Gender-transformative Bandebereho Couples' Intervention to Promote Male Engagement in Reproductive and Maternal Health and Violence Prevention in Rwanda: Findings from a Randomized Controlled Trial

"...culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched inequalities and a range of health-related behavioral outcomes."

Male engagement interventions have evolved from seeking to involve men to overcome specific barriers, such as women's access to health care, to be increasingly gender transformative. However, rigorous evidence of the effectiveness of these interventions, particularly on how these interventions impact relationship power dynamics and women's decision-making, remains limited, especially in low- and middle-income countries (LMICs). Conducted in Rwanda, this randomised controlled trial (RCT) assessed the impact of Bandebereho (meaning "role model" in Kinyarwanda), a gender-transformative couples' intervention, on multiple behavioural and health-related outcomes influenced by gender norms and power relations.

The Bandebereho intervention engaged men and their partners in participatory, small group sessions of critical reflection and dialogue, with the goal of transforming norms around masculinity by demonstrating positive models of fatherhood. The Rwanda Men's Resource Center (RWAMREC), a local Rwanda non-governmental organisation (NGO), implemented the intervention as part of MenCare+, a 4-country initiative coordinated by Rutgers and Promundo and financed by the Dutch Ministry of Foreign Affairs. The intervention used a structured 15-session curriculum adapted from Program P, an open-source manual for engaging men in maternal and child health created by Promundo, CulturaSalud, and REDMAS, which includes a curriculum for fathers/couples and resources for designing health provider training and community campaigns.

Sessions addressed: gender and power; fatherhood; couple communication and decision-making; intimate partner violence (IPV); caregiving; child development; and male engagement in reproductive and maternal health. The sessions aimed to create a structured space for men and women to: (i) question and critically reflect on gender norms and how these shape their lives; (ii) rehearse equitable and non-violent attitudes and behaviours in a comfortable space with supportive peers; and (iii) internalise these new gender attitudes and behaviours and apply them in their own lives and relationships.

Couples were recruited from local communities in Karongi, Musanze, Nyaruguru and Rwamagana districts in Rwanda from February 19 to March 17 2015 and followed over a period of 21 months for this study. Expectant/current fathers and their partners were randomised to the intervention (n = 575 couples) or control group (n = 624 couples).

The study found that the Bandebereho intervention led to substantial improvements in multiple reported outcomes. Compared to the control group, women in the intervention group reported: less past-year physical (odds ratio (OR) 0.37, p<0.001) and sexual IPV (OR 0.34, p<0.001); and greater attendance (incidence rate ratio (IRR) 1.09, p<0.001) and male accompaniment at antenatal care (ANC) (IRR 1.50, p<0.001). In addition, women and men in the intervention group reported: less child physical punishment (women: OR 0.56, p = 0.001; men: OR 0.66, p = 0.005); greater modern contraceptive use (women: OR 1.53, p = 0.004; men: OR 1.65, p = 0.001); and higher levels of men's participation in childcare and household tasks (women: beta 0.39, p<0.001; men: beta 0.33, p<0.001).

Furthermore, the intervention reduced men's dominance in household decision-making, which is associated with negative health-related outcomes for women and children. In the intervention group, 56.08% of women (OR 0.31, 95% confidence interval (CI) 0.24-0.42, p<0.001) and 45.47% of men (OR 0.35, 95% CI 0.25-0.48, p<0.001) reported that the man had the final say on decisions regarding the household's income and expenses, compared to 78.74% and 70.27% in the control group, respectively. For decisions about having children or the spacing of children, 34.91% of women (OR 0.57, 95% CI 0.45-0.72, p<0.001) and 31.94% of men (OR 0.48, 95% CI 0.36-0.63, p<0.001) in the intervention group reported that the man had the final say, compared to 47.81% and 49.03% in the control group, respectively. These findings "suggest that by emphasizing joint decision-making through skills-based activities and by creating spaces for couple communication, the intervention was successful at targeting underlying, unequal gendered power dynamics."

The researchers note that, while the findings "show substantial positive effects, high rates of inequality and violence persist: about one in three women in the intervention group reported experiencing IPV in the past 12 months, the vast majority of parents used physical punishment, and men still dominated household decisions. Further research should examine whether these rates can be lowered if the intervention is implemented over longer time periods or with additional components. Future research could also directly measure health outcomes and use health facility or biomarker data to corroborate self-reported behavior change, and examine the effect of the intervention if implemented over longer time periods, when implemented with greater numbers and in other settings, or when delivered through the public sector."

All that said, "the findings highlight the promise of the Bandebereho intervention, designed and adapted to fit the particular cultural context. Targeting the transition into fatherhood and parenting, and supporting couples with skills to make their relationships stronger and more equitable, had important effects on the intervention outcomes."