some of the proj-ects
transformative, since inequitable gender
norms typically deprive women of rights.
FEMME Project (Foundations for Enhancing
Management of Maternal Emergencies)49
Country: Peru
Implementing organizations: CARE/Peru; the Peruvian
Ministry of Health; Columbia University
This project was implemented in a region of
Peru’s Southern Highlands. The technical com-ponent
of the FEMME Project aimed at improv-ing
clinical quality of care in obstetric
emergencies through standardized handling of
clinical cases using a new set of emergency
obstetric care guidelines. The project combined
this intervention with a rights component
stressing women’s rights to decent and humane
care, and including information for patients,
privacy during care, and an emphasis on
respect for local customs and beliefs.
Of the four projects reviewed in this sec-tion,
the FEMME project had the most exten-sive
evaluation. It used a quasi-experimental
study design with a non-equivalent control
group, incorporated both quantitative and qual-itative
methods of data collection, and mea-
23
Table 3.1
49 CARE, 2007.

sured health outcomes rather than process
variables only. The evaluation covered five
intervention and five control health facilities.
The study found that the FEMME approach was
well accepted among health personnel (doctors,
obstetricians, and nurses). The evaluation
results show markedly higher scores in the
intervention facilities in the correct use of clin-ical
obstetric protocols, dramatic increases in
the treatment of obstetric complications, and a
reduction of over 80 percent in case fatalities.
The maternal mortality rate declined by 49
percent in the intervention facilities, compared
with a 25 percent decline in the comparison
group. The total cost of the FEMME Project was
approximately US$750,000, including the years
of intervention as well as administrative closure
and documentation activities (2000-2006).
Men in Maternity Project (MiM)50
Country: India
Implementing organizations: The Employees’ State Insurance
Corporation (ESIC) and the Population Council.
This project tested a model that encouraged
husbands’ participation in their wives’ antena-tal
and postpartum care. Addressing the fact
that many women depend on men for access to
healthcare, further complicated by socio-cul-tural
norms on appropriate sexual behavior for
men and women, the interventions included: 1)
individual or group counseling sessions for men
and women separately, in the antenatal clinic;
2) couples’ counseling sessions during antena-tal
and postnatal clinics; 3) screening of all
pregnant women for syphilis; and 4) syndromic
management of men reporting urethral dis-charge
and men and women reporting genital
ulcers.
The MiM project used a non-equivalent con-trol
group study design to examine the effects
of the intervention. Three of 34 ESIC dispensa-ries
in Delhi with the highest antenatal clinic
attendance that also had laboratory facilities
were selected as intervention sites and three as
control sites. Concerning FP/RH outcomes, the
study found improved knowledge of FP among
both men and women and improved knowledge
of pregnancy danger signs among women but
not men, and no improvements in STI knowl-edge
24
or condom use. There was a significant
increase in screening of pregnant women for
syphilis with the establishment of a universal
syphilis screening program.
As for gender outcomes, husbands’ involve-ment
was significantly higher in the interven-tion
group during antenatal consultation, family
planning consultation, postpartum visit, and
presence during labor and delivery.
Communication between spouses increased in
the postpartum period on baby’s health, breast-feeding,
and family planning issues, but com-munication
on STIs was low and did not
significantly increase. More women from the
intervention group compared to the control
group reported making joint decisions on fam-ily
health and family planning issues.
Improvements were also documented in client-provider
interaction and satisfaction.
50 Varkey et al., 2004.

Improving Maternal Health Case Study
Intervention:
Involving Men in Maternity Care
Country: South Africa
Type of Intervention: ANC and postpartum care program
Implementing Organizations: Reproductive Health Research Unity (RHRU), University of the Witwatersrand, FRONTIERS,
KwaZulu Natal Department of Health
cost: Total cost of intervention only = $97,552; Cost per clinic = $16,258
Improving Maternal Health 25
In the traditional Zulu community where
this intervention took place, family plan-ning
has been predominately the woman’s
responsibility. Men, however, are often the
primary household authority, controlling
income and expenditures and granting per-mission
for their partner to seek health
care. It is usually the male partner who
decides which contraceptive method, if
any, will be used. These gender roles
impact a woman’s reproductive health
decisionmaking abilities and communica-tion
with her partner. These roles also limit
men’s understanding of RH and MH, and
their participation as supportive and
engaged partners. The contradiction
between women’s expected responsibilities
and limited agency, coupled with norms
indicating that men are the sole decision-makers
in a household, can negatively
affect reproductive health outcomes.
Objective
The main goal of the intervention was to
design and test an expanded antenatal and
postpartum care program to improve
women’s and men’s reproductive health by
increasing the use of postpartum family
planning and protective behaviors for STIs
and HIV/AIDS. The intervention (imple-mented
from 2000 – 2003) sought to
encourage men’s participation in their part-ners’
maternity care by adjusting services
to welcome men and encourage couples’
counseling.
Strategy
Two clinic-based strategies were used. The
first strategy, improving existing antenatal
care services, included information, educa-tion,
and communication through dissemi-nation
of an information leaflet and an
antenatal booklet for couples. The second
strategy, couples’ counseling, trained
health providers on constructive engage-ment
of men and invited partners of
women to attend counseling during and
post pregnancy.
Formative research was carried out to
inform the intervention, including: a facility-based
analysis; a case study on syphilis
screening and management in antenatal cli-ents;
client flow analysis and a time motion
study of how providers spent their time;
focus group discussions; and record
reviews.
To ensure program support, several
meetings were held with key stakeholders,
including Department of Health officials at
local, provincial, and national levels; clinic
managers; and health care providers.
Several technical working groups developed
information, education, and communication
materials and in-service training modules,
and made recommendations for creating a
couple-friendly environment.
Two trainings were held, one for all
clinic and support staff and a second for 65
professional nurses working in the interven-tion
clinics. Topics in this second training
included pregnancy, preparation for delivery,
postnatal care, involving men in maternity,
sexual health, basic counseling, quality
improvement, and infection control.
Each clinic developed its own plan
regarding how to schedule couple counsel-ing.
Invitation letters were sent encouraging
men’s participation in the counseling ses-sions
(two letters during antenatal care and
one post-delivery) and attendance certifi-cates
were given to men who attended
counseling sessions during work hours to
present to their employers. Nurses facili-tated
the interactive group couple-counsel-ing
sessions, which covered antenatal care
procedures, physiological and emotional
changes, pregnancy danger signs and care
seeking, delivery plan, post-delivery care for
mother and baby, STI and HIV/AIDS preven-tion
and management, family planning, and
infant feeding.
Evaluation Design: Cluster
randomized-controlled trial
The study design was a cluster random-ized-
controlled trial with six clinics imple-menting
the intervention and six control
clinics continuing to provide services as
normal. Individual interviews were col-lected
to evaluate the program. Baseline
interviews (995 respondents in the inter-vention
group and 1081 in the control
group) were collected prior to the women’s
first antenatal appointment. Follow-up
interviews were conducted six months
post-delivery (follow-up rate: 68 percent
for women and 80 percent for men). Focus
group discussions were conducted with
health providers at intervention clinics to
evaluate their satisfaction with the inter-vention
activities. Cost data were collected
on the costs of planning, implementing,
and monitoring the intervention.
In emergency situations, a significantly
higher proportion of men in the intervention
group assisted their partners compared to
men in the control group. Significantly
more couples in the intervention
continued on next page

group discussed topics related to STIs,
sexual relations, immunization, and breast-feeding.
Among women exposed to counseling
and the booklet, the intervention signifi-cantly
improved the knowledge of condoms
for dual protection; no similar improvement
was seen in their male partners.
Compared to those in the control
group, women in the intervention group
were significantly more likely to be assisted
by their partners when experiencing prob-lems
during pregnancy. There were no sig-nificant
differences in knowledge of
obstetric danger signs or in the following
indicators: use of contraception or methods
at six months postpartum, STI and HIV/
AIDS knowledge and risk behavior, syphilis
testing and management, and breastfeeding
practices.
Gender Outcomes
As mentioned above, communication among
the couples improved and couples were
more likely to discuss such topics as STIs
and sexual relations.
Limitations
The intervention failed to achieve significant
outcomes on some of the indicators. One
explanation for this may be that the evalua-tion
results under-represent the project’s
impact due to possible contamination
effects in service delivery. The same super-visors
and managers were responsible for
both the intervention and control clinics,
and may have unknowingly changed ser-vices
at the control clinics because of their
experience at the intervention clinics.
Clinic statistics were used to match
clinics and randomly assign them to the
Issues Discussed by Matched Couples
topics discussed control Couples % intervention couples %
treatment groups. Clinic records were not
always accurate, however, and some could
not achieve the expected numbers of partici-pants.
This meant that some clinics had too
few participants to be included in statistical
comparisons.
A number of project and research
design components could have been
improved to address the overall low levels
of significance. Programming could have
been enhanced by extending the interven-tion
period or including mass communica-tion
strategies, and the research design
could have been strengthened by reducing
chances for contamination.
Conclusions
The intervention successfully demonstrated
that male participation in this context is fea-sible.
That one-third of couples attended the
counseling is notable, given that this was a
new concept in a community where there
was negligible male participation in mater-nity
care and most couples were not cohabi-tating.
Other men expressed willingness to
participate, but were unable due to work
schedules, lack of permission from employ-ers,
or not being told about the counseling
by their female partners.
The evaluation provided evidence that
the intervention was effective in significantly
changing couple communication and part-ner
assistance during emergency situations
and improving knowledge of condoms as a
dual protection method.
References
B. Kunene, M. Beksinska, S. Zondi, N.
Mthembu, S. Mullick, E. Ottolenghi, I.
Kleinschmidt, S. Adamchak, B. Janowitz,
and C. Cuthbertson, Involving Men in
Maternity Care: South Africa. Frontiers, Final
Report (Washington, DC: Population
Council, 2004).
(n=528) (n=588)
STI 64 75*
Sexual relation 75 81*
Family planning 70 77
Whether to have more children 49 54
Immunization 75 81*
Breastfeeding 83 87*
Baby's health 71 78
* p<0.05
Source: Frontiers.
Table 3.2

Improving Maternal Health Case Study
Intervention:
Country: India
Type of Intervention: Community-based mobilization and government RH services
Implementing Organizations: Foundation for Research in Health Systems (FRHS), ICRW
Cost: Total cost of implementation and evaluation: $93,248. (Social mobilization – 42%; Government services – 18%;
Research and administration – 40%.)
Improving Maternal Health 27
Rates of adolescent marriage and early child-bearing
in India are among the highest in
South Asia. Sexual and reproductive health
education is a taboo subject for unmarried
girls and so young women who enter into
marriage are likely to be uninformed about
issues such as contraception, pregnancy,
STIs, and disease prevention. After marriage,
gender restrictions and social norms (includ-ing
limited mobility and decisionmaking), in
addition to an unsupportive environment for
young women’s reproductive health, may
prevent young women from accessing RH
care and family planning services. Mothers-in-
law often play a significant role in their
daughters-in-law’s lives and control their
health-seeking behavior.
Objective
This study, implemented from 2001 – 2006,
examined the relative effectiveness of
addressing supply versus demand con-straints
to improve RH for young married
women.
Strategy
The intervention targeted newly married
couples in two comparable neighborhoods
of Ahmednagar district in Maharashtra.
Social mobilization and government health
service improvement strategies were used
to address the demand and supply con-straints,
respectively. The strategies were
developed in response to formative research
carried out from 1996–1999 as part of a
larger program that identified constraints to
women’s reproductive health.
The social mobilization strategy was
implemented through existing community-based
organizations and in collaboration
with youth and women’s groups. These
groups served as interactive health educa-tion
sessions for married adolescent girls.
Young girls’ husbands participated in male
group forums. FRHS anticipated that engag-ing
male youth groups and women’s groups
would encourage husbands and mothers-in-law
to participate in and support young
women’s reproductive health-seeking,
thereby creating a more supportive environ-ment.
Two FRHS social workers and two
members from the government’s district
training center organized the social mobili-zation
activities.
The government health service
improvement strategy was implemented in
partnership with the government health sys-tem
and focused on training local health
officials. Government health providers were
also sensitized to adolescents’ health needs
and trained on how to provide couple coun-seling
to married adolescent girls and their
husbands.
Evaluation Design:
4-Cell experimental design
Four interventions were each implemented
in one primary health center (PHC) area:
One PHC had only social mobilization strate-gies;
a second focused only on improving
government health services; a third had
both strategies concurrently (SM+GS); and
a fourth, the control area, received neither.
The interventions and control PHC were
assigned randomly. Across the four PHCs,
22 sub-center villages were encompassed.
FRHS conducted a baseline survey of
1,866 married girls and women ages 16-22
years across the study villages, collecting
data on adolescent girls’ health needs and
constraints; health-seeking patterns; and
experiences and perceptions of quality of
care for a number of reproductive health
outcomes. Similar surveys were completed
at the midpoint (N=2,100) and endline
(N=2,359).
Mid-intervention, 972 husbands of
young women were surveyed to collect data
on their knowledge of, and involvement in,
their wives’ health-seeking. Similarly, 75
mothers-in-law were interviewed at mid-point
to assess their attitudes toward their
daughters-in-law.
Of the four study arms, the two arms that
included social mobilization strategies saw
the greatest improvement in reproductive
health outcomes. The social mobilization area
was most effective in improving women’s
knowledge of maternal health, contraceptive
side effects, and abortion, and increasing
behaviors related to postnatal check-ups,
contraceptive use, treatment of gynecological
disorders, and partner treatment of reproduc-tive
tract infections and STIs.
The SM+GS site saw the greatest increase in
basic awareness of reproductive health and
infertility. One explanation for this outcome
may be that a new female doctor who took a
special interest in these issues began work-ing
in this site in the middle of the interven-tion.
The government services-only site did
not see significant improvements in most
outcomes.
Gender Outcomes
Qualitative interviews with mothers-in-law
indicated that the social mobilization inter-vention
contributed to an increase in sup-portive
attitudes toward daughters-in-law’s
health-care seeking.
Surveys of husbands at mid-point
showed that most had gained an awareness

of basic maternal care issues and were will-ing
to seek treatment for problems during
pregnancy and childbirth.
Limitations
Due to the popularity of the health educa-tion
sessions, representatives in the control
arm began implementing their own health
education sessions. Therefore, some con-tamination
of the research design may have
Percent Change from Baseline to Endline, By Strategy
Need for full ANC 66.1 18.5 -3.4 50.2
Need for PNC 129.5 43.5 24.6 81.7
Spacing FP methods 14.4 14.1 12.4 9.7
Had PNC check-ups 40.5 -17.8 2.9 2.9
High-risk delivery care 4.7 4.2 29.8 24.4
Treatment-RTI symptoms 49.5 44.8 98.2 26.7
occurred.
Although husbands’ data showed
increased awareness and willingness to
seek maternal care for their wives, only a
minority of husbands actually accompanied
wives to the health care centers. This may
be partly because social norms and health
centers, which offer minimal privacy, dis-courage
male participation.
Conclusions
This study illustrates the effectiveness of
social mobilization in increasing young mar-ried
women’s knowledge of RH, increasing
use of RH services, and changing social
norms and attitudes of mothers-in-law
toward their daughters-in-law’s RH.
The research team expected the com-bination
arm to generate the best outcomes,
by addressing both the demand and supply
constraints of women’s health-seeking. The
SM-only arm, however, performed better for
many outcomes; having a more focused
and concentrated intervention may be one
explanation for this.
The project’s work with mothers-in-law
and husbands showed some success as
well. The evaluators found the inroads with
husbands to be especially notable because
maternal care in this society typically is
regarded as a “woman’s issue.” Efforts
should continue to be made to encourage
male participation in their wives’ maternal
care.
SM GS SM + GS Ctrl
References
International Center for Research on
Women, “Social Mobilization or Government
Services: What Influences Married
Adolescents’ Reproductive Health in Rural
Maharashtra, India?” in Briefing Kit,
Improving the Reproductive Health of
Married and Unmarried Youth in India
(Washington, DC: ICRW, 2006).
R. Pande, K. Kurz, S. Walia, K. MacQuarrie,
and S. Jain, “Improving the Reproductive
Health of Married and Unmarried Youth in
India: Evidence of Effectiveness and Costs
from Community-Based Interventions”
(Washington, DC: ICRW, 2006).
Source: ICRW, 2006.
28
Table 3.3

Reducing HIV/AIDS
and Other STIs
Much has been written about the effect of
gender on the HIV/AIDS pandemic.51
Gender contributes to the epidemic by increas-ing
vulnerability to the virus and exacerbating
the impact of living with HIV and AIDS.
Gender norms affect both women’s and
men’s sexual behavior and ability to protect
against HIV/AIDS. When gender norms, cus-toms,
and laws relegate women to a lower sta-tus
than men it makes women particularly
vulnerable to HIV. In a review of Ghana’s
response to HIV/AIDS, the authors write that
“[g]ender issues are at the core of the
Ghanaian – and sub-Saharan – epidemic” and
add that the epidemic is “basically fueled by
sexual behavior and women often have little or
no decision-making power in sexual rela-tions.”
52 Worldwide, almost half of the people
living with HIV or AIDS are women; in sub-
Saharan Africa, 61 percent of those living with
HIV or AIDS are women.53
Gender norms pertaining to men—norms
that prescribe roles such as early, risky sex
with multiple partners—also puts them at
increased risk.54 Moreover, men may be reluc-tant
to seek medical information and services
for HIV and AIDS, because of gender norms
that portray health-seeking behavior as weak
and non-masculine. Failure to access such ser-vices
30
negatively impacts both men and their
partners.
A UNAIDS report notes that in many coun-tries
women are “receiving more than expected
coverage for antiretroviral therapy,” and that
additional research is needed to explore the rea-sons
for the imbalance. In one study of antiret-roviral
treatment (ART) centers in 13 countries
that included over 33,000 individuals, 60 per-cent
of the patients on treatment were women.
Noting masculine roles that present barriers for
men accessing treatment, the study concluded
that, “More attention needs to be paid to ensur-ing
that HIV-infected men are seeking care and
starting HAART [Highly Active Anti-Retroviral
Therapy].”55 It is important to assess whether or
not treatment coverage mirrors patterns of
infection to determine if any groups are facing
unequal access to services.
Economic realities can also compound gen-der
inequality and power relations as a risk fac-tor
for HIV/AIDS and a barrier to treatment.
While women are generally resilient and play
key roles in the fight against HIV/AIDS, women
are also less likely to have access to resources
and more likely to depend on men for financial
survival for themselves and their children.
Women, particularly young women, have a
range of motivations for seeking out multiple
Program Country
Somos Diferentes, Somos Iguales Nicaragua
Men as Partners South Africa
Yaari Dosti India
Play Safe Cambodia
Mothers2Mothers Program South Africa
Integration of RH Services for Men Bangladesh
in Health & Family Welfare Centers
Involving Men in Sexual and
Reproductive Health Services Ecuador
CASE STUDY: Tuelimishane Tanzania
CASE STUDY: Stepping Stones South Africa
CASE STUDY: Program H Brazil
51 See UNIFEM, Gender and AIDS Web Portal, 2009.
52 Antwi and Oppong, 2003, p.6.
53 UNAIDS, 2007.
54 UNAIDS, 2007.
55 Britstein et al., 2008, p. 48.
4

Reducing HIV/AIDS and Other STIs 31
partners, and operate on a continuum of voli-tion56
that often makes it difficult to negotiate
safer sex, regardless of their motivation. For
many women, having more than one partner
and engaging in cross-generational and transac-tional
sex are economic survival strategies to
support themselves and their dependents.57
Moreover, the economic disadvantage of
women in many societies leads to a lack of sexual
negotiation power. Women’s need for economic
support from husbands or partners—particu-larly
if they have children—can lead women to
remain silent on matters of sex and fidelity in
relationships that confer some level of eco-nomic
security. The fear of economic abandon-ment
by husbands or partners may be greater
when extramarital relationships are explicit,
resulting in an increased powerlessness to
negotiate safe sex just when the risks of STI
transmission are the highest.58
In some countries, HIV-positive women
(and men) face employment discrimination
because of their HIV status. For example, some
employers require HIV testing as a condition of
employment, while others have abused the
employment rights of workers who test posi-tive.
59 Legal frameworks that insure nondis-crimination
on the basis of sex can empower
women. Conversely, inequality under the law,
for example with regard to property and inheri-tance
rights, can increase women’s vulnerabil-ity
to HIV/AIDS. For many women, loss of a
husband to HIV/AIDS is followed by loss of
property and land, exacerbating the impact of
the disease and limiting their ability to protect
themselves and their families.60
Interventions
Evaluations of a number of interventions in this
chapter provide strong evidence that address-ing
gender norms, promoting policies and pro-grams
to extend equality in legal rights, and
expanding services for women and men can
result in improved HIV/AIDS and gender out-comes.
It should be noted that the outcomes
identified in these projects are intermediary
outcomes such as knowledge, risk perceptions
and behavior change such as increased condom
use. These outcomes are routinely measured in
behavioral surveys that constitute second-gen-eration
surveillance, and are considered for-bearers
to reductions in HIV incidence.
Measuring reductions in HIV incidence would
require longer-term interventions and evalua-tions
than would be possible with the projects
included in this review.
The evaluations show that changing gender
norms requires long-term interventions. As
aptly noted by Mozambique’s former Prime
Minister, Pascoal Mocumbi, “To change funda-mentally
how girls and boys learn to relate to
each other and how men treat girls and women
is slow, painstaking work. But surely our chil-dren’s
lives are worth the effort.”61
Of the 10 interventions reviewed in this
chapter, six undertook gender transformative
approaches and four focused primarily on
accommodating gender differences. Among the
gender transformative interventions, six
addressed gender norms related to HIV and
AIDS. Three projects were selected as case
studies: Tuelimishane, Stepping Stones, and
Program H. Tuelimishane in Tanzania is a
community-based HIV and anti-violence pro-gram
for young men in Dar es Salaam that
combined community-based drama and peer
education.62 The interventions for young men
were designed around three themes that
emerged from formative research, namely, infi-delity,
sexual communication, and conflict.
Stepping Stones, originally designed to address
the HIV epidemic in Uganda in the mid-1990s,
is now among the most widely used prevention
interventions around the world, having been
used in over 40 countries.63 Program H in
Brazil was developed on the premise that gen-der
norms, which are passed on by families,
peers, and institutions, and are interpreted and
internalized by individuals, can be changed.
The 10 interventions indicate that strategies
to reduce HIV/AIDS and other STIs that incor-porate
gender are becoming increasingly
sophisticated in their approach to addressing
gender dynamics. Gender integration in HIV
and other STI prevention projects is primarily
3311
56 Weissman et al., 2006.
57 Hope, 2007.
58 Boender et al., 2004.
59 Human Rights Watch, 2004.
60 Human Rights Watch, 2002.
61 Edwards, 2001: 1.
62 Mbwambo and Maman, 2007; Maganja et al., 2007.
63 Jewkes et al., 2007.

transformative in nature in that the focus is on
changing the dynamics of interaction between
women and men. The projects reviewed in this
chapter focused on increasing women’s empow-erment
and on challenging gender norms that
affect men’s health. While behavior takes lon-ger
to change than knowledge and attitudes,
these projects show promising results toward
achieving this behavior change.
Table 4.1 lists the key gender strategies
used to reduce HIV/AIDS and other STIs in the
programs reviewed.
Table 4.1
Somos Diferentes, Somos Iguales
(We’re Different, We’re Equal)64
Country: Nicaragua
Implementing organizations: Puntos de Encuentro; Evaluation
by PATH, Horizons/Population Council, the National
Autonomous University of Nicaragua’s Centro de
Investigacion de Demografia y Salud (CIDS), local consul-tants,
and Puntos de Encuentro.
This Nicaraguan project used a communica-tions
for social change strategy aimed at pro-moting
the empowerment of young men and
women and preventing HIV infection.The proj-ect
considered machismo (a construction of
masculinity that emphasizes power, aggressive-ness,
and sexual prowess, among other charac-teristics)
as a risk factor for HIV/AIDS. Somos
Diferentes, Somos Iguales used the weekly
drama TV series Sexto Sentido (Sixth Sense),
which was also broadcast in Costa Rica,
Guatemala, Honduras, Mexico, and the U.S.,
and the call-in radio program Sexto Sentido, to
promote the gender transformative and HIV-prevention
32
messages. It worked with nearly
300 partners and local organizations to reduce
access barriers and provide SRH services for
young people.
The impact evaluation of Somos Diferentes,
Somos Iguales included a cohort of 4,800
young peoples ages 13 to 24 who were ran-domly
selected in three cities in Nicaragua in
2003 and who were interviewed three times (at
the beginning, middle, and end of the interven-tion).
Two hundred young people were included
in focus group discussions and in-depth inter-views
with participants and non-participants.
Baseline data found that young people had
good knowledge about HIV/AIDS; however,
AIDS-related stigma was prevalent and safer
sex was not regularly practiced. The final sur-vey
found widespread exposure to the project,
particularly the TV series Sexto Sentido, and
that high exposure to project activities led to a
significant reduction in stigmatizing and gen-der-
inequitable attitudes, an increase in knowl-edge
and use of HIV-related services, and a
significant increase in interpersonal communi-cation
about HIV prevention and sexual behav-ior.
The evaluation found that participants with
greater exposure to the intervention had a 44
percent greater probability of having used a
condom during last sex with a casual partner
compared to their counterparts with less expo-sure
to the intervention. It also found that men
with greater exposure to the intervention had a
56 percent greater probability of condom use
with casual partners during the past six
months.
The evaluation highlighted that the SRH
realities of Nicaraguan youth are complex and
difficult to capture with simple outcome mea-sures
such as condom use, and that individual
behavior is embedded in social contexts and
processes. An interesting gender-related finding
of the evaluation was that while, over time, the
sample of young people moved toward greater
equity in gender norms, that movement did not
appear to result in changes in sexual norms that
are also affected by gender relations.
64 Solórzano et al., 2008.
Strategies Used to Reduce HIV/AIDS and Other STIs
Participatory learning workshops
Follow-on community activities to put training into action
Community-wide condom social marketing campaign using
gender-equitable messages
Community-based drama and peer education about HIV and violence
Weekly TV drama and radio call in show, linked with SRH services and
organizations
BCC and condoms distributed through both van outreach and peer
educators
Female peer educators and social support
Increasing male awareness and participation in RH services, including
RTI/STI

Men as Partners (MAP) Program65
Implementing organizations: EngenderHealth
The Men as Partners (MAP) Program, developed
in 1996, has two interrelated goals.The first is
to increase access to information and services
that could improve men's sexual and reproduc-tive
health and to promote the constructive
role that men could play in both the prevention
of HIV/STIs and gender-based violence as well
as in maternal care and family planning. The
second goal is to actively promote gender
equality by engaging men to challenge the atti-tudes
and behaviors that compromise their
own – and women’s and children’s – health and
safety. The MAP program is based on applying
three related elements of constructive men’s
engagement in both service delivery and com-munity
settings:
n That gender roles often give men the ability
to influence and/or determine the reproduc-tive
health choices made by women;
n That gender roles also compromise men’s
health by encouraging men to equate a
range of risky behaviors with being a “real
man,” while encouraging them to view
health-seeking behaviors as a sign of weak-ness;
and
n That men have a personal investment in
challenging the current gender order and
can serve as allies to improve their own
health as well as the health of women and
children who are often placed at risk of vio-lence
and ill-health by these gender roles.
An external evaluation of one MAP workshop
in Western Cape, South Africa found that partic-ipants
came away from the workshops with
more equitable beliefs than were held by a com-parison
group of men. For example, workshop
participants were three times as likely to believe
that women should have the same rights as men
and that it was not normal for men to beat their
wives, and to be aware that children from abu-sive
homes could become abusive parents and
that sex workers could be raped.66
Yaari Dosti (Friendship/Bonding Among Men)67
Country: India
Implementing organizations: CORO and Horizons/Population
Council with support from Instituto Promundo
This project is an adaptation of Program H for
young men in Mumbai, India that was under-taken
first as a six-month pilot program on gen-der,
sexuality, masculinity, and educational
activities with 126 young men.The evaluation
of the pilot project included pre- and post-intervention
surveys that used the GEM scale
(see explanation in the case study of Program
H on page 42) and other outcome measures
and qualitative interviews with 31 participants.
The survey findings were similar to those in
Brazil: at the start of the program, a substantial
portion of the young men supported many
inequitable gender norms which shifted to
much less support for inequitable gender norms
after the program (most changes were signifi-cant
at the p<.05 level). Yaari Dosti was then
expanded to include a rural area of Uttar
Pradesh and, in some sites, to include a com-munity-
based social marketing campaign to
promote gender equality and HIV prevention.68
The sample of young men included married
and unmarried young men ages 16-29 in the
urban areas and ages 15-24 in the rural set-tings.
In the pre-intervention survey, 886 young
men were included in Mumbai and 1,040 in
Uttar Pradesh. The post-intervention surveys
included 537 young men from Mumbai and 601
from Uttar Pradesh.
The findings were similar to those of the
pilot. Gender-equitable beliefs and attitudes
improved, partner communication got better,
and there was a significant increase in condom
use at last sex with all types of partners in the
intervention sites. Logistic regression showed
that men in the Mumbai and rural Uttar
Pradesh interventions sites were more likely
(1.9 times and 2.8 times, respectively) to have
used condoms with all types of partners than in
the comparison sites. Furthermore, self-reported
violence against partners declined in
the intervention sites.
65 Levack, 2001.
66 Kruger, 2000, cited in Levack, 2001.
67 Verma et al., 2006; see also Verma et al., 2008
68 Verma et al., 2008.

Play Safe69
Country: Cambodia
Implementing organizations: Reproductive Health Initiative
for Youth in Asia; evaluation by CARE International.
This adolescent reproductive health project was
conducted under EU/UNFPA’s Reproductive
Health Initiative for Youth in Asia (RHIYA). It
incorporated concepts of gender equality and
human rights into activities in response to grow-ing
evidence of criminal behavior toward women
within Cambodia by middle class young men.
The project used male peers as a way to engage
young men with information about HIV/STIs
and to change their behavior. Play Safe also
seeks to empower young males to create positive
social networks and to use them to encourage
safe and responsible sexual practice.
Information and behavior change communica-tion
(BCC) materials and messages and con-doms
were distributed through both van
outreach and peer educators. An evaluation, car-ried
out by CARE International in Cambodia,
used primarily qualitative techniques, including
a peer interview tool to collect data from 77
young people and the “most significant change
(MSC)” technique, a story approach in which
participants answer questions about change.
The MSC was used to collect data from 20 peer
educators and 40 youth. These techniques do
not generate data representative of the group
exposed to the project, but do provide in-depth
explanations of behavioral outcomes and their
potential associations with the project. Data
were collected at two points during the project
between 2004 and 2006.
The evaluation of Play Safe found that
young men had a variety of sexual partner-
Improving Sexual Health for Men Who Have Sex with Men (MSM)
must be taken in reaching MSM and TG
individuals with programs and services.
The three projects described in this
box provide examples of gender-transfor-mative
approaches used to meet the needs
of MSM, including promoting legal and
social rights and social acceptance. All
three took place in Asia.
Bandhu Social Welfare Society
(BSWS) Project70
Country: Bangladesh
Implementing organizations: BSWS with
FHI, USAID, and PEPFAR
The Bandhu Society began as a male repro-ductive
health organization in 1997, offering
counseling and services through outreach,
drop-in centers, and health services. In
2000, FHI began supporting BSWS on a
range of activities, including strengthening
advocacy, research, and communication
69 Hayden, 2007.
70 FHI, 2007.
Among sexual minorities, gender relations
and power dynamics within individual rela-tionships
and the community, and between
those communities and larger societies,
affect the vulnerability to and the impact of
HIV/AIDS. For example, gender-related
issues facing men who have sex with men
(MSM) and transgendered (TG) people are
complex and relate to stigma against
same-sex relationships and against individ-uals
whose behavior deviates from
“accepted” masculine behavior in many
societies. These populations lack power in
society, are often socially marginalized, and
have limited legal rights and protection. In
addition, these populations are subject to
gender-based violence – both within rela-tionships
and against MSM and TG by
other groups. Much more work is needed
to understand and address the gender
dynamics among sexual minorities and
societies, and the factors that increase vul-nerability
and magnify impact. Special care
systems. BSWS adapted the Naz Foundation
International sexual health promotion model
or service framework, which consists of:
center services, including drop-in services,
counseling, education and training; field ser-vices,
including outreach, community mobi-lization,
condom and lubricant distribution,
and referrals; and health services, including
STI and general health treatment, HIV test-ing,
and pre- and post-test counseling.
BSWS also conducted sensitization meet-ings
with media representatives and journal-ists,
local leaders and elites, law
enforcement agencies, activists, and stu-dents.
They also held coordination meetings
with representatives from government and
non-governmental organizations and partici-pated
in World AIDS Day activities.
An evaluation was conducted of
BSWS’s activities, with outcomes assessed
through Behavioral Surveillance Surveys
(BSS) at two points in time. No outcomes
were measured related to the advocacy and

ships, ranging from “sweethearts” to casual
partners to sex workers. Men’s perceptions and
treatment of these partners differed, with
sweethearts being treated the best and sex
workers often subjected to the degrading prac-tice
of bauk, or forced group sex—perceived by
young men as a fun way to bond with buddies
and have sex inexpensively. The second round
of the evaluation found that the project was
successful in reducing the practice of bauk, but
only in that young men were more concerned
about their own health rather than any aware-ness
of the effects of bauk on women, who
were in effect being gang raped. One conclu-sion
reached by the evaluation was that, “While
it appears that these young men are increas-ingly
able to make ‘safe’ and ‘responsible’ deci-sions
for themselves; to use condoms with
‘risky’ partners, access services, and seek infor-mation;
they appear unable or unwilling to
extend the concepts of safety and responsibility
into their interactions with their female part-ners.
Amongst the group of young men targeted
by this research and Play Safe, this is clearly
not an issue of knowledge, but of attitudes.” In
the evaluation, the messages related to gender
concepts, social change, and human rights were
the least well-recalled and least well-followed.
The evaluation called for more research on
gender identity in Cambodian youth culture
and for stronger programs to help men develop
alternative ways to express and affirm their
masculinity that are respectful of women and
promote gender equality and respect for rights.
In this context, stronger gender-transformative
approaches are needed in future interventions
in order to impact gender norms related to
masculinity and women’s status that underlie
the practices exhibited in bauk.
communication activities. The evaluation
found a sharp increase in distribution of
condoms from 6,672 in 2000 to 321,112 in
2004 and of lubricant from zero to 5,870
tubes during the same period. Risk percep-tion
rose from 3 to 30 percent and condom
use with all partner types increased. Uptake
of STI services also increased.
Aksi Stop AIDS (ASA)71
Country: Indonesia
Implementing organizations: FHI, USAID,
and PEPFAR
This project sought to decrease HIV preva-lence
among MSM, male sex workers
(MSW), and waria (transgender) popula-tions
in selected Indonesian provinces by
increasing and sustaining safer sex and
health seeking behaviors (including use of
condoms and lubricants). In addition, ASA
worked to create a favorable environment
71 FHI, 2007.
72 FHI, 2007: 48.
73 FHI, 2007.
to support program implementation and
behavior change through advocacy with
government agencies and networking with
other organizations. Outcomes were
assessed through Behavioral Surveillance
Surveys (BSS) and/or Integrated Biological
and Behavioral Surveys (IBBS) in 2002 and
2004. The evaluation for waria found that
all key sexual and health seeking behaviors
showed increases during the two-year time
period between BSS, including a number of
statistically significant increases. However,
testing remained low at 43 percent among
waria in Jakarta and 20 percent in
Surabaya. One benefit noted for the pro-gram
for waria was that staff providing
services were also waria, which facilitated
contact with beneficiaries. BSS results for
MSM and MSW showed positive trends in
the two cities; however, given low coverage
of the project, it is difficult to confirm the
effect of the intervention on the results. No
gender outcomes were measured.
In an analysis of the three interven-tions
for MSM, the evaluation recom-mended
that a stronger advocacy strategy
be developed that “includes a local or field-level
focus, with staff at different levels
working more with local police officers,
religious leaders, shopkeepers, guards and
other gatekeepers, to enable staff to con-duct
field activities more effectively and to
influence community norms.”72
Blue Diamond Society73
Country: Nepal
Implementing organizations: Blue Diamond
Society and FHI
In Nepal, MSM are stigmatized, harassed,
and often subject to brutal violence. As a
result, SRH services for this population
have often been neglected by both the gov-ernment
and NGOs, while MSM are often
continued on next page

Improving Sexual Health for Men Who Have Sex with Men (MSM) continued from previous page
hesitant to seek such services, leaving them
more vulnerable to contracting HIV and
other STIs. Since 2001, the Blue Diamond
Society has worked to improve SRH of the
MSM community in Nepal, employing five
broad strategies, including behavior change
communication (BCC), local advocacy and
networking, social and community mobiliza-tion,
links to services and products, and
capacity building. The BCC has included
group education meetings, distribution of
materials, referrals for STI treatment and
counseling, and condom distribution and
demonstrations. The advocacy and network-ing
activities addressed gender-related barri-ers
to HIV prevention by seeking to raise
awareness of the legal and social rights of
MSM, improve social acceptance of this
population, and inform and educate the
MSM community. Meetings were held with
various stakeholders, including NGOs,
police, journalists, lawyers, and media. The
Society coordinated events and special days
as well as media campaigns. Film and docu-mentaries
were used to inform MSM on var-ious
issues such as sexual orientation.
FHI conducted an evaluation of the
components of the Blue Diamond Society
program that they started supporting in
2002, namely: behavior change communica-tion,
legal advocacy and networking, social
and community mobilization, and linkages to
services and products. The evaluation
showed significantly increased knowledge
and safer sex behaviors among MSM who
were exposed to the interventions. Although
evidence of police brutality persisted, the
program appeared to increase awareness of
the MSM community and the need to
respect their rights.
mothers2mothers (m2m) Program74
Implementing organizations: mothers2mothers (an NGO head-quartered
in South Africa); Evaluation by Horizons/Population
Council with Health Systems Trust.
This program focused on prevention of mother-to-
child transmission of HIV (PMTCT), empower-ing
pregnant and postpartum women to improve
their health and the health of their babies, fight-ing
stigma, and encouraging and supporting dis-closure.
The program offered educational and
psychosocial support to HIV-positive pregnant
women and new mothers, assisted women to
access PMTCT services, and followed up to
ensure care of mothers and infants after delivery.
The evaluation of the m2m program was under-taken
in KwaZulu Natal, South Africa, by
HORIZONS/Population Council in collaboration
with Health Systems Trust, using a pre- and post-quasi-
experimental design. At baseline, 183 HIV-positive
pregnant women and 178 HIV-positive
postpartum women were interviewed; at follow-up,
one year after m2m was introduced, 345 HIV-positive
pregnant women and 350 HIV-positive
postpartum women were interviewed. In addition
to a number of knowledge and practice outcomes
that were measured, the evaluation assessed psy-chosocial
well-being among the women. The eval-uation
found that the m2m program provided a
strong continuum of care to the women and
infants. Compared to non-participants, m2m par-ticipants
had greater psychosocial well-being and
greater use of PMTCT services and outcomes.
Postpartum program participants were signifi-cantly
more likely than non-participants to have
disclosed their status to someone, and to have
done so prior to delivery.
Integration of RH Services for Men in Health
and Family Welfare Centers75
Country: Bangladesh
Implementing organizations: National Institute for Population
Research and Training (NIPORT), Directorate of Family
Planning, and FRONTIERS/ Population Council.
This intervention research study focused on
training service providers about men’s sexual
health needs, raising awareness in the commu-nity
about reproductive tract infections (RTIs)
and sexually transmitted infections (STIs) in
men, and improving RTI and STI services. The
evaluation used a quasi-experimental non-equiv-alent
control group design, with eight Health
and Family Welfare Centers as intervention sites
and four as control sites. Data were collected
through service provider interviews, focus group
discussions, inventory surveys, client exit inter-
74 Baek et al., 2007.
75 Hossain et al., 2004; Alam, Rob, and Khan, 2004.

views, and client registers. The intervention
resulted in increases in male clients seeking ser-vices
at the intervention clinics from 131 to 337
per month. Most, however, still came for general
health issues. The number of male RTI/STI cli-ents
increased from one to more than five per
month at intervention sites. Men were able to
attend services during regular clinic hours.
Adding RH services for men did not have an
adverse affect on the number of female clients
seeking services. Finally, the intervention
resulted in increased knowledge among service
providers about male reproductive health issues
and RTIs/STIs. The study found that female ser-vice
providers can successfully provide services
to men.
Involving Men in Sexual and
Reproductive Health76
Country: Ecuador
Implementing organizations: APROFE (Association for the
Benefit of the Ecuadorian Family)
This initiative was undertaken as part of
APROFE’s efforts to increase the number of
male clients receiving the organization’s ser-vices.
The initiative started in the mid-1990s
and coincided with APROFE’s efforts to become
more financially sustainable, to improve quality
of care, and to increase focus on gender equality
throughout the organization. After an initial
unsuccessful attempt at establishing male clin-ics,
the Involving Men initiative sought to attract
men to clinics attended by women. Providers
encouraged clients to bring their partners and
the organization used mass media to encourage
men and couples to use APROFE’s services.
Hours in some clinics were extended to 7:00 pm
and Saturday morning to accommodate work
schedules. An evaluation was conducted by the
Harvard School of Public Health through analy-sis
of APROFE’s documents, interviews with pro-viders
at all levels in four clinics, 28
semi-structured individual interviews, and four
focus group discussions. From 1999 to 2000, the
evaluation revealed an increase in the number
of male clients who accompanied their partners,
from an average 545 to 1,121 per month. The
number of male clients who came alone also
increased. For example, service statistics for
urology visits registered an increase of almost
2,000 men in 2001. The gender issues raised by
this intervention included the need to protect
privacy of male clients and the need to get wom-en’s
consent for the parts of the visits in which
they wanted their partners to participate.
76 Shepard, 2004.

HIV/AIDS/STI Case Study
Intervention:
Tuelimishane (“Let’s Educate Each Other”)
Country: Tanzania
Type of Intervention: Community theater and peer support
Implementing Organizations: Tuelimishane Project
In Dar es Salaam the links between HIV, vio-lence,
and infidelity are influenced by gender
norms, expectations, and relationship struc-tures
that characterize youth sexual relation-ships,
including transactional sex. Research
has shown the link between transactional
sex, HIV, and intimate partner violence (see
more on IPV in chapter 5).
In Dar es Salaam, transactional sex is a
survival strategy for some women. And in
cases of infidelity or gender-based violence,
women may be unlikely to stand up to their
partners for fear of losing financial support.
Objective
The objective of the intervention was to
reduce HIV-risk behaviors and reported vio-lence
by young men.
Strategy
The program was designed based on forma-tive
research among young men and women
regarding the context of sexual relationships
among youth at risk for HIV, including gen-der
norms and roles, partner violence, and
sexual behavior. The theme of transactional
sex and the roles of young men and women
in the practice also emerged in the formative
research.
The intervention was composed of two
main components: community theater and
peer support groups. The community theater
groups developed three skits, each focusing
on a different theme (sexual communication,
infidelity, and conflict resolution.) There were
a total of 21 public performances in locations
where young men frequently hang out. The
performances communicated information
regarding violence, sexual negotiation, sexual
responsibility, and HIV risk, and engaged the
audience in discussion surrounding the main
theme. Low-literacy print comics were also
distributed.
Peer support groups of 10-12 young
men were formed to create a safe place to
discuss topics related to social norms, gen-der,
HIV/AIDS, infidelity, sexual communica-tion,
and conflict resolution. The support
groups developed key messages that were
used in the drama intervention, and then
reinforced those messages. In addition to
the same-sex peer groups, mixed-sex and
mixed-age groups were formed to encour-age
dialogue across a broader audience and
to give young men the opportunity to hear
different perspectives related to sexual
behavior and gender-based violence.
Evaluation Design:
Pretest-posttest control group
design
The evaluation consisted of four phases:
formative, baseline survey, implementation,
and post-intervention research. Forty men
and 20 women (ages 16-24 years) were
interviewed and 14 focus groups were con-ducted
during the formative phase. A com-munity
mapping exercise identified social
venues for youth, transportation routes, and
other community features that could affect
the intervention. Baseline surveys were con-ducted
in the intervention and control sites,
with 503 and 448 respondents, respectively.
Table 4.2
Variable Control Intervention
Did not use condom during last sex with primary partner 78 (56.9%) 91 (44.8%)
N=137 N=203
Condom use reported less than half the time with partners 70 (55.1%) 60 (36.4%)
in past 6 months N=127 N = 165
Proportion of men who agree or strongly agree with
statement that violence vs. women could be justified if:
She does not complete household work 53 (20.6%) 25 (8.3%)
N = 257 N = 301
A woman disobeys her partner 61 (23.7%) 29 (9.7%)
N = 257 N = 300
He suspects she is unfaithful 32 (12.4%) 17 (5.6%)
N = 258 N = 302
He learns she is unfaithful 56 (21.7%) 26 (8.6%)
N = 258 N = 301
She asks him to use condoms 26 (10.2%) 13 (4.3%)
N = 256 N = 301
Source: Mbwambo and Maman, 2007.
3388 Gender Perspectives Improve Reproductive Health Outcomes: New Evidence 38

Table 4.3
Gender Outcomes
Significant Gender Outcomes Of those who agreed/strongly
agreed at baseline, proportion
of men who disagreed/strongly
Control Intervention
Men should have the final say in all family matters 34 (19.0%) 104 (51.2%)
There is nothing a woman can do if her partner wants 43 (47.3%) 81 (80.2%)
to have other girlfriends N=91 N=101
A wife should tolerate being beaten to keep the 59 (46.5%) 72 (61.0%)
family together N=127 N=118
A woman needs her husband’s permission to work 31 (14.4%) 68 (30.4%)
It’s a woman’s job to take care of her home and cook 37 (17.5%) 94 (42.3%)
for her family. N=212 N=222
Source: Mbwambo and Maman, 2007.
The baseline surveys recorded information
regarding demographics, gender roles and
norms, attitudes toward and experiences of
violence, HIV risk behaviors, and use of
physical and sexual violence. The post-inter-vention
assessment interviewed a total of
315 men in the intervention community
(62.6%) and 266 men in the control com-munity
(59.4%). The post-intervention and
baseline survey were identical in the control
community, with an added section on inter-vention
exposure for men in the intervention
site. Female partners of 20 men were inter-viewed
as part of the post-intervention
assessment.
Two of the six variables measuring HIV-risk
behaviors were found to be significant. Men
in the intervention community were signifi-cantly
more likely to have used a condom
disagreed at endline
N=179 N=203
N=215 N=224
during their last sexual experience and in
the past six months.
While there were no significant differ-ences
regarding reported use of violence,
the study did find improvement in attitudes,
with men in the intervention village signifi-cantly
less likely to report that violence
against women is justified under various
scenarios.
Young men in the intervention commu-nity
were significantly more likely to have
favorably changed their attitudes regarding
gender norms. In an interview, one 20-year
old female partner said, “Yes, for example,
our communication has become much bet-ter
than the way it used to be; now he
shows that he understands me and he
agrees with most of the things which I
advise him.”
Limitations
It was difficult to keep men engaged in the
peer support component of the intervention,
perhaps because in urban settings like Dar
es Salaam many of the men migrate. In
rural settings, where young men are less
mobile, a 12-month program may be more
successful in keeping men engaged.
Conclusions
This community-based communication
intervention was designed to reduce rates of
HIV-risk behaviors and reported use of vio-lence
by young men. The evaluation showed
some evidence that men had changed their
behaviors related to condom use for HIV
prevention. Though there were no signifi-cant
changes in use of violence, results
showed significant changes in norms and
attitudes regarding violence among men in
the intervention community.
Youth who participated in the drama
group portrayed stories that happened within
their own community. The participatory
nature of the community drama intervention
demonstrated that solutions to combating
HIV/AIDS are available from within the com-munity
itself. Youth were able to develop a
deeper understanding of HIV/AIDS and
capacity to communicate about these issues
with other community members.
References
R.K. Maganja, S. Maman, A. Groves, and
J.K. Mbwambo. “Skinning the Goat and
Pulling the Load: Transactional Sex Among
Youth in Dar es Salaam, Tanzania.” AIDS
Care 19, no. 8 (2007): 974-981.
Jessie Mbwambo and Suzanne Maman, HIV
and Violence Prevention. Horizons Final
Report (Washington, DC: Population
Council, 2007).
39 Reducing HIV/AIDS and Other STIs 39

In South Africa, gender norms influence
male and female power dynamics, resulting
in gender-inequitable intimate relationships.
Norms limit women’s agency in many areas,
including restricting their ability to negotiate
sex and to demand condom use from their
partners. This is particularly true of partners
of migrant laborers who are most at risk of
HIV and others STIs. Because educational
and economic opportunities for women are
limited, some women use transactional and
commercial sex work as a survival strategy,
and research has shown the link between
these behaviors and increased HIV risk.
Objective
Stepping Stones is a gender-transformative
HIV-prevention program that aims to
improve sexual health through building
stronger, more gender-equitable relation-ships
with better communication between
partners.
Strategy
The Stepping Stones intervention is imple-mented
using participatory learning
approaches in single-sex peer groups. The
evaluation was implemented from 2003
–2005. Eleven same-sex project staff mem-bers,
slightly older than the participants,
were trained for three weeks prior to imple-mentation.
They facilitated the sessions
(described below), employing adult educa-tion
methods including role play, spider dia-grams,
and similar exercises.
The program contains 13 sessions,
each three-hours long, and three peer group
meetings. The issues covered in the 13 ses-sions
include reflecting on love, sexual
health joys and problems, body mapping,
menstruation, contraception and conception
(including infertility), sexual problems,
unwanted pregnancy, HIV/STIs, safe sex,
gender-based violence, motivations for sex-ual
behavior, and dealing with grief and loss.
The intervention relied on same-sex peer
groups “as this format gives the best oppor-tunity
for frank discussion and a supportive
environment for exploring behaviour
change.”77 The male and female groups
were conducted in parallel sessions and
came together in three meetings to present
exercises and promote dialogue. During
these three sessions, groups present exer-cises
they have been working on that pro-mote
dialogue and communication.
The second intervention (the control
arm) was a single two- to three-hour ses-sion
with exercises about HIV and safer sex
practices drawn from the Stepping Stones
curriculum.
Efforts were made to gain community
support for the project by involving impor-tant
stakeholders and holding community
meetings. The project had an active commu-nity
advisory board composed of members
from Departments of Health and Education,
from municipalities, local traditional leaders,
the National Association for People with
HIV/AIDS, the University of Transkei
(UNITRA), and young people approximately
the same age as study participants.
Evaluation Design: Cluster
randomized-controlled trial
The evaluation was completed in 70 clusters
(each cluster was usually a village) at least
10 kilometers apart. Study participants
included 1360 men and 1416 women, ages
15–26 years. Study villages were assigned
to receive either the complete Stepping
Stones intervention or the single 2-3 hour
session control. Participants were inter-viewed
prior to the implementation and gave
blood for an HIV and Herpes test.
Participants were re-interviewed and re-tested
12 and 24 months after the first
interview.
Qualitative research was completed in
two of the clusters with 10 women and 11
men. Each participant was interviewed prior
to and after participating in Stepping
Stones.
Women in the intervention arm had 15 per-cent
fewer new HIV infections than those in
the control arm [incidence rate ratio = 0.85
(95% CI: 0.60, 1.20)] and 31 percent fewer
Herpes infections [incidence rate ratio =
Intervention:
Stepping Stones
Type of Intervention: HIV prevention
Implementing Organizations: Medical Research Council
77 Jewkes et al., 2006: 5.

0.69 (95% CI: 0.47, 1.03)]. Neither was sig-nificant
at the 5% level.
Findings did, however, show significant
improvement in a number of reported risk
behaviors in men, with men reporting fewer
partners and higher condom use, as well as
less transactional sex, perpetration of inti-mate
partner violence, and substance use.
The same behavior changes were not found
in women, and there was actually an
increase in transactional sex. This finding
could be linked to possible under-reporting
of sexual activity by women at baseline.
Gender Outcomes
Qualitative data suggest that the intervention
improved couple communication and
increased men’s and women’s awareness
that violence against women was wrong.
Limitations
The scope of the Stepping Stones interven-tion
for the randomized control trial, includ-ing
the age ranges included, was limited by
resources available for the study and the
evaluation. A large proportion of the partici-pants
did not attend all the sessions and,
therefore, the full impact of the intervention
may have been underestimated. Another
limitation is that an overly optimistic
assumption about the reduction in HIV
infections limits the statistical analysis due
to a small sample size.
Replication
The Stepping Stones intervention was ini-tially
developed for use in Uganda. Over the
last 10 years the intervention has been used
in 40 countries, adapted for at least 17 set-tings,
and translated into at least 13 lan-guages.
Stepping Stones has developed an
adaptation guide, to provide guidance to
organizations adapting the program for the
first time or for organizations wishing to
make changes to an existing Stepping
Stones curriculum.
Conclusions
Evaluation of the Stepping Stones program
suggests that the intervention reduced new
HIV and other STI infections among women.
The intervention showed significant
improvement in reducing risk behaviors in
men. The program has been widely repli-cated
throughout the world, and translated
into multiple languages.
References
Family Health International. “Barriers to HIV
Prevention.” Accessed online Dec. 1, 2009,
at www.fhi.org/en/HIVAIDS/pub/guide/cor-rhope/
corrbar.htm.
R. Jewkes, M. Nduna, J. Levin, N. Jama, K.
Dunkle, N. Khuzwayo, M. Koss, A. Puren, K.
Wood, and N. Duvvury. "A Cluster
Randomized-Controlled Trial to Determine
the Effectiveness of Stepping Stones in
Preventing HIV Infections and Promoting
Safer Sexual Behaviour Amongst Youth in
the Rural Eastern Cape, South Africa: Trial
Design, Methods And Baseline Findings." In
Tropical Medicine and International Health
11, no.1 (2006): 3-16.
Dunkle, A. Puren, and N. Duvvury. “Impact
of Stepping Stones on HIV, HSV-2 and
Sexual Behaviour in Rural South Africa:
Cluster Randomised Controlled Trial.” In
British Medical Journal 337, no.71
(2008):a506.
Dunkle, K. Wood, M. Koss, A. Puren, and N.
Duvvury. Evaluation of Stepping Stones: A
Gender Transformative HIV Prevention
Intervention (Pretoria: MRC, 2007).

Intervention:
Program H
Country: Brazil
Type of Intervention: HIV/AIDS prevention
Implementing Organizations: Instituto Promundo
Costs: $35,856.97 (group education and lifestyle marketing campaign n = 258); and $21,060.28 (group education only
n = 250). Cost analysis for replications of Program H has shown intervention costs to range from $25,000 - $50,000.
In Latin America there exist many traditional
beliefs on masculinity, including that men
have more and stronger sexual urges than
women, men have the right to decide when
and where to have sex, sexual and repro-ductive
health issues are women's con-cerns,
men have the right to outside
partners or relationships, and men have the
right to dominate women. These traditional
macho beliefs promote inequitable intimate
relationships and sustain and support risky
behaviors among men who have internalized
such norms. Women are often unable to
negotiate safe sexual practices with their
partners. Additionally, women are unlikely to
carry out risk-reducing or protective behav-iors,
such as carrying condoms with them,
for fear of gaining a reputation of being pro-miscuous.
Objective
The study examined the effectiveness of
interventions designed to improve young
men’s (ages 14–25) attitudes toward gender
norms and to reduce HIV/STI risk.
Strategy
The intervention focused on helping young
men to question traditional norms related to
masculinity and to discuss inequitable gen-der-
related views and the advantages of
more gender-equitable behaviors. It used
group education activities that encouraged
reflection on what it means to “be a man.”
Intervention activities included two
main components: a field-tested curriculum
used in same-sex groups and a lifestyle
social marketing campaign. One intervention
site, Bangu, received both the group educa-tion
and lifestyle social marketing campaign,
and the second site, Maré, received only the
group education component.
The group education component con-tained:
1) a 20-minute no-word cartoon
video highlighting one man’s experiences
from childhood to early adulthood; and 2)
70 activities (role plays, brainstorming exer-cises,
discussion sessions, and individual
reflection) covering five themes (sexuality
and reproductive health, fatherhood and
care-giving, from violence to peaceful coex-istence,
reasons and emotions [including
communication skills, substance abuse, and
mental health], and preventing and living
with HIV/AIDS). Weekly two-hour sessions
were held over a period of six months. Five
male facilitators were trained on the ratio-nale
for the intervention; intervention mate-rials;
study objective, design, and
methodology; timeline for group activities;
and logistics.
The social marketing campaign (a
behavior change communication campaign)
promoted a more gender-equitable lifestyle
and HIV/STI/violence prevention at the com-munity
level, reinforcing the messages given
in the group education sessions. Peer pro-moters,
young men recruited from the com-munity,
helped to implement the campaign.
They identified sources of information and
cultural outlets in the community. They also
developed intervention messages using radio
spots, billboards, posters, postcards, and
dances, about how “cool and hip” it was to
be a gender-equitable man. Additionally, the
campaign presented condom use and negoti-ation
as elements of a gender-equitable life-style,
aiming to increase the availability of a
new condom brand (Hora H) through strate-gic
distribution, including bars, community
dances, and parties.
Evaluation Design:
Quasi-experimental control design
The Gender-Equitable Men (GEM) Scale was
used to determine men’s attitudes toward
gender norms at baseline (n = 780) and
post-intervention in three sites (two inter-vention
and one control/delayed.)
Multivariate logistic regression analyses for
correlated data were used, controlling for
age, family income, and education.
Findings indicate that improvements in gen-der
norm scale scores were associated with
changes in at least one key HIV/STI risk out-come
(e.g., STI symptoms, condom use).
For both intervention sites, positive changes
in attitudes toward inequitable gender
norms over one year was significantly asso-ciated
with decreased reports of STI symp-toms
(p < .001). In the intervention sites of
Bangu and Maré, young men were approxi-mately
four times and eight times less likely
to report STI symptoms over time, respec-tively.
A significant association was not
found for condom use, but a trend in the
4422 42
Gender Perspectives Improve Reproductive Health Outcomes: New Evidence 42

expected direction was seen in one interven-tion
village.
Gender Outcomes
At six months, agreement with inequitable
gender norms significantly decreased in
both intervention sites (10 out of 17 items
improved in Bangu and 13 out of 17 items
improved in Maré). These positive changes
were sustained at the one-year follow-up
period. Only one out of 17 items improved
in the control area.
Limitations
Similar to other interventions involving
young men, Program H struggled with
attendance issues. Nearly 30 percent of the
participants attended the majority of the
sessions, while more than 50 percent of the
participants attended less than half. Work
was the number one reason given for miss-ing
a session. Among participants who
attended the majority of the sessions and
those who attended less than half, there
were no significant differences in work sta-tus,
age group, education level, number of
sexual partners, and attitudes toward gender
at baseline. Monitoring data showed that
some groups had higher than average par-ticipation
rates, and some facilitators were
more successful in generating interest and
consistent participation.
Replication
Program H has been replicated in several
places throughout Brazil and the world. An
evaluation of Yaari Dosti (Program H
replicated in Mumbai, India, see page 33)
showed similar gender outcomes, with
significantly more men supporting gender-equitable
norms.
Two additional programs, Program M
and Program D, have been developed utiliz-ing
the same strategies as Program H to
promote young women’s health and reduce
homophobia, respectively.
Conclusions
The young men in the study, from three
low-income communities (favelas) in Rio de
Janeiro, started the study reporting substan-tial
risk of HIV and STIs. Support for inequi-table
gender norms and roles was
significantly associated with HIV risk. The
program resulted in significantly smaller
percentages of young men supporting ineq-uitable
gender norms. Significant improve-ments
were also found in HIV/AIDS
outcomes, including STI symptoms and
condom use, particularly in the area with the
combination of group discussions and
social marketing. Decrease in support for
inequitable gender norms was associated
with decreased reports of STI symptoms.
The positive changes in attitudes
toward gender norms were equally signifi-cant
for both groups of young men exposed
to either the combination intervention or
education activities alone. This implies that
the group education component was likely
most successful in addressing gender-related
attitudes. However, findings show
changes were often greater for young men
exposed to the combined intervention. This
highlights the importance of both interper-sonal
and community-level communication
strategies.
Evaluation of Program H illustrates the
link between gender-inequitable attitudes
and HIV/STI risk behaviors and outcomes. It
also shows that group education programs
focusing on gender-equitable relationships
and BCC campaigns combating inequitable
gender norms can lead to more gender-equitable
relationships and improved HIV/
STI outcomes.
References
J. Pulerwitz, G. Barker, M. Segundo, and M.
Nascimento. Promoting More Gender-equitable
Norms and Behaviors Among
Young Men as an HIV/AIDS Prevention
Strategy (Washington, DC: Horizons, 2006).
R.K. Verma, J. Pulerwitz, V. Mahendra, S.
Khandekar, G. Barker, P. Fulpagare, and S.K.
Singh (2006). “Challenging and Changing
Gender Attitudes Among Young Men in
Mumbai, India.” Reproductive Health
Matters 14, no. 28 (2006): 135.
43 Reducing HIV/AIDS and Other STIs 43

Harmful Practices: Barriers
to Reproductive Health
Although the 2004 “So What?” report did
not include a chapter devoted to harmful
practices, this chapter has been added in this
publication for two reasons: first, because of
the substantial role of such practices in under-mining
RH, especially among young women;
and second, because some of the most innova-tive,
gender-transformative work in the repro-ductive
and sexual health field focuses on the
reduction of harmful practices. Interventions
are classified here by three types of harmful
practices: early marriage and childbearing
(EM&C); female genital mutilation/cutting
(FGM/C); and gender-based violence, specifical-ly,
intimate partner violence/sexual violence
(IPV/SV).
I. Early Marriage and Childbearing
Early marriage and childbearing (EM&C) is asso-ciated
with a wide range of negative social and
health consequences. It is an abuse of girls’
human rights, robbing them of educational and
economic opportunities as well as the chance
simply to be children. In some settings, mar-riages
are arranged in infancy and there is varia-tion
in the age at which co-habitation begins. In
other settings, both the husband and the wife
are married in their teenage years. Often, how-ever,
female brides are much younger than their
husbands, and they are unready for sex, espe-cially
with an older stranger. In these situations,
sexual initiation after an early marriage often
amounts to socially sanctioned rape, in some
cases legal, and in others (where marriages take
place before the statutory minimum age) techni-cally
illegal but virtually never prosecuted.
Early marriage almost always leads to early
childbearing.78 About 15 million young women
between 15 and 19 years of age give birth every
year, accounting for over 10 percent of the
births worldwide. Most of these young mothers
are married.79 Early childbearing has been
shown to contribute to mortality and morbidity
during pregnancy, labor, and delivery, and
increases the risk of premature births.80 It also
contributes to rapid population growth. In
countries where contraceptive use is at least
moderately high, increasing the number of
years between generations by increasing the
age at which women begin having children may
have a greater impact in reducing population
growth than further reducing fertility rates.81
EM&C Interventions
The three EM&C interventions reviewed are
broad in focus. All employed gender transfor-
78 Adhikari, 2003.
79 ICRW, 2004.
80 UNICEF, 2001.
81 Bongaarts, 1994; Caldwell and Caldwell, 2003.
5
Program Country
EM&C:
Behane Hewan Ethiopia
Building Life Skills to Improve Adolescent Girls’ India
Reproductive and Sexual Health
CASE STUDY: India
Delaying Age at Marriage in Rural Maharashtra
FGM/C:
Navrongo FGM/C Experiment Ghana
Awash FGM/C Elimination Project Ethiopia, Kenya
Five Dimensional Approach for the Eradication of FGM/C Ethiopia
CASE STUDY: Senegal
Tostan Community-based Education Program
Gender-Based Violence:
Soul City South Africa
Through Our Eyes Liberia
One Man Can Campaign South Africa
CASE STUDY: Intervention with Microfinance South Africa
for AIDS and Gender Equity (IMAGE)

Table 5.1
Harmful Practices: Barriers to Reproductive Health 45
mative approaches and sought to influence atti-tudes
and behaviors of a range of community
stakeholders. One of them, Delaying Age at
Marriage In Rural Maharashtra, is one of the
case studies (see p. 52). It is a life skills educa-tion
project with unmarried adolescent girls on
a variety of topics.
Table 5.1 lists the gender strategies used to
reduce early marriage and childbearing in the
projects reviewed.
Behane Hewan82
Country: Ethiopia
Implementing organizations: Ethiopian Ministry of Youth and
Sport, with the Amhara Regional Youth Bureau, and UNFPA,
with technical assistance from the Population Council
This pilot program in a village in rural Ethiopia
sought to sensitize communities to the risks
and disadvantages associated with child mar-riage,
promote education to prevent early mar-riage
among adolescents, and provide support
for girls who were already married. The inter-ventions
included social mobilization of adoles-cent
girls who formed groups led by female
mentors, with encouragement to stay in school,
nonformal education and livelihood programs
for out-of-school girls, community dialogue on
early marriage and health issues affecting girls,
and fiscal incentives to families who did not
marry off their daughters during the project
period.
Using a quasi-experimental case control
design, the Behane Hewan program evaluation
focused on four areas of interest: education,
social networks and participation, marital sta-tus,
and RH. The evaluation results showed sig-nificant
impacts in all four areas:
n Girls in the intervention village were three
times as likely to be in school as girls in the
control village;
n Knowledge and communication on HIV,
STIs, and FP increased in the intervention
village, compared with the control village;
n Younger adolescents (ages 10-14) were 90
percent less likely to be married than con-trol
group girls of the same age;
n Not a single girl ages 10-14 in the interven-tion
area was married during the year
between the two surveys (although marriag-es
in this village accelerated after the age of
15 years, probably because the expectation
that girls should marry during adolescence
persisted); and
n Use of contraception among girls, which was
at comparable levels in the two sites at the
beginning of the project, was three times
higher in the intervention village at the end
of the project.
Building Life Skills to Improve Adolescent
Girls’ Reproductive and Sexual Health Project83
Country: India
Implementing organizations: ICRW with Swaasthya
This intervention was carried out by ICRW
with Swaasthya in two urban slums in Delhi.
The program provided life skills education for
unmarried adolescent girls, focusing on girls’
age at marriage, self-esteem, and nutritional
needs. The project in the first site, Tigri, ran
from 1998-2001, followed by a sustainability
study ending in 2005; a replication at the sec-ond
site, Naglamachi, ran from 2003-2006.
While the target participants for the program
were unmarried girls, Swaasthya also included
a component to encourage adults to be more
supportive of adolescent girls and sensitive to
their needs.
The Building Life Skills Project was evalu-ated
using baseline and endline surveys with-out
control groups. In one site, the evaluation
found that exposure to skills-building modules,
social support, and one-on-one interaction with
a Swaasthya fieldworker was associated with
high knowledge of sexual and reproductive
health among the unmarried girls and young
82 Erulkar and Muthengi, 2009.
83 Pande et al., 2006.
Strategies Used to Reduce Early Marriage and Childbearing
(EM&C)
Encourage boys and girls to examine notions of gender
Include messages about risks of early marriage and childbearing
Increase skills of providers to reach young women and men
Sensitize communities about EM&C
Institute life skills for unmarried adolescent girls (nutrition, self-esteem,
and age at marriage)

women involved in the project, a strong per-ception
of support from mothers and other
gatekeepers, and a positive perspective on life.
In the second, more socially conservative site,
the findings were weaker. The sustainability
analysis in the first site showed that some out-comes,
such as changes in knowledge, were
largely sustained, but that the program inter-ventions
were not continued by Swaasthya
fieldworkers after outside support was with-drawn.
Knowledge of sexual and reproductive
health also decreased, suggesting that consis-tent
input is needed to maintain knowledge
among this target group.
II. Female Genital Mutilation/
Cutting (FGM/C)
The practice of FGM/C affects between 100 mil-lion
and 140 million women and girls world-wide,
most of whom live on the African
continent. In some settings, the cutting is
much more extensive than in others. The prac-tice
of FGM/C tends to be associated with par-ticular
ethnic groups more than with nations or
religions, socio-economic status, or educational
levels.84 In Kenya, for example, almost all
women of reproductive age among the Somali,
Kisii, and Maasai ethnic groups have undergone
some type of FGM/C.85 Forms of FGM/C range
from infibulation, the most severe, in which all
external genitalia is removed and the vaginal
opening is stitched and narrowed, leaving a
small hole for urine and menstrual flow, to less
extreme cutting in which the clitoris or clitoral
hood is nicked or removed.86 FGM/C can lead
to immediate complications, such as hemor-rhaging
and infection. The more severe forms
can lead to long-term effects, such as poor
maternal and newborn health outcomes, pro-longed
labor, and socially debilitating condi-tions
such as malodorous urine retention or
painful and difficult sexual relations with
resulting problems between couples.87
In the last two decades, FGM/C has gained
international recognition as a health and
human rights issue and funding for interven-tion
projects and research has increased. The
most promising approaches include commu-nity-
based solutions and addressing rights as
well as the social, legal, economic, and health
dimensions of FGM/C. Several donor organiza-tions
have reached consensus about the most
effective approach to FGM/C interventions, as
articulated in “Toward a Common Framework
for the Abandonment of FGM/C”.88
FGM/C Interventions
The four FGM/C projects reviewed are all set in
Africa, and all four approaches are gender
transformative to some extent. The projects
combine FGM/C interventions with interven-tions
on other topics and all have emphasized
community involvement, taking into account
community attitudes regarding gender roles.
The case study presented here is Tostan’s
Community-Based Education Program. This
Senegalese NGO project seeks to transform cul-tural
norms rather than just behavior (see p.
54). Tostan, plus two of the other interventions
— by Navrongo and CARE — have been exten-sively
evaluated, while IntraHealth’s interven-tion
in Ethiopia had a much more limited
evaluation.
Table 5.2 lists the gender strategies used in
the projects to reduce FGM/C that were
reviewed.
Navrongo FGM/C Experiment89
Country: Ghana
Implementing organizations: Navrongo Health Research
Center (NHRC)
This project employed a mixed gender strat-egy—
transformative in attempting to influence
cultural expectations regarding girls and
women, but also accommodating gender expec-tations
by training girls in domestic tasks as
they would be trained as part of the rituals sur-rounding
FGM/C. The objective of the project
was to accelerate abandonment of FGM/C in six
villages of the Kassena-Nanka district of
Northern Ghana. The project employed a
strong community engagement and mobiliza-tion
component, using an approach known
locally as alagube (“connoting the process by
84 Chege et al, 2004; see also PRB, 2008.
85 Kenya DHS, 2003.
86 WHO, 2008.
87 See H. Jones et al., 1999; L. Morison et al., 2001; WHO,
2006; PRB, 2008.
88 UNICEF, 2007.
89 Feldman-Jacobs and Ryniak et al., 2006.

Table 5.2
Strategies Used to Reduce Female Genital Mutilation/
Cutting (FGM/C)
Promote model for change: girls right to education; women’s union to
demand rights; strengthening women’s position in the family
Influence cultural expectations regarding girls and women
Train girls in domestic tasks they would learn as part of FGM/C rituals
Promote dialogue between women and men on gender and FGM/C health-related
issues
which people solve a common problem by pool-ing
their individual and community social
resources”).90 The target audience (women and
adolescent girls) was involved in one of three
sets of activities: 1) FGM/C-related education
alone; 2) livelihood and development activities
alone (such as learning how to do handicrafts
or about micro-lending); and 3) a combination
of FGM/C education and livelihood and devel-opment
activities. In both the education and
livelihood and development sessions, women
and girls met in large groups (70 participants)
twice monthly for two-hour sessions.
The project used a “4-cell experiment” design,
with each cell, or community, receiving one of
four interventions: 1) No intervention or control
group; 2) education activities; 3) livelihood and
development activities; 4) combination of educa-tion
and livelihood and development activities.
A baseline survey covered 3,221 respondents;
follow-up surveys were undertaken each year
between 1999 – 2003 to monitor and evaluate
outcomes. Cox Proportional Hazard regression
models were used to analyze the survey data
and measure the impact of the interventions on
girls’ likelihood of being cut. The results of the
analysis indicate impressive reductions in
FGM/C in the experimental groups: one year of
the FGM/C education strategy was associated
with a 93 percent decrease in the risk of being
cut; one year of the combination education
plus livelihood was associated with a 94 per-cent
decrease in the risk, compared to the con-trol
group. However, substantial reductions of
FGM/C in the comparison area plus the reliabil-ity
of self-reporting on a practice that is against
the law in that country, raise questions about
the validity of the responses.
Awash FGM/C Elimination Project91
Country: Kenya and Ethiopia
Implementing organizations: CARE with local organizations
and Population Council
This project sought to empower women to
attend and participate in meetings to discuss
health-related issues with their male partners.
Set in six villages in Ethiopia and two refugee
camps in Kenya, the project focused on behav-ior
change communication (BCC) education
and advocacy, with an emphasis on creating
dialogue between women and men on FGM/C
and other topics related to health and gender,
and strengthening spousal communication
regarding family planning. A variety of commu-nication
channels were used: a) meetings with
community groups, women’s groups, health
education groups, and schools; b) performances
by popular theatre groups; c) evening video ses-sions
that showed recorded discussions by reli-gious
leaders speaking out on FGM/C issues;
and d) mass media activities. CARE believed
that the feasibility of these projects depended
on FGM/C being linked with a broader set of
RH issues rather than as a stand-alone inter-vention,
thus reducing the danger of it being
seen as an agenda imposed by outsiders.
The Population Council/FRONTIERS con-ducted
an operations research study that com-pared
two Awash interventions, each with a
control group. Using a quasi-experimental
design, the intervention sites were purposively
selected to correspond to Awash FGM/C
Elimination project areas and nearby sites were
selected for comparison purposes. The actual
intervention, which began with the introduc-tion
of expanded (in Kenya) and new (in
Ethiopia) FGM/C abandonment activities,
occurred over a 21-month period from January
2001 through June 2002 (in Kenya) and
October 2002 (in Ethiopia). The study assessed
the effectiveness of BCC and advocacy activi-ties
versus no interventions in Ethiopia, while
in Kenya the comparison was between BCC
strategies alone and the combination of BCC
and advocacy activities.
The interventions were more successful in
Ethiopia than Kenya. In all knowledge and atti-
91 Care, 2005.

tude indicators assessed, the intervention site
in Ethiopia showed more positive change than
Kenya, and it is not clear if the advocacy strat-egy
added much value to the intervention in
Kenya. Moreover, in Kenya the comparison site
performed better on all attitude and intended
behavior indicators. The evaluators attributed
this unexpected result to a failure to implement
the advocacy strategy effectively as well as to
pre-existing socio-economic differences in the
intervention and control populations. In both
countries the study designs were not adhered
to; project interventions as well as influences
from outside the project affected the outcomes
of interest. They also cited contamination in
the study design in both Kenya and Ethiopia
due to population movements into and out of
the intervention and comparison areas.
In both countries, there was active public
debate on the merits of continuing the prac-tice,
and some uncut girls, men, women, and
families publicly stated that they did not want
to continue the practice. In both countries, tra-ditional
leaders began to address the issue of
protection of those wishing to remain uncut, an
area of adjudication never-before addressed. In
Ethiopia, 70 elders made open declarations
that their villages would henceforth not cut
their daughters.
Five-Dimensional Approach for the Eradication
of Female Genital Mutilation/Cutting92
Country: Ethiopia
Implementing organizations: IntraHealth International
The objective of this multi-pronged project was
to both increase knowledge about FGM/C and
to change behavior. It encouraged women’s
empowerment while acknowledging their lack
of power by helping them to voice their con-cerns
about FGM/C to influential men.
Abandonment of FGM/C was addressed through
five perspectives: health, gender, law/human
rights, religion, and information. IntraHealth
emphasized community empowerment and
mobilization along with advocacy to encourage
long-term sustainability. Undertaken from
2003-2005, the project was introduced across
eight sites in regions with higher than average
prevalence of FGM/C (in one site it was as high
as 99 percent). While the project was designed
to include all community members with a stake
in the practice of FGM/C, specific groups were
identified and targeted through tailored inter-ventions.
More than 4,200 community mem-bers,
both men and women, participated in the
project’s training, information, education, and
communication community mobilization activi-ties,
and many more were reached through
related national and local media programs,
including broadcasts on television and radio,
and printed materials in local languages.
Interventions included national and regional
workshops, training of trainers, community
leadership training and community mobiliza-tion,
Public Declarations, and a religious lead-ers’
forum.
As a result of one IntraHealth workshop,
teachers, media, and religious leaders joined
together to make a public declaration that they
would work to stop gender inequities and
oppression and the practice of FGM/C. The
project also formed associations of non-circum-cised
girls and mothers of non-circumcised
girls as well as a community network to protect
girls from FGM/C and report any occurrence to
the regional gender bureau and police station.
The qualitative evaluation conducted by
IntraHealth included focus group discussions
with community leaders and suggested a
change in attitudes regarding marriage to non-circumcised
girls. However, there was no sub-stantiation
of attitudinal or behavior change.
Plans to do a quantitative evaluation were dis-rupted
by calls for a national election, which
occupied many of the community leaders.
III. Gender-Based Violence
Gender-based violence, including intimate part-ner
violence (IPV) and sexual violence (SV),
are worldwide public health problems associ-ated
with a wide range of negative physical,
psychological, social, and economic conse-quences
for abused women themselves and for
children whose mothers are exposed to vio-lence.
93 The reported prevalence of IPV/SV var-ies
considerably across settings. A
multi-country WHO study reported rates as
93 Garcia-Moreno et al., 2005; Heise and Garcia-Moreno,
2002; Heise, Ellsberg, and Gottemoeller, 2002; Heise,
Pitanguy, and Germain, 1994.

Table 5.3
high as 71 percent in rural Ethiopia and
between 21 and 47 percent in most countries.94
In analyses of data from the Demographic and
Health Surveys (DHS) conducted between 1995
and 2004 in 12 countries, prevalence of domes-tic
violence ranged from 18 to 53 percent.95
Gender-Based Violence Interventions
The gender-based violence (GBV) interventions
featured here focused on intimate partner vio-lence
(IPV), physical violence perpetrated by
men against their female partners, as well as
sexual violence (SV). Although psychological
violence is also a common form of IPV/SV, none
of the interventions directly addressed it, per-haps
because it tends to be more subjectively
defined and, therefore, difficult to measure.
Like many of the EM&C and FGM/C interven-tions
described above, the projects with docu-mented
success in addressing IPV/SV also
adopted multi-sectoral, multi-dimensional
approaches to reducing harmful practices. All
of the evaluated interventions that were found
on IPV/SV were gender transformative in
nature as they sought to change a harmful
behavior rooted in gender inequality. They all
were situated in Africa, particularly in South
Africa, where rates of IPV/SV are among the
highest in the world.96
Only one of the four interventions discussed
in this GBV section focuses primarily on engag-ing
men: the One Man Can Campaign in South
Africa. The objective of this project is to stop
IPV/SV, promote healthy relations, and prevent
HIV/AIDS. (Another example from South Africa,
“Men as Partners,” is described in the chapter
on HIV/AIDS; and “Visions,” a nonformal educa-tion
program for youth in Egypt described in the
youth chapter, also includes the topic of IPV/
SV.) Soul City and IMAGE (case study, p. x) had
the most rigorous evaluations.
Table 5.3 lists the gender strategies
employed in the projects reviewed to reduce
IPV/SV.
Soul City97
Implementing organizations: South African Soul City Institute
for Health and Development Communication (a multi-media
health promotion project) working with the National Network
on Violence Against Women
This project began with the premise that
behavior change interventions aimed solely at
individuals have limited impact. Soul City,
therefore, sought to influence women and men
at multiple mutually-reinforcing levels — indi-vidual
and community as well as socio-political
environment — through prime-time radio and
television dramas and print material. This
method has been dubbed “edutainment,”
where social issues are integrated into enter-tainment
formats such as television and radio
to reach marginalized rural communities in
particular.
Domestic violence was the major focus in
Soul City’s fourth television and radio series,
aired between July and December 1999. The
intervention sought to create an enabling envi-ronment
for behavior change by advocating for
the implementation of the 1998 Domestic
Violence Act (DVA). The series provided role
models for the use of the DVA and a helpline
was established to provide more information.
The series also promoted interpersonal and
community dialogue and encouraged collective
efficacy and action to shift social norms,
increase supportive behavior, and link people
to sources of support. At the individual level,
the intervention aimed to influence knowledge,
awareness, attitudes, self-efficacy, intention to
change, and practices.
94 Garcia-Moreno et al., 2005.
95 Kishor and Johnson, 2004.
96 Mathews et al., 2004.
97 Usdin et al., 2005.
Strategies Used to Reduce Intimate Partner Violence/
Sexual Violence
Engage men to stop violence against women through participatory work-shops
and community interventions
Institute microfinance-based poverty alleviation programs and participatory
trainings
Address individual, community, and socio-political levels – ‘edutainment’
Amplify voices from within the community through participatory community
engagement in producing video tapes on IPV/SV and health issues
Create action kits to engage men in stopping violence against women

The evaluation of Soul City was multifac-eted,
consisting of several inter-related studies,
triangulated to improve validity of the results.
These included national-level pre/post surveys
and a qualitative impact assessment using 29
focus groups and 32 in-depth interviews. The
evaluation showed an impact on attitudes,
help-seeking behaviors, and participation in
community action, though not in the actual
incidence of IPV/SV.98 There was a shift in
knowledge regarding domestic violence, with
41 percent of respondents gaining knowledge
about the project’s helpline. Attitudinal shifts
following the intervention include a 10 percent
increase in respondents disagreeing that IPV/
SV is a private affair and a 22 percent shift in
perceptions of social norms regarding IPV/SV.
Differences between male and female respon-dents
on these outcomes were not reported.
The evaluation concluded that 1) the inter-vention
played a decisive role in implementa-tion
of the Domestic Violence Act, and 2) a
strong association existed between exposure to
the intervention and a number of factors indic-ative
of and necessary to bring about social
change.
Through Our Eyes99
Country: Liberia
Implementing organizations: The American Refugee
Committee (ARC) and Communication for Change
This is a unique behavior change project set in
Liberian refugee camps and launched in 2006
by Liberian refugees in Guinea with support
from the American Refugee Committee (ARC)
and its partner, Communication for Change. By
producing video tapes on the subjects of IPV/
SV and health issues, which are played back to
the community, it aims to amplify voices from
within the community through participatory
community engagement. The Liberia-based
team has produced more than 30 videos and
conducted dozens of playback sessions about
such highly sensitive subjects as rape, forced
marriage, teenage prostitution, unintended
pregnancy, STIs, and equal rights for women
and girls. Recent videos have focused on gen-der
roles and women’s empowerment (e.g.
“Making Family Decisions,” “Women are
Roosters Too,” “Women Freedom in Society,”
“Nennie Nyan Daa Porlie Gehye: Women Can
Do It”), seeking to promote more nuanced and
sustainable aspects of gender transformation
that focus on shifting social and cultural norms.
The intervention is being replicated in Asia and
elsewhere in Africa.
The evaluation of Through Our Eyes dem-onstrates
a unique way to evaluate a project
with little resources and considerable commu-nity
involvement. It was conducted through
focus group discussions during each video play-back
session. The findings suggest an increase
in women’s use of reproductive health services
in target areas, and a reduction in stigma asso-ciated
with discussing sexual violence and
other matters related to women’s health and
rights. They also suggest that the women felt
more confident in articulating their concerns
about IPV/SV and reproductive health, and
pride in their new skills in making videotapes.
(A series of formal participatory evaluations are
being planned.)
One Man Can (OMC) Campaign100
Implementing organizations: Sonke Gender Justice
The One Man Can Campaign, a partnership on
HIV and gender violence in southern Africa, is
a flagship initiative of the South African NGO
Sonke Gender Justice (Sonke). Begun in 2006,
it encourages and supports men and boys to
take action to stop IPV/SV and to promote
healthy, equitable relationships between men
and women. OMC has been implemented in all
of South Africa’s nine provinces as well as in
several other southern African countries (in
the latter, by partner organizations). By July
2007, through the implementation of 10 OMC
projects, Sonke had trained 465 people in six
provinces to implement OMC activities; had
conducted two 4-day workshops for more than
2,000 people in six provinces; and had reached
tens of thousands of people through commu-nity
OMC partnerships.
98 Impact on actual incidence of IPV/SV is problematic to
measure in the context of an intervention project, in any
case, because such interventions typically encourage
women who have kept their abuse secret to openly discuss
their situations.
99 Information from www.c4c.org/eyes.html
100 Peacock, 2008.

The OMC project interventions were devel-oped
based on results from formative research
that included literature reviews, surveys, and
focus group discussions with survivors of vio-lence,
faith-based leaders, and teachers and
coaches. The surveys asked boys and men how
they understood the problem of men’s violence
against women and what they would be willing
to do about it.
Based on the findings, Sonke developed a
kit to provide men with resources to act on
their concerns about domestic and sexual vio-lence.
This Action Kit includes such materials
as stickers, clothing, posters, music, video
clips, and fact sheets, and provides specific
information and strategies on how men can
support a survivor, use the law to demand jus-tice,
educate children early and often, chal-lenge
other men to take action, make schools
safer for girls and boys, and raise awareness in
churches, mosques, or synagogues. Sonke
implements OMC workshops with groups of
men in communities across South Africa and
has provided training on the OMC Campaign to
a broad range of key stakeholders including
government departments at the national and
provincial levels, traditional healers, faith-based
leaders, the police, youth service organizations,
in- and out-of-school youth, teachers, and other
CBOs and NGOs. Groups of men and boys
attend workshops and develop community
teams to put the training into action.
Phone surveys with a random sample of
program participants and routine data collec-tion
from government sources and NGOs were
completed to evaluate a number of behavioral
outcomes. Results showed positive results, with
91 percent of participants who had witnessed
domestic violence reporting it to authorities
(police, community structure, NGOs). Sixty-one
percent of respondents also reported that
they had increased their condom use after
attending a workshop.
Pre/post tests in connection with specific
workshops suggested dramatic attitudinal
changes. For example, pre/post test results
from a workshop with members of a traditional
court showed that before the workshop, 100
percent of the male respondents believed that
they had the right, as men, to decide when to
have sex with their female partners. This
dropped to 25 percent after the workshop. In
another case, 63 percent of participants from a
local tribal authority said they believed that,
under some circumstances, it is acceptable for
men to beat their female partners. Post-workshop,
83 percent of respondents disagreed
with this statement. Similarly, before the work-shop,
96 percent of the participants believed
that they should not interfere in other people’s
relationships even in cases of violence. After
the workshop, all participants said they
believed that they should interfere.

Harmful Practices Case Study
Intervention:
Delaying Age at Marriage in Rural Maharashtra
Country: India
Type of Intervention: Life skills program
Implementing Organizations: ICRW with Institute of Health Management, Pachod (IHMP)
In rural Maharashtra, there are few alterna-tives
to marriage for young girls. Parents are
reluctant to send girls to school because of
safety concerns, and outside employment
opportunities for women are very limited. In
order to ensure a daughter will be taken care
of in the future, parents are anxious to find a
suitable husband. Her consent is often not
taken, and she is often married to a much
older man. This marriage arrangement cre-ates
significant power imbalances between
the girl and her husband, leaving her vulnera-ble
to many harmful outcomes. For example,
she may be unable to negotiate contraceptive
use or she and her husband may not have
access to appropriate information about fam-ily
planning. Thus, early marriage often leads
to early child bearing. The age difference also
means that girls are at greater risk of HIV
from their husbands, who may be more sex-ually
experienced.
Objective
The intervention study sought to test the
effectiveness of a life skills program in
increasing girls’ self-esteem and literacy and
delaying age at marriage in Maharashtra.
Strategy
The program specifically addressed gender-related
barriers by trying to improve the
social status of adolescent girls through
increasing their skills related to gender, legal
literacy, and team building. The life skills
training approach recognizes that early mar-riage
and poor sexual and reproductive
health are closely linked with girls’ low self-esteem,
social vulnerability, and limited life
options. The program was implemented in
multiple year-long phases, with one-hour
education sessions held each weekday eve-ning.
This case study focuses on the first
implementation year completed in 1998 –
1999. It targeted unmarried adolescent girls
ages 12 – 18, focusing on out-of-school and
working girls.
The sessions concentrated on improv-ing
the girls’ skills and knowledge in the fol-lowing
areas: Social Issues and Institutions,
Local Bodies (i.e. local government and civil
society structures), Life Skills, Child Health
and Nutrition, and Health. One example of
an activity in the life skills course is the edu-cation
practicum, in which girls in the com-munity
conduct an informal education
course, such as teaching literacy skills to
non-participating girls.
Parents were engaged throughout the
development of the program and implemen-tation
of the intervention. IHMP organized 10
focus group discussions with mothers and
their unmarried daughters in order to develop
the program’s content. Once IHMP had devel-oped
the curriculum, parents were given the
opportunity to learn about it, give feedback,
and participate in monthly meetings.
Already established village develop-ment
committees collaborated with IHMP to
recruit and hire teachers for the life skills
program. The teachers were required to
have at least seven years of formal educa-tion
(the same level required for the village-based
anganwadi, workers in the
State-operated Integrated Child
Development Services) so the program
could be replicated throughout the country
if successful.
Evaluation Design:
Quasi-Experimental pretest-posttest
control group design
The study compared 17 intervention and 18
control villages, with a total of 1,146 partici-pants.
Two noncontiguous primary health
centers (PHC) were randomly assigned to
the intervention and control group. Each
PHC was broken down into smaller geo-graphical
units, each with a population of
1,000 – 1,500, with 17 and 18 units making
up the intervention and control groups
respectively. The girls were grouped accord-ing
to their level of participation in the pro-gram,
and ranged from not attending to fully
attending. Teachers tracked the participants
for one year following completion of the life
skills course, noting who married within that
year.

Table 5.4
Comparing only the girls who participated
fully in the life skills program and a ran-domly
selected group from the control area,
logistic regression analysis indicates that
the control group was four times more likely
to marry before 18 than the group who fully
participated.
From the study sample, nine percent of
the girls who completed the course were
married before the age of 18 years, com-pared
to almost 30 percent of the girls who
never attended. Logistic regression shows
that, controlling for background characteris-tics,
girls who never attended the course
were more than two-and-a-half times as
likely to get married before age 18 com-pared
to girls who completed the course.
These findings show that the program
significantly delayed marriage of both pro-gram
participants and nonparticipants in the
intervention areas as a whole. The median
age at marriage rose from 16 to 17 years
from 1997–2001, and the proportion of
marriages to girls younger than 18 dropped
from 81 percent to 62 percent. There was
no significant change in the control group.
Gender Outcomes
Qualitative interviews suggested that after
attending the life skills course, girls acted
more confidently and autonomously. They
influenced household decisions, including
decisions regarding their own marriage,
spoke without hesitation or fear, demon-strated
more self-discipline, and were more
independent in daily activities. A pre- and
post-test of the life skills course showed
that while the intervention and control group
had similar pre-test scores, only the inter-vention
group exhibited significant changes,
with correct answers increasing by 1.5 to
3.0 times.
Scale-up
By the end of the study, the state govern-ment
of Maharashtra had adapted and
scaled up IHMP’s life skills model for rural
Maharashtra.
Conclusions
The evaluation suggests that the life skills
program provided the girls with skills and
knowledge that increased their confidence
and helped them to become more involved
in household decisions, including decisions
regarding their own marriage. Inclusion of
parents in developing program content and
implementation helped to achieve broad
community support, evidenced by delayed
marriages occurring within the whole inter-vention
area, not just among program par-ticipants.
References
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and S. Jain, Improving the Reproductive
Health of Married and Unmarried Youth in
India: Evidence of Effectiveness and Costs
from Community-based Interventions. Final
Report of the Adolescent Reproductive
Health Program in India (New Delhi: ICRW,
2006).
Attendance # of girls % married < 18 yrs Adjusted OR+
Complete 166 9.1 1 (reference)
Partial 243 22.6 2.42*
None 737 29.3 2.58*
N=1146; *p<0.05; +Adjusted for girls’ age, current schooling status, education, SES, family type,
mother’s education, parents’ occupation
Source: ICRW, Delaying Age at Marriage in Rural Maharashtra.

Female genital cutting (FGC)101 is a common
practice throughout Senegal. The practice of
FGC is perpetuated by the belief that it is a
rite of passage to womanhood and neces-sary
for suitable marriage prospects.
Because of these factors, mothers often
believe they are acting in their daughters’
best interests. Because it is culturally
expected for women to undergo FGC, it may
be difficult for individuals to stand up to this
social norm.
Objective
Tostan’s goal was to help communities,
especially women, improve living and health
conditions, and to mobilize villages to hold
public declarations supporting the abandon-ment
of harmful practices, particularly FGC
and child marriage.
Strategy
Tostan seeks to empower people to make
informed decisions for the benefit of their
personal and community development. The
educational program includes modules on
human rights, problem solving, environmen-tal
hygiene, and women’s health. Through
participatory educational methods for com-munication
of technical information, discus-sion
of human rights issues, and
development of strategies for social trans-formation,
the NGO hopes to improve the
confidence and self-determination of
women.
Implementation of the program typi-cally
follows six phases over the course of
18-24 months. In the first, a village sets up
a committee to adapt and manage the pro-gram.
In the second phase, about 30 partici-pants
in each village receive training and
Prevalence of FGC Among Daughters of Participants
Participants in intervention area 87% n = 550 84% n=340 79%* n=353
Non-participants in intervention area 85% n=213 78%* n=199
Comparison Group 93% n = 272 -- 89% n = 232
* Statistically significant at p<0.05
education courses three times a week for
two hours each covering hygiene, women’s
health, human rights, and problem-solving.
Training emphasizes enabling participants to
analyze their own situation and find the best
solution. In the third and fourth phases,
trainees share what they are learning with
others, and the group begins to organize
public discussions around issues identified
by the trainees. Participants serve as dis-cussion
leaders and facilitate a process of
community consensus-building in renounc-ing
FGC. In the fifth phase, community
members reach out and spread educational
activities to neighboring villages. Finally, a
group of villages organizes a public declara-tion
to indicate their collective intention to
renounce harmful practices
Evaluation Design: Quasi-experimental
case-control design
A quasi-experimental control design was
used to evaluate differences between men
and women in 20 intervention and 20 con-trol
villages. At baseline, 576 women, 373
men, and 895 daughters were surveyed in
the intervention villages. In the control vil-lages,
199 women, 184 men, and 396
daughters were surveyed.
Baseline Post-intervention Endline
In the intervention villages, a survey
was administered to both participants and
non-participants (immediately before the
intervention at baseline, immediately after
the intervention, and two years after the
intervention/endline). Those living in the
control villages were interviewed twice, at
baseline and endline. In addition, qualitative
data were collected to gauge the community
mobilization process and people’s percep-tions,
attitudes, and behaviors.
The prevalence of FGC among daughters at
baseline was 87 percent and 93 percent for
the intervention and control groups, respec-tively.
By the endline, FGC prevalence
among daughters of women in the interven-tion
group had significantly declined. No
significant change could be seen in the
comparison group (see table. 5.5).
The proportion of women who thought
FGC was necessary significantly declined in
the intervention group. A decrease was also
Intervention:
Tostan Community-Based Education Program
Country: Senegal
Type of Intervention: Community engagement and education program
Implementing Organizations: Tostan; evaluation by Population Council.
Table 5.5
101 While USAID and many NGOs and donors
refer to this practice as female genital
mutilation/cutting or FGM/C, Tostan pre-fers
to use what it considers the non-pejo-rative
term of FGC, female genital
cutting.

Table 5.6
found in the control group; however, the dif-ference
in this change was less than in the
intervention group (see table above).
Awareness of at least two conse-quences
of FGC significantly increased
among men (from 11 to 83 percent) and
women (from 7 to 83 percent) immediately
after participating in the program, although
it declined somewhat (to 66 percent for men
and 70 percent for women) by the time of
the endline survey.
Among the majority of women partici-pating
in the program who disapproved of
FGC at the endline, 85 percent said that they
had changed their mind after the Tostan
program and 10 percent said their disap-proval
dated back several years.
In addition to FGC, the evaluation
showed a wide range of positive RH out-comes
including:
• Significant declines in women’s per-sonal
experience of violence during the
last 12 months in both the intervention
and comparison group (the intervention
group declined significantly more than
the comparison group);
• Significant increase in knowledge of
contraceptive methods by men and
women in the intervention group;
• Significant increase in awareness of
STIs at endline by women participants
and nonparticipants in the intervention
villages (no increase was observed in
the comparison group), and a signifi-cant
increase in men who knew at least
two kinds of STIs compared to the
comparison group.
Gender Outcomes
After the intervention, there was a signifi-cant
increase among women in the interven-tion
groups who agreed with the statement
that “girls ought to go to school” and
agreed that women’s unions had a role in
demanding rights. Levels were sustained
through to the endline. The comparison
group also revealed similar significant
trends.
Partner approval of contraceptive use,
as perceived by the women, improved sig-nificantly
in the intervention group. These
levels were maintained at endline.
Discussion with partners about family plan-ning
was higher among the participants (30
percent) than among the non-participants
(17 percent).
Limitations
The evaluation showed improvements in a
number of the measured RH outcomes in
both the intervention and the comparison
villages. For example, awareness of gender-based
violence reached the same level of
improvement in the comparison villages as
in the intervention villages. This could be a
result of changing social factors in the com-munity,
as well as contamination because
Tostan radio programs were broadcast
throughout the region.
Conclusions
Knowledge about FGC issues among both
men and women increased significantly dur-ing
the study period. Those who participated
in the education program increased their
knowledge more than others living within
the villages. Most disapproved of FGC and
declared that they had no intention of cut-ting
their daughters in the future. The same
tendency was observed in the comparison
group, but to a lesser extent, suggesting
that there is a widespread shift in attitude,
which this program may have accelerated in
the intervention villages.
Levels of awareness of family planning,
pregnancy surveillance, child health, and
STI/HIV issues increased after the program,
and comparisons show a statistically signifi-cant
increase by the intervention group over
the comparison group for all but one health
indicator.
References
N.J. Diop, M.M. Faye, A. Moreau, J. Cabral,
H. Benga, F. Cisse, B. Mane, I. Baumgarten,
and M. Melching. The Tostan Program:
Evaluation of a Community Based Education
Program in Senegal (New York: Population
Council: 2004).
Proportion of Women Who Thought FGC Was a Necessity
Baseline Post-intervention Endline
Participants 70% n = 550 21% 15%
Non-participants 33% 29%
Comparison Group 88% n = 272 -- 61%

Intervention:
Intervention with Microfinance for AIDS and Gender Equity (IMAGE)
Type of Intervention: Cross-sectoral
Implementing Organizations: Small Enterprise Foundation (SEF)
Intimate partner violence/sexual violence
(IPV/SV) is highly prevalent across sub-
Saharan Africa. Women living in poverty are
more likely to suffer from violence. Evidence
points to a link between violence and HIV/
AIDS status. In the Limpopo Province,
acceptance by women of their husband’s
extra-marital affairs is commonplace.
Women often tolerate these behaviors from
their husbands because they are the main
income earners in the family and, therefore,
have a position of authority in the house-hold.
Additionally, men and women may
have internalized norms that perpetuate
male control and acceptance of violence.
Objective
The IMAGE project, implemented from 2001
– 2005, sought to increase women’s
empowerment through micro-lending, gen-der
awareness, and HIV training, and to
decrease women’s experience of IPV/SV.
Strategy
Women (ages 18 and older) who lived in the
poorest households in each village were
selected as participants using SEF’s partici-patory
wealth-ranking criteria. The interven-tion
included two strategies: a micro-lending
program and a gender-focused training
component called “Sisters for Life.”
Microfinance Program. The IMAGE micro-lending
program followed the Grameen
model, and supported women’s new and
existing business ventures. In this model,
groups of five women acted as each other’s
benefactor, and all women in the group had
to repay their loans in order to move up to
the next credit level. Women met every two
weeks to repay their loans, apply for credit,
and discuss their business plans.
Sisters for Life Program. The gender aware-ness
and HIV-training component was imple-mented
in two phases alongside the
microfinance program. Phase one consisted
of 10 one-hour sessions on gender roles,
cultural beliefs, relationships, communica-tion,
domestic violence, and HIV infection,
with the goal of strengthening communica-tion
skills, critical thinking, and leadership. In
phase two, women who were identified by
their loan centers as “natural leaders”
received additional training on leadership and
community mobilization to lead initiatives in
their own families and communities. Based
on participatory learning and action (PLA)
principles, phase two was an open-ended
program that encouraged broad community
mobilization to engage men and boys.
Evaluation Design:
Cluster randomized-control trial
During the recruitment period of the evalua-tion,
430 loan recipients and 430 matched
control participants were enrolled. The
multi-level evaluation was designed to mea-sure
changes at the individual, household,
and community level. Matched villages were
randomly assigned to receive the interven-tion
either at the beginning or the end of the
evaluation period. Participatory wealth rank-ing
was used to form matched experimental
and control groups based on age and pov-erty
level. Reproductive health data were
collected, including sexual behavior and HIV
status. Gender outcomes investigated
included economic and social benefits,
intra-household communication, decision-making,
and gender relations.
Nine empowerment indicators relevant
to South Africa were used. Seven focus
group discussions supplemented the quanti-tative
data.
Researchers measured women’s expe-rience
of IPV/SV during the past year, as
well as two secondary outcomes, including
experience of controlling behavior from
partners and attitudes toward the accept-ability
of IPV/SV.
Results showed that experience of IPV/SV in
the past year decreased by half in the inter-vention
villages. An analysis of trends
showed a consistent decrease in IPV/SV
over time for all four intervention villages,
whereas IPV/SV remained constant or
increased in the control villages. The study
also showed that, compared to the control
group, at endline women in the intervention
group reported less controlling behavior
from their partners and less accepting atti-tudes
toward violence. For the intervention
group, there was not a substantial decrease
from baseline to endline in experiencing
controlling behavior (see table 5.7).
Gender Outcomes
The intervention measured a number of
gender outcomes, including effects on eco-nomic
well-being and empowerment.
Participants in the intervention group
reported increased assets, expenditures, and
membership in savings groups.
Participation in the intervention was
associated with greater self-confidence and
financial confidence, more progressive atti-tudes
toward gender norms, increased
autonomy in decisionmaking, greater part-ner
appreciation of their household contri-bution,
improved household
communication, better partner relationships,
and higher levels of participation in social
groups and collective action (see table 5.8).

Table 5.7
Baseline Follow-up (2 years
after baseline)
Intervention (%) Control (%) Intervention (%) Control (%)
Intimate partner violence
Experience of past year IPV/SV 11.4 9.0 5.9 12.01
Progressive attitudes to IPV/SV … … 52.4 35.5
Experienced controlling behavior
by partner 34.7 22.5 33.7 41.7
Source: Kim et al., 2007: 1974-1802.
Table 5.8
RH Outcomes
Limitations
Research has shown that women often
underreport experiencing IPV/SV due to its
sensitive and stigmatized nature.
Willingness to disclose often increases as
awareness increases of IPV/SV definitions
and its prevalence. This reporting bias may
have underestimated the impact of the inter-vention
on IPV/SV.
Scale-up
The IMAGE project is currently being scaled-up
in partnership with AngloPlatinum Mines
in 150 villages.
Conclusions
The evaluation found women’s risk of physi-cal
or sexual violence was reduced by more
than half following the intervention, and
improvements were shown in all nine dimen-sions
of women’s empowerment measured in
the study. The research team attributes these
results to women’s enhanced ability to chal-lenge
the acceptability of violence, their
expectation of better treatment from male
partners, their willingness to leave abusive
relationships, and heightened public aware-ness
about intimate partner violence.
This intervention is noteworthy for com-bining
development and health interventions
to achieve reductions in IPV/SV. Achieving a
strong partnership between the microfinance
institute and HIV/AIDS prevention organiza-tion
was key to the successful implementa-tion
of this cross-sectoral intervention.
References
P.M. Pronyk, J.C. Kim, J.R. Hargreaves,
M.B. Makhubele, L.A. Morison, C. Watts,
and J.D.H. Porter, “Microfinance and HIV
Prevention: Emerging Lessons from Rural
South Africa,” in Small Enterprise
Development 16, no.3(2005): 26-38.
J.C. Kim, C.H. Watts, J.R. Hargreaves, L.X.
Hdhlovu, G. Phetla, L.A. Morison, J. Busza,
J.D.H. Proter, and P. Pronyk, “Understanding
the Impact of a Microfinance-Based
Intervention on Women's Empowerment
and the Reduction of Intimate Partner
Violence in South Africa,” in American
Journal of Public Health 97, no.10(2007):
1974-1802.
Gender Outcomes
Baseline Follow-up
Intervention group
Empowerment
Greater financial confidence 45.5 72.0
Challenging gender norms 37.4 61.2
Autonomy in decisionmaking 27.7 57.1
Taking part in collective action 41.0 75.7
Economic well-being
Estimated household asset value > 2000 rand 48.2 58.2
Savings group membership 24.5 36.2

Nearly half of the world’s population is below
the age of 25, including an estimated 1.2 bil-lion
adolescents ages 10-19, and most of those
young people live in developing countries.102
Adolescence is a time of transition from child-hood
to adulthood and, as such, is a critical time
to provide young people with the knowledge and
skills they need to ensure a lifetime of good sex-ual
and reproductive health. Adolescents, and
particularly adolescent girls, face a range of
reproductive health risks once they become sex-ually
active, including STIs, HIV/AIDS, and unin-tended
pregnancy. Pregnancy is the leading
cause of death for young women ages 15 to 19
worldwide, with complications of childbirth and
unsafe abortion leading the list.103 In 2007, an
estimated 5.4 million young people (ages 15-24)
were infected with HIV. Prevalence was highest
in sub-Saharan Africa, where 90 percent of HIV-positive
children live; young women in the
region have rates that are even higher than
those of young men.104
6
Program Country
African Youth Alliance Ghana, Tanzania,
Uganda
Guria Adolescent Health Project Georgia
Transitions to Adulthood - Adolescent Livelihoods India
Training
Transitions to Adulthood - Tap and Reposition Youth Kenya
New Visions Egypt
CASE STUDY: Ishraq Egypt
CASE STUDY: First-time Parents India
Gender and sexual norms are established
early105 and dictate such things as when and
with whom to have sex, and whether to use
protection. Gender norms related to sex can
have detrimental effects on men as well as
women, particularly for STIs and HIV and for
risk of violence.106
Waiting to have sex, known as “delaying
sexual debut,” can reduce the number of sexual
partners and, therefore, reduce the risk of con-tracting
HIV.107 Opinions vary on what are the
appropriate programs for adolescents, ranging
from teaching abstinence-only until marriage to
providing comprehensive sex education
(including means of protection from pregnancy
and disease). Evidence has been available for
quite some time that in countries with strong
youth-friendly sexual and reproductive health
services, the incidences of teenage pregnancy,
abortion, and STIs are consistently much lower
than in countries where these services are not
available.108
Interventions
The seven interventions highlighted here
focused on addressing gender norms, providing
information, and building skills related to SRH.
Readers should note that several of the inter-ventions
in other chapters of this publication
(particularly in Chapter 4, Reducing HIV/AIDS)
are relevant to young people, risky behaviors,
and negative health outcomes.
All seven interventions undertook gender
transformative approaches, in whole or in part.
Four sought to improve adolescent reproductive
health by promoting gender equitable norms.
The two projects selected as case studies were
Ishraq (enlightenment) in Egypt and the First-time
Parents in India. Ishraq focused on devel-opment
of life skills and opportunities for girls,
while the First-time Parents sought to reach
102 UN Population Division, 2008.
103 WHO, 2004.
104 See Children and HIV and AIDS at www.unicef.org/aids/.
See also UNAIDS, 2007.
105 Eggleston, Jackson, and Hardee, 1999; Blakemore, 2003
106 See Pulerwitz, Barker, and Nascimento, 2006.
107 Pettifor et al., 2004 , in Gay et al., 2005.
108 Grunseit, 1997.

young married women with RH information
and services, empowering them to address their
own needs (see p. X).
Table 6.1 lists the strategies employed by
these programs to meet the needs of youth.
The African Youth Alliance (AYA)109
Country: Uganda, Tanzania, Ghana, and Botswana
Implementing organizations: PATH, Pathfinder International,
and UNFPA with funding by the Bill and Melinda Gates
Foundation; Evaluation by JSI.
The AYA project was designed to be an “inno-vative,
collaborative and comprehensive pre-vention
program” for improving adolescent
(ages 10-24) sexual and reproductive health in
four African counties.110 The intervention had
six components: policy and advocacy coordina-tion;
institutional capacity building; coordina-tion
and dissemination; BCC, including life
planning skills; youth friendly services; and
integration of adolescent sexual and reproduc-tive
health with livelihood skills training. There
were three cross-cutting themes: gender; part-nerships;
and active participation of youth. AYA
program materials note that, “Gender-sensitive
approaches are applied at different levels to
challenge gender biases that exist at multiple
levels and maintain unequal status, access, and
life experience for males and females.”111
John Snow, Inc. (JSI) evaluated the AYA
project in three of the four countries (Uganda,
Tanzania, and Ghana) using a post-intervention
analysis to ascertain the impact of exposure to
AYA’s comprehensive integrated program on
sexual and reproductive health behavior among
youth. The evaluation compared knowledge,
attitudes, and behavioral outcomes between
intervention and control sites and youth who
were and were not exposed to the AYA inter-vention.
The evaluation did not measure any
gender outcomes. The analysis used two ana-lytic
techniques for measuring impact using
data collected at one point in time (cross-sec-tional
Table 6.1
Strategies to Meet the Needs of Youth
Employ comprehensive approach addressing policy, community and
individual levels
Address structural issues and underlying factors affecting poor RH,
including gender inequity
Address notions of gender through community theater
Empower rural, out-of-school girls and work with young males to promote
life skills, including RH and gender equity
Improve women’s economic prospects through livelihoods and microcredit
(integrated with RH)
Empower young married women with RH information and services
Perform gender analysis throughout project development and
implementation
data): propensity score matching and
instrumental variable regression. The evalua-tion
found that AYA positively impacted a num-ber
of variables, including contraceptive and
condom use, partner reduction, and several
self-efficacy and knowledge antecedents to
behavior change. Areas in which there was lit-tle
evidence of impact included delay of sexual
debut and abstinence among females and
males, and partner reduction among males.
The impact of AYA was greater on young
women than on young men. The evaluation
concluded that AYA program approaches need
to be refined to better reach young men.
Guria Adolescent Health Project (GAHP)112
Country: Georgia
Implementing organizations: CARE
This project was implemented in the Guria
region of Georgia as part of a wider effort by
USAID and CARE to strengthen underlying
causes of poor family planning/reproductive
health (FP/RH) in order to yield sustainable
health outcomes. The Guria project used an
inter-generational approach to “influence
social, cultural and gender norms and inequali-ties
[to] improve promotion of reproductive
health rights and responsibilities of adults and
adolescents.”113 This meant working with par-ents
on how to involve adolescents in designing
and implementing a program on sexual and
reproductive health for young people.
Meeting the Needs of Youth 59
109 African Youth Alliance, 2008; see also Williams et al.,
2007.
110 See www.jsi.com/Managed/Docs/Publications/Evaluation/
aya_evaluation_uganda.pdf, accessed online Dec. 1, 2009.
111 AYA, 2008.
112 CARE, 2005; CARE 2007.
113 CARE, 2007, p. iii.

Components of the project included the use of
youth and adult change agents; promotion of
health education and social marketing; and
implementation of micro-grants and youth-friendly
services.
This project was evaluated using baseline
and endline surveys as well as through qualita-tive
methods and document review. The evalu-ation
found impressive changes in knowledge,
attitudes, and behaviors in support of access to
family planning information and services. The
percentage of young women and men aware
that it is possible to prevent unwanted preg-nancy
nearly doubled from 50 percent to 93
percent. Knowledge of contraception also
improved, with young people knowing about
more methods and more effective methods.
The evaluation also found more support for
adolescent rights, including protection of girls
from kidnapping. The project promoted
increased discussion of gender topics, most
notably masculinity.
Transitions to Adulthood—
Adolescent Livelihoods Training114
Country: India
Implementing organizations: Population Council and
CARE/India
This project integrated a livelihoods component
into an existing reproductive health project that
had been serving adolescent girls and boys in
the slums of Allahabad, India for years.The aim
was to expand girls’ decisionmaking power
through building and strengthening social net-works
and developing financial and income-gen-erating
capabilities. The livelihoods approach
sought to provide skills to transform the ways
girls perceive themselves and are perceived
within their communities. Peer educators
recruited adolescent girls to participate in the
program. Girls in the experimental and control
areas received information on RH; in the experi-mental
areas girls also received vocational coun-seling,
information on savings accounts, and
follow-up support from a peer educator.
The evaluation, conducted by the
Population Council and the Centre for
Operations Research and Training (CORT),
used a pre- and post-test design, with baseline
surveys of adolescents and one of their parents.
It found that, as a result of the intervention,
girls in the experimental areas were more likely
to be members of a group and to know where
unmarried women could safely congregate.
These girls also scored higher on measures of
social skills and self-esteem and knowledge of
reproductive health. The project did not have
an appreciable effect on gender role attitudes,
girls’ mobility, girls’ expectations for work, or
how the girls used their time.
The evaluation of the livelihoods compo-nent
noted that, while such a short-term proj-ect
can raise awareness and change attitudes, it
cannot be expected to change the structure of
opportunities available for girls. It concluded
that, in order to reduce deeply entrenched gen-der
disparities that exist and enhance girls’
ability to have a greater voice in influencing
their lives, future programs should include
more contact with the girls and stronger efforts
to develop group cohesion and to improve the
communication, negotiation, and decision-mak-ing
skills of adolescent girls. Since this evalua-tion,
CARE-India has incorporated the
livelihoods approach into its ongoing adoles-cent
60
programs in India.
Transitions to Adulthood—
Tap and Reposition Youth (TRY)115
Country: Kenya
Implementing organizations: Population Council with K-Rep
Development Agency (KDA).
This savings and microcredit project, which
also focused on gender attitudes, targeted out-of-
school adolescent girls and young women in
low-income and slum areas of Nairobi, Kenya.
The objective was to improve adolescents’ live-lihood
options as a way to reduce vulnerabili-ties
to adverse social and reproductive health
outcomes. The TRY model included group-based
micro-finance, such as integrated sav-ings,
credit, business support, and mentoring.
The project was implemented first as a pilot
project (1998–2000) and was then scaled-up
and evaluated from 2001–2004.
The evaluation was a quasi-experimental,
pre- and post-test design, with surveys con-ducted
at baseline and at the conclusion of the
project. In total, 326 participants and their
114 Sebastian, Grant, and Mensch, 2005.
115 Erulkar and Chong, 2005.

matched controls were interviewed at baseline,
and 222 pairs were interviewed again at endline.
Compared to the control group, TRY partici-pants
had significantly higher levels of income
and household assets. TRY participants who
saved, compared to control group savers, had
significantly higher savings. TRY participants
also shifted to more equitable gender attitudes.
Their RH knowledge was not significantly
higher, although the TRY participants had some-what
greater ability to refuse sex and insist on
condom use. At endline, TRY participants and
controls held similar views on five of the eight
issues, while TRY girls were significantly more
liberal on three issues: that wives should be able
to refuse sex, that marriage is not the best
option for an unschooled girl, and that it is not
necessary to have a husband in order to be
happy. A score was calculated using responses to
the gender attitude statements, with a maximum
possible score of eight. At baseline, the aggregate
gender score for controls was significantly
greater than the TRY girls. At endline, however,
TRY girls had marginally greater gender attitude
scores at the level of p<0.1, suggesting the proj-ect
may have had an impact on participants’
gender attitudes.
The intervention faced challenges in meet-ing
the diverse needs of different groups of ado-lescent
girls. A significant number of
participants, particularly younger adolescents,
dropped out of the program. The experience
from TRY suggests that rigorous micro-finance
models may be an appropriate intervention to
improve young girls’ economic opportunities
and reproductive health outcomes for older and
less vulnerable girls. For this subset of girls, the
model appeared to be effective in improving
girls’ status on a range of economic indicators.
New Visions116
Country: Egypt
Implementing organizations: CEDPA and 216 local
organizations
In a survey carried out by CEDPA, 36 percent
of young Egyptian males ages 12–20 could not
name one mode of transmission for HIV/AIDS.
According to a national survey, one out of three
married women have been abused, and more
than half of young boys thought a man was jus-tified
in beating his wife in certain circum-stances.
In response to this data, New Visions
was designed to encourage the development of
life skills and to increase gender sensitivity and
RH knowledge among boys and young men ages
12-20 in order to ultimately improve outcomes
for girls and women.
The New Visions course consisted of 64 ses-sions,
each 1 ½ to 2-hours long, over a six-month
period, facilitated by young college
graduates. The curriculum contained messages
related to gender equity, partnership with
women, responsibilities to self, family and com-munity,
and civil and human rights. Skills
development included anger management,
planning, negotiation, communication, and
decisionmaking. The evaluation compared pre-and
post-test responses of 1,477 New Visions
participants. Outcome measures consisted of
12 scales based on the subjects’ reported
knowledge, attitudes, and behaviors in: gender-equity
attitudes, gender roles attitudes, gender-based
violence attitudes, domestic violence
attitudes, female genital mutilation/cutting atti-tudes,
RH knowledge, HIV knowledge, male
roles and MCH/FP attitudes, substance-related
behavior, self-confidence, decisionmaking, and
environmental behaviors.
Results showed that exposure to the pro-gram
was a highly statistically significant pre-dictor
of better RH knowledge and attitudes
outcome scores. There were significant changes
in knowledge of a source of family planning and
knowledge about HIV. At endline, only 11 per-cent
of boys could not name one mode of HIV
transmission, compared with 36 percent at
baseline. Significant positive shifts were
recorded in attitudes toward male-female inter-action,
female genital mutilation, and gender-based
violence. Respondents’ views on shared
responsibility between men and women in fam-ily
decisionmaking, community service, politi-cal
participation, and household duties all
improved; participants were more likely than at
baseline to support equitable treatment for
boys and girls regarding attire, work, and age of
marriage. By engaging young men, who are
often the gatekeepers to improving young girls’
health, the intervention was successful in
improving RH and gender outcomes for both
girls and boys.
116 CEDPA, 2005.

Youth Case Study
Intervention:
Ishraq (“Enlightenment”)
Country: Egypt
Type of Intervention: Nonformal education
Implementing Organizations: Save the Children, Population Council, the Egyptian-NGO CARITAS, and CEDPA
Adolescent girls in Upper Egypt face many
barriers to leading healthy and productive
lives, including discrimination and social
isolation. Twenty-six percent of girls ages
13–19 in rural Upper Egypt have received
two years or less of schooling. Community
norms limit adolescent girls’ mobility and
decisionmaking. Girls do not have access to
safe meeting places outside the home and
remain closely supervised until a husband is
chosen for them. Early arranged marriages
often lead to early childbearing and succes-sive
pregnancies, perpetuating the cycle of
isolation, illiteracy, and poverty into the next
generation.
Objective
The Ishraq project aims to improve the life
opportunities of rural out-of-school girls,
13-15 years of age, in four villages in Minya
Governorate. The project’s objectives are to
improve literacy, recreational opportunities,
livelihood skills, health practices, and mobil-ity;
to influence policies and social norms
regarding girls’ life opportunities; and to
promote support for girls’ education.
Strategy
The three-year pilot initiative was carried out
from 2001 – 2004. Prior to implementing
the Ishraq intervention, the project identified
community stakeholders and the necessary
community structure in which to implement
the project. Women “promoters” or interme-diaries
were identified who would help the
girls gain access to public spaces. Village
committees were formed, composed of a
broad range of stakeholders, who helped to
support recruitment and program activities.
To recruit adolescent girls to the pro-gram,
Ishraq followed four strategies: word
of mouth, public announcements, parents’
meetings, and home visits by promoters.
The home visits played a critical role in
increasing parents’ understanding of and
comfort level with the program and, thus,
allowing their daughters to participate.
The Ishraq project consisted of four
main components:
1) Twice-weekly literacy classes for 24
months that utilized the Caritas Learn to be
Free curriculum as well as a core curriculum
of Arabic and mathematics. The course also
helped to prepare girls to sit for the national
education entrance exam;
2) CEDPA’s New Horizons life skills program
that presented reproductive health informa-tion
and basic life skills—girls attended two
90-minute sessions each week for 12
months;
3) A sports and physical activity curriculum
developed by Population Council to encour-age
fun in a safe environment, develop
social networks, and improve girls’ self-con-fidence.
This was implemented in two
phases, with the first introducing girls to
traditional games (three months) and the
second phase teaching table tennis and one
team sport (10 months). The girls attended
two 90-minute sessions each week;
4) A home skills and livelihoods training pro-gram
instructed girls on basic domestic skills
as well as a choice of vocational skills devel-opment,
including electrical appliance man-agement
and repair, hairdressing (the most
popular option), and sweets production.
Evaluation Design:
Quasi-experimental design
The evaluation compared the Ishraq partici-pants
with a matched control group of ado-lescent
girls.
A household census was used to iden-tify
eligible girls ages 13 to 15. A baseline
survey was administered using a structured,
individual questionnaire before the program
was implemented. A mid-point survey was
completed of girls who had joined the pro-gram
at a later date, and an endline survey
was completed of all baseline and midpoint
respondents. In total there were 587
respondents.
In addition, focus group discussions
and unstructured interviews were used to
monitor the changes taking place in girls,
the promoters, and families.
One clear impact was a decline in support
for FGM/C among girls who had participated
in the program for a year. Evaluation results
showed a significant decline (from 71% to
18%) in percent of Ishraq girls who intend
to circumcise their daughters in the future
compared with the control group. One per-cent
of program participants compared with
76 percent of nonparticipants said they
believed FGM/C was necessary. Girls who
lived in the intervention villages but did not
participate in the program showed a greater,
though statistically insignificant, decline in
support for FGM/C than the control village.
This suggests that knowledge and attitudes
may be shifting through peer networks.
Differences in attitudes toward violence
at endline were statistically significant: 64
percent of program participants compared

Mean Scores on the Gender Role Attitudes Index, Baseline and
Endline Surveys
10
8
6
4
2
to 93 percent of the control group believed
that a girl should be beaten if she disobeys
her brother.
The proportion of girls preferring to
marry before the age of 18 dropped sub-stantially
among all groups, intervention and
control. The longer the exposure to Ishraq,
the greater the decline in the proportion of
girls preferring marriage before age 18.
Paired comparisons did not show significant
results.
Gender Outcomes
The evaluation included questions on atti-tudes
toward gender roles. Results show
that respondents participating in the pro-gram
for more than one year developed
more gender-equitable attitudes.
Limitations
The final evaluation of the project was car-ried
out four months after its completion. A
long-term assessment may be more suc-cessful
in capturing the full impact of the
intervention, as girls reach important transi-tions
in their lives, including marriage and
childbearing, and become decisionmakers in
their households.
Conclusions
The Ishraq program integrated various
approaches to improve the health and well-being
of adolescent girls in rural Upper
Egypt. One key contribution of the interven-tion
study is to show how addressing harm-ful
gender norms, which often dictate how a
girl is to behave and the opportunities avail-able
to her, can lead to positive health and
gender outcomes. The findings indicate that
the project was successful in program areas
and among program participants in obtain-ing
space in which girls could safely meet,
increasing literacy, increasing support
among girls for later age at marriage and for
a say in choosing their husbands, reducing
support for FGM/C, and increasing feelings
of self-confidence. Through participation in
Ishraq activities, parents adopted increas-ingly
progressive views related to girls’
roles, rights, and capabilities.
References
Ishraq: Safe Places for Out-of -School
Adolescent Girls to Learn, Play and Grow.
Empowering Rural Girls in Egypt (Westport,
CT: Save the Children, 2004).
M. Brady, R. Assaad, B. Ibrahim, A. Salem,
R. Salem, and N. Zibani. Providing New
Opportunities to Adolescent Girls in Socially
Conservative Settings: The Ishraq Program
in Rural Upper Egypt. Full Report (New
York: Population Council, 2007).
0
Control
villages
(N=130)
None
(N=71)
12
months
(N=110)
13-29
months*
(N=50)
Full
participation*
Mean Score
Level of participation in Ishraq
Baseline
Endline
Figure 6.1
* Significant at p=0.001
Source: Brady et al., 2007.

Youth Case Study
Intervention:
First-time Parents
Country: India
Type of Intervention: Counseling, support, and peer groups
Implementing Organizations: Population Council in partnership with the Child in Need Institute of West Bengal and the
Deepak Charitable Trust in Gujarat
Recently married adolescent girls in India
face one of the most vulnerable periods of
their lives, including increased restrictions
on their mobility and decision-making capa-bilities
and social isolation. They are often
not empowered enough to make decisions
for themselves that will lead to positive out-comes.
These girls are also often under
pressure to conceive soon after marriage,
even though the risks of early childbearing
are well known. While these young married
girls are now sexually active, they are often
unable to negotiate sex with their husbands.
Objective
This project aimed to develop and test an
integrated package of health and social
interventions to improve young married
women's reproductive and sexual health
knowledge and practices, and to expand
their ability to act in their own interests.
Strategy
The intervention, carried out from January
2003 – December 2004, focused on young
women who were newly married, pregnant,
or first-time postpartum in Diamond
Harbour Block in West Bengal and Vadodara
Block in Gujarat. Husbands of these young
women, senior family members, and health
care providers were also included. The inter-vention
consisted of three components:
information provision; healthcare service
adjustments; and group formation.
Female and male outreach workers
provided RH information to 2,305 young
married women and 1,481 of their husbands
through home visits. Husbands were
reached by male outreach workers and by
participation in discussions in neighborhood
meetings. Senior family members were
reached in a more ad hoc manner when
opportunities arose.
Topics included prevention of repro-ductive
tract infections; contraception; sex
as a voluntary, safe, and pleasurable experi-ence;
planning for delivery of the first birth;
care during pregnancy and postpartum;
breastfeeding; ways for husbands to sup-port
wives during pregnancy, childbirth, and
the postpartum period; and the importance
of communication, respect, and joint deci-sionmaking
between husband and wife.
The project worked closely with health
care providers to educate them on the spe-cial
needs of young, newly married couples
and first-time parents. The project supplied
safe delivery kits and refresher-training
courses for traditional birth attendants and
provided transportation for couples to health
services.
The project also formed groups of 8-12
young women who met for 2-3 hours each
month. The meetings gave girls the oppor-tunity
to interact with peers and mentors,
exposing the young women to new ideas
and increasing their self-confidence to com-municate
and act in their own interests. The
girls identified topics to focus on, including
legal literacy, vocational skills, pregnancy
and postpartum care, gender dynamics
within and outside the family, relationship
issues, and nutrition.
Evaluation Design:
Quasi-experimental study design
Pre- and post-intervention surveys were
administered to young women in both the
intervention and control sites. In total, 2,862
and 4,555 women were interviewed at base-line
and endline, respectively. Data were col-lected
on topics such as young women's
agency and social networks, reproductive
health knowledge and practices, and partner
support and communication.
The intervention had significant, positive
effects on girls’ autonomy, RH knowledge
and practice, and couple relationships.
RH knowledge and practices improved
significantly among program participants in
both intervention sites. After controlling for
potentially confounding effects, young
women who were exposed to the interven-

tion in Diamond Harbour were significantly
more likely to have had comprehensive
antenatal check-ups. The intervention group
saw a 62 percent increase in those who
made delivery preparations, as opposed to
only a 40 percent increase in the control
group. In the experimental group, the pro-portion
that had a postpartum check-up
increased by 40 percent, while there was
only minimal increase in the proportion
seeking postpartum care among controls.
Women exposed to the intervention were
also significantly more likely to have breast-fed
their babies immediately after birth and
fed their babies colostrum when compared
to the control. In Vadodara, participation
had a significant, positive net effect on rou-tine
postpartum check-ups and use of con-traceptives
for delaying the first birth.
In both sites, young women who par-ticipated
in the intervention were more likely
to have discussed contraceptive use and
timing of first pregnancy with their hus-bands,
although the net effect was statisti-cally
significant only in Vadodara.
Gender Outcomes
The intervention had significant effects on
partner communication. Young married
women from both sites who participated in
the intervention had significantly greater say
in household decision-making than young
married women in control villages. They
were also more likely to discuss contracep-tive
use and timing of first pregnancy with
their husbands. Young women in Diamond
Harbour were more likely than women in the
control villages to express their opinion
when they disagreed with their husbands. In
some sites, young married women who
were exposed to the intervention had more
mobility and were more likely to adhere to
more equitable gender norm attitudes.
Limitations
The study faced numerous limitations to its
research design. First, there were a number
of differences between the intervention and
control villages (e.g. programmatic activities
and socio-demographic characteristics of
young married girls) that limit their compa-rability.
Comparison of background charac-teristics
also show that self-selection into
intervention activities did occur. Additionally,
many of the young women were lost at fol-low-
up due to their frequent movement
between natal and marital homes.
Conclusions
Young married girls face many gender barri-ers
that limit their capacity to act in ways
and make decisions that are in their own
interest. The First-time Parents project
sought to address these barriers by empow-ering
women with knowledge, reducing their
social isolation, and making healthcare ser-vices
more youth-friendly. The intervention
was successful in producing positive repro-ductive
health and gender outcomes, includ-ing
health practices and spousal
communication.
References
K.G. Santhya and N. Haberland,
Empowering Young Mothers in India:
Results of the First-time Parents Project
(New York: Population Council, 2007).
K.G. Santhya, N. Haberland, A. Das et al.,
Empowering Married Young Women and
Improving Their Sexual and Reproductive
Health: Effects of the First-time Parents
Project (New Delhi: Population Council,
2008).
Population Council, Meeting the Health and
Social Needs of Married Girls in India: The
First-time Parents’ Project’s Implementation
and Reach (New Delhi: Population Council,
2006).

In the past five years there has been a clear
increase in the evidence that integrating gen-der
does improve reproductive health out-comes.
Many of these programs also improve
gender outcomes. Thanks to early pioneers117
whose efforts articulated the links between gen-der
and development, donors have set gender
equality and gender mainstreaming as core
principles of their programming.118 Attention to
gender issues in development assistance has
been the policy of USAID since 1982.119 In
2007, the UN adopted a system-wide policy for
gender mainstreaming and that same year the
World Health Assembly adopted Resolution
WHO 60.25 for integrating gender analysis and
actions at all levels of health policies and pro-grams
in member states.120
The Programme of Action of the 1994
International Conference on Population and
Development (ICPD) called for a gender per-spective
to be “adopted in all processes of pol-icy
formulation and implementation and in the
delivery of services, especially in sexual and
reproductive health, including family plan-ning.”
121 Many of the strategies highlighted in
the ICPD Programme of Action are clearly evi-dent
in the programs described in this report.
Today, women and men are reaping the ben-efits
of gender-integrated programming and
stronger evaluations are measuring the effects.
This update of the 2004 “So What?” report
makes an important contribution to the growing
body of literature on gender-based approaches
to policy and programming. The evidence pre-sented
here suggests that incorporating gender
strategies contributes to reducing unintended
pregnancy, improving maternal health, reducing
HIV/AIDS and other STIs, eliminating harmful
practices, and meeting the needs of youth – all
broadly included under the term “reproductive
health.” As stated earlier, the interventions
reviewed here were of two broad types: those
that accommodate existing gender differences
and inequities to achieve RH goals; and those
that seek to transform gender norms and ame-liorate
gender inequities to overcome RH barri-ers.
Significantly, a majority of the interventions
in this review employ transformative approaches
and this must be counted as a big step forward.
Indeed, substantial progress has been made
and several of the recommendations made in
2004 can now be listed as achievements, notably:
1) Gender and Measures of Outcomes. There
has been progress in the last five years and this
review found several projects that do integrate
gender perspectives and promote gender equal-ity.
Moreover, gender equality and gender-equi-table
outcomes are measured more often than
they were five years ago. Many organizations
are funding and implementing innovative gen-der-
integrated programs, and some are also pri-oritizing
strong evaluations of gender-integrated
programs. For example, USAID has long sup-ported
operations research projects, which has
included evaluation of gender-integrated pro-gramming.
Operations research, along with
other program evaluations, has moved the field
forward in terms of documenting and measur-ing
what difference a gender perspective can
make in improving RH as well as gender equity
outcomes. The authors did find examples of
additional programs that seemed innovative but
were lacking in evaluation, thus the impact
they may be generating is not known and they
were not included in this review.
2) Added Value. While it is still difficult to iso-late
the effects of a gender-equitable project on
RH/HIV/AIDS, several of the projects reviewed
Conclusions
117 See 1948 Universal Declaration of Human Rights; see also
Overholt et al., 1985; Longwe, 1991; and Moser, 1993.
118 Pfannanschmidt et al., 1996; UN, 2002; WHO, 2002; Sida,
2005.
119 USAID, 1982.
120 See www.who.int/gender/mainstreaming/investing/en/
index3.html.
121 UN, 1999.
7

Conclusions 67
were quite convincing in demonstrating the
“added value” of a gender component. In these
projects, control or comparison groups represent
the basic RH services to which the gender com-ponent
was added. One could argue that much
of what was done in the intervention sites really
addressed quality of care as much as gender, but
the overlap between these two concepts at the
operational level should not be seen as invalidat-ing
the test of a gender-integrated intervention.
Similarly, Chapter 5 (Harmful Practices) docu-ments
reproductive health outcomes of inter-ventions
that involved gender as their central
theme—for example, interventions to stop
FGM/C. Again, because of the use of control
groups, the extent to which the adoption of a
gender perspective in program design contrib-uted
to positive gender outcomes is clear. A
number of interventions across the chapters,
and particularly those related to HIV/ AIDS and
youth, focused on changing gender norms
related to masculinity, behavior related to sex,
and health-seeking. The strong evaluation
designs used in most of these programs
strengthen the conclusion that adopting a gen-der-
transformative approach contributed to posi-tive
RH and gender outcomes.
3) Rigorous Evaluations. While there are many
ethical, logistical, and financial reasons that not
all evaluations can be randomized controlled tri-als
(RCTs)—the gold standard of evaluations—the
projects reported here demonstrate creativity and
innovation in the use of other rigorous evaluation
techniques. The development of approaches such
as the use of participatory learning methods with
youth or the efforts to involve men in maternity
care should not be jettisoned just because of the
difficulty of isolating the gender component in an
evaluation. Qualitative evaluations should not be
disregarded due to their inability to quantify
change; their conclusions lend powerful insight to
the processes of change.
4) Beyond HIV/AIDS. While gender concerns
have received more attention in HIV/AIDS/STI
prevention work due to the well-documented
link between inequitable gender relations and
the spread of HIV/AIDS and STIs, the role of
gender in the various other RH areas included
in this report is increasingly demonstrated.
Allowing for double-counting of interventions
that address multiple RH areas, 18 of the pro-grams
reviewed focus on improved outcomes
related to harmful practices; 16 addressed HIV/
AIDS and other STIs; 13 addressed unintended
pregnancy; 12 were directed at youth; and 7
addressed maternal health. Most of the pro-grams
related to youth also have objectives to
improve HIV/AIDS/STI outcomes. Clearly, the
importance of gender is being acknowledged
across many facets of RH and health.
One conclusion from the 2004 report
remains true: “Achieving a change in gender
relations is a long-term process that may not be
reflected in a relatively short-term interven-tion.”
122 The importance of long-term invest-ments
in transforming inequitable gender
norms that may compromise RH cannot be
over-emphasized. Such long-term investments
will facilitate dealing with the root causes of
inequity rather than only the symptoms of it.
Gender norms are learned and reinforced over
many years; undoing those norms takes time.
The need for evaluations to likewise measure
impact over longer spans of time persists.
New Findings
Many projects related to each RH issue (unin-tended
pregnancy, maternal health, etc.) sought
to change underlying beliefs and attitudes that
shape norms related to power dynamics between
women and men, including sexual dynamics.
These programs, working with men and women
of all ages, have had success in improving gen-der-
equitable views. Some programs have been
successful in changing behavior, most commonly
condom use, but also, in some cases, reducing
gender-based violence. Addressing gender norms
is time-intensive and requires examination of
both male and female norms.
All of the 40 programs reviewed here
achieved positive reproductive health out-comes,
though some were much more limited
than the implementers had hoped for, often
because the research designs were “contami-nated”.
As in the 2004 review, there is always
the possibility of reporting bias by participants,
but given the increased rigor of many of the
evaluations reviewed for the present report, the
authors believe this bias has been reduced.
As before, changes are more likely to be seen
in knowledge and attitudes than in reproductive 122 Boender et al., 2004: 65.

health behaviors. Some of the most common RH
outcomes measured include knowledge and use
of contraceptives (11 interventions each),
knowledge of HIV/AIDS transmission and pre-vention,
condom use, and use of HIV/AIDS and
pregnancy care services (see Table 1.3 on page
10). Thirty of the 40 interventions reviewed for
the present report measured gender impact; all
of these reported positive changes on a range of
gender outcomes. The most frequently mea-sured
gender outcomes were attitudes regarding
gender equity and women’s rights and partner
communication about FP and other RH issues
(nine and 11 evaluations, respectively; see Table
1.4). Most of the other gender outcomes that
were measured reflected various dimensions of
women’s empowerment; for example, self-confi-dence
or self-esteem, community participation
and social networks, mobility, decision-making
power, and practical skills. Three evaluations
used empowerment scales to measure impact on
gender outcomes.
Based on this review, the key findings from
this analysis of 40 projects with evaluation out-comes
are that:
n Gender-integrated strategies are stronger and
better evaluated than five years ago. The
analysis found that the strategies used to inte-grate
gender were grounded in deeper theo-retical
and practical knowledge of the effects
of gender on RH. The most promising strate-gies
for improving RH outcomes include those
that seek to directly confront harmful or ineq-uitable
gender norms (e.g. IMAGE, Program
H, Stepping Stones), increase community
awareness and dialogue around gender and
RH (e.g. Soul City, Through our Eyes, Somos
Diferentes Somos Iguales), or increase couple
communication (e.g. First-time Parents
Project). In the current analysis, the evalua-tion
methodologies were much more likely to
use experimental and quasi-experimental
designs. No evaluation in 2004 used random-ized
control trials; five evaluations herein
used this “gold standard” methodology.
Evaluating gender outcomes is necessary to
understanding further the mechanisms and the
degree to which intervention strategies affect
behavior and attitudes. Continued evaluation
rigor will further inform and enrich program
development and, ultimately, RH outcomes.
n Incorporating gender into a range of strate-gies
leads to a better understanding of RH
issues. Each chapter of this review focused
on the gender strategies used to address the
various RH issues. Looking at the programs
in each chapter as a whole, it is clear that
careful incorporation of gender into program
strategies leads to a better understanding of
the RH issue at hand. This is clear in HIV/
AIDS programming: inequitable gender rela-tions
in the ability to negotiate safe sex and
expectations of intimate relationships fuel
transmission of HIV. Strategies to meet the
needs of youth focus on establishing strong
foundations for young women and men to
grow into adulthood with good reproductive
health, and understanding the gender roles
that guide their behavior leads to more effec-tive
programs. Programs for youth work to
strengthen communication and negotiation
skills. Programs for young women also pro-vide
livelihood skills and establish communi-ty
networks for this group, especially
important because young women are often
isolated. Examining harmful practices, one
can see that they are clearly rooted in gen-der
roles, and that any effort to mitigate
these practices needs to encompass the
social constructions of gender that have
legitimated those practices over time.
If any areas seem to be lagging behind, they
would be the areas involving unintended
pregnancy and maternal mortality. The unin-tended
pregnancy interventions appeared to
incorporate gender in less ambitious and
accommodating ways compared to other RH
areas. In addition, fewer interventions were
found here than in the 2004 review of reduc-ing
unintended pregnancy. Maternal health
had the fewest number of evaluated interven-tions
of any of the RH topics. Nonetheless,
evidence exists that the healthy timing and
spacing of pregnancy can be improved by
incorporating gender in programs, with the
result of healthier mothers and families.
n Formative research is critical. As noted in
many of the interventions reviewed, forma-tive
research is critical for designing gender
interventions. Programs to integrate gender
benefit greatly from initial formative
research to determine specific social and
gender dynamics in project areas. This type

Conclusions 69
of groundwork can help determine which
groups should be included in specific inter-ventions.
Formative research can also help
ensure that the project is meeting local
needs and that it is being implemented with
an understanding of the local context.
n Programs that integrate gender can benefit
from working at multiple levels. The 40
projects reviewed include work with indi-viduals,
couples, families, community lead-ers,
providers, and policymakers, among
other groups. Many of the projects also link
individual-level interventions with commu-nity-
level interventions, such as mass media
or social marketing campaigns.
Gender-integrated components of reproduc-tive
health programming are often embedded
in participatory or community empowerment
initiatives. This theme is common in many
of the projects, including Through Our Eyes,
Stepping Stones, Program H, AYA, and moth-ers2mothers.
Some of these programs seek to
empower both women and communities. The
various programs have involved married
women, men, youth, parents, and communi-ty
leaders. Some programs worked not only
with the health sector, but also in the areas
of agriculture, education, and economic
development. Because changing norms is a
community process, projects will benefit
from careful consideration of the multiple
levels at which gender norms operate and
inclusion of a community involvement or
mobilization component.
n Projects that integrate gender need to
focus on costs, scale up, and identifying
policy and systemic changes required to
“mainstream” gender. Notably absent from
many of the projects reviewed here is ade-quate
attention to the costs of the projects
and the feasibility of scaling up the inter-ventions.
Given the time-intensive nature of
some of the interventions, particularly for
those that seek to examine and change per-sonal
views about gender norms, consider-ations
for scale up are critical. Moreover,
few of the projects included discussion
about national or sectoral policies that
might exacerbate gender inequality or, con-versely,
enhance gender equality.
Future Directions
This publication makes a critically important
contribution to the continuing quest for con-clusive
evidence that incorporating gender
components to programs improves RH out-comes.
While the reviewers might wish for
more conclusive data and more in-depth
descriptions of what makes a program gender
transformative, there can be no doubt that the
field has come a long way in the last five years.
Many challenges remain, not the least of
which is that more investment still needs to be
made in monitoring and evaluation if we are to
prove beyond a shadow of doubt that integrating
gender yields improvements in RH outcomes.
Donors should be encouraged to focus their fund-ing
efforts on gender integration interventions
and evaluations, and, in turn, to encourage imple-menting
organizations to measure gender impact.
Given the evidence presented here, we
recommend that development experts focus
particularly on:
n Scaling up and replicating the programs that
have been proven to work;
n Focusing on transformative approaches in
interventions, particularly in those that seek
to reduce unintended pregnancy;
n Undertaking cost-effectiveness research to
shed light on how to achieve these improve-ments
in RH in a manner that is affordable
and feasible for both donors and governments;
n Institutionalizing these achievements
through policy change; and
n Conducting sustainability analyses to learn
how long these changes last, and what fol-low-
up may be needed over time to ensure
that the positive impacts of interventions to
improve gender-equity are maintained and
passed on to future generations.
It is the fervent hope of the authors that
more program planners, policymakers, and
funders will insist on incorporating gender into
RH programs. The way forward, focusing on
well-evaluated projects that address policy, sys-tems,
and cost issues, scaling up gender inte-gration,
and addressing sustainability of
equitable gender relations over time, will make
important contributions to health and lives of
women, men, and families.

Appendix: Quick Reference Guide
The following tables summarize the objectives, strategies,
reproductive health outcomes, and gender outcomes of the
interventions included in this report. The tables, like this
report, are organized by RH issue area (unintended pregnancy,
maternal health, STIs/HIV/AIDS, harmful practices, and youth).
Table A.2 identifies interventions by evaluation methodologies.

Appendix: Table A.1 71
Table A.1
Program Name Organization Objectives Strategies RH Outcomes Gender Outcomes Cou ntries page number
Cultivating Men's
Interest in FP
Male Motivation
Campaign
PRACHAR I II
PROCOSI
Reproductive Health
Awareness
Project Concern
International, Institute
for Reproductive
Health (Georgetown
University)
Johns Hopkins
Bloomberg School of
Public Health CCP,
Guinean Ministry of
Health
Pathfinder
International, local
NGOs
PROCOSI, Population
Council
KAANIB Foundation
Increase men's
involvement in FP
decision-making and
practice
Increase access and
demand for health
care services; improve
quality of care;
improve coordination
among health care
providers and services
Improve the health
and welfare of young
mothers and their
children by changing
traditional customs of
early childbearing
Assess the impact and
cost of incorporating a
gender perspective in
reproductive health
service delivery
Improve men's
involvement in RH
matters
Integration of FP mes-sages
into water and
sanitation program
Community outreach
to religious leaders;
social mobilization
through advocacy and
multimedia interven-tions
Nonformal education;
parent and community
involvement; provision
of contraceptives
Institutionalize a gen-der
perspective in RH
service delivery
Education sessions on
RH and partner com-munication
Greater contraceptive
knowledge by women
and men; greater fer-tility
knowledge by
women and men
knowledge; greater
family planning use
Lengthened first birth
interval; improved
knowledge, attitudes
toward, and use of
contraception;
increased knowledge
of risks of early child-bearing;
fewer teenage
pregnancies
Increased client satis-faction
with providers
and care; decline in
unmet need for con-traceptives
Greater knowledge
of women's fertile
period; increased
knowledge and
practice of self breast
and testicular exams;
greater contraceptive
knowledge
Greater partner com-munication
regarding
family planning and
communication
Increased partner
communication about
family planning
None
Increased partner
communication about
FP and sexual rela-tions
Great partner
communication
around family
planning
El Salvador
Guinea
India
Bolivia
Philippines
14
13
16
20
15
Program Quick-Reference Guide

72
Table A.1
REWARD
Together for a Happy
Family
Women's
Empowerment Model
to Train Midwives
and Doctors
FEMME Project
Nepal Red Cross
Society, Centre for
Research on
Environment, Health
and Population
Activities, CEDPA
Jordanian National
Population Committee,
Johns Hopkins
Bloomberg School of
Public Health CCP
Family Health Alliance
CARE Peru, Peruvian
Ministry of Health
Strengthen women's
capabilities for
informed decision-making
to prevent
unintended pregnancy
and improve repro-ductive
health
Enlist men's support
in making informed
decisions with their
wives toward using
family planning
Address maternal
mortality in
Afghanistan by
preventing unwanted
pregnancies and
promoting birth
spacing through the
expansion of family
planning services
Improve access,
use, and quality of
emergency obstetric
care (EMOC) for
pregnant women
Expand access to and
delivery of quality,
gender-sensitive FP
and health informa-tion;
promote an
enabling environment
that strengthens wom-en's
informed RH
decision-making
National multimedia
campaign to involve
men in family
planning
Empowerment
strategies and training
of female health
providers
Multi-component
strategy to standardize
handling of cases and
encourage women's
right-based approach
to obstetric care
through organization
changes
Increased contracep-tive
prevalence rate;
increased registration
for ANC
use by men; greater
contraceptive knowl-edge
Greater provider
knowledge of family
planning and STI
detection and trans-mission;
improved
clinical skills
Increase in meeting
women's EMOC
needs; reduced
case-fatality rate
None
Increased spousal
communication about
FP reported by men
None
None
Nepal
Jordan
Afghanistan
Peru
17
14
18
23

Table A.1
Involving Men in
Maternity Care
(South Africa)
Men in Maternity
(India)
Social Mobilization or
Government Services
Integration of RH
Services for Men in
Health and Family
Welfare Centers
Involving Men
in Sexual and
Reproductive
Health
Reproductive Health
Research Unit (RHRU)
University of the
Witwatersrand,
KwaZulu Natal
Department of Health,
Population Council
Employee's
State Insurance
Corporation,
Population
Council
Foundation for
Research in Health
Systems, ICRW
NIPORT and
Directorate of Family
Planning, FRONTIERS/
Population Council
Association for the
Benefit of the
Ecuadorian Family
(APROFE)
Expand antenatal and
post-partum care pro-gram
to improve RH;
increase the use of
appropriate post-par-tum
family planning
Investigate the feasi-bility,
acceptability
and cost of a model of
maternity care that
encourages husbands’
participation in
antenatal and
postpartum care
Examine the effective-ness
and cost of
addressing 'supply'
versus 'demand' con-straints
to improve RH
for young married
women
Integrate male repro-ductive
health services
within the existing
government female-focused
health care
delivery system
Increase the number
of male clients seek-ing
and receiving RH/
STI services
Clinic-based: strength-en
existing antenatal
package and service
monitoring; train
health providers
Individual/couple/
group counseling, STI
screening, and syn-dromic
management
Social mobilization
through community-based
organizations;
strengthening govern-ment
services through
training for service
providers
Community outreach
and mobilization;
training for service
providers
Encourage female users
to involve male part-ners;
radio campaigns;
adjust clinic hours to
men’s schedules
Greater knowledge of
dual protection pro-vided
by condoms;
increased assistance
by men during an
emergency situation
knowledge for women
and men; greater FP
use; greater knowl-edge
of warnings
signs in pregnancy;
increase in screening
of pregnant women
for syphilis
Greater knowledge
of maternal health,
contraceptive side
effects, and abortion;
increased use of
services
Increased clinic visits
by men; increased
clinic visits by women
by men
Increased partner
communication on
STIs, sexual relations,
immunization, and
breastfeeding
Greater inter-spousal
communication
on baby's health;
increased joint
decisionmaking on
family health and FP
Improved community
support for young
women's health needs
None
None
South Africa
India
India
Bangladesh
Ecuador
25
24
27
36
37
Reducing HIV/AIDS and other STIs

Table A.1
Men as Partners
mothers2 mothers
Play Safe
Program H
Somos Diferentes,
Somos Iguales
Stepping Stones
EngenderHealth
mothers2mothers
Reproductive Health
Initiative for Youth in
Asia (EU/UNFPA)
Instituto Promundo
Puntos de Encuentro
Medical Research
Council
Increase information
and services to
improve men’s RH;
promote male engage-ment
to challenge
gender norms
Provide education and
psychosocial support
to HIV-positive preg-nant
women and new
mothers; help them to
access health care
services for PMTCT
and postpartum care
Promote healthy
behaviors about sex,
drug use, and gender
relations among mid-dle-
class male youth
Improve young men’s
attitudes toward gen-der
norms; reduce
HIV/STI risk
Empower young men
and women to prevent
HIV infection in
Nicaragua
Improve sexual health
by building stronger,
more gender-equitable
relationships with bet-ter
communication
between partners
Multiple macro- and
micro-level strategies
including workshops,
media, and advocacy
Peer education and
mentoring
Peer education and out-reach
(pilot project)
A validated curriculum
for group education;
lifestyle social market-ing
campaign
Mass media: Sexto
Sentido television series
Participatory learning
approaches in single-sex
peer groups
Improvement in
knowledge about RH;
improved attitudes
toward IPV and deci-sion-
making
Increased exclusive
breastfeeding; greater
knowledge of MTCT
transmission; greater
receipt and ingestion
of nevirapine; greater
CD4 testing; greater
contraception use
HIV/AIDS; reduction in
frequency of commer-cial
sex; greater con-dom
use; greater use
of reproductive health
services
Increased understand-ing
of association
between gender and
HIV/AIDS; reduced
STI symptoms
Greater knowledge
and use of RH servic-es;
greater knowledge
of HIV/AIDS transmis-sion
and prevention;
greater condom use
with partners
Lower STI symptoms;
greater condom use in
last 12 months; fewer
partners; lower per-petuation
of IPV/SV
Increased gender-equitable
attitudes
regarding women's
rights
Greater psychosocial
well-being
None
Increased support of
gender-equitable
norms; support for
gender-equity in GEM
Scale
Reduced stigmatizing
and gender-inequitable
attitudes; higher gen-der
index values;
increased self-efficacy
Improved partner
communication;
changes in attitudes
regarding acceptability
of IPV/SV
South Africa
South Africa
Cambodia
Brazil
Nicaragua
South Africa
33
36
34
42
32
40

Table A.1
Tuelimishane
Yaari Dosti
Behane Hewan
Building Life Skills to
Improve Adolescent
Girls’ RSH
Delaying Age at
Marriage in Rural
Maharashtra
Tuelimishane Project
Instituto Promundo,
CORO, Horizons/
Population Council
Ethiopian Ministry of
Youth and
Sport, Amhara
Regional Youth
Bureau, UNFPA,
Population Council
Swaasthya, ICRW
Institute of Health
Management Pachod,
ICRW
Reduce HIV risk
behaviors and vio-lence
by young men
through gender-focused,
community-based
interventions,
including drama and
peer support
Examine the effective-ness
of interventions
designed to improve
young men’s attitudes
toward gender norms
and to reduce HIV/STI
risk
Sensitize communities
to the risks and disad-vantages
of child mar-riage;
promote
education to prevent
early marriage
Improve the social
and health status of
adolescent girls; pro-mote
self-develop-ment
and increase
self-confidence and
self-esteem; delay age
at marriage
Increase girls’ self-esteem
and literacy;
delay age at marriage
Community theater and
peer support groups to
promote dialog on gen-der
and HIV
A validated curriculum
and lifestyle social mar-keting
campaign (an
adaptation of Program
H)
Harmful Practices
Social mobilization
of adolescent girls;
nonformal education
and livelihood programs
for out-of-school girls;
community dialogue on
early marriage; fiscal
incentives to families
A one-year life skills
training course; infor-mation,
education, and
communication cam-paign
A one-year life skills
training course; parent
and community
involvement
Positive shift in atti-tudes
toward violence
against women;
decreased HIV risk
behaviors; increased
use of condoms at
last sex with primary
partner
Increased understand-ing
of association
between gender
norms and HIV/AIDS;
increased condom use
with all partners;
reduction in self-reported
IPV
Increased knowledge
and communication
on HIV, STIs, and FP;
reduced likelihood that
younger adolescents
were married;
increased contracep-tive
use
Greater S/RH knowl-edge;
improved
menstrual hygiene
Increased age at
marriage; improved
S/RH knowledge
Positive changes in
attitudes toward
norms regarding gen-der
roles and IPV
Increased support of
gender-equitable
norms; improvements
in partner communi-cation
Increased school
attendance for girls
Improved perceived
self-determination
Improved cognitive
and practical skills;
increased willingness
to act autonomously
Tanzania
India
Ethiopia
India
India
38
33
45
45
52
early marriage and childbearing

Table A.1
Awash FGM/C
Elimination Project
Five Dimensional
Approach for the
Eradication of FGM/C
Navrongo FGM/C
Experiment
Tostan Community-based
Education
Program
IMAGE
CARE Ethiopia, local
NGOs, Population
Council
IntraHealth
International
Navrongo Health
Research Center
Tostan, GTZ,
Population Council
Small Enterprise
Foundation
Empower women for
greater participation
in community and to
discuss FGM/C with
partners
Increase knowledge
about FGM/C and
change behavior
Accelerate abandon-ment
of FGM/C in
the Kassena-Nanka
district of Northern
Ghana
Provide information to
support a strategy to
improve women's
health and abandon-ment
of FGC
Increase women’s
empowerment
through micro-lending,
gender
awareness, and HIV
training
BCC and educational
activities to break the
silence surrounding
FGM/C; meetings with
community groups;
performances
Improve women's
empowerment and initi-ate
community dialog
through the perspec-tives
of health, gender,
law/rights, religion, and
information
Community involve-ment,
FGM/C education,
livelihood and develop-ment
activities for
young girls
Basic education pro-gram
including hygiene,
problem solving, wom-en's
health, and human
rights
Micro-finance through
women’s groups and
gender-focused training
Increased knowledge
regarding conse-quences
of FGM/C;
greater contraceptive
knowledge; greater
family planning use
Change in attitudes
regarding FGM/C;
increased community
action against FGM/C
Decreased FGM/C
incidence
Improved knowledge
of contraception, STIs,
prenatal care, and
violence; decreased
incidence of violence;
greater awareness of
FGC consequences;
decreased FGC
incidence
Decreased IPV/SV;
more progressive
attitudes toward IPV/
SV; decreased control-ling
behavior by
intimate partner
Spousal communica-tion
regarding family
planning; increased
public discussion of
FGM/C
Teachers, media, and
religious leaders made
public declarations
against FGM/C
None
Improved attitudes
toward girls' school-ing;
improved atti-tudes
toward role of
women's unions to
demand rights
Increased score on
women's empower-ment
scale; increased
progressive attitudes
toward gender norms
Ethiopia, Kenya,
Sudan
Ethiopia
Ghana
Senegal
South Africa
47
48
46
54
56
Female Genital Mutilation/Cutting
Gender-based Violence

Table A.1
One Man Can
Campaign
Soul City
Through Our Eyes
African Youth
Alliance Program
First-time Parents
Project
Sonke Gender Justice
Soul City Institute for
Health Development
Communication,
National Network on
Violence Against
Women
American Refugee
Committee,
Communication
for Change
UNFPA, PATH,
Pathfinder
International
Child in Need Institute,
Deepak Charitable
Trust, Population
Council
Male involvement to
take action against
domestic and sexual
violence
Address gender
norms at the commu-nity
and individual
levels through
‘edutainment’
Provide participants
with a safe environ-ment
to share experi-ences,
develop new
ideas, and address
gender-based violence
in their communities
Improve adolescent
sexual and reproductive
health and to prevent
transmission of HIV/
AIDS
Develop an integrated
package of health and
social interventions to
improve married young
women's S/RH knowl-edge/
practices, and
self-determination
BCC campaign and
Action Kit to promote
the idea that all men
have a role to play in
ending violence against
women
Multi-media health pro-motion
campaign using
TV and radio broadcasts
incorporating social
issues into entertain-ment
formats
Participatory communi-ty
engagement with
video and community
playback sessions
Implementation
and scaling up a
comprehensive set
of integrated ASRH
interventions using
existing institutions
Educational home vis-its;
counseling ses-sions;
girls' group
formation; training for
health care providers
HIV/AIDS transmis-sion
and prevention;
decrease in men's
beliefs that violence
against women is jus-tified
in some circum-stances
Increased knowledge
of IPV/SV resources;
decreased beliefs that
men are justified in
beating their partners;
increased number of
respondents taking
action to stop IPV/SV
Increased uptake of
reproductive health
services; increased
capacity to make
healthy decisions to
mitigate consequences
of risky sexual behavior
Increased HIV/AIDS
knowledge; increased
confidence in
negotiating condom
use; increased delay
of sexual debut;
increased contracep-tive
use
for maternal health;
greater family plan-ning
use; improved
partner communica-tion
More gender-equitable
beliefs in
sex decision-making
Women's increased
awareness of self-worth
and identity
Improved gender
relations; women
more articulate in
discussing IPV/SV
and RH
None
Increased mobility,
social networks devel-oped;
increased part-ner
support and
communication
South Africa
South Africa
Liberia
Ghana, Tanzania,
Uganda
India
50
49
50
59
64

Guria Adolescent
Health Project
Ishraq
New Visions
Transitions to
Adulthood -
Livelihoods Training
Transitions to
Adulthood - Tap
Reposition Youth
CARE International
Caritas, Save the
Children, Population
Council, CEDPA
CEDPA, local NGOs
CARE India,
Population Council
K-Rep Development
Agency, Population
Council
Achieve improvements
in reproductive health
through improving life
skills of adolescents;
provide youth-friendly
information and ser-vices;
raise communi-ty
awareness
Improve the life
opportunities of rural
out-of-school girls by
improving literacy and
education, livelihoods,
health knowledge, and
social policies
Develop life skills
and increase gender
sensitivity and RH
knowledge among
boys and young men
in order to improve
outcomes for girls and
women
Deliver technical skills
and transform the way
girls view themselves
Improve livelihood
options; reduce
unplanned pregnan-cies;
decrease vulner-ability
to STIs, HIV,
and unsafe abortion
Health education and
social marketing; the-ater;
micro-grants;
youth-friendly services
Nonformal educational
sessions; female cham-pions;
sports and physi-cal
activity; home skills/
livelihoods training
A series of 64 nonfor-mal
educational ses-sions
facilitated by peer
leaders
Group education;
vocational training;
financial counseling;
peer mentors
Financial empowerment
through microcredit,
combined with a focus
on gender attitudes
knowledge; greater
family planning use
Decline in acceptance
of early marriage;
decline in girls' favor-able
attitudes toward
FGM/C; improved atti-tudes
toward violence
Increased positive
responses about IPV/
SV and FGC; greater
knowledge of family
planning sources;
greater knowledge of
HIV/AIDS transmis-sion
Greater RH knowledge
Greater ability to
negotiate condom use
with partner; greater
ability to refuse sex
Decreased tolerance
for kidnapping
Increased levels
of self-confidence;
improved gender
attitudes
Increased gender-equitable
beliefs about
gender roles and equi-table
treatment
Greater social skills;
increased group
membership
Increased liberal
gender attitudes;
increased income and
household assets
Georgia
Egypt
Egypt
India
Kenya
59
62
61
60
60
Table A.1

Table A.2
Evaluation Methodologies, by Category and Program Name
Type of evaluation methodology # Main (and sub categories) Program name (and country)
Experimental Design (Randomized control 5 HP/IPV/SV (UP, HIV/AIDS/STI) IMAGE (South Africa)
trial, 2x2 or 4 cell) MH (Youth) Involving Men in Maternity Care (South Africa)
HP/FGM/C (Youth) Navrongo FGM/C Experiment (Ghana)
MH (UP, Youth) Social Mobilization or Government Services (India)
HIV/AIDS/STI Stepping Stones (South Africa)
Quasi –Experimental Designs, Including: 17 HP/FGM/C (Youth) Awash FGM/C (Ethiopia, Sudan, Kenya)
• Pretest-posttest, cluster sample HP/EM (Youth) Behane Hewan (Ethiopia)
• Pretest-posttest, control group design UP (MH) Cultivating Men’s Interest in FP (El Salvador)
• Non-equivalent control group HP/EM (Youth) Delaying Age at Marriage in Rural Maharashtra (India)
• Quasi-experimental control group MH FEMME Project (Peru)
• Case-control group Youth (UP, MH) First Time Parents (India)
HIV/AIDS/STI (MH) Integration of RH Services for Men in Health and Family
Welfare Centers (Bangladesh)
Youth (HP/EM) Ishraq (Egypt)
MH (UP) Men in Maternity (India)
HIV/AIDS/STI (MH) mothers2mothers (South Africa)
UP (HP/EM, MH) PRACHAR I II (India)
HIV/AIDS/STI Program H (Brazil)
HIV/AIDS/STI Somos Diferentes, Somos Iguales (Nicaragua)
HP/FGM/C (UP, MH) Tostan Community Empowerment Program
(Senegal, Burkina Faso)
Youth (UP, HIV/AIDS/STI) Transition to Adulthood – Tap and Reposition Youth (Kenya)
HIV/AIDS/STI (HP/GBV) Tuelimishane (Tanzania)
UP (MH) Reproductive Health Awareness (Philippines)
Non-Experimental Study Design 15 Youth (HIV/AIDS/STI) Africa Youth Alliance (Ghana, Tanzania, Uganda)
HP/EM (Youth) Building Life Skills to Improve Adolescent Girls’ Reproductive
and Sexual Health (India)
Youth (UP) Guria Adolescent Health Project (Georgia)
HIV/AIDS/STI Involving Men in Sexual and Reproductive Health (Ecuador)
UP Male Motivation Campaign (Guinea)
HIV/AIDS/STI (HP/GBV) Men as Partners (South Africa)
Youth (HIV/AIDS/STI, HP/GBV) New Visions (Egypt)
HP/GBV (HIV/AIDS/STI) One Man Can Campaign (South Africa)
UP PROCOSI (Bolivia)
UP (MH) REWARD (Nepal)
HP/GBV Soul City (South Africa)
UP Together for a Happy Family (Jordan)
Youth Transitions to Adulthood – Livelihoods Training (India)
UP (MH) Women’s Empowerment Model to Train for Midwives and
Doctors (Afghanistan)
HIV/AIDS/STI (HP/GBV) Yaari Dosti (India)
Qualitative 3 HP/FGM/C Five Dimensional Approach for the Eradication of FGM/C
(Ethiopia)
HIV/AIDS/STI (HP/GBV, Youth) Play Safe (Cambodia)
HP/GBV Through Our Eyes (Liberia)

Table A.3
Selected Reproductive Health Outcomes of Interventions Highlighted in this Report
Outcomes Related To: Page Number
Healthy Timing, Spacing, and Limiting of Pregnancies
Greater contraceptive knowledge
Awash FGM/C 47
Behane Hewan 45
Tostan Community Empowerment Program 54
Guria Adolescent Health Project 59
Involving Men in Maternity Care (South Africa) 25
Male Motivation Campaign 13
Men in Maternity (India) 24
Reproductive Health Awareness 15
Social Mobilization or Government Services 27
Together for a Happy Family 14
Greater contraceptive use
African Youth Alliance Program 59
Awash FGM/C 47
Behane Hewan 45
First-time Parents Project 64
Guria Adolescent Project 59
mothers2mothers 36
PRACHAR I II 16
REWARD 17
Greater awareness of fertility
Maternal Mortality and Safe Motherhood
Increase in use of skilled pregnancy care
REWARD 17
Increase in joint decision-making with partner about contraception
Men as Partners 33
Reduced case fatality rate
FEMME Project 23
Increase in client satisfaction with providers and care
PROCOSI 20
Decline in unmet need for contraceptives
PROCOSI 20
Increase in screening of pregnant women for Syphilis
Increase in women’s emergency obstetric care needs being met
FEMME Project 23
Greater knowledge of warnings signs in pregnancy
Improved provider clinical skills knowledge of FP methods STI care
Women’s Empowerment Model to Train Midwives and Doctors 18
Increase in awareness of prenatal care
Tostan Community-based Education Program 54

Table A.3
HIV/AIDS and Other STIs
Greater knowledge of HIV/AIDS transmission and prevention
Behane Hewan 45
Men as Partners 33
New Visions 61
One Man Can 50
Play Safe 34
Somos Diferentes, Somos Iguales 32
Greater condom use:
At last sex:
Program H 42
Tuelimishane 38
Yaari Dosti 33
With primary partner:
Play Safe 34
Stepping Stones 40
Yaari Dosti 33
Increase in visits to centers that provide HIV/AIDS and STI services
Integration of RH Services for Men in Health and Family Welfare Centers 36
Involving Men in Sexual and Reproductive Health 37
Play Safe 34
Lower reported STI symptoms
Program H 42
Stepping Stones 40
Greater knowledge of STI symptoms
Increased exclusive breastfeeding
mothers2mothers 36
Greater receipt ingestion of Nevirapine
mothers2mothers 36
Greater CD4 testing
mothers2mothers 36
Harmful Practices (early marriage, intimate partner violence, female genital mutilation/cutting)
Decrease in belief that IPV/SV is justified under some circumstances
One Man Can Campaign 50
Soul City 49
Stepping Stones 40
Greater knowledge of IPV/SV resources
Soul City 49
Decrease in incidence of violence
Stepping Stones 40
Yaari Dosti 33
Increased community action and protest against harmful practices
Five Dimensional Approach for the Eradication of FGM/C 48
Soul City 49

Table A.3
Attitudes toward IPV/SV
IMAGE 56
Men as Partners 33
New Visions 61
Tuelimishane 38
Decrease in risk of IPV/SV
IMAGE 56
Decrease in controlling behavior by intimate partner
IMAGE 56
Increased uptake of RH services
Through Our Eyes 50
Greater knowledge of harmful consequences of FGM/C and advantages of not cutting girls
Awash FGM/C 47
Ishraq 62
Attitudes toward FGM/C
Five Dimensional Approach for the Eradication of FGM/C in Ethiopia 48
New Visions 61
Increase in number of men who marry uncircumcised girls
Five Dimensional Approach for the Eradication of FGM/C in Ethiopia 48
Decrease in FGM/C incidence
Navrongo FGM/C Experiment 46
Increase in age at marriage
Delaying Age at Marriage in Rural Maharashtra 52
Increase in interval between marriage and first birth
PRACHAR I II 16
Greater knowledge of risks of early childbearing
PRACHAR I II 16
Fewer adolescent pregnancies
PRACHAR I II 16
Fewer adolescent marriages
Behane Hewan 45
Youth Reproductive Health
Greater sexual and reproductive health knowledge
Building Life Skills to Improve Adolescent Girls’ RSH 45
Transitions to Adulthood - Livelihoods Training 60
Increase in decision-making ability related to:
Condom use:
Transitions to Adulthood - Tap and Reposition Youth 60
Sex:
Transitions to Adulthood - Tap and Reposition Youth 60
Increase in age at sexual debut

Table A.4
Selected Gender Outcomes of Interventions Highlighted in this Report
Increased gender-equitable attitudes and beliefs
IMAGE 56
Men as Partners 33
New Visions 61
One Man Can Campaign 50
Program H 42
Tap and Reposition Youth 60
Tuelimishane 38
Yaari Dosti 33
Increased partner communication about reproductive health or family planning
Awash FGM/C 47
Involving Men in Maternity Care (South Africa) 25
PROCOSI 20
Stepping Stones 40
Yaari Dosti 33
Women's increased self-confidence, self-esteem, or self-determination
Building Life Skills to Improve Adolescent Girls’ RSH 45
Ishraq 62
mothers2mothers 36
Soul City 49
Women's increased participation in the community and development of social networks
Behane Hewan 45
Increased support (emotional, instrumental, family planning, or general support) from partners or community
Higher scores on an empowerment scale for women
IMAGE 56
Ishraq 62
Increased life and social skills
Women's increased decision-making power
Through Our Eyes 50
Higher formal educational participation for women or girls
Behane Hewan 45
Women's increased mobility
Improved gender relations within the community
Through Our Eyes 50
Women more articulate in discussing IPV/SV and RH
Through Our Eyes 50
Decreased tolerance for kidnapping of girls
Guria Adolescent Health Project 59

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Glossary
4-Cell Design. Study designs that involve four treatment arms are called factorial designs, 4-cell designs, or
2x2 designs. These designs aims to test two different interventions (each alone and combined) against a con-trol,
which receives no intervention. The following diagram illustrates this study design for two interventions
Glossary 93
(A and B):
Group 1 A B A only Group 2
Group 3 B only Control (Neither A or B) Group 4
Antiretroviral Therapy (ART). Antiretroviral drugs are medications for the treatment of infection by HIV. Different
classes of antiretroviral drugs act at different stages of the HIV life cycle. These drugs are also known as ARVs.
In people who have been infected with HIV, ART can lengthen and improve their quality of life.
Baseline. Baseline refers to the period prior to (or at the introduction of) an intervention. Data is gathered at
this point to compare with performance after the intervention to determine what change has taken place.
Chi Square Test. A statistical test that measures whether the distribution of observed data systematically differs
from what we would expect if the data were distributed evenly, with no difference between the comparison
groups.
Cluster Randomized Control Trial. In this type of RCT, clusters, such as communities, hospitals, or other groups
of people, are randomized, and all consenting persons in the group are enrolled.
Community-Based Survey. A survey where the participants are selected from a pre-defined community.
Community-based research often involves more interaction with the community, such as the use of peers or
members of the community to recruit or conduct the survey, or community input into the research questions
and design of the survey.
Contamination. Contamination occurs when there is communication about the intervention between groups of
participants (usually treatment and control). This can lead to a diffusion of treatment, because, consciously or
subconsciously, the control group receives part or all of the intervention. Contamination can also occur if the
intervention is not fully implemented.
Control Group. When an intervention is randomly assigned in an experimental study design, the control group
does not receive the intervention. The control group is supposed to be comparable to the intervention group,
which receives the intervention. If entire groups or communities are randomly assigned, it is referred to as a
‘control area’.
Correlated Data. When data are correlated, there is a relationship between two or more sources of data. This
means that they tend to vary, be associated, or occur together in a way not expected on the basis of chance
alone. For example, if a group of participants in a study respond in a predictable manner, there is a correla-tion
among that group. This is often the case among participants who are selected through one health facility.
Cost Effectiveness Analysis. This form of analysis seeks to determine the costs and effectiveness of surveillance
and response strategies and activities. It can be used to compare similar or alternative strategies and activities
to determine the relative degree to which they will obtain the desired objectives or outcomes. The preferred
strategy or action is one that has the least cost to produce a given level of effectiveness, or provides the great-est
effectiveness for a given level of cost.

Cox Proportional Hazard. This is a form of statistical analysis. It is a survival analysis measuring the proportional
difference in the length of time to an event between two populations.
Endline. Endline refers to the period after an intervention is completed. Data gathered at this point is usually
compared with performance before the intervention to determine what change has taken place.
Equality. Gender equality is equal treatment of women and men in laws and policies and equal access to
resources and services within families, communities, and society at large.
Equity. Gender equity connotes fairness and justice in the distribution of opportunities, responsibilities, and
benefits available to men and women, and the strategies and processes used to achieve gender equality. Equity
is the means, equality is the result.
Evaluation. The use of social science research procedures to systematically investigate the effectiveness of
social intervention programs that are designed to improve social conditions.
Experimental. Experimental studies control the allocation of treatment (intervention) to subjects (participants).
The distinguishing feature of experimental studies in evaluation is randomization. In evaluation research, par-ticipants
or groups are randomly assigned to either an intervention group or a control group. Randomly
assigning the groups helps ensure that the intervention and control groups are comparable to each other so
that any differences at endline can be attributed to the intervention.
Female Genital Mutilation/Cutting. Often referred to as a harmful traditional practice, this involves the cutting or
alteration of the female genitalia for social rather than medical reasons.
Focus Group Discussion. Focus groups are a form of qualitative data collection. Focus groups usually consist of
8-10 people who are similar in background. They may be randomly or purposively selected to participate.
Conversation is guided by a facilitator. Focus groups tend to weed out extreme or false views, and uncover
underlying group norms.
Follow-up. This is often used interchangeably with the term endline. In some cases, however, follow-up refers
to data collection that occurs some period of time after endline. In these cases, endline is the data collection
point at the end of the intervention, and follow-up occurs later to see what changes are sustained over time
without the intervention.
Formative Research. Formative research takes place before or during the design of the intervention itself. The
results of formative research guide the design of the program to make it most effective and acceptable to the
target population. Formative research is often done as a needs assessment, pretesting to ensure the interven-tion
can be implemented, or collection of qualitative data such as focus groups.
Gender. This term refers to the socially constructed roles, behaviors, activities, and attributes that a given soci-ety
considers appropriate for men and women.
Gender-based Violence. A term used to distinguish violence that targets individuals or groups of indiciduals on
the basis of their gender from other forms of violence; may result in physical sexual or psychological harm.
Terms such as Intimate Partner Violence, Sexual Violence, and Domestic Violence are used to describe gen-der-
based violence in its various forms.
Gender Norms. Societal messages that dictate what is appropriate or expected behavior for males and females.
Highly Active Antiretroviral Therapy (HAART). A combination of several (usually three or four) antiretroviral drugs
is known as Highly Active Antiretroviral Therapy. HAART is often more effective than using one antiretroviral
drug alone. See antiretroviral therapy.
Incidence. The rate of new cases of a disease or event in a population. While prevalence is the measure of all
cases at one point in time, incidence measures the number of new cases during a time period.
Intrapartum. Occurring during or pertaining to labour and/or delivery.
Matched Control. When randomization is not possible, individual cases may be matched with individual con-trols
that have similar characteristics, such as age. By carefully selecting matches for the intervention cases or
groups, the intervention and comparison groups should be similar.

Maternal Morbidity. This refers to a diseased state, illness, or departure from health as a result of pregnancy,
termination of pregnancy, labour and delivery, or from any cause related to or aggravated by the pregnancy or
its management.
Maternal Mortality. A maternal death is the death of a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggra-vated
by the pregnancy or its management but not from accidental causes. The Maternal Mortality Ratio is
Glossary 95
the number of maternal deaths out of 100,000 live births in a given year.
Monitoring Data. Data that come from the regular observation, surveillance, or checking of changes in a condi-tion
or situation, or changes in activities. Health facilities often use systematic collection of data on specified
indicators to provide management with indications of the extent of progress and achievement of objectives.
Non-Equivalent Control Group. In quasi-experimental study designs, in which treatment and comparison groups
are not randomly assigned, the group that does not receive the intervention is called a non-equivalent control
group. The term ‘comparison group’ is also used.
Non-Experimental. Non-experimental study designs do not involve randomization or comparison groups. These
designs are not able to determine the effect or impact of an intervention, but may be helpful to determine rea-sons
why a problem exists or why a program was successful. Non-experimental evaluation designs include
post-test only, pretest-posttest without comparison groups, observational studies, or studies using only qualita-tive
data.
Pilot Project. Pilot projects, similar to formative research, are designed to inform about the success of an inter-vention
prior to launching a full-scale intervention. Pilot projects are usually a shorter version of the interven-tion
or include a smaller population. Pilots can help to inform whether the population understands, responds,
or uses the intervention in the anticipated manner. The results of a pilot study are used to refine the interven-tion
before the full-scale program.
Postpartum. Of, occurring, or referring to the period after childbirth.
Prenatal. Occurring or existing before birth, or preceding birth. It refers to both the care of the woman during
pregnancy and the growth and development of the fetus. It is also known as antenatal.
Pretest-Posttest. This is a study design in which both the experimental (intervention) and control groups
receive an initial measurement observation (known as baseline or pretest). The experimental group then
receives the intervention, but the control group does not. After the intervention, a second set of measurement
observations is made (known as endline or posttest).
Prevalence. The amount of a given disease in a population at a certain time. Prevalence is the measure of all
cases at a point in time, while incidence is the measure of new cases during a time period.
Process Variable. An indicator or measurement that is used as part of an evaluation to gauge the implementa-tion
or monitor the intervention or program. The variable focuses on the process of the intervention, which is
the set of activities conducted to achieve the results. Process variables often focus on the quality, access, or
reach of a program.
Qualitative Data. Qualitative data include virtually any type of information that cannot be captured in a numer-ical
format. In social research, it most often refers to open-ended, in-depth interviews with individuals or
focus group discussions, but can also include observations or the results of activities such as word associations
or free listing. Qualitative data cannot be quantified, but lend insight to processes, feelings, and experiences.
Quantitative Data. Data that are collected in a numerical, quantifiable way. Statistical methods of analysis can
be applied. Quantitative data can be measurements, counts, ratings, scores, or classifications to which numer-ical
values can be applied.
Quasi-Experimental. In many field research situations, it is simply not possible or feasible to meet the random
assignment criteria of a true experimental study design. Quasi-experimental studies do not meet the random-ization
criteria, but are strong study designs that help the researchers to control some of the outside influ-ences
that could interfere with the quality or accuracy of the data. Examples of quasi-experimental designs
include time series studies, pretest-posttest with non-equivalent control groups, and separate sample pretest-posttest.

Randomized Control Trial. A randomized controlled trial (RCT) is a planned experiment designed to asses the
efficacy of an intervention in human beings by comparing the intervention to a control condition. The alloca-tion
to intervention or control is determined purely by chance through randomization. An RCT is the gold
standard for determining causality in research.
Regression Analysis. Regression analysis is a statistical method for describing a “response” or “outcome” vari-able
as a simple function of “explanatory” or “predictor” variables. In a simple linear regression, one predic-tor
variable is used to predict a response. In multiple linear regression, two or more predictor variables are
used to predict the response. This allows for control of additional background characteristics. Logistic regres-sion
analysis is used when the outcome is a binary or dichotomous variable. Logistic regression can be simple,
using one predictor, or multiple, using two or more predictors.
Sample Size. Number of clusters/households/individuals that a survey sets out to include, i.e. interview. The
aim of sample size calculation is to have a large enough sample in each group to estimate a population mean
or difference in means (or proportions) within a narrow interval. Statistical calculations can determine how
large a study sample needs to be in order to have confidence in the results of the statistical analysis.
Sex. Refers to the biological and physiological characteristics that define men and women.
Statistically Significant. A result that tells us only that any observed difference between groups is unlikely to be
due to chance. Statistical significance is usually measured at the 0.05 level, which means the observed differ-ence
would occur by chance less than five percent of the time.
Student’s T Test. This is a statistical hypothesis test that is used when the distribution of values in a population
is assumed to be a normal distribution (bell curve) but the standard deviation is unknown. The Student’s T
Test is a simple statistical tool that is frequently used to compare a mean (average) measure between two pop-ulations.
Syndromic Management. This is one of several biomedical approaches to the treatment of sexually transmitted
infections, or STIs. In syndromic management, a clinician (such as a nurse) bases treatment not on clinical
tests for disease, but on the symptoms or effects that the individual is experiencing. Treatment is then offered
for all diseases that could cause that symptom, or syndrome. In treating STIs, this enables clinicians to offer
treatment faster than waiting for test results or in locations where clinical testing is unavailable.
Transactional Sex. Sexual behavior that results in women or men receiving money or goods in exchange for sex;
usually differentiated from commercial sex or prostitution.
Triangulation. Using two or more methods or sources of data to investigate something. It is preferable that the
methods and sources have different strengths and weaknesses so that the strengths of one can help counter-balance
the weaknesses of the others.
Validity. The degree to which a measurement or finding actually measures or detects what it is supposed to
measure. Validity refers to the accuracy or truthfulness of a study’s conclusions.

The Interagency Gender Working Group (IGWG),
established in 1997, is a network comprising non-governmental
organizations
(NGOs), the United States Agency for International
Development (USAID), cooperating agencies (CAs), and the USAID
Bureau for Global Health (GH). The IGWG promotes gender equity with
population, health, and nutrition (PHN) programs with the goal of
improving reproductive health/HIV/AIDS outcomes and fostering
sustainable
development. For more information, go to www. igwg.org.
For additional copies contact:
Population Reference Bureau
1875 Connecticut Ave., NW, Suite 520
Washington, DC 20009-5728
www.prb.org
phone: (202) 483-1100
email: prborders@prb.org

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