Long-term impacts of the Bandebereho programme on violence against women and children, maternal health-seeking, and couple relations in Rwanda: a six-year follow-up of a randomised controlled trial.

Background: Programmes that work with parents to build couple relationship and parenting skills and include critical reflection on gender norms are a promising approach for reducing violence against women and children. However, there is limited evidence of their longer-term impact. In Rwanda, the Bandebereho programme engaged expectant and current parents of children under five years. At 21-months, Bandebereho demonstrated positive impacts on intimate partner violence (IPV), child physical punishment, maternal health-seeking, and couple relations. This study seeks to explore whether those outcomes are sustained six years later. Methods: A six-year follow-up to a two-arm, multi-site randomised controlled trial was conducted in four districts of Rwanda between May and September 2021. At baseline, couples were randomly assigned to either the 15-session intervention (n = 575) or a control group (n = 624). At this follow-up, 1003 men and 1021 women were included in intention to treat analysis. Generalised estimating equations with robust standard errors were used to fit the models. This study was registered with Clinicaltrials.gov (NCT04861870). Findings: Bandebereho has lasting effects on IPV and physical punishment of children, alongside multiple health and relationship outcomes. Compared to the control group: intervention women report less past-year physical (OR = 0.45, 95% CI 0.34-0.60 p < 0.001), sexual (OR = 0.50, 95% CI 0.37-0.67, p < 0.001), economic (OR = 0.47 95% CI 0.34-0.64, p < 0.001), and moderate or severe emotional (OR = 0.40 95% CI 0.29-0.56, p < 0.001) IPV. Intervention couples report less child physical punishment (OR = 0.72, p = 0.009 for men; OR = 0.68, p = 0.017 for women), fewer depressive symptoms (OR = 0.52, p < 0.001 for men; OR = 0.50, p < 0.001 for women), less harmful alcohol use, and improved maternal health-seeking, father engagement, and division of household labour and decision-making. Interpretation: Our study expands the evidence, demonstrating that programmes engaging men and women to promote collaborative and non-violent couple relations can result in sustained reductions in family violence six years later. Funding: The Echidna Giving Fund, Grand Challenges Canada, the Oak Foundation, and Wellspring Philanthropic Fund supported this study.

Implementing Interventions to Address Gender and Power Inequalities in Early Adolescence: Utilizing a Theory of Change to Assess Conditions for Success.

PURPOSE: To create a set of criteria to assess facilitators and barriers to implementation among gender transformative interventions that target very young adolescents (VYAs) across different cultural settings. METHODS: Interventionists and researchers involved in the Global Early Adolescent Study created a Theory of Change (ToC) based on summarizing intervention components from five different gender transformative intervention curricula. Embedded within the ToC is a set of criteria labeled, 'Conditions of Success' which were developed to illustrate that change cannot happen unless interventions are implemented successfully. To test the feasibility of these criteria, implementation data collected across the five interventions in Global Early Adolescent Study were mapped onto the 'Conditions for Success' criteria and used to identify common facilitators and barriers to implementation. RESULTS: Using the 'Conditions for Success' criteria, we found that gender transformative interventions targeting VYAs were most challenged in meeting program delivery and facilitation conditions and needed to build more multisectoral support to shift rigid gender norms. Parents and caregivers also needed to be engaged in the program either as a separate target population or as codesigners and implementers for the interventions. DISCUSSION: The Conditions for Success criteria provide a useful framework for assessing facilitators and barriers to implementation among gender transformative interventions for VYAs. Additional research is underway to examine whether interventions that meet more conditions of success result in greater program impact, which will be used to further refine the overall ToC.

Optimizing the Construction of Outcome Measures for Impact Evaluations of Intimate Partner Violence Prevention Interventions.

Most impact evaluations of intimate partner violence (IPV) prevention interventions use binary measures of "any" versus "no" physical and/or sexual IPV as their primary outcome measure, missing opportunities to capture nuance. In this study, we reanalyzed secondary data from six randomized controlled trials conducted in low- and middle-income countries-Bandebereho (Rwanda), Becoming One (Uganda), Indashyikirwa (Rwanda), MAISHA CRT01, MAISHA CRT02 (Tanzania), Stepping Stones Creating Futures (South Africa), and Unite for a Better Life (Ethiopia), to assess how different conceptualizations and coding of IPV variables can influence interpretations of the impact of an intervention. We compared the standard outcome measures to new measures that reflect the severity and intensity of violence and whether interventions prevent new cases of IPV or reduce or stop ongoing violence. Results indicate that traditional binary indicators masked some of the more subtle intervention effects, and the use of the new indicators allowed for a better understanding of the impacts of the interventions. Conclusions on whether a program is perceived "to work" are highly influenced by the IPV outcomes that the investigators choose to report, and how they are measured and coded. Lack of attention to outcome choice and measurement could lead to prematurely abandoning strategies useful for violence reduction or missing essential insights into how programs may or may not affect IPV. While these results must be interpreted cautiously, given differences in intervention types, the underlying prevalence of violence, sociodemographic factors, sample sizes, and other contextual differences across the trial sites, they can help us move toward a new approach to reporting multiple outcomes that allow us to unpack the "impact" of an intervention by assessing intervention effect by the severity of violence and type of prevention, whether primary and secondary.

Improved Relationship Quality, Equitable Gender Attitudes, and Reduced Alcohol Abuse as Key Mechanisms to Reduce Intimate Partner Violence in the Bandebereho Couples' Randomized Trial in Rwanda.

Over the past decade, there has been rapid growth in the evidence for programs to prevent or reduce intimate partner violence (IPV)-the most common form of men's violence against women. IPV interventions targeting heterosexual couples have shown significant impact. However, our understanding of how these interventions achieve their impacts on violence-the mechanisms through which change occurs-remains limited. Using data from two follow-up rounds of a randomized controlled trial of the Bandebereho intervention in Rwanda, we constructed conceptually driven structural equation models to represent the processes by which hypothesized mediating variables linked treatment assignment to IPV. We found significant differences in the expected direction between the intervention and control participants on all mediating variables, including men's alcohol use, communication frequency, emotional closeness, frequency of quarreling, and men's attitudes related to gender and violence. Several mechanisms-more positive couple dynamics including emotional closeness and communication frequency; men's gender-equitable attitudes; men's alcohol use-accounted for the largest proportions of the effect of assignment to the Bandebereho intervention on IPV. Overall, our findings highlight that no one particular component is driving the reductions in violence; instead, the multiple components and pathways account for the intervention's effects, suggesting that the holistic nature of the intervention may be integral to its positive impact. The Bandebereho trial from which data was used in this analysis was registered on ClinicalTrials.gov prior to completion ( NCT02694627 ).

Associations of attitudes and social norms with experiences of intimate partner violence among married adolescents and their husbands in rural Niger: a dyadic cross-sectional study.

BACKGROUND: Prior cross-sectional research suggests that both men's and women's attitudes towards intimate partner violence (IPV) are predictive of women's IPV experience, although this can vary greatly by context. In general, women who have experienced IPV are likely to report attitudes accepting of it. Men who perpetrate IPV may also report attitudes accepting of it, although some research has found that there is not always an association. Studies that investigate these dynamics often conflate attitudes with social norms, or use attitudes as a proxy for social norms, given that valid measures on social norms are usually lacking. Here we conduct a secondary data analysis to ask how are men's and women's IPV-related attitudes associated with women's reports of IPV and how are men's and women's perceived social norms associated with women's reports of IPV. METHODS: Dyadic data were collected from a representative sample of married adolescent girls and their husbands in 48 rural villages of the Dosso region of Niger (N = 1010). Assessments included logistic regression analyses of husbands' and wives' reports of individual attitudes towards IPV, and social norms based on husbands' and wives' perceptions of their communities' beliefs related to gender roles and acceptability of IPV. RESULTS: Eight percent of women in this sample reported IPV. We found that, consistent with other research, wives who have reported IPV are more likely to report attitudes in support of IPV, while for husbands whose wives report IPV, that relationship is insignificant. On the other hand, husbands who report that people in their community believe there are times when a woman deserves to be beaten are more likely to have perpetrated IPV, while for wives there is no association between the community norm and IPV reporting. Finally, wives who report that people in their community hold inequitable gender norms in general are more likely to have experienced IPV, while for husbands, community gender norms are not predictive of whether their wives have reported IPV. CONCLUSIONS: Our results are evidence that IPV prevention interventions focused solely on individual attitudes may be insufficient. Targeting and assessment of social norms are likely critical to advancing understanding and prevention of IPV.

Quantitative Proxies for Social Norms: A Proposed Approach for Interrogating Clustering, Reference Groups, and Validity.

A growing number of researchers studying intimate partner violence (IPV) employ aggregate measures of relevant attitudes to serve as proxy measures for norms around IPV. However, there is a lack of consistency in how these measures are constructed and how their validity is confirmed. The first aim of this study is to demonstrate and validate innovative techniques for exploring social norms proxies in quantitative data and identifying the relative appropriateness of different available reference groups. The second aim is to demonstrate how such an approach can contribute to IPV research. The analysis employed data from the 2016 Tanzania International Men and Gender Equality Survey, including 1008 men and 1008 women ages 15-49 years. An attitudinal score measuring acceptance of IPV and two measures for individual-level descriptive and injunctive norms were constructed. The intraclass correlation coefficient (ICC) was used to assess the extent of clustering for the attitudinal score within several sets of groupings. Bivariate multi-level Ordinary Least Squares regressions estimated the predictive effect of an individual's group norm proxy on their descriptive or injunctive norms. Attitudinal clustering was most significant for reference groups defined as males only across villages and males only across a combination of villages and marital status, with ICCs of 0.229 and 0.236, respectively. Men's social norms were found to be correlated with reference groups comprised of both men only and women only, though men's norms were substantially more correlated with the attitudes of men in their reference group than with women's. Results highlight the importance of critically examining the validity of proxy measures for social norms prior to their inclusion in analysis. Findings also underscore the importance of collecting attitudinal data from men to better understand norms around IPV.

Measuring social norms and attitudes about age-disparate transactional sex: Psychometric testing of the NAATSS.

Background: Transactional sex between girls under 18 years-old and adult men at least ten years older, known as age-disparate transactional sex (ADTS), is an established risk factor for HIV, STI and early pregnancy among girls and women. Social norms or beliefs about what others expect from you and what others do can sustain behaviours such as ADTS even when individuals may be personally against them. In order to evaluate interventions to change social norms, validated instruments for measuring change in personal beliefs and social norms regarding ADTS are needed. Methods: Items for the Norms and Attitudes on Age-Disparate Transactional Sex Scale (NAATSS) were generated based on qualitative interviews and expert panel review. The reliability and validity of the NAATSS was tested in a representative sample (N = 431) from Brazilian favelas. Factor analysis assessed construct validity, Cronbach's alpha assessed reliability, and t-tests and analysis of variances tested hypothesized differences between gender, age, and previous experience with ADTS in both the social norms and personal beliefs domains. Findings: Factor analysis revealed three factors in each domain. The factors were labelled "Attributions to Girls' Behaviour" which has 5 items, "Men's Motivations" with 5 items, and "Girls' Readiness to have Sex" with 3 items. The subscales evidenced acceptable reliability with Cronbach's alphas ranging from 0.72 to 0.83 for the social norms subscales and 0.59 to 0.82 for the personal beliefs subscales. Interpretation: The items were developed based on qualitative research and expert rankings and the resulting Norms and Attitudes on ADTS Scale exhibits strong psychometric properties. Each of the three subscales within the two domains illustrate good factor structure, acceptable internal consistency reliability, and are supported by the significance of the hypothesized group differences. Funding: This work was supported by the OAK Foundation [grant number OCAY-16-188].

Cost Analysis of Community-Based Violence Prevention Programs: Manhood 2.0 and Job Skills Programs.

Purpose: Sexual violence (SV) and adolescent relationship abuse (ARA) are common in the U. S. and have strong associations with negative health and wellbeing outcomes. Manhood 2.0 is the first U.S. program designed for community settings to build bystander skills while also challenging harmful gender norms. A cluster-randomized trial comparing Manhood 2.0 to Job Skills, a job readiness training control condition, demonstrated that it is a promising strategy to prevent sexual violence and adolescent relationship abuse. Such community-based interventions may be particularly relevant in lower resource urban settings, and the costs of such prevention programs have not been considered previously. Methods: The aim of the present study is to perform systematic and standardized cost calculations associated with implementing Manhood 2.0 among adolescent males. In addition, this study provides detailed cost information of the community-based intervention program, as well as costs associated with implementing the Job Skills control program. Program implementation data were recorded throughout the study period (2015-2019) by the Manhood 2.0 study team. Results: The cost of implementing Manhood 2.0 is $4,771 per complete round of program delivery and $451 per participant, which is approximately the same cost as the control Job Skills program ($4,432 and $453 per participant). The marginal cost per additional round of Manhood 2.0 program is $3,682. Conclusion: Implementation of a community-based program requires substantial resources and collaborations with community partners especially in economically disadvantaged neighborhoods. This study provides a snapshot of the cost information of a community-based intervention program from the implementing agency's perspective, which is essential in helping decision-makers understand the costs they will incur by implementing prevention programs and ensuring program feasibility and sustainability.

Understanding the Relationship Between Adverse Childhood Experiences, Peer-Violence Perpetration, and Gender Norms Among Very Young Adolescents in Indonesia: A Cross-Sectional Study.

PURPOSE: This study assesses the role of gender norms on the relationship between adverse childhood experiences (ACEs) and peer-violence perpetration among very young adolescents in three urban poor cities of Indonesia. METHODS: A cross-sectional study was conducted in Bandar Lampung, Denpasar, and Semarang in Indonesia. A total of 2,974 participants (boys: 44.79%, girls: 55.21%) between 10 and 14 years were included in the analysis. Logistic regression, mediation, and moderation analyses were conducted stratified by sex. RESULTS: Risk factors of peer-violence perpetration among boys and girls included three (boys: adjusted odds ratio [aOR] 2.51, 95% confidence interval [CI] 1.32-4.75; girls: aOR 1.82, 95% CI .95-3.52) and four or more (boys: aOR 6.75, 95% CI 3.86-11.80; girls: aOR 5.37, 95% CI 3.07-9.37) history of ACE. Risk factors of peer-violence perpetration among boys included having inequitable sexual double standard (SDS) indices (aOR 1.46, 95% CI 1.09-1.95). SDS measures the perception boys are rewarded for romantic relationship engagement, whereas girls are stigmatized or disadvantaged for the experience. Other risk factors included lifetime tobacco use among boys and girls and lifetime alcohol use among boys. Protective factors included parental closeness among girls. CONCLUSIONS: Based on the research in three Indonesian communities, this study demonstrates that boys are disproportionately exposed to adversities including history of ACE, inequitable SDS, lifetime alcohol use and tobacco use in comparison to girls. Programs targeting ACE and gender norms which engage boys, girls, and families are more likely to be successful in reducing peer-violence perpetration and promoting gender equitable norms.

The relationship between inequitable gender norms and provider attitudes and quality of care in maternal health services in Rwanda: a mixed methods study.

BACKGROUND: Rwanda has made great progress in improving reproductive, maternal, and newborn health (RMNH) care; however, barriers to ensuring timely and full RMNH service utilization persist, including women's limited decision-making power and poor-quality care. This study sought to better understand whether and how gender and power dynamics between providers and clients affect their perceptions and experiences of quality care during antenatal care, labor and childbirth. METHODS: This mixed methods study included a self-administered survey with 151 RMNH providers with questions on attitudes about gender roles, RMNH care, provider-client relations, labor and childbirth, which took place between January to February 2018. Two separate factor analyses were conducted on provider responses to create a Gender Attitudes Scale and an RMNH Quality of Care Scale. Three focus group discussions (FGDs) conducted in February 2019 with RMNH providers, female and male clients, explored attitudes about gender norms, provision and quality of RMNH care, provider-client interactions and power dynamics, and men's involvement. Data were analyzed thematically. RESULTS: Inequitable gender norms and attitudes - among both RMNH care providers and clients - impact the quality of RMNH care. The qualitative results illustrate how gender norms and attitudes influence the provision of care and provider-client interactions, in addition to the impact of men's involvement on the quality of care. Complementing this finding, the survey found a relationship between health providers' gender attitudes and their attitudes towards quality RMNH care: gender equitable attitudes were associated with greater support for respectful, quality RMNH care. CONCLUSIONS: Our findings suggest that gender attitudes and power dynamics between providers and their clients, and between female clients and their partners, can negatively impact the utilization and provision of quality RMNH care. There is a need for capacity building efforts to challenge health providers' inequitable gender attitudes and practices and equip them to be aware of gender and power dynamics between themselves and their clients. These efforts can be made alongside community interventions to transform harmful gender norms, including those that increase women's agency and autonomy over their bodies and their health care, promote uptake of health services, and improve couple power dynamics.

The global politics of the age-gender divide in violence against women and children.

Decades of collective and cumulative work by practitioners, activists and researchers have made violence prevention an important part of international development agendas. However, violence prevention and response work addressing women and children has historically been siloed. Those working at the intersection of violence against women (VaW) and violence against children (VaC) have wrestled with the age-gender divide. Addressing the historical and political influences that underpin this divide will likely enhance progress towards more integrated strategies. This paper examines the origins and development of this polarisation and potential strategies for a more coordinated and collaborative agenda. This paper draws on the insights gained from eleven (11) semi-structured interviews conducted with key violence prevention actors in VaW and VaC from across the globe, alongside relevant published literature. Informants were purposively sampled on the basis of their expertise in the field. Findings reveal key differences and tensions between the two fields, including in collection and use of research and evidence, core conceptual frameworks, and the development, funding and implementation of policy and practice. Potential opportunities for future synergies between the two fields are highlighted, particularly through a focus on the adolescent girl.

Harmful masculinities among younger men in three countries: Psychometric study of the Man Box Scale.

In response to growing evidence of associations between harmful masculinities and adverse health outcomes, researchers developed the Man Box Scale to provide a standardized measure to assess these inequitable gender attitudes. In 2019, we evaluated the psychometric properties of the 17-item Man Box Scale and derived a 5-item short form. Using previously collected data (in 2016) from men aged 18-30 years across the United States (n = 1328), the United Kingdom (n = 1225), and Mexico (n = 1120), we conducted exploratory (EFA) and confirmatory factor analyses (CFA), assessed convergent validity by examining associations of the standardized mean Man Box Scale score with violence perpetration, depression, and suicidal ideation, and assessed internal consistency reliability of the full scale. We used item response theory (IRT) to derive a 5-item short form, and conducted CFA and additional assessments for reliability and convergent validity. We identified a single underlying factor with 15 items across all three countries. CFA resulted in good model fit. We demonstrated significant associations of standardized mean Man Box Scale score with violence perpetration (OR range = 1.57-5.49), depression (OR range = 1.19-1.73), and suicidal ideation (OR range = 1.56-2.59). IRT resulted in a 5-item short form with good fit through CFA and convergent validity, and good internal consistency. The Man Box Scale assesses harmful masculinities and demonstrates strong validity and reliability across three diverse countries. This scale, either short or long forms, can be used in future prevention research, clinical assessment and decision-making, and intervention evaluations.

Knowledge, attitudes, and practices related to family planning and gender equity among husbands of adolescent girls in Niger.

Despite having the highest fertility rate in the world, research on Niger men and family planning (FP) is limited. We collected survey data collected in the Dosso region of Niger in 2016 from 1136 men who are the husbands of adolescent girls. We report descriptive statistics, bivariate and multivariable logistic regression on three dichotomous outcomes: (a) knowledge of modern contraceptives, (b) beliefs that only husbands should make FP decisions, and (c) current FP use. About 56% had ever heard of the pill, 6% had ever heard of an intrauterine device, and 45% had ever heard of an injectable. In our multivariable analyses, we found: a man knowing at least one modern method was significantly associated with his age, wife's education level, gender ideology, and wife's say in healthcare decisions; men's belief that men alone should make FP decisions was associated with husband's Quranic education, gender ideology, and attitudes towards violence against women; men's reports of adolescent wives' current family planning use was associated with men's Quranic education, women's involvement in her own healthcare decisions, and belief that men alone should decide about family planning. Finding suggests that interventions should target aim to reduce gender inequities to increase family planning utilisation.

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.

BACKGROUND: Rigorous evidence of the effectiveness of male engagement interventions, particularly on how these interventions impact relationship power dynamics and women's decision-making, remains limited. This study assessed the impact of the Bandebereho gender-transformative couples' intervention on impact on multiple behavioral and health-related outcomes influenced by gender norms and power relations. METHODS: We conducted a multi-site randomised controlled trial in four Rwandan districts with expectant/current fathers and their partners, who were randomised to the intervention (n = 575 couples) or control group (n = 624 couples). Primary outcomes include women's experience of physical and sexual IPV, women's attendance and men's accompaniment at ANC, modern contraceptive use, and partner support during pregnancy. At 21-months post-baseline, 1123 men and 1162 partners were included in intention to treat analysis. Generalized estimating equations with robust standard errors were used to fit the models. FINDINGS: 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 (OR 0.37, p<0.001) and sexual IPV (OR 0.34, p<0.001); and greater attendance (IRR 1.09, p<0.001) and male accompaniment at antenatal care (IRR 1.50, p<0.001); and 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); 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); and less dominance of men in decision-making. CONCLUSIONS: Our study strengthens the existing evidence on male engagement approaches; together with earlier studies our findings suggest that culturally adapted gender-transformative interventions with men and couples can be effective at changing deeply entrenched gender inequalities and a range of health-related behavioral outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02694627.

Exploring opportunities for coordinated responses to intimate partner violence and child maltreatment in low and middle income countries: a scoping review.

Intimate partner violence (IPV) and child maltreatment (CM) by a parent or caregiver are prevalent and overlapping issues with damaging consequences for those affected. This scoping review aimed to identify opportunities for greater coordination between IPV and CM programmes in low- and middle-income countries (LMIC). Nine bibliographic databases were searched and grey literature was identified through the scoping review team. Eligible studies were published in English; described primary prevention programmes in LMIC that addressed IPV and CM, or addressed one form of violence, but reported outcomes for the other; reported IPV and CM outcomes; and evaluated with any study design. Six studies were identified published between 2013 and 2016 (four randomised controlled trials, one pre-post non-randomised study and one qualitative study). Programmes were based in South Africa (2), Uganda, (2), Liberia (1) and Thailand (1). All except one were delivered within parenting programmes. The emphasis on gender norms varied between programmes. Some parenting programmes addressed gender inequity indirectly by promoting joint decision-making and open communication between caregivers. Conclusions are tentative due to the small evidence base and methodological weaknesses. More robust evaluations are needed. Improved coherence between IPV and CM programmes requires equal attention to the needs of women and children, and the involvement of fathers when it is safe to do so.

Risk factors for men's lifetime perpetration of physical violence against intimate partners: results from the international men and gender equality survey (IMAGES) in eight countries.

This paper examines men's lifetime physical intimate partner violence (IPV) perpetration across eight low- and middle-income countries to better understand key risk factors that interventions can target in order to promote gender equality and reduce IPV. We use data from men (n = 7806) that were collected as part of the International Men and Gender Equality Survey (IMAGES) in Bosnia and Herzegovina, Brazil, Chile, Croatia, Democratic Republic of Congo (DRC), India, Mexico, and Rwanda. Results show that there is wide variation across countries for lifetime self-reported physical violence perpetration (range: 17% in Mexico to 45% in DRC), men's support for equal roles for men and women, and acceptability of violence against women. Across the sample, 31% of men report having perpetrated physical violence against a partner in their lifetime. In multivariate analyses examining risk factors for men ever perpetrating physical violence against a partner, witnessing parental violence was the strongest risk factor, reinforcing previous research suggesting the inter-generational transmission of violence. Additionally, having been involved in fights not specifically with an intimate partner, permissive attitudes towards violence against women, having inequitable gender attitudes, and older age were associated with a higher likelihood of ever perpetrating physical IPV. In separate analyses for each country, we found different patterns of risk factors in countries with high perpetration compared to countries with low perpetration. Findings are interpreted to identify key knowledge gaps and directions for future research, public policies, evaluation, and programming.

Global pathways to men's caregiving: mixed methods findings from the International Men and Gender Equality Survey and the Men Who Care study.

Promoting men's participation in unpaid care work is part of the Programme of Action for the International Conference on Population and Development. However, men's involvement in care work does not mirror the advances women have made in paid work outside the home. This mixed method study explores which men are more involved in caregiving, and what childhood and adulthood factors influence their level of involvement. Quantitative research presents findings from 1169 men across six countries with children aged 0-4, and a qualitative study presents findings from in-depth interviews with 83 men engaged in atypical caregiving practices. Survey research finds that being taught to care for children, witnessing one's father take care of one's siblings, respondents' present attitudes about gender equality and having outside help (or none, in some cases) were all also associated with men's higher level of involvement. Qualitative research reveals that men's experiences of violence, the normalisation of domestic work as children and life circumstances rather than greater-than-average beliefs in gender equality all propelled them into care work. Findings suggest that engaging more men into care work implies changes to policies and structural realities in the workplace coupled with changing gender attitudes. These insights inform policy and practice aimed at promoting greater involvement in care work by men.

Medicaid reimbursement of hearing services for infants and young children.

As newborn hearing-screening programs have expanded, more and more infants and young children need hearing services. Medicaid is one of the primary sources of funding for such services and, by law, must establish payment rates that are sufficient to enlist enough providers to provide services. In this study we compared 2005 Medicaid reimbursement rates for hearing services for infants and young children in 15 states with the payment rates for the same services by Medicare and commercially available health insurance. On average, Medicaid rates for the same services were only 67 as high as Medicare and only 38 as high as commercial fees. Furthermore, most Medicaid rates declined from 2000 to 2005, and many states did not have billing codes for a significant number of the hearing services needed by infants and young children. These factors likely contribute to infants and young children with hearing loss not being able to get the hearing services they need to benefit from early identification of hearing loss. These data also raise questions about the extent to which states are meeting the federal requirement that Medicaid payments be sufficient to enlist enough providers so that care and services are adequately available to the general population in the geographic area.