Gender-transformative programmes: implications for research and action
Authors: Anna Kågesten, Venkatraman Chandra-Mouli
Journal: The Lancet Global Health (2019)

During the 25 years since the 1994 International Conference on Population and Development, the global health community has increasingly recognised gender as a social determinant of health. This recognition has resulted in a shift towards approaches that seek to examine and change harmful gender and power imbalances—ie, gender-transformative programmes.1Dworkin SL Fleming PJ Colvin CJ The promises and limitations of gender-transformative health programming with men: critical reflections from the field.Cult Health Sex. 2015; 17: S128-S143Crossref PubMed Scopus (148) Google Scholar In The Lancet Global Health, Jessica Levy and colleagues2Levy JK Darmstadt GL Ashby C et al.Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents and young adults: a systematic review.Lancet Glob Health. 2019; (published online Dec 23)https://doi.org/10.1016/S2214-109X(19)30495-4Summary Full Text Full Text PDF Scopus (78) Google Scholar present findings from a global systematic review on the effect of the most rigorously evaluated programmes of gender-transformative intent on the health and wellbeing of children and young people. Building on a broader review in the Lancet Series on gender equality, norms, and health,3Heymann J Levy JK Bose B et al.Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms.Lancet. 2019; 393: 2522-2534Summary Full Text Full Text PDF PubMed Scopus (80) Google Scholar Levy and colleagues2Levy JK Darmstadt GL Ashby C et al.Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents and young adults: a systematic review.Lancet Glob Health. 2019; (published online Dec 23)https://doi.org/10.1016/S2214-109X(19)30495-4Summary Full Text Full Text PDF Scopus (78) Google Scholar put forward several key findings with implications for research and practice. First, the review shows that gender-transformative approaches4Interagency Gender Working GroupThe Gender Integration Continuum. Population Reference Bureau, 2017https://www.igwg.org/wp-content/uploads/2017/12/17-418-GenderContTraining-2017-12-12-1633_FINAL.pdfDate accessed: December 6, 2019Google Scholar are being widely used; that they are mainly targeting adolescents aged 10–19 years; that they have a focus on sexual and reproductive health, HIV, and violence (reflecting the wider reality of research and programmes); and that many of these approaches are effective—to a point. Three-quarters of the included 59 initiatives were found to significantly improve one or more health-related indicators, with a focus on knowledge, attitudes, and behaviours. Many programmes targeted early adolescence (age 10–14 years), which reaffirms both the potential and need to intervene during this crucial period of life, when gendered attitudes and behaviours are shaped that, in turn, affect health trajectories.5Blum RW Mmari K Moreau C It begins at 10: how gender expectations shape early adolescence around the world.J Adolesc Health. 2017; 61: S3-S4Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 6Kågesten A Gibbs S Blum RW et al.Understanding factors that shape gender attitudes in early adolescence globally: a mixed-methods systematic review.PLoS One. 2016; 11e0157805Crossref PubMed Scopus (204) Google Scholar The review shows that even short-term programmes can produce substantial changes that could lay the foundation for future health and wellbeing. Second, the review reiterates that the potential of programmes to actually shift norms and improve long-term health outcomes is unknown,1Dworkin SL Fleming PJ Colvin CJ The promises and limitations of gender-transformative health programming with men: critical reflections from the field.Cult Health Sex. 2015; 17: S128-S143Crossref PubMed Scopus (148) Google Scholar largely because of the absence of appropriate measures. The programmes reviewed overwhelmingly assessed changes in knowledge, attitudes, and behaviours, and although some (21%) also included outcomes such as HIV incidence and mental health, only 7% assessed effects beyond 3 years. Very few programmes captured actual norm change—rather than personal attitudes—as the underlying mechanism of effect. The overall absence of reflection on social norm change, including potential repercussions faced by participants, echoes the need for better measures that can be adapted for different contexts,1Dworkin SL Fleming PJ Colvin CJ The promises and limitations of gender-transformative health programming with men: critical reflections from the field.Cult Health Sex. 2015; 17: S128-S143Crossref PubMed Scopus (148) Google Scholar and the need to leverage the use of validated tools using resources such as the EMERGE initiative. Additionally, to be truly transformative, interventions must use an intersectional approach to address the link between gender and other social determinants, such as race, ethnicity, sexual orientation, poverty, disability, and class,1Dworkin SL Fleming PJ Colvin CJ The promises and limitations of gender-transformative health programming with men: critical reflections from the field.Cult Health Sex. 2015; 17: S128-S143Crossref PubMed Scopus (148) Google Scholar which fewer than 10% of reviewed programmes did. Third, evaluation approaches are needed that capture both the complex nature of programmes and what it takes to implement them with quality. Although the review points to essential elements of high-quality initiatives (such as multisectoral, multilevel action with diverse, complementary approaches), more work can be done to share lessons about implementation. Qualitative evidence synthesis7Flemming K Booth A Garside R Tunçalp Ö Noyes J Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods.BMJ Glob Health. 2019; 4e000882Crossref PubMed Google Scholar could provide much-needed evidence on the underlying mechanisms of change. This evidence synthesis could include examining aspects such as balancing fidelity with adaptation to the local context, acceptability and meaningfulness of activities from the perspective of the participants, and unexpected effects (eg, an adolescent girl deciding—contrary to the objectives of the programme that empowered her—that she wants a child now). Fourth, the review calls for gender transformative initiatives that seek to improve the health of all children and young people. Most initiatives that worked with men and boys did so to improve the situation of their female peers, underscoring the need to also focus directly on boys for whom masculinity norms typically encourage risky lifestyles that harm both themselves and others.8Amin A Kågesten A Adebayo E Chandra-Mouli V Addressing gender socialization and masculinity norms among adolescent boys: policy and programmatic implications.J Adolesc Health. 2018; 62: S3-S5Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar Such initiatives need to be carefully implemented so as not to reinforce male privileges and take away the space and support for women's rights and empowerment created over the past decades.9Leek C Understanding feminist resistance to "men-streaming".Glob Soc Welf. 2019; 6: 219-229Crossref Scopus (2) Google Scholar No programmes focused on LGBTQ or other gender-diverse populations, which reflects the need to challenge norms that stigmatise these populations. Finally, efforts to target restrictive gender attitudes, norms, and behaviours are important, but are only one part of a broader strategy to achieve the Sustainable Development Goals. The findings by Levy and colleagues2Levy JK Darmstadt GL Ashby C et al.Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents and young adults: a systematic review.Lancet Glob Health. 2019; (published online Dec 23)https://doi.org/10.1016/S2214-109X(19)30495-4Summary Full Text Full Text PDF Scopus (78) Google Scholar suggest that these approaches are both doable and worth doing, as well as simultaneously working to create structural changes that set the foundation for real gender equality.10Malhotra A Amin A Nanda P Catalyzing gender norm change for adolescent sexual and reproductive health: investing in interventions for structural change.J Adolesc Health. 2019; 64: S13-S15Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar By empowering children and young people to be active agents in their own lives, programmes can undoubtedly contribute to building a foundation for future health. Improving individual agency might indeed be enough for some individuals to find ways to challenge and change unequal norms and practices, but for others, it might not. Targeting societal structures, including policies and institutions, as well as social movements and access to quality and responsive services, is therefore essential to leverage individual changes and achieve long-lasting effects.10Malhotra A Amin A Nanda P Catalyzing gender norm change for adolescent sexual and reproductive health: investing in interventions for structural change.J Adolesc Health. 2019; 64: S13-S15Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar Although progress has, and is, being made in gender-transformative programmes, the full capacity and synergy of these programmes with macro-level initiatives is yet to be explored. We declare no competing interests. Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic reviewThis review can accelerate efforts to improve global health by leading to more strategic investment in programmes that promote gender equality and target restrictive gender norms among young people. Such programmes can lead to a lifetime of improved health and wellbeing by challenging not only attitudes and behaviours related to gender at an early age, but also the gendered systems that surround them. Full-Text PDF Open Access