Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews

Objectives Working with men/boys, in addition to women/girls, through gender-transformative programming that challenges gender inequalities is recognised as important for improving sexual and reproductive health and rights (SRHR) for all. The aim of this paper was to generate an interactive evidence and gap map (EGM) of the total review evidence on interventions engaging men/boys across the full range of WHO SRHR outcomes and report a systematic review of the quantity, quality and effect of gender-transformative interventions with men/boys to improve SRHR for all. Methods For this EGM and systematic review, academic and non-academic databases (CINAHL, Medline, PsycINFO, Social Science Citation Index-expanded, Cochrane Library, Campbell Collaboration, Embase, Global Health Library and Scopus) were searched using terms related to SRHR, males/masculinities, systematic reviews and trials (January 2007–July 2018) with no language restrictions for review articles of SRHR interventions engaging men/boys. Data were extracted from included reviews, and AMSTAR2 was used to assess quality. Outcomes were based on WHO reproductive health strategy. Results From the 3658 non-duplicate records screened, the total systematic reviews of interventions engaging men/boys in SRHR was mapped through an EGM (n=462 reviews) showing that such interventions were relatively evenly spread across low-income (24.5%), middle-income (37.8%) and high-income countries (37.8%). The proportion of reviews that included gender-transformative interventions engaging men/boys was low (8.4%, 39/462), the majority was in relation to violence against women/girls (n=18/39, 46.2%) and conducted in lower and middle-income countries (n=25/39, 64%). Reviews of gender-transformative interventions were generally low/critically low quality (n=34/39, 97.1%), and findings inconclusive (n=23/39, 59%), but 38.5% (n=15/39) found positive results. Conclusion Research and programming must be strengthened in engagement of men/boys; it should be intentional in promoting a gender-transformative approach, explicit in the intervention logic models, with more robust experimental designs and measures, and supported with qualitative evaluations.


Category B
Did not seek to include gendertransformative interventions, yet at least one gender-transformative intervention was included.
Terms related to males and masculinities were developed and tested in a number of databases to ensure they captured all relevant papers. An edited Pearl Harvesting approach to searching databases for systematic reviews was utilised to identify systematic review papers (Sandieson, 2006). Two terms were removed from Sandieson's original Systematic Review search string due to them producing a large number of irrelevant articles ("qualitative synthesis" and "realist synthesis"). While the Pearl Harvesting approach produced a large number of search results, after testing a number of more simplified searches for systematic reviews it was found that a number of potentially relevant articles would be missed without it. Search terms related to trials were adapted from Cochrane approved guidance (Eady, Wilczynski, & Haynes, 2008;Watson & Richardson, 1999). SRHR, men and masculinities, systematic review, and trial search strings were combined and tested in three key databases (Medline, PsycINFO, Embase) before final agreement for terms was reached.

Search terms used
Search combination: #1 AND #2 AND #3 AND #4 (limited to Human; 2007-present) #1 SRHR sexual health or reproductive health or maternal health or maternal welfare or maternal mortality or neonatal health or perinatal care or perinatal health or prenatal care or prenatal health or antenatal health or ante-natal health or postnatal health or post-natal health or post-part* or post part* or newborn health or family planning or contracepti* or condoms or condom or pregnan* or abortion or induced abortion or abort* or birth or miscarriage or spontaneous abortion or stillb* or Minimum Initial Service Package or obstetric* or gynecology or gynaecology or safe motherhood or safe delivery or skilled birth attend* or sexually transmitted infection* or sexually transmitted disease* or HIV or Human immunodeficiency virus or AIDS or acquired immune deficiency syndrome or PMTCT or rectovaginal fistula or urethra fistula or urinary tract fistula or genital trauma or genital injury or vaginal trauma or vaginal injury or gender-based violence or gender based violence or partner violence or family violence or violence against women or domestic violence or sexual abuse or sex crime or sexual crime or domestic violence or sexual violence or rape or intimate partner violence or partner violence or partner abuse or sexual assault or sexual harassment or sexual coercion or forced sex or sexual slavery or sexual exploitation or coercive control or child prostitut* or child trafficking or trafficking of child* or female genital mutilation or FGM or female genital cutting or FGMC or female circumcis* or fertile* or infertil* or (early and marriage) or (child and marriage) or (forced and marriage) or (arranged and marriage) or (abduction and marriage) #2 Males/ Masculinities men or man or male or males or boy or boys or masculin* or father* or gender or equality #3 Systematic Review "data synthesis" or "evidence synthesis" or metasynthesis or meta-synthesis or "narrative synthesis" or "quantitative synthesis" or "research synthesis" or "synthesis of evidence" or "thematic synthesis" or metaanaly* or metaanaly* or metaanalysis or meta-analysis or systematic or "systematic map*" or "systematic overview*" or "systematic review*" or "systematically review*" or "bibliographic search" or "database search" or "electronic search" or handsearch* or "hand search*" or "keyword search" or "literature search" or "search term*" or "article reviews" or "literature review" or "overview of reviews" or "review literature" or "reviewed the literature" or "reviews studies" or "this review" or "scoping stud*" or "overview study" or "overview of the literature" or meta-ethnograph* or meta-epidemiological or "data extraction" or "meta-regression" [title only] #4 Trials random* or trial or placebo or group or groups or intervention or interventions ["Gender-transformative" is defined by the World Health Organization (WHO) as programmes 'that addresses the causes of gender-based health inequities by including ways to transform harmful gender norms, roles and relations. The objective of such programmes is often to promote gender equality between women and men' (WHO, 2011: 78). In our case we are looking for gender-transformative approaches with menso they have to engage men in transforming either a. gender norms (masculinities); or b. gender roles (men's practices); or c. gender relations (unequal relations between men and women) to achieve sexual and reproductive health outcomes. The review should state whether or not it included, or wholly focussed on, gender-transformative approaches to outcomes.] Yes No Can't tell 5. Were the interventions delivered in high, middle, or low income countries? Low Middle High Can't tell

Appendix 4. Systematic Review of Reviews Data Extraction form (Post-pilot version)
1.
The AMSTAR2 tool (Shea et al., 2017) was used to assess the methodological quality of these systematic reviews. This version of the original AMSTAR tool was developed specifically for the purposes of assessing quality of systematic reviews reporting on interventions that utilised either randomised or non-randomised study designs in healthcare settings. In accordance with guidance by Shea et al. (2017), the overall rating represented the reviewers' overall confidence in the results of each review. A high quality rating was assigned if no or one non-critical weakness was identified, moderate quality with more than one non-critical weakness, low quality with one critical flaw and critically low quality with more than one critical flaw. Reasons for included reviews being rated as critically low were the identification of more than one major methodological weaknesses, such as (i) not reporting explicitly that the review methods were established prior to the conduct of the review with a registered protocol; (ii) an inadequate search of the literature; (iii) no justification for excluding individual studies; (iv) no assessment of the risk of bias from individual studies included; (v) no consideration of risk of bias when interpreting results from the review; and/or (vi) no assessment of publication bias.