Joan Marie Kraft
Karin Gwinn Wilkins
Guiliana J. Morales
Monique Widyono
Susan E. Middlestadt
Publication Date
September 10, 2014

Centers for Disease Control and Prevention (Kraft), University of Texas at Austin (Wilkins), Gillings School of Global Public Health, University of North Carolina at Chapel Hill (Morales), Bureau for Global Health , U. S. Agency for International Development (Widyono), Indiana University School of Public Health (Middlestadt)

This article provides a framework for understanding gender-integrated interventions and explores the extent to which these interventions address and change gender dynamics (e.g., gender norms, gender inequalities), as well as promote behaviours relevant to child survival and development in low- and middle-income countries. It was written through work of an evidence review team (ERT) to address the goals of the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change, which was held in Washington, DC, United States (US), June 3-4 2013. The Summit was hosted by the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF) and the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the U.S. Centers for Disease Control and Prevention, The Communication Initiative, and the American Psychological Association. The summary below is part of a special issue of the Journal of Health Communication that is a product of the Evidence Summit.

Based on the Interagency Gender Working Group’s Gender Equality Continuum (2013), the ERT identified gender-integrated interventions that were gender accommodating (compensate for gender dynamics) or transformative (change gender dynamics).  The ERT’s conceptual model, "Gender-integrated interventions to improve child health" (figure 2), shows the movement from: 1) gender-integrated interventions, such as counselling for men and women, couples communication and decision-making interventions, and women's economic empowerment; to 2) gender dynamic outcomes, such as increased school attendance by girls, reduced son preference, and norms opposing gender based violence (GBV); to 3) behavioural outcomes, such as increased age of marriage and first childbirth, increased use of family planning (FP), and exclusive breastfeeding - all moving towards improved child health.

Using that conceptual model and focusing on gender accommodating and gender transformative interventions, the search and eligibility criteria applied to studies yielded 23 eligible intervention studies (some with multiple reports).  Intervention studies were eligible if: “an intervention: addressed gender dynamics (i.e., norms, unequal access to resources), measured relevant behavioral outcomes (e.g., family planning, antenatal care, nutrition), used at least a moderate evaluation design, and were implemented in low- or middle-income countries). Of those, 22 addressed reproductive and maternal-child health behaviors (e.g., birth spacing, antenatal care, breastfeeding) that improve child health. Eight interventions were accommodating (i.e., acknowledged, but did not seek to change gender dynamics), and 15 were transformative (i.e., sought to change gender dynamics)."  The summary and synthesis of findings divided interventions into two main groups:  accommodating and transformative, and further sub-divided interventions on the basis of health behaviors (family planning and maternal and child health) and population (adolescents, adult women, adult men or couples, and broader community).

The results showed that many of the interventions, including accommodating and transformative interventions, had null or mixed effects. This was particularly true for interventions that engage men (or couples) in support of family planning use or maternal and child health.  For example, where a study evaluated a breastfeeding intervention, which provided education and counseling (in-person and video), and encouraged men to help their wives with chores during the breastfeeding period, there was more exclusive breastfeeding, relative to those exposed to standard care, but "the protective effect of the father’s involvement was stronger among fathers with higher levels of education who may have been more open to messages concerning shared domestic responsibilities."

"Evidence was most compelling for empowerment approaches (i.e., participatory action for maternal-child health; increase educational and economic resources, and modify norms to reduce child marriage)."  For example, an intervention in Ethiopia was implemented over several months and included: (a) community mobilization around child marriage norms, (b) mentor-led groups to provide informal education and encourage girls to stay in school, (c) livelihood programs for girls not in school, and (d) incentives to families whose girls stayed in school. The results were mixed, with positive effects on family planning use regardless of age, and varied effects on school enrollment and age at marriage (i.e., increased age at marriage for 10–14-year-olds only...)"

In another example, a meta-analysis of 7 interventions in Asia (n=6) and Africa n=1) that "used a four-phase participatory approach to address maternal and child health showed positive effects.  The interventions gathered community women to meet with a facilitator for several months to (a) identify and prioritize problems, (b) plan actions, (c) implement locally feasible strategies, and (d) assess activities. Across the seven studies, women in communities with participatory action groups experienced significantly reduced maternal mortality (37%) and reduced neonatal mortality (23%)....[A]ctions that were identified by women participating in a similar participatory intervention in Malawi, including support for kitchen gardens, bicycle ambulances, health education, and bednets. Actions that required external support (e.g., building a small health facility) were less likely to have been implemented...."   Despite these promising finds, little is known about the sustainability or scalability of these approaches.

Though research on engaging men showed mixed effectiveness on increasing their support for women’s and children's health, "[a]s a body, these studies suggest that expanding the scope of behavior change interventions to address social and structural factors, such as gender norms and inequalities, may be beneficial for effective program intervention. The strongest evidence of effectiveness in controlled settings comes from interventions that seek to empower women to take actions to address health issues and from interventions that seek to empower adolescents and their families and to change community norms around child marriage. As a group, these interventions tend to raise issues of gender norms and rights, and seek to give women access to resources (e.g., education for girls, community networks for decision making for women) to improve health behaviors and health outcomes. The interventions were found to delay age at marriage, increase use of family planning, reduce child stunting, and reduce maternal and child mortality." Despite the promise of empowerment approaches, little is known about the sustainability or scalability of these approaches.  More research needs to be done to determine how best to engage men for improved child health and how to scale-up and sustain all gender-integrated interventions.


Journal of Health Communication: Special Issue: Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: A Review of the Evidence, Volume 19, Supplement 1, 2014, pages 122-141, and email from Joan Kraft to The Communication Initiative on October 2 2014. Image credit: Core Group