Assessing the Impact of CHARM2, a Family Planning Program on Gender Attitudes, Intimate Partner Violence, Reproductive Coercion, and Marital Quality in India

"CHARM2 shows promise in improving men's and women's attitudes towards gender equality and male perceptions of marital quality."

Men's gender attitudes and engagement in family planning can play a crucial role in improving women's health outcomes in low- and middle-income countries (LMICs). In patriarchal societies like India, men can often be the chief decision-makers and influence women's access to reproductive and maternal healthcare. Using a two-armed cluster randomised controlled trial (RCT), CHARM2 (Counselling Husbands to Achieve Reproductive health and Marital equity), a 5-session gender equity (GE) and family planning (FP) intervention for couples in rural India, showed an impact on FP outcomes in primary trial analyses. This study examines its effects on gender-equitable attitudes, intimate partner violence (IPV), reproductive coercion (RC), and marital quality.

As detailed at Related Summaries, below, the CHARM2 intervention was implemented in the Junnar block of the Pune district in Maharashtra, India, between September 2018 and November 2018. Participants included male-female couples in which women were 18-29 years. Counselling sessions were delivered over four to six months, with one month between sessions, and were held at the health provider's office or at the participants' home. GE elements of the programme included dialogue on the importance of respect for women and girls, social norms related to son preference, and the effect male dominance and marital violence can have on healthy and positive marital dynamics and the health of women and children.

The researchers used multilevel mixed-effects models to assess the intervention impact on each outcome. Both male (adjusted incidence rate ratio (aIRR) at 9 months: 0.64, confidence interval (CI): 0.45, 0.90; aIRR at 18 months: 0.25, CI: 0.18, 0.39) and female (aIRR at 9 months: 0.57, CI: 0.46, 0.71; aIRR at 18 months: 0.38, CI.: 0.23, 0.61) intervention participants were less likely than corresponding control participants to endorse attitudes accepting physical IPV at 9- and 18-month follow-ups. Men in the intervention, compared to those in the control condition, reported more gender-equitable attitudes at 9 and 18 months (ß at 9 months: 0.13, CI: 0.06, 0.20; ß at 18 months: 0.26, CI: 0.19, 0.34) and higher marital quality at the 18-month follow-up (ß: 0.03, CI: 0.01, 0.05).

Reflecting on these findings, the researchers note that CHARM2 encouraged participants to reflect on gender inequalities and traditional social norms underlying IPV, RC, and son preference and emphasised the importance of shared decision-making and healthy communication for a happy married life. These factors may have led to a shift in attitudes towards more egalitarian gender norms.

However, the researchers found no effects on women's experiences of IPV, RC, or marital quality. Per the researchers, it could be the case that additional sessions were needed to translate attitudinal change into behavioural change. CHARM2 included content on sexual violence in only two of five sessions (one session each for men and women separately), and a higher dosage may have extended the intervention's impact on behaviours. It is also possible that the content of the intervention needs to be modified to include explicit discussions of power and privilege underlying gender-based violence and more opportunities for critical reflection to achieve impact on IPV and RC. Other explanatory factors for the lack of findings in these areas include the low prevalence of IPV among these young couples (vs. older couples, where IVP is more prevalent), leading to a ceiling effect, as well as the stressors associated with the COVID-19 pandemic.

In conclusion: "CHARM2 provides a template for programming on gender-equitable attitudes that healthcare professionals could implement. Future studies can test the effectiveness of the intervention in improving gender-equitable attitudes in urban areas in India."