"The burden is upon your shoulders to feed and take care of your children, not religion or culture": qualitative evaluation of participatory community dialogues to promote family planning's holistic benefits and reshape community norms on family success in rural Uganda.

BACKGROUND: Family planning has significant health and social benefits, but in settings like Uganda, is underutilized due to prevalent community and religious norms promoting large family size and gender inequity. Family Health = Family Wealth (FH = FW) is a multi-level, community-based intervention that used community dialogues grounded in Campbell and Cornish's social psychological theory of transformative communication to reshape individual endorsement of community norms that negatively affect gender equitable reproductive decision-making among couples in rural Uganda. METHODS: This study aimed to qualitatively evaluate the effect of FH = FW's community dialogue approach on participants' personal endorsement of community norms counter to family planning acceptance and gender equity. A pilot quasi-experimental controlled trial was implemented in 2021. This paper uses qualitative, post-intervention data collected from intervention arm participants (N = 70) at two time points: 3 weeks post-intervention (in-depth interviews, n = 64) and after 10-months follow-up (focus group discussions [n = 39] or semi-structured interviews [n = 27]). Data were analyzed through thematic analysis. RESULTS: The community dialogue approach helped couples to reassess community beliefs that reinforce gender inequity and disapproval of family planning. FH = FW's inclusion of economic and relationship content served as key entry points for couples to discuss family planning. Results are presented in five central themes: (1) Community family size expectations were reconsidered through discussions on economic factors; (2) Showcasing how relationship health and gender equity are central to economic health influenced men's acceptance of gender equity; (3) Linking relationship health and family planning helped increase positive attitudes towards family planning and the perceived importance of shared household decision-making to family wellness; (4) Program elements to strengthen relationship skills helped to translate gender equitable attitudes into changes in relationship dynamics and to facilitate equitable family planning communication; (5) FH = FW participation increased couples' collective family planning (and overall health) decision-making and uptake of contraceptive methods. CONCLUSION: Community dialogues may be an effective intervention approach to change individual endorsement of widespread community norms that reduce family planning acceptance. Future work should continue to explore innovative ways to use this approach to increase gender equitable reproductive decision-making among couples in settings where gender, religious, and community norms limit reproductive autonomy. Future evaluations of this work should aim to examine change in norms at the community-level. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04262882).

Effects of a community-based, multi-level family planning intervention on theoretically grounded intermediate outcomes for couples in rural Uganda: Results from a mixed methods pilot evaluation.

OBJECTIVES: This study tested the theoretically grounded conceptual model of a multi-level intervention, Family Health = Family Wealth (FH = FW), by examining FH = FW's effect on intermediate outcomes among couples in rural Uganda. FH = FW is grounded in the social-ecological model and the social psychological theory of transformative communication. DESIGN: A pilot quasi-experimental controlled trial. METHODS: Two matched clusters (communities) were randomly allocated to receive the FH = FW intervention or an attention/time-matched water, sanitation and hygiene intervention (N = 140, 35 couples per arm). Quantitative outcomes were collected through interviewer-administered questionnaires at baseline, 7-months and 10-months follow-up. Focus group discussions (n = 39) and semi-structured interviews (n = 27) were conducted with subsets of FH = FW participants after data collection. Generalized estimated equations tested intervention effects on quantitative outcomes, and qualitative data were analysed through thematic analysis-these data were mixed and are presented by level of the social-ecological model. RESULTS: The findings demonstrated an intervention effect on family planning determinants across social-ecological levels. Improved individual-level family planning knowledge, attitudes and intentions, and reduced inequitable gender attitudes, were observed in intervention versus comparator, corroborated by the qualitative findings. Interpersonal-level changes included improved communication, shared decision-making and equitable relationship dynamics. At the community level, FH = FW increased perceived acceptance of family planning among others (norms), and the qualitative findings highlighted how FH = FW's transformative communication approach reshaped definitions of a successful family to better align with family planning. CONCLUSIONS: This mixed methods pilot evaluation supports FH = FW's theoretically grounded conceptual model and ability to affect multi-level drivers of a high unmet need for family planning.

Gender Role Discrepancy Stress and COVID-19 Prevention Behaviors Among Men in the United States.

PURPOSE: To examine the associations between gender role discrepancy (non-conformity to socially prescribed masculine gender role norms) and discrepancy stress (distress arising from this discrepancy) on COVID-19 prevention behaviors among men, and the potential moderating effects of race/ethnicity, sexual orientation, and income on these relationships. DESIGN: A national online survey was conducted between May and June 2021. SETTING: The United States. SUBJECTS: 749 adult men residing in the United States. MEASURES: A scale measured gender role discrepancy and discrepancy stress. COVID-19 prevention outcomes were constructed and included self-reported vaccination status/intentions, social distancing, mask-wearing, and hand-sanitizing. ANALYSIS: Multivariate generalized linear models were performed in SPSS. RESULTS: Gender role discrepancy associated with greater odds of vaccination (AOR = 1.35, 95% CI = 1.02-1.78, P = .04), while discrepancy stress associated with lower odds of vaccination (AOR = .48, 95% CI = .35-.68, P < 0. 001) and mask-wearing (AOR = .54, 95% CI = .37-.79, P = .001) for men overall. Discrepancy stress's negative effect on specific COVID-19 prevention behaviors was only apparent or was amplified for men in lower income brackets (vaccination, social distancing, mask-wearing), racial/ethnic minority men (vaccination), and sexual minority men (social distancing). CONCLUSION: This study demonstrates that gender role discrepancy stress negatively affects men's engagement in COVID-19 prevention, particularly for men in marginalized populations.

Mechanisms Linking Masculine Discrepancy Stress and the Perpetration of Intimate Partner Violence Among Men in the United States.

Although studies show that masculine discrepancy stress (i.e., the intrapsychic strain associated with failing to meet internalized masculine ideals) is associated with intimate partner violence (IPV) perpetration, little is known about the processes underlying this association. There may be other social psychological constructs at play that explain this relationship further. The present study uses recently collected data from a national survey of men living in the United States (n = 711) to formally test whether the effects of discrepancy stress on three different forms of IPV perpetration are mediated by anger, self-esteem, and perceived powerlessness. We find that discrepancy stress is directly associated with higher levels of anger, lower levels self-esteem, a sense of powerlessness, and a greater odds of perpetrating any physical IPV and severe physical IPV resulting in injuries, but not sexual IPV perpetration in our sample of men. Our mediation analyses confirms that masculine discrepancy stress is indirectly associated with perpetrating all three forms of IPV through the mechanism of anger. Self-esteem and perceived powerlessness are not supported as mediators. These findings add to our understanding of the link between masculinity and violence perpetration and can inform IPV reduction interventions. Gender transformative interventions that reduce discrepancy stress among men by shifting men's adherence to traditional masculine norms, and that integrate anger management strategies, should be explored in future research.