J. Biosoc. Sci., (2015) 47, 667–686, 6 Cambridge University Press, 2015 doi:10.1017/S0021932014000418 First published online 18 Feb 2015
INTERACTIVE WORKSHOPS TO PROMOTE G E N D E R EQ U I T Y A N D F A M I L Y P L A N N I N G IN RURAL COMMUNITIES OF GUATEMALA: R E S U L T S OF A C O M M U N I T Y R A N D O M I Z E D ST U D Y SIDNEY RUTH SCHULER*1, GEETA NANDA, LUIS F. RAMI´REZ† and MARIO CHEN* *FHI 360, Washington DC, USA and †APAES, Guatemala City Summary. In Guatemala, especially in rural areas, gender norms contribute to high fertility and closely spaced births by discouraging contraceptive use and constraining women from making decisions regarding the timing of their pregnancies and the size of their families. Community workshops for men, women and couples were conducted in 30 rural communities in Guatemala to test the hypothesis that the promotion of gender equity in the context of reproductive health will contribute to gender-equitable attitudes and strengthen the practice of family planning. Communities were randomly assigned to intervention and control groups. Pre/post surveys were conducted. Odds ratios estimated with mixed effect models to account for community-level randomization and repeated measures per participant were compared. The analyses showed statistically significant effects of the intervention on two of the three outcomes examined: gender attitudes and contraceptive knowledge. Findings regarding contraceptive use were suggestive but not significant. The results suggest that it is possible to influence both inequitable gender norms and reproductive health knowledge and, potentially, behaviours in a short span of time using appropriately designed communications interventions that engage communities in re-thinking the inequitable gender norms that act as barriers to health.
Introduction There are few published studies documenting the impact of interventions intended to alter gender norms on family planning (Boender et al., 2004; Rottach et al., 2009). Most of the exceptions are studies of interventions designed to educate men about family planning, engage them in discussions about it and encourage them to discuss it with their wives (Terefe & Larsen, 1993; Amatya et al., 1994; Shattuck et al., 2006; Hartmann et al., 1
Corresponding author. Email: [email protected]
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2012); these studies did not address gender norms directly, and did not work with couples. Here findings are presented from a study testing a short-duration intervention designed specifically to influence the inequitable gender norms that constrain the practice of family planning. In 2011–2012, the C-Change Project (a USAID-supported project implemented by FHI 360) conducted an intervention study with Asociacio´n Pro Bienestar de la Familia de Guatemala (APROFAM) to test the hypothesis that communication strategies promoting gender equity in the context of reproductive health will contribute to gender-equitable attitudes and practice of family planning in traditional, rural settings. C-Change employs an ecological framework of social and behaviour change communication (SBCC) that examines the factors contributing to health and social problems at various levels, from characteristics of the broader environment, such as the governmental level, which can enable or inhibit change, to the level of the individual (Fig. 1). Cross-cutting these levels are factors such as information, motivation, ability to act and the norms that may support or constrain action. In this case, APROFAM’s experience in rural areas of Guatemala suggested that gender norms contributed to high fertility and closely spaced births by discouraging contraceptive use, constraining women from making decisions regarding the timing of their pregnancies and the size of their families, discouraging couple communication about family planning and distancing men, who have more decisionmaking power, from reliable family planning information and services. APROFAM was already providing reproductive and sexual health information and services (described below) at the community level and wanted to identify strategies to address these gender norms. The intervention was inspired in part by the work of Instituto Promundo, based in Brazil, which has shown success in reducing HIV/AIDS risk behaviours by holding interactive discussion sessions with groups of young men, in which the men are encouraged to examine and question prevailing stereotypes and norms of masculinity (Barker et al., 2004, 2006; Pulerwitz & Barker, 2006). The APROFAM intervention addressed the inequitable gender norms that influence individual attitudes and behaviours related to sexuality and family planning by engaging couples and peers in community settings, with the sanction of local leaders, in recognizing and reconsidering their gender attitudes. The objective of this paper is to investigate the effects of the intervention on three main outcomes: gender attitudes, knowledge of modern contraception and contraceptive use. Setting Guatemala has made significant progress in expanding access to family planning in recent years, but the country lags behind its regional neighbours, and there are sizeable gaps between indigenous and non-indigenous women related to contraceptive prevalence, fertility rates and unmet need for family planning. According to the 2008 National Survey of Maternal and Child Health, the total fertility rate (TFR) in the country declined from 4.4 children per woman in 2002 to 3.6 in 2008 (Guatemala Ministerio de Salud, 2009). In that year, the TFR was 4.2 among rural, and 4.5 among indigenous women, compared with just 2.9 among urban, and 3.1 among non-indigenous women. (Indigenous people comprise about 42% of the country’s population.) That year, the contraceptive prevalence rate was only 46% among rural and 40% among indigenous women, compared with 66% among urban, and 63% for non-indigenous women. Unmet need for family planning
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Socio-Ecological Model for Change
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Fig. 1. C-Change social and behaviour change model. Adapted from C-Modules: A Learning Package for Social and Behavior Change Communication (C-Change, FHI 360, Washington DC).
among indigenous women was 30% among indigenous women – twice as high among non-indigenous women (15%); it was 25% among all rural women. One explanation for the lower contraceptive prevalence rates and higher unmet need among mostly rural indigenous Guatemalans is a legacy of suspicion related to the brutal civil war that lasted over three decades, from 1960 to 1996, in which many villages were destroyed and indigenous people killed. To some extent, government-run family planning programmes are still seen as part of a ladino plot to diminish the indigenous population (Bertrand et al., 2001; Ishida et al., 2012). Inegalitarian gender norms are thought to be another factor. Women’s ability to make decisions about their own reproduction is limited by the fact that men have more decision-making power on issues of family planning and use of services (Netzer & Mallas, 2008; Guatemala Ministerio de Salud, 2009). Other gender equity indicators are consistent with this
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picture. For example, the percentage of women classified as economically active among ages 15þ was 48% for women compared with 88% for men (Population Reference Bureau, 2011). Although school attendance is compulsory in Guatemala starting at age 7, indigenous girls in particular are educationally disadvantaged; according to government data from 2000, primary school completion rates for indigenous girls are 58% those of indigenous boys, with only 20% of indigenous girls age 18 having completed primary school (Hallman et al., 2007). The 2013 Human Development Report of the United Nations Development Program (UNDP, 2013) ranked Guatemala 114 of 186 countries (186 being the highest level of inequality) on its Gender Inequality Index, which synthesizes a variety of indicators. The project was fielded in 30 rural communities in the western highlands, in the departments of Sacatepe´quez, Chimaltenango, Solola´, Huehuetenango and San Marcos. Communities were selected from rural areas where APROFAM, a private, non-profit, Guatemalan IPPF affiliate founded in 1964, provides mobile services and trains promotores (female and male community-based volunteers promoting sexual and reproductive health) to help overcome barriers and increase access to reproductive health services. Since 1975, APROFAM has operated a community-based distribution programme to provide information, education and communication services on sexual and reproductive health in rural communities combined with the provision of family planning methods. The programme includes a network of 3400 voluntary promoters (men and women), 55 educators (men and women) and four field supervisors. The Rural Development Program works in co-ordination with APROFAM mobile medical units. These units include a team of physicians and nurses that travel across the country, providing temporary and permanent family planning methods as well as other reproductive health services. The voluntary promoters carry out more than 100,000 visits per year, providing personalized education and information to rural families on the different components of reproductive health, selling condoms and oral contraceptives at nominal prices, referring pregnant women and children under 5 years of age to local health centres and identifying and referring women interested in long-acting methods to mobile clinics. Educational talks and meetings are also carried out in hospitals, health centres, markets, co-operatives and other public places, approximately 5512 times a year, to provide information and education on maternal and child health, cervical cancer prevention, STI prevention, family planning and others topics. After the talk, personalized and confidential counselling is given upon request, in Mayan languages when appropriate. The study included communities speaking Quiche´ and Kakchiquel, two predominant Mayan languages. In aggregate, the communities had approximately equal numbers of indigenous and non-indigenous inhabitants. The latter were included in the study because they live in the same communities and face similar resource constraints as indigenous inhabitants. Methods Interventions The interventions consisted of a series of six interactive workshop sessions with couples: two for the men, two for the women and two for both members of the couple
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– four workshop sessions per individual, over the period of a month. The reason for this arrangement is that APROFAM field staff felt that if the initial sessions included both men and women, the women might feel too shy to speak up but that, after the women had become used to the interactive format of the sessions, mixed-gender groups would be feasible. Also, certain topics were more suited to women-only sessions: for example, strategies for communicating effectively with male partners. A total of about 1200 individuals were recruited for the workshops – an average of 20 couples in each of the 30 communities. The workshops were conducted in March and April of 2012. APROFAM conducted mobile clinics in all sites, soon after the workshops were complete in the intervention sites and soon after the baseline survey in the control sites. Participants were recruited by promotores, who visited homes and also asked people to spread the word among others in the communities. To be eligible, an individual was supposed to live in the community and be married or in civil union, with the wife between 18 and 40 years of age, and both members of the couple had to agree to participate. They were also supposed to be well known and respected within their community and have good communication with others. APROFAM hoped that selection of such people as participants would facilitate the spread of the ideas discussed in the workshops to other members of the communities (but this possibility was not addressed in the research design because of the short time available for the study). In practice the age criterion was relaxed in some cases to avoid discrimination against older women, and there were a few cases in which only one member of the couple attended the workshop. The workshop sessions were led by trained facilitators, selected from among APROFAM’s educators. Priority was given to those familiar with the communities in question and/or those who spoke the prevalent Mayan dialects. The facilitators used a manual developed by the C-Change Project that incorporates games, role plays and other exercises. Its purpose is to raise awareness of gender inequality and the gender issues that act as barriers to sexual and reproductive health, and to encourage gender-equitable attitudes and interest in family planning. The manual adapted material from a number of sources, including Stepping Stones, the EngenderHealth Men as Partners manual and the Population Council’s Sakhi Saheli manual (Welbourn, 2007; EngenderHealth and Promundo, 2008; Population Council, 2008). The facilitators also distributed information sheets on contraceptive methods. For example, one role play session was designed to strengthen women’s ability to negotiate contraceptive use with their male partners. The facilitator asked three women to volunteer to be women and three to volunteer as their male partners. She then put them in pairs and asked another volunteer to be a baby for the third pair. Each pair was given 10–15 minutes to create a small play about sex, fear of pregnancy and family planning, using one of three scenarios. One was the following: Role play 3. A man proposes sex but the wife says the baby is in the room. The man asks why she always wants to sleep with the baby, who is already 3 years old. As the man tries to convince the wife to loosen her skirt, the baby starts crying and the husband threatens to find another woman to have sex with him. The wife gives in, reasoning loudly that it is better she accepts than have him go to another woman. The women then performed their plays in front of the group. After each play, the facilitator asked the rest of the group to briefly discuss the following questions:
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S. R. Schuler et al. Is this dialogue realistic? Who is in control? Does the man seem to care whether his partner gets pregnant? Can the woman understand whether he wants her to get pregnant? Does the woman seem to care whether she gets pregnant? Can the man understand whether she wants to get pregnant? Is there a risk of an unplanned pregnancy? Do they have a good relationship? What would make this situation better?
Study design Communities were randomly assigned to intervention and control groups, stratifying by department, as follows. First, APROFAM selected nine communities in each of five departments in the western highlands, based on the availability of an APROFAM educator familiar with the communities and/or speaking the local Mayan dialect, who could be trained to facilitate the workshops. In each department, the nine communities were randomly assigned to three groups: Group 1 (intervention group), Group 2 and Group 3, resulting in a total of fifteen communities in each of the three groups, across the five departments. The interventions in the Group 2 communities were delayed so they could serve as control sites. Group 3, where service statistics alone were to have been used to assess change in contraceptive use, was subsequently dropped because of time constraints and problems with the service statistics data. In the remaining two groups, surveys were undertaken to measure changes in gender attitudes among workshop participants, comparing changes among participants in the intervention group with future participants in the control group, where changes might be attributed to the Hawthorne effect (the possibility that simply asking about gender attitudes in the survey could bring about change) or to extraneous factors. The simultaneous recruitment of participants in the control communities was a strategy to minimize selection bias. In this way, participants would not be compared with groups of people who might not have been willing to attend the workshops. Gender attitudes were measured using the Gender and Family Planning Equity (GAFPE) Scale, containing 20 items (Table 1). Three were drawn from the Gender Equitable Men (GEM) Scale (Pulerwitz & Barker, 2008) and the rest designed for this project to reflect gender norms that influence family planning. The selection of items was influenced by extensive discussions with local field staff of APROFAM and the items all reflected attitudes that arguably could have been influenced by the interventions. Informal pre-tests were conducted with indigenous clients of an urban APROFAM clinic to verify that they were understood as intended and that study participants would be willing to respond to them. The 20 items, statements reflecting norms and practices related to sexuality and family planning that were either equitable or inequitable, were read to participants, who were asked whether they agreed, partially agreed or disagreed with each statement. For example, ‘You don’t talk about sex, you just do it’ (yes ¼ inequitable) measured couple communication; ‘It is a man’s responsibility to make sure his wife will not get pregnant if she does not want to’ (yes ¼ equitable) measured
Interactive workshops to promote gender equity Table 1. C-Change Gender and Family Planning Equity (GAFPE) Scale
673 a
GAFPE Scale statements (agree, partially agree, disagree)b Couple communication and mutuality You don’t talk about sex, you just do it! (from GEM Scale) disagree ¼ equitable A couple should decide together if they want to have children, and how many children they want. agree ¼ equitable If a man gets a woman pregnant, the child is the responsibility of both. agree ¼ equitable It is the responsibility of both the man and the woman to avoid pregnancy. agree ¼ equitable Having sex using contraception is more exciting because you do not have to worry about pregnancy. agree ¼ equitable A man and a woman should decide together what contraceptive method they will use. agree ¼ equitable Patriarchal norms Contraceptive use makes it easier for a woman to have more than one sexual partner (from GEM Scale). disagree ¼ equitable I would get mad if my wife/female partner asked me to use condoms./My husband/male partner would be justifiably angry if I asked him to use condoms (from GEM Scale). disagree ¼ equitable Having sex without using contraceptives is more exciting because a woman can get pregnant. disagree ¼ equitable The man is the one with the power to impregnate, so he should decide whether to use contraceptives. disagree ¼ equitable It is the husband who should decide how many children to have, since he is the one who has to support them. disagree ¼ equitable If your church says you should use only natural methods of family planning, you should follow that. disagree ¼ equitable Male responsibility It is man’s responsibility to make sure his wife will not get pregnant if she does not want to. agree ¼ equitable A man should not have sex without knowing if his partner wants to get pregnant. agree ¼ equitable If a woman does not want to get pregnant and is not using contraceptives, her partner should do so. agree ¼ equitable If a woman experiences side-effects from using a FP method, her husband or partner should help her find a method that suits her better. agree ¼ equitable If a woman cannot use a FP method without side effects, her partner should use a method. agree ¼ equitable Women’s rights In my opinion, a woman can suggest using condoms like a man can. agree ¼ equitable The woman has the right to decide to use contraceptives because she is the one who will get pregnant. agree ¼ equitable The woman can decide what type of contraceptive to use because she is the one who will use it. agree ¼ equitable a b
Scale developed by Sidney Ruth Schuler, Senior Advisor for Research and Gender. One point is assigned for each equitable response and points are summed to derive equity score.
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constructive male engagement; ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (yes ¼ inequitable) measured male dominance in family planning decision-making; and ‘If your church says you should use only natural family planning methods, you should follow that’ (yes ¼ inequitable) measured respect for a patriarchal institution. One point was given for each response that indicated an equitable attitude and zero for an inequitable or partially equitable attitude. After all responses were tallied, points were summed to create a continuous gender equity score for each individual, at baseline and at follow-up. The individuals who expressed the most gender-equitable attitudes thus accumulated the greatest number of points. The two other outcome variables were knowledge of modern contraceptive methods and modern contraceptive use. To measure knowledge, respondents were asked what modern contraceptive methods they knew about, first unprompted, then prompted. For each method named, the respondent received a point. Points were summed to create a continuous knowledge variable. A dichotomous contraceptive knowledge variable was also created, with the cut-off point based on the distribution of the summed knowledge variable: knowledge of five or more modern methods. Modern contraceptive use was measured using a dichotomous variable indicating whether or not the respondent was currently using a modern contraceptive method; these included tubal ligation, vasectomy, oral contraceptive pills, emergency contraceptive pills, IUDs, injectables, implants, male and female condoms and spermicide gel. Survey implementation The baseline survey was administered by APAES to all participants in the intervention and in the control group. It was administered verbally, face-to face, in Spanish or in a Mayan dialect, depending on the preference and language ability of the respondent. The duration was approximately 45 minutes. The follow-up survey was conducted about 2 months after the baseline survey in each site. A total of 1122 interviews were completed in the baseline survey, and 603 individuals were re-interviewed for the follow-up survey. To qualify for the follow-up survey in the intervention sites, the potential respondent had to have been interviewed in the baseline survey and participated in at least one of the workshops. Using these criteria, it was possible to re-interview 55.4% (328) of the baseline sample. Among those not interviewed, 10% had participated in the workshops but either refused a second interview or were not available for re-interview, and 35% did not participate in any of the workshops. In the control group, where workshops had not yet been held, 59% (275) of the baseline sample were re-interviewed in the follow-up survey. Data analysis The programs SPSS v.21 and SAS v.9.3 were used to analyse the survey data. Variables measuring gender attitudes and contraceptive knowledge and use were compared within the intervention and control groups, and levels of change were compared between the groups. In descriptive bivariate analyses of the individual items in the GAFPE Scale, differences in the level of change – positive and negative ‘equity points’ – were calculated by subtracting the mean scores of the control group from those of the intervention group.
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Negative numbers indicated that the intervention group had fewer equity points than the control group or that control group scores dropped by fewer points than the intervention group between baseline and follow-up. Positive numbers show gains in equity points for the intervention group, relative to the control group. An aggregate GAFPE indicator for each respondent was created by summing the equity points for the individual items. Tests of significance were conducted using mixed effect models. A linear mixed model was used to assess changes in the aggregate GAFPE indicator, and a logistic mixed model was used for contraceptive knowledge and use, as these were measured dichotomously. Models included random effects to account for the community-level randomization and repeated measures per participant. Study group (i.e. intervention and control) and time of the assessment (i.e. baseline and follow-up) were included as fixed effects in the model. No additional covariates were included since time-invariant factors as well as unobserved heterogeneity are controlled for when the interest is on the comparison of change in outcomes between the study groups (i.e. difference in difference) and the same individuals are followed up (i.e. panel data) (Cheng, 2003). The analysis for contraceptive use included non-pregnant women only. Since the focus of this study is on the assessment of changes, the analysis was restricted to participants interviewed at both baseline and follow-up. Results On average, 66% of those recruited (395/600) in the intervention group attended a session. In addition, a few people who did not initially register later joined. A total of 1122 interviews were completed in the baseline survey and 603 re-interviewed in the followup. In an analysis of drop-outs at baseline, Table 2 presents a comparison of participant characteristics between those who completed both surveys and those who dropped out. More males than females dropped out in both study groups, while participants with higher numbers of children completed the surveys significantly more in the intervention than in the control group. Differences between the drop-outs and those completing the surveys were also noted in the religion distribution in the control group. Participant characteristics at baseline At baseline, the intervention group was slightly older, somewhat less educated and had more children than the control group (Table 2). The mean age of participants in the intervention group was 31, and 29 in the control group. On average, the men were 2 years older than the women (not shown). The mean number of living children per couple was 3.0 in the intervention group and 2.2 in the control group. In addition, 10.1% of the women in the intervention group and 9.6% in the control group were pregnant. A little over 50% of the respondents in the intervention group and 57% of those in the control group were Catholic; 38% and 31%, respectively, were Evangelical. The remainder said they did not attend a particular church. Slightly over half of the participants in both groups considered themselves to be indigenous (Mayan). Spanish was as predominant as native languages, spoken by 55% of the participants. Kakchiquel and Quiche were the respective languages of 15% and 1%.
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Table 2. Socio-demographic characteristics and analysis of drop-outs compared with participants, by group at baseline, Guatemala Intervention group Characteristic Mean age Age group 44 Gender Female Male Religion Catholic Evangelical Other Mean years of schooling None Primary (partial or complete) Partial secondary Complete secondary or some university Indigenous ethnic group Mean number of children
Drop-outs (n ¼ 269)
Participants (n ¼ 328)
Control group Drop-outs (n ¼ 213)
Participants (n ¼ 275)
30.2
30.7
29.5
28.6
5.9% 21.9% 43.5% 22.3% 6.3%
3.7% 19.8% 46.0% 25.9% 4.6%
5.6% 23.9% 45.1% 23.5% 1.9%
5.1% 26.9% 48.0% 17.8% 2.2%
42.8% 57.2%
57.0% 43.0%
(89) 41.8% (124) 58.2%
54.2% 45.8%
44.2% 37.9% 17.8% — 14.1% 53.2% 19.0% 13.8%
50.3% 38.4 11.3% 5.4 15.5% 54.9% 15.5% 14.0%
(96) 45.1% (87) 40.8% (30) 14.1% — (23) 10.8% (91) 42.7% (50) 23.5% (49) 23.0%
57.1% 30.5% 12.4% 6.3 11.6% 48.0% 24.0% 16.4%
— 2.4
54.9% 3.0
— 2.5
52.0% 2.2
Gender equity scores In the baseline survey, women in both the intervention group and the control group had considerably higher gender equity scores than the men (Table 3). Both men and women in the control group had significantly higher scores than their counterparts in the intervention group. In the follow-up survey, the scores of both women and men in the intervention group increased; men’s scores registered a more dramatic gain, but remained slightly below those of the women. In the control group, men’s mean score did not change, while women’s mean score dropped by more than one point, to a level slightly below that of the men. Although the scores of both women and men in the control group started at considerably higher levels than the scores of the intervention group, the follow-up survey scores of women in the intervention group exceeded those of women in the control group, and the scores of men in the intervention group nearly caught up with those in the control group. Table 3 also shows that there were no significant differences between participants and drop-outs in the intervention group, but that both male and female drop-outs from the control group had significantly lower scores than participants.
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a
Table 3. Mean scores on GAFPE Scale, by group at baseline and follow-up, Guatemala Intervention group Mean GAFPE score Baseline Follow-up
Women
Control group Men
Women
Men
Drop-outs (n ¼ 115)
Participants (n ¼ 187)
Drop-outs (n ¼ 154)
Participants (n ¼ 141)
Drop-outs (n ¼ 89)
Participants (n ¼ 149)
Drop-outs (n ¼ 124)
Participants (n ¼ 126)
14.8 NA
14.7 14.9
14.0 NA
13.5 14.6
14.6 NA
15.3* 14.5
13.9 NA
14.7* 14.7
a The lowest possible value on this scale is 0 and the highest possible value is 20. There were no significant differences between participants and drop-outs in the intervention group. In the control group, the scores of both male and female participants were significantly higher than those of the drop-outs ( p < 0.05).
There was considerable variation between baseline and follow-up in the responses across the 20 individual components of the GAFPE Scale (Table 4). The control group showed a greater increase in the percentage of equitable responses on some variables, and the intervention group on others; the percentages of equitable responses went down for some items. For the women in the intervention group, the greatest percentage change in a positive (equitable) direction relative to the control group was observed for the statement: ‘You don’t talk about sex, you just do it’. The percentage of equitable responses in the control group fell 22.2% points, while it increased 4.3% points in the intervention group (26.5 percentage point difference between the groups). The second comparative gain for women in the intervention group was on the statement: ‘It is a man’s responsibility to make sure his wife will not get pregnant if she does not want to’ (11.6 percentage points). The next largest comparative gain for women in the intervention group was on two statements addressing men’s and women’s roles in decisionmaking relating to fertility and contraception: ‘The man is the one with the power to impregnate, so he should decide whether to use contraceptives’ (10.8 percentage points) and ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (10.6 percentage points). The greatest gains among men in the intervention group compared with the control group were on statements on mutual decision-making: ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (23.3 percentage point change in equitable direction); contraceptive use and sexual pleasure: ‘Having sex without using contraceptives is more exciting because a woman can get pregnant’ (21.8 percentage points), ‘Having sex using contraception is more exciting because you do not have to worry about pregnancy’ (18.8 percentage points); and men’s responsibility to use condoms if a partner experiences side-effects from contraceptive methods: ‘If a woman cannot use a family planning method without side-effects, her partner should use a method’ (14.5 percentage points). The next largest comparative gain was on the statement about following church teachings on the use of contraception: ‘If your church says you should use only natural family planning methods, you should follow that’ (10.5 percentage points). There was no item on which women or men in the control group had a percentage gain in the equitable direction of 10% or more relative to the intervention group.
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Table 4. GAFPE Scale statements, percentage change in equitable responses from baseline to follow-up, by group and gender, Guatemala Intervention group GAFPE Scale statements Couple communication and mutuality You don’t talk about sex, you just do it! A couple should decide together if they want to have children, and how many children they want. If a man gets a woman pregnant, the child is the responsibility of both. It is the responsibility of both the man and the woman to avoid pregnancy. Having sex using contraception is more exciting because you do not have to worry about pregnancy. A man and a woman should decide together what contraceptive method they will use. Patriarchal norms Contraceptive use makes it easier for a woman to have more than one sexual partner. I would get mad if my wife/female partner asked me to use condoms./My husband/ male partner would be justifiably angry if I asked him to use condoms. Having sex without using contraceptives is more exciting because a woman can get pregnant. The man is the one with the power to impregnate, so he should decide whether to use contraceptives. It is the husband who should decide how many children to have, since he is the one who has to support them. If your church says you should use only natural methods of family planning, you should follow that. Male responsibility It is man’s responsibility to make sure his wife will not get pregnant if she does not want to. A man should not have sex without knowing if his partner wants to get pregnant. If a woman does not want to get pregnant and is not using contraceptives, her partner should do so.
Women (n ¼ 187)
Control group
Men (n ¼ 141)
Women (n ¼ 149)
Men (n ¼ 126)
4.3 3.7
2.9 0.7
22.2 2.0
4.0 2.4
3.8
0.7
0.6
1.6
0.5
5.6
0.7
0.8
5.3
9.2
0.0
9.6
0.5
4.3
0.0
3.1
1.6
0.8
0.0
3.1
0.5
11.3
1.3
6.4
8.1
10.7
10.8
11.1
7.5
9.2
3.3
11.1
3.2
17.7
7.4
5.6
0.6
12.1
5.4
1.6
0.5
2.9
12.1
5.5
0.6
16.4
5.4
8.7
1.1
7.8
6.0
7.9
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Table 4. (Continued) Intervention group Women (n ¼ 187)
GAFPE Scale statements If a woman experiences side-effects from using a family planning method, her husband or partner should help her find a method that suits her better. If a woman cannot use a family planning method without side-effects, her partner should use a method. Women’s rights In my opinion, a woman can suggest using condoms like a man can. The woman has the right to decide to use contraceptives because she is the one who will get pregnant. The woman can decide what type of contraceptive to use because she is the one who will use it.
Men (n ¼ 141)
Control group Women (n ¼ 149)
Men (n ¼ 126)
0.0
4.3
0.7
0.0
4.3
17.7
4.7
3.2
3.8
5.0
2.7
10.3
1.1
0.7
3.4
8.8
7.5
4.2
0.6
6.3
Table 5. Linear mixed model estimates of intervention effect on gender attitudes, Guatemala
Women (n F 334) Intervention group: FU–Baseline Control group: FU–Baseline Difference in difference Men (n F 267) Intervention group: FU–Baseline Control Group: FU–Baseline Difference in Difference
Estimates
95% CI
0.18 0.79 0.96
[0.22, 0.58] [1.23, 0.34] [0.36, 1.57]
1.10 0.00 1.10
[0.64, 1.56] [0.49, 0.49] [0.43, 1.77]
p-value 0.370 0.001 0.003
INTERACTIVE WORKSHOPS TO PROMOTE G E N D E R EQ U I T Y A N D F A M I L Y P L A N N I N G IN RURAL COMMUNITIES OF GUATEMALA: R E S U L T S OF A C O M M U N I T Y R A N D O M I Z E D ST U D Y SIDNEY RUTH SCHULER*1, GEETA NANDA, LUIS F. RAMI´REZ† and MARIO CHEN* *FHI 360, Washington DC, USA and †APAES, Guatemala City Summary. In Guatemala, especially in rural areas, gender norms contribute to high fertility and closely spaced births by discouraging contraceptive use and constraining women from making decisions regarding the timing of their pregnancies and the size of their families. Community workshops for men, women and couples were conducted in 30 rural communities in Guatemala to test the hypothesis that the promotion of gender equity in the context of reproductive health will contribute to gender-equitable attitudes and strengthen the practice of family planning. Communities were randomly assigned to intervention and control groups. Pre/post surveys were conducted. Odds ratios estimated with mixed effect models to account for community-level randomization and repeated measures per participant were compared. The analyses showed statistically significant effects of the intervention on two of the three outcomes examined: gender attitudes and contraceptive knowledge. Findings regarding contraceptive use were suggestive but not significant. The results suggest that it is possible to influence both inequitable gender norms and reproductive health knowledge and, potentially, behaviours in a short span of time using appropriately designed communications interventions that engage communities in re-thinking the inequitable gender norms that act as barriers to health.
Introduction There are few published studies documenting the impact of interventions intended to alter gender norms on family planning (Boender et al., 2004; Rottach et al., 2009). Most of the exceptions are studies of interventions designed to educate men about family planning, engage them in discussions about it and encourage them to discuss it with their wives (Terefe & Larsen, 1993; Amatya et al., 1994; Shattuck et al., 2006; Hartmann et al., 1
Corresponding author. Email: [email protected]
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2012); these studies did not address gender norms directly, and did not work with couples. Here findings are presented from a study testing a short-duration intervention designed specifically to influence the inequitable gender norms that constrain the practice of family planning. In 2011–2012, the C-Change Project (a USAID-supported project implemented by FHI 360) conducted an intervention study with Asociacio´n Pro Bienestar de la Familia de Guatemala (APROFAM) to test the hypothesis that communication strategies promoting gender equity in the context of reproductive health will contribute to gender-equitable attitudes and practice of family planning in traditional, rural settings. C-Change employs an ecological framework of social and behaviour change communication (SBCC) that examines the factors contributing to health and social problems at various levels, from characteristics of the broader environment, such as the governmental level, which can enable or inhibit change, to the level of the individual (Fig. 1). Cross-cutting these levels are factors such as information, motivation, ability to act and the norms that may support or constrain action. In this case, APROFAM’s experience in rural areas of Guatemala suggested that gender norms contributed to high fertility and closely spaced births by discouraging contraceptive use, constraining women from making decisions regarding the timing of their pregnancies and the size of their families, discouraging couple communication about family planning and distancing men, who have more decisionmaking power, from reliable family planning information and services. APROFAM was already providing reproductive and sexual health information and services (described below) at the community level and wanted to identify strategies to address these gender norms. The intervention was inspired in part by the work of Instituto Promundo, based in Brazil, which has shown success in reducing HIV/AIDS risk behaviours by holding interactive discussion sessions with groups of young men, in which the men are encouraged to examine and question prevailing stereotypes and norms of masculinity (Barker et al., 2004, 2006; Pulerwitz & Barker, 2006). The APROFAM intervention addressed the inequitable gender norms that influence individual attitudes and behaviours related to sexuality and family planning by engaging couples and peers in community settings, with the sanction of local leaders, in recognizing and reconsidering their gender attitudes. The objective of this paper is to investigate the effects of the intervention on three main outcomes: gender attitudes, knowledge of modern contraception and contraceptive use. Setting Guatemala has made significant progress in expanding access to family planning in recent years, but the country lags behind its regional neighbours, and there are sizeable gaps between indigenous and non-indigenous women related to contraceptive prevalence, fertility rates and unmet need for family planning. According to the 2008 National Survey of Maternal and Child Health, the total fertility rate (TFR) in the country declined from 4.4 children per woman in 2002 to 3.6 in 2008 (Guatemala Ministerio de Salud, 2009). In that year, the TFR was 4.2 among rural, and 4.5 among indigenous women, compared with just 2.9 among urban, and 3.1 among non-indigenous women. (Indigenous people comprise about 42% of the country’s population.) That year, the contraceptive prevalence rate was only 46% among rural and 40% among indigenous women, compared with 66% among urban, and 63% for non-indigenous women. Unmet need for family planning
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Socio-Ecological Model for Change
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*These concepts apply to all levels (people, organizations, and institutions). They were originally developed for the individual level.
Fig. 1. C-Change social and behaviour change model. Adapted from C-Modules: A Learning Package for Social and Behavior Change Communication (C-Change, FHI 360, Washington DC).
among indigenous women was 30% among indigenous women – twice as high among non-indigenous women (15%); it was 25% among all rural women. One explanation for the lower contraceptive prevalence rates and higher unmet need among mostly rural indigenous Guatemalans is a legacy of suspicion related to the brutal civil war that lasted over three decades, from 1960 to 1996, in which many villages were destroyed and indigenous people killed. To some extent, government-run family planning programmes are still seen as part of a ladino plot to diminish the indigenous population (Bertrand et al., 2001; Ishida et al., 2012). Inegalitarian gender norms are thought to be another factor. Women’s ability to make decisions about their own reproduction is limited by the fact that men have more decision-making power on issues of family planning and use of services (Netzer & Mallas, 2008; Guatemala Ministerio de Salud, 2009). Other gender equity indicators are consistent with this
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picture. For example, the percentage of women classified as economically active among ages 15þ was 48% for women compared with 88% for men (Population Reference Bureau, 2011). Although school attendance is compulsory in Guatemala starting at age 7, indigenous girls in particular are educationally disadvantaged; according to government data from 2000, primary school completion rates for indigenous girls are 58% those of indigenous boys, with only 20% of indigenous girls age 18 having completed primary school (Hallman et al., 2007). The 2013 Human Development Report of the United Nations Development Program (UNDP, 2013) ranked Guatemala 114 of 186 countries (186 being the highest level of inequality) on its Gender Inequality Index, which synthesizes a variety of indicators. The project was fielded in 30 rural communities in the western highlands, in the departments of Sacatepe´quez, Chimaltenango, Solola´, Huehuetenango and San Marcos. Communities were selected from rural areas where APROFAM, a private, non-profit, Guatemalan IPPF affiliate founded in 1964, provides mobile services and trains promotores (female and male community-based volunteers promoting sexual and reproductive health) to help overcome barriers and increase access to reproductive health services. Since 1975, APROFAM has operated a community-based distribution programme to provide information, education and communication services on sexual and reproductive health in rural communities combined with the provision of family planning methods. The programme includes a network of 3400 voluntary promoters (men and women), 55 educators (men and women) and four field supervisors. The Rural Development Program works in co-ordination with APROFAM mobile medical units. These units include a team of physicians and nurses that travel across the country, providing temporary and permanent family planning methods as well as other reproductive health services. The voluntary promoters carry out more than 100,000 visits per year, providing personalized education and information to rural families on the different components of reproductive health, selling condoms and oral contraceptives at nominal prices, referring pregnant women and children under 5 years of age to local health centres and identifying and referring women interested in long-acting methods to mobile clinics. Educational talks and meetings are also carried out in hospitals, health centres, markets, co-operatives and other public places, approximately 5512 times a year, to provide information and education on maternal and child health, cervical cancer prevention, STI prevention, family planning and others topics. After the talk, personalized and confidential counselling is given upon request, in Mayan languages when appropriate. The study included communities speaking Quiche´ and Kakchiquel, two predominant Mayan languages. In aggregate, the communities had approximately equal numbers of indigenous and non-indigenous inhabitants. The latter were included in the study because they live in the same communities and face similar resource constraints as indigenous inhabitants. Methods Interventions The interventions consisted of a series of six interactive workshop sessions with couples: two for the men, two for the women and two for both members of the couple
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– four workshop sessions per individual, over the period of a month. The reason for this arrangement is that APROFAM field staff felt that if the initial sessions included both men and women, the women might feel too shy to speak up but that, after the women had become used to the interactive format of the sessions, mixed-gender groups would be feasible. Also, certain topics were more suited to women-only sessions: for example, strategies for communicating effectively with male partners. A total of about 1200 individuals were recruited for the workshops – an average of 20 couples in each of the 30 communities. The workshops were conducted in March and April of 2012. APROFAM conducted mobile clinics in all sites, soon after the workshops were complete in the intervention sites and soon after the baseline survey in the control sites. Participants were recruited by promotores, who visited homes and also asked people to spread the word among others in the communities. To be eligible, an individual was supposed to live in the community and be married or in civil union, with the wife between 18 and 40 years of age, and both members of the couple had to agree to participate. They were also supposed to be well known and respected within their community and have good communication with others. APROFAM hoped that selection of such people as participants would facilitate the spread of the ideas discussed in the workshops to other members of the communities (but this possibility was not addressed in the research design because of the short time available for the study). In practice the age criterion was relaxed in some cases to avoid discrimination against older women, and there were a few cases in which only one member of the couple attended the workshop. The workshop sessions were led by trained facilitators, selected from among APROFAM’s educators. Priority was given to those familiar with the communities in question and/or those who spoke the prevalent Mayan dialects. The facilitators used a manual developed by the C-Change Project that incorporates games, role plays and other exercises. Its purpose is to raise awareness of gender inequality and the gender issues that act as barriers to sexual and reproductive health, and to encourage gender-equitable attitudes and interest in family planning. The manual adapted material from a number of sources, including Stepping Stones, the EngenderHealth Men as Partners manual and the Population Council’s Sakhi Saheli manual (Welbourn, 2007; EngenderHealth and Promundo, 2008; Population Council, 2008). The facilitators also distributed information sheets on contraceptive methods. For example, one role play session was designed to strengthen women’s ability to negotiate contraceptive use with their male partners. The facilitator asked three women to volunteer to be women and three to volunteer as their male partners. She then put them in pairs and asked another volunteer to be a baby for the third pair. Each pair was given 10–15 minutes to create a small play about sex, fear of pregnancy and family planning, using one of three scenarios. One was the following: Role play 3. A man proposes sex but the wife says the baby is in the room. The man asks why she always wants to sleep with the baby, who is already 3 years old. As the man tries to convince the wife to loosen her skirt, the baby starts crying and the husband threatens to find another woman to have sex with him. The wife gives in, reasoning loudly that it is better she accepts than have him go to another woman. The women then performed their plays in front of the group. After each play, the facilitator asked the rest of the group to briefly discuss the following questions:
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S. R. Schuler et al. Is this dialogue realistic? Who is in control? Does the man seem to care whether his partner gets pregnant? Can the woman understand whether he wants her to get pregnant? Does the woman seem to care whether she gets pregnant? Can the man understand whether she wants to get pregnant? Is there a risk of an unplanned pregnancy? Do they have a good relationship? What would make this situation better?
Study design Communities were randomly assigned to intervention and control groups, stratifying by department, as follows. First, APROFAM selected nine communities in each of five departments in the western highlands, based on the availability of an APROFAM educator familiar with the communities and/or speaking the local Mayan dialect, who could be trained to facilitate the workshops. In each department, the nine communities were randomly assigned to three groups: Group 1 (intervention group), Group 2 and Group 3, resulting in a total of fifteen communities in each of the three groups, across the five departments. The interventions in the Group 2 communities were delayed so they could serve as control sites. Group 3, where service statistics alone were to have been used to assess change in contraceptive use, was subsequently dropped because of time constraints and problems with the service statistics data. In the remaining two groups, surveys were undertaken to measure changes in gender attitudes among workshop participants, comparing changes among participants in the intervention group with future participants in the control group, where changes might be attributed to the Hawthorne effect (the possibility that simply asking about gender attitudes in the survey could bring about change) or to extraneous factors. The simultaneous recruitment of participants in the control communities was a strategy to minimize selection bias. In this way, participants would not be compared with groups of people who might not have been willing to attend the workshops. Gender attitudes were measured using the Gender and Family Planning Equity (GAFPE) Scale, containing 20 items (Table 1). Three were drawn from the Gender Equitable Men (GEM) Scale (Pulerwitz & Barker, 2008) and the rest designed for this project to reflect gender norms that influence family planning. The selection of items was influenced by extensive discussions with local field staff of APROFAM and the items all reflected attitudes that arguably could have been influenced by the interventions. Informal pre-tests were conducted with indigenous clients of an urban APROFAM clinic to verify that they were understood as intended and that study participants would be willing to respond to them. The 20 items, statements reflecting norms and practices related to sexuality and family planning that were either equitable or inequitable, were read to participants, who were asked whether they agreed, partially agreed or disagreed with each statement. For example, ‘You don’t talk about sex, you just do it’ (yes ¼ inequitable) measured couple communication; ‘It is a man’s responsibility to make sure his wife will not get pregnant if she does not want to’ (yes ¼ equitable) measured
Interactive workshops to promote gender equity Table 1. C-Change Gender and Family Planning Equity (GAFPE) Scale
673 a
GAFPE Scale statements (agree, partially agree, disagree)b Couple communication and mutuality You don’t talk about sex, you just do it! (from GEM Scale) disagree ¼ equitable A couple should decide together if they want to have children, and how many children they want. agree ¼ equitable If a man gets a woman pregnant, the child is the responsibility of both. agree ¼ equitable It is the responsibility of both the man and the woman to avoid pregnancy. agree ¼ equitable Having sex using contraception is more exciting because you do not have to worry about pregnancy. agree ¼ equitable A man and a woman should decide together what contraceptive method they will use. agree ¼ equitable Patriarchal norms Contraceptive use makes it easier for a woman to have more than one sexual partner (from GEM Scale). disagree ¼ equitable I would get mad if my wife/female partner asked me to use condoms./My husband/male partner would be justifiably angry if I asked him to use condoms (from GEM Scale). disagree ¼ equitable Having sex without using contraceptives is more exciting because a woman can get pregnant. disagree ¼ equitable The man is the one with the power to impregnate, so he should decide whether to use contraceptives. disagree ¼ equitable It is the husband who should decide how many children to have, since he is the one who has to support them. disagree ¼ equitable If your church says you should use only natural methods of family planning, you should follow that. disagree ¼ equitable Male responsibility It is man’s responsibility to make sure his wife will not get pregnant if she does not want to. agree ¼ equitable A man should not have sex without knowing if his partner wants to get pregnant. agree ¼ equitable If a woman does not want to get pregnant and is not using contraceptives, her partner should do so. agree ¼ equitable If a woman experiences side-effects from using a FP method, her husband or partner should help her find a method that suits her better. agree ¼ equitable If a woman cannot use a FP method without side effects, her partner should use a method. agree ¼ equitable Women’s rights In my opinion, a woman can suggest using condoms like a man can. agree ¼ equitable The woman has the right to decide to use contraceptives because she is the one who will get pregnant. agree ¼ equitable The woman can decide what type of contraceptive to use because she is the one who will use it. agree ¼ equitable a b
Scale developed by Sidney Ruth Schuler, Senior Advisor for Research and Gender. One point is assigned for each equitable response and points are summed to derive equity score.
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constructive male engagement; ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (yes ¼ inequitable) measured male dominance in family planning decision-making; and ‘If your church says you should use only natural family planning methods, you should follow that’ (yes ¼ inequitable) measured respect for a patriarchal institution. One point was given for each response that indicated an equitable attitude and zero for an inequitable or partially equitable attitude. After all responses were tallied, points were summed to create a continuous gender equity score for each individual, at baseline and at follow-up. The individuals who expressed the most gender-equitable attitudes thus accumulated the greatest number of points. The two other outcome variables were knowledge of modern contraceptive methods and modern contraceptive use. To measure knowledge, respondents were asked what modern contraceptive methods they knew about, first unprompted, then prompted. For each method named, the respondent received a point. Points were summed to create a continuous knowledge variable. A dichotomous contraceptive knowledge variable was also created, with the cut-off point based on the distribution of the summed knowledge variable: knowledge of five or more modern methods. Modern contraceptive use was measured using a dichotomous variable indicating whether or not the respondent was currently using a modern contraceptive method; these included tubal ligation, vasectomy, oral contraceptive pills, emergency contraceptive pills, IUDs, injectables, implants, male and female condoms and spermicide gel. Survey implementation The baseline survey was administered by APAES to all participants in the intervention and in the control group. It was administered verbally, face-to face, in Spanish or in a Mayan dialect, depending on the preference and language ability of the respondent. The duration was approximately 45 minutes. The follow-up survey was conducted about 2 months after the baseline survey in each site. A total of 1122 interviews were completed in the baseline survey, and 603 individuals were re-interviewed for the follow-up survey. To qualify for the follow-up survey in the intervention sites, the potential respondent had to have been interviewed in the baseline survey and participated in at least one of the workshops. Using these criteria, it was possible to re-interview 55.4% (328) of the baseline sample. Among those not interviewed, 10% had participated in the workshops but either refused a second interview or were not available for re-interview, and 35% did not participate in any of the workshops. In the control group, where workshops had not yet been held, 59% (275) of the baseline sample were re-interviewed in the follow-up survey. Data analysis The programs SPSS v.21 and SAS v.9.3 were used to analyse the survey data. Variables measuring gender attitudes and contraceptive knowledge and use were compared within the intervention and control groups, and levels of change were compared between the groups. In descriptive bivariate analyses of the individual items in the GAFPE Scale, differences in the level of change – positive and negative ‘equity points’ – were calculated by subtracting the mean scores of the control group from those of the intervention group.
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Negative numbers indicated that the intervention group had fewer equity points than the control group or that control group scores dropped by fewer points than the intervention group between baseline and follow-up. Positive numbers show gains in equity points for the intervention group, relative to the control group. An aggregate GAFPE indicator for each respondent was created by summing the equity points for the individual items. Tests of significance were conducted using mixed effect models. A linear mixed model was used to assess changes in the aggregate GAFPE indicator, and a logistic mixed model was used for contraceptive knowledge and use, as these were measured dichotomously. Models included random effects to account for the community-level randomization and repeated measures per participant. Study group (i.e. intervention and control) and time of the assessment (i.e. baseline and follow-up) were included as fixed effects in the model. No additional covariates were included since time-invariant factors as well as unobserved heterogeneity are controlled for when the interest is on the comparison of change in outcomes between the study groups (i.e. difference in difference) and the same individuals are followed up (i.e. panel data) (Cheng, 2003). The analysis for contraceptive use included non-pregnant women only. Since the focus of this study is on the assessment of changes, the analysis was restricted to participants interviewed at both baseline and follow-up. Results On average, 66% of those recruited (395/600) in the intervention group attended a session. In addition, a few people who did not initially register later joined. A total of 1122 interviews were completed in the baseline survey and 603 re-interviewed in the followup. In an analysis of drop-outs at baseline, Table 2 presents a comparison of participant characteristics between those who completed both surveys and those who dropped out. More males than females dropped out in both study groups, while participants with higher numbers of children completed the surveys significantly more in the intervention than in the control group. Differences between the drop-outs and those completing the surveys were also noted in the religion distribution in the control group. Participant characteristics at baseline At baseline, the intervention group was slightly older, somewhat less educated and had more children than the control group (Table 2). The mean age of participants in the intervention group was 31, and 29 in the control group. On average, the men were 2 years older than the women (not shown). The mean number of living children per couple was 3.0 in the intervention group and 2.2 in the control group. In addition, 10.1% of the women in the intervention group and 9.6% in the control group were pregnant. A little over 50% of the respondents in the intervention group and 57% of those in the control group were Catholic; 38% and 31%, respectively, were Evangelical. The remainder said they did not attend a particular church. Slightly over half of the participants in both groups considered themselves to be indigenous (Mayan). Spanish was as predominant as native languages, spoken by 55% of the participants. Kakchiquel and Quiche were the respective languages of 15% and 1%.
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Table 2. Socio-demographic characteristics and analysis of drop-outs compared with participants, by group at baseline, Guatemala Intervention group Characteristic Mean age Age group 44 Gender Female Male Religion Catholic Evangelical Other Mean years of schooling None Primary (partial or complete) Partial secondary Complete secondary or some university Indigenous ethnic group Mean number of children
Drop-outs (n ¼ 269)
Participants (n ¼ 328)
Control group Drop-outs (n ¼ 213)
Participants (n ¼ 275)
30.2
30.7
29.5
28.6
5.9% 21.9% 43.5% 22.3% 6.3%
3.7% 19.8% 46.0% 25.9% 4.6%
5.6% 23.9% 45.1% 23.5% 1.9%
5.1% 26.9% 48.0% 17.8% 2.2%
42.8% 57.2%
57.0% 43.0%
(89) 41.8% (124) 58.2%
54.2% 45.8%
44.2% 37.9% 17.8% — 14.1% 53.2% 19.0% 13.8%
50.3% 38.4 11.3% 5.4 15.5% 54.9% 15.5% 14.0%
(96) 45.1% (87) 40.8% (30) 14.1% — (23) 10.8% (91) 42.7% (50) 23.5% (49) 23.0%
57.1% 30.5% 12.4% 6.3 11.6% 48.0% 24.0% 16.4%
— 2.4
54.9% 3.0
— 2.5
52.0% 2.2
Gender equity scores In the baseline survey, women in both the intervention group and the control group had considerably higher gender equity scores than the men (Table 3). Both men and women in the control group had significantly higher scores than their counterparts in the intervention group. In the follow-up survey, the scores of both women and men in the intervention group increased; men’s scores registered a more dramatic gain, but remained slightly below those of the women. In the control group, men’s mean score did not change, while women’s mean score dropped by more than one point, to a level slightly below that of the men. Although the scores of both women and men in the control group started at considerably higher levels than the scores of the intervention group, the follow-up survey scores of women in the intervention group exceeded those of women in the control group, and the scores of men in the intervention group nearly caught up with those in the control group. Table 3 also shows that there were no significant differences between participants and drop-outs in the intervention group, but that both male and female drop-outs from the control group had significantly lower scores than participants.
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a
Table 3. Mean scores on GAFPE Scale, by group at baseline and follow-up, Guatemala Intervention group Mean GAFPE score Baseline Follow-up
Women
Control group Men
Women
Men
Drop-outs (n ¼ 115)
Participants (n ¼ 187)
Drop-outs (n ¼ 154)
Participants (n ¼ 141)
Drop-outs (n ¼ 89)
Participants (n ¼ 149)
Drop-outs (n ¼ 124)
Participants (n ¼ 126)
14.8 NA
14.7 14.9
14.0 NA
13.5 14.6
14.6 NA
15.3* 14.5
13.9 NA
14.7* 14.7
a The lowest possible value on this scale is 0 and the highest possible value is 20. There were no significant differences between participants and drop-outs in the intervention group. In the control group, the scores of both male and female participants were significantly higher than those of the drop-outs ( p < 0.05).
There was considerable variation between baseline and follow-up in the responses across the 20 individual components of the GAFPE Scale (Table 4). The control group showed a greater increase in the percentage of equitable responses on some variables, and the intervention group on others; the percentages of equitable responses went down for some items. For the women in the intervention group, the greatest percentage change in a positive (equitable) direction relative to the control group was observed for the statement: ‘You don’t talk about sex, you just do it’. The percentage of equitable responses in the control group fell 22.2% points, while it increased 4.3% points in the intervention group (26.5 percentage point difference between the groups). The second comparative gain for women in the intervention group was on the statement: ‘It is a man’s responsibility to make sure his wife will not get pregnant if she does not want to’ (11.6 percentage points). The next largest comparative gain for women in the intervention group was on two statements addressing men’s and women’s roles in decisionmaking relating to fertility and contraception: ‘The man is the one with the power to impregnate, so he should decide whether to use contraceptives’ (10.8 percentage points) and ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (10.6 percentage points). The greatest gains among men in the intervention group compared with the control group were on statements on mutual decision-making: ‘It is the husband who should decide how many children to have, since he is the one who has to support them’ (23.3 percentage point change in equitable direction); contraceptive use and sexual pleasure: ‘Having sex without using contraceptives is more exciting because a woman can get pregnant’ (21.8 percentage points), ‘Having sex using contraception is more exciting because you do not have to worry about pregnancy’ (18.8 percentage points); and men’s responsibility to use condoms if a partner experiences side-effects from contraceptive methods: ‘If a woman cannot use a family planning method without side-effects, her partner should use a method’ (14.5 percentage points). The next largest comparative gain was on the statement about following church teachings on the use of contraception: ‘If your church says you should use only natural family planning methods, you should follow that’ (10.5 percentage points). There was no item on which women or men in the control group had a percentage gain in the equitable direction of 10% or more relative to the intervention group.
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Table 4. GAFPE Scale statements, percentage change in equitable responses from baseline to follow-up, by group and gender, Guatemala Intervention group GAFPE Scale statements Couple communication and mutuality You don’t talk about sex, you just do it! A couple should decide together if they want to have children, and how many children they want. If a man gets a woman pregnant, the child is the responsibility of both. It is the responsibility of both the man and the woman to avoid pregnancy. Having sex using contraception is more exciting because you do not have to worry about pregnancy. A man and a woman should decide together what contraceptive method they will use. Patriarchal norms Contraceptive use makes it easier for a woman to have more than one sexual partner. I would get mad if my wife/female partner asked me to use condoms./My husband/ male partner would be justifiably angry if I asked him to use condoms. Having sex without using contraceptives is more exciting because a woman can get pregnant. The man is the one with the power to impregnate, so he should decide whether to use contraceptives. It is the husband who should decide how many children to have, since he is the one who has to support them. If your church says you should use only natural methods of family planning, you should follow that. Male responsibility It is man’s responsibility to make sure his wife will not get pregnant if she does not want to. A man should not have sex without knowing if his partner wants to get pregnant. If a woman does not want to get pregnant and is not using contraceptives, her partner should do so.
Women (n ¼ 187)
Control group
Men (n ¼ 141)
Women (n ¼ 149)
Men (n ¼ 126)
4.3 3.7
2.9 0.7
22.2 2.0
4.0 2.4
3.8
0.7
0.6
1.6
0.5
5.6
0.7
0.8
5.3
9.2
0.0
9.6
0.5
4.3
0.0
3.1
1.6
0.8
0.0
3.1
0.5
11.3
1.3
6.4
8.1
10.7
10.8
11.1
7.5
9.2
3.3
11.1
3.2
17.7
7.4
5.6
0.6
12.1
5.4
1.6
0.5
2.9
12.1
5.5
0.6
16.4
5.4
8.7
1.1
7.8
6.0
7.9
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Table 4. (Continued) Intervention group Women (n ¼ 187)
GAFPE Scale statements If a woman experiences side-effects from using a family planning method, her husband or partner should help her find a method that suits her better. If a woman cannot use a family planning method without side-effects, her partner should use a method. Women’s rights In my opinion, a woman can suggest using condoms like a man can. The woman has the right to decide to use contraceptives because she is the one who will get pregnant. The woman can decide what type of contraceptive to use because she is the one who will use it.
Men (n ¼ 141)
Control group Women (n ¼ 149)
Men (n ¼ 126)
0.0
4.3
0.7
0.0
4.3
17.7
4.7
3.2
3.8
5.0
2.7
10.3
1.1
0.7
3.4
8.8
7.5
4.2
0.6
6.3
Table 5. Linear mixed model estimates of intervention effect on gender attitudes, Guatemala
Women (n F 334) Intervention group: FU–Baseline Control group: FU–Baseline Difference in difference Men (n F 267) Intervention group: FU–Baseline Control Group: FU–Baseline Difference in Difference
Estimates
95% CI
0.18 0.79 0.96
[0.22, 0.58] [1.23, 0.34] [0.36, 1.57]
1.10 0.00 1.10
[0.64, 1.56] [0.49, 0.49] [0.43, 1.77]
p-value 0.370 0.001 0.003
