RESUMO
Background: Gender inequity, a deeply-rooted driver of poor health globally, is expressed in society through gender norms, the unspoken rules that govern gender-related roles and behavior. The development of public health interventions focused on promoting equitable gender norms are gaining momentum internationally, but there remain critical gaps in the evidence about how these interventions are working to change behavioral outcomes. Methods: A four-arm cluster randomized control trial (cRCT) was conducted to evaluate the effects of the Reaching Married Adolescents in Niger (RMA) intervention on modern contraceptive use and intimate partner violence (IPV) among married adolescent girls and their husbands in Dosso, Niger (T1: 1042 dyads; 24 mos. follow-up: 737 dyads, 2016-2019). This study seeks to understand if changes in perceived inequitable gender norms among husbands are the mechanism behind effects on modern contraceptive use and IPV. We estimated natural direct and indirect effects via these gender norms using inverse odds ratio weighting. An intention-to-treat approach and a difference-in-differences estimator in a hierarchical linear probability model was used to estimate prevalence differences, along with bootstrapping to estimate confidence intervals. Results: The total effects of the RMA small group intervention (Arm 2) is estimated to be an 8% reduction in prevalence of IPV [95% CI: -0.18, 0.01]. For this arm, the natural indirect effect through gender inequitable social norms is associated with a 2% decrease (95% CI: -0.07, 0.12), accounting for 22.3% of this total effect, and the natural direct effect with a 6% decrease (95% CI: -0.20, -0.02) in IPV. Of the total effect of the RMA household visit intervention (Arm 1) on contraceptive use (20% increase), indirect effects via inequitable gender norms were associated with an 11% decrease (95% CI: -0.18, -0.01) and direct effects with a 32% increase (95% CI: 0.13, 0.44) in contraceptive use. For the combination arm, of the total effects on contraceptive use (19% increase), indirect effects were associated with a 9% decrease (95% CI: -0.20, 0.02) and direct effects with a 28% increase (95% CI: 0.12, 0.46). Conclusion: The present study contributes experimental evidence that the small group RMA intervention reduced IPV partially via reductions in perceived inequitable gender norms among husbands. Evidence also suggests that increases in perceived inequitable gender norms resulted in decreased contraceptive use among those receiving the household visit intervention component. Not only do these results open the "black box" around how the RMA small group intervention may create behavior change to help inform its future use, they provide evidence supporting behavior change theories and frameworks that postulate the importance of changing underlying social norms in order to reduce IPV and increase modern contraceptive use.
RESUMO
In Niger, independent mobile health units intended to meet the needs of nomadic populations have proved ineffectual and excessively costly. Primary health care services should be based on fixed structures with a reasonably wide radius of coverage and sufficient flexibility and mobile capacity to fulfil their obligations to all sectors of the population.
PIP: In Niger, mobile health teams provided the first health services for nomadic populations, but these services have proved ineffective and costly. Since 1971, many dispensaries have been established in the rural areas to perform immunization. A 1990 evaluation of the Agadez region, in the northeast showed poor returns on investments. Immunization has been carried out by the mobile medical service since 1968 using 2 teams, each comprising 2 nurses, 2 vaccinators, and a driver/guide. The Expanded Program on Immunization (EPI) was launched in 1988 with both mobile teams and fixed health services. By the end of the year the region had achieved coverages of 40% for BCG (bacillus Calmette-Guerin) in children 1 year of age, 54% for 3rd dose of diphtheria-pertussis-tetanus (DPT3) immunization, 35% for children protected against tetanus, and 47% for 2nd dose of tetanus toxoid. The mobile medical service provided less than 10% of first dose DPT (DPT1) and measles immunizations and under 5% of DPT3 coverage which continued in the first 6 months of 1991. A survey in Mali during 1974 showed that the per capita cost of immunization by mobile units was 11 times higher than that performed by fixed units. The health district consists of the rural dispensaries, the first point of contact for patients who may have to travel up to 30 kilometers; and medical posts, which are intermediate referral facilities usually with an ambulance vehicle. These 2 types of health services cannot cover the rural areas effectively and do not involve the community. Fixed health facilities should not be limited to a radius of 5 kilometers, they should establish seasonal circuits as the population moves, and 1 or more areas should be served by an intermediate fed health post. Health teams should carry out immunization and family planning, as well as the education and the supervision of first level workers. In the nomadic areas, every health district should have at least 1 health post.