The USAID Transform Primary Health Care Project supports the Ethiopian government in its efforts to strengthen health systems and prevent maternal and child deaths. The project’s gender analysis in 2018 identified male engagement as a crucial driver of improved reproductive, maternal, and child health outcomes. After a comprehensive literature review, the project decided to adapt a male engagement curriculum from Rwanda, Promundo’s Bandebereho, designed to bolster male support for family planning and antenatal care, which was evaluated through a randomized controlled trial in 2015. In this poster presentation, we share details of a participatory formative research and collaborative adaptation process program carried out by the Transform project in 2019-20 to successfully adapt this male engagement intervention to the cultural context of the two diverse regions in Ethiopia where it will be implemented. The poster sheds light upon the extremely important, but often understudied application of evaluation techniques for adapting evidence-based interventions across different countries and contexts.
Statement of Relevance
The USAID Transform: Primary Health Care project in Ethiopia faced budgetary and staffing constraints when adapting a male engagement curriculum from Rwanda—Promundo’s Bandebereho—designed to bolster male support for family planning and antenatal care through a series of community dialogue sessions. Bandebereho was evaluated through a randomized controlled trial (RCT) in 2015 (Doyle, Levtov, Barker et al. 2018). Rather than conduct a new RCT in Ethiopia, the Transform project carried out a formative research evaluation and adaptation workshop in 2019-20 to successfully adapt this evidence-based, male engagement intervention for implementation in two diverse regions. This poster presentation shares how the Transform project adapted a proven male-engagement intervention to a new cultural context by grounding it in the lived experiences and local realities of community members in rural Ethiopia (SenGupta, Hopson, and Thompson-Robertson 2004).
Before adapting the curriculum, trained data collectors conducted 16 semi-structured key informant interviews with healthcare workers and male community leaders, as well as eight focus group discussions with men, and eight with their partners. Combined with 95 quantitative attitudinal and behavioral surveys with couples that incorporated the Gender Equitable Men (GEM) Scale (Pulerwitz and Barker 2008), these data collection events comprised the project’s formative evaluation efforts. Formative evaluation—a “rigorous assessment process designed to identify potential and actual influences on the progress and effectiveness of implementation efforts”—not only provided contextual knowledge on how to adapt the curriculum to the needs of the intervention communities, but also helped anticipate potential implementation challenges (Stetler et al. 2006).
The research team shared the formative research findings and conclusions at a Curriculum Adaptation Workshop in January 2020. Workshop participants validated the results and collaboratively determined strategies to adapt sessions to best fit the local context and integrate the community’s feedback. Based on these discussions, the resulting adapted curriculum emphasized educating fathers about contraception, pregnancy, and early childhood; reflecting on power dynamics and gender roles; and resolving conflict and preventing intimate-partner violence. In February 2020, the research team gathered community facilitators for a training to prepare them to implement the dialogue groups, ground truth each session, and make last revisions to the curriculum to ensure each activity and the language used was easily comprehensible and relevant.
International development practitioners often identify promising evidence-based interventions that could drive change in other countries and communities, but they lack the resources to conduct RCTs in new, diverse settings. By engaging in a participatory formative research and collaborative adaptation process, the Transform project adapted a proven male engagement intervention to a new cultural context, grounding it in the lived experiences and local realities of community members in rural Ethiopia.
Doyle, K., Levtov, R. G., Barker, G., Bastian, G. G., Bingenheimer, J. B., Kazimbaya, S., et al. 2018. 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. PLoS ONE 13(4): e0192756.
Pulerwitz, J. and Barker, G. 2008. Measuring attitudes toward gender norms among young men in Brazil: development and psychometric evaluation of the GEM scale. Men and Masculinities, 10(3), pp.322-338.
SenGupta, S., Hopson, R. and Thompson-Robinson, M. 2004. Cultural Competence in Evaluation: An Overview. New Directions in Evaluation. (102) 5-19
Stetler, C. B., Legro, M. W., Wallace, C. M., Bowman, C., Guihan, M., Hagedorn, H., Kimmel, B., Sharp, N. D., and Smith, J. L. 2006. The Role of Formative Evaluation in Implementation Research and the QUERI Experience. Journal of General Internal Medicine, 21 Suppl. 2 (Suppl. 2), S1–S8.