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“We live in a country where we have huge numbers of children exposed to parental incarceration. When we talk about the need to reform the criminal justice and mass incarceration systems, we also need to talk about the unintended victims of the current system,” says Christine Leibbrand of the University of Washington. “Incarceration exposes families to poverty and disadvantage, and the system can self-perpetuate inequality.”

About 3.5% of U.S. children under age 18—or one child in every classroom of about 29 students—had a parent behind bars in 2015, mainly their fathers.¹

Black children were more than five times more likely than white children to be separated from a parent by incarceration, report sociologists Bryan Sykes of University of California, Irvine and Becky Pettit of University of Texas at Austin. These patterns reflect a system that disproportionately imprisons disadvantaged and minority men, they argue.

A growing body of research documents the toll U.S. incarceration takes on the families of those imprisoned, widening disparities and exacerbating existing disadvantages. New research supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development provides further evidence on the wide-ranging ways a parent’s incarceration shapes the lives and life chances of their partners and children, from the neighborhoods where they live to the levels of adversity their children experience.

Children of Incarcerated Fathers Are More Likely to Live in High-Poverty Neighborhoods and Move More Often

Children whose fathers were incarcerated move more frequently and live in neighborhoods that are more socioeconomically disadvantaged than their peers whose fathers have never been in prison, find Leibbrand and Erin Carll of the University of Washington, Angela Bruns of the University of Michigan now at Gonzaga University, and Hedwig Lee of Washington University in St. Louis.²

Using data from the national Fragile Families and Child Wellbeing Study—research following thousands of families in 20 large U.S. cities since 1998—the team examined the neighborhoods of children whose fathers were in prison or recently released. Families with a father currently or recently in prison tend to live in neighborhoods with higher percentages of residents who are single mothers, receive public assistance, lack a high school diploma, and live below the poverty line, they show.

The financial hardship families with imprisoned members face, researchers say, perpetuates what they call “downward mobility.” A father in prison is one less wage earner at home or paying child support. Families with limited income have fewer choices of where to live, they may move often, and the neighborhoods they end up in may be marked by lower quality schools, greater unemployment, and higher rates of crime and violence, Leibbrand and her colleagues report.

“When we think about where people live or move to, we think of people weighing the pros and cons of different places. That’s far too simple. Many families may be forced to move because of eviction or budget constraints, for example, and these forced moves are often to worse neighborhoods where families have little choice of where they would like to live,” says Leibbrand.

Mothers With a Partner in Prison Are More Likely to Hold Multiple Jobs

Mothers with incarcerated partners are more likely to work multiple jobs than women in otherwise similar circumstances, finds Bruns in another study.³

Partner incarceration is linked to additional employment—a third shift—on top of the paid work and caregiving women already do, she finds, based on analysis of Fragile Families and Child Wellbeing Study data.

An additional job may cover basic expenses but also compounds the burden that women with incarcerated partners already shoulder, she points out.

“Staying in touch and supporting an inmate—responding to his requests for food, clothing and books, preparing packages to the correctional institution’s specifications, coordinating family member visits, and keeping up with legal cases and appeals—can feel like a second job in and of itself,” explains Bruns.

Mothers with partners who are incarcerated usually have sole responsibility for children who may be “struggling with the absence of their fathers,” according to Bruns. Holding multiple jobs is also a known stressor that could raise mothers’ risk of stress-related health conditions.

Low-skilled women are often stuck in low-wage, dead-end jobs that can barely pay the bills, she asserts.

“Balancing multiple work roles in addition to family member incarceration may keep women from going to school or participating in other activities that improve their socioeconomic standing over the long-term,” writes Bruns.

Youth With a Parent in Prison Face More Trauma and Adversity

Youth ages 11 to 17 who experience the incarceration of a parent are more likely to have behavioral problems or mental health issues than their counterparts whose parents have never been jailed, Samantha J. Boch, Barbara L. Warren, and Jodi L. Ford of Ohio State University show.⁴

The team finds that household poverty plays a role, as does the number of traumatic events the young person has experienced, including homelessness, eviction, foster care, and serious injury or death in the family. Overall, they find that youth who deal with the incarceration of a parent experience three times as many adverse childhood experiences (ACEs) as their unaffected peers.

The researchers base their analysis on interviews with more than 600 parents or other caregivers participating in the Adolescent Development in Context study, a representative sample of Columbus, Ohio, and its surrounding suburbs.

The behavioral problems and mental health issues exhibited more frequently in children who experience a parent’s incarceration include poor attention, excessive anxiety, and externalizing behaviors such as rule breaking, temper outbursts, and property destruction, the analysis finds.

The researchers examined a wide-ranging set of 30 ACEs that includes aspects of financial distress and household churning or instability such as changes in household composition (for example, when a parent or parent’s new partner leaves or joins the household or when a child goes to live with grandparents) and residential moves.

“Well-documented research investigating the cumulative effect of ACEs indicates that youth exposed to parental incarceration may have a much greater likelihood for engaging in maladaptive coping behaviors (such as cigarette, alcohol, and illicit drug use, or violent delinquent behaviors) and experiencing depression, anxiety and post-traumatic stress disorder across the lifespan,” the researchers report.

They argue that mental health providers should view a parent’s incarceration as an important consideration of the child’s and family’s well-being that warrants continued observation, support, and follow-up. More research is needed to determine the best ways to screen and identify these youths using non-stigmatizing approaches that build on their strengths, they suggest. 

A Parent’s Incarceration Can Shape a Child’s Identity and Influence Anti-Social Behavior

Among young adults with an incarcerated parent, those who had a high need for parental approval were more likely to identify themselves as a troublemaker or partier during young adulthood than those who were emotionally independent, a recent study finds.⁵

Self-identities influence behavior, including criminal activity, making understanding the precursors of self-identity important to interventions designed to improve the life prospects of children with incarcerated parents, according to the researchers Jessica G. Finkeldey of the State University of New York at Fredonia, and Monica A. Longmore, Peggy C. Giordano, and Wendy D. Manning of Bowling Green State University.

The team examined publicly available incarceration records and analyzed data from the Toledo Adolescent Relationships Study, a regional survey of more than 900 men and women ages 18 to 28 interviewed five times between 2001 and 2011.

Developing “high emotional independence, or values, beliefs, and identities in contrast to and separate from an incarcerated parent,” may set young adults on a path shaped by different choices than those made by their incarcerated parent, the researchers suggest.

“It is possible that exposing children of incarcerated parents to positive role models and mentors, such as through mentorship programs, might help to reduce the transmission of antisocial identities and behaviors and should be investigated,” says Finkeldey.

This article was produced under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The work of researchers from the following NICHD-funded population dynamics research centers was highlighted in this article: University of Washington, University of Michigan, Ohio State University, Bowling Green State University, and University of Texas at Austin.

PACE’s Youth Multimedia Campaigns training program equips youth advocates with the skills to create innovative digital campaigns, tell compelling population health stories, and build movements for policy change within their countries.

Using data-driven multimedia and events, youth participants collaborate with their peers to share powerful advocacy messages focused on the health and well-being of their communities. The PACE training program supports the institutional growth of youth-led organizations as well as a burgeoning network of youth leaders passionate about population dynamics and reproductive health.

PACE has partnered with competitively selected youth-led teams in Kenya, Nigeria, Pakistan, South Sudan, and Uganda to amplify their policy advocacy on topics such as youth-friendly family planning services, female genital mutilation/cutting (FGM/C), child marriage, gender-based violence (GBV), fistula prevention, and maternal health.

Three youth-led advocacy organizations—from Malawi, Nepal, and Nigeria—joined the 2021 training program, where they built or strengthened their storytelling, video production, policy communication, and social media engagement skills. Youth used these skills to develop a new multimedia advocacy campaign pushing for advancements in youth sexual and reproductive health or environmental protection in their communities. Alumni fellows from Bridge Connect Africa Initiative were among the training coaches for the 2021 program and presented several sessions.

Participating youth and their organizations receive tailored technical and leadership training and ongoing mentorship around techniques in policy communication, fact-based and data-driven advocacy, and multimedia production (text, graphics, images, video, and audio). Using accessible technology, including mobile phones and social media platforms, PACE-trained advocates build engaging campaigns focused on specific policy advocacy objectives, targeted at their peers, communities, and key decisionmakers. As part of the program, youth advocates are also expected to provide technical assistance and training to other youth in their communities, passing down their skills, expanding the reach of their campaigns, and sustaining local youth-led policy advocacy.

PARTNER SPOTLIGHT: Bridge Connect Africa Initiative

Two Nigerian activists, Sani Muhammad and Mubarak Idris, participated in the inaugural year of PACE’s Youth Multimedia Campaigns training program in 2018 and quickly established themselves as outstanding and committed population and reproductive health youth champions. With support from PACE, Muhammad and Idris successfully launched their youth-led organization, Bridge Connect Africa Initiative (BCAI), and partnered with PACE to lead the 2019 training program for two new youth teams in the Kano and Kaduna States of northern Nigeria.

The two campaigns, focused on ending child marriage and increasing access to youth-friendly family planning services, each generated positive policy change. After seeing the PACE-sponsored video and social media campaign generate broad support, the governor of Kano State made a public declaration to end child marriage through support of the Child Protection Bill. While the legislation is still pending, sections of the bill that provide for compulsory schooling for all children as a way of tackling child marriage have been adopted into a state-level policy. In Kaduna State, the governor’s chief of staff committed to sharing a video message to call on the state government to promote availability and access of family planning services for women and young people.

Alumni Showcase

Multimedia campaigns produced by alumni from each cohort of the Youth Multimedia Campaigns training program are highlighted here.

2020 Campaigns: Kenya, Nigeria, Pakistan, and South Sudan

2019 Campaigns: Kano and Kaduna States, Nigeria

• Accessibility of Family Planning Services in Kaduna State: A Story from Rigasa Community.
• Child Marriage in Kano Nigeria: A Call for the Domestication of the Child Protection Bill.

2018 Campaigns: Kenya, Nigeria, and Uganda

The United States doesn’t have the world’s oldest population, but relatively high levels of age-related disease could affect the proportion of Americans who become critically ill because of COVID-19.

Older Americans on average have a higher level of age-related health problems than their counterparts in Europe and many other countries (see table). That’s according to a recent Lancet study that shows the United States ranked 53rd out of 195 countries when it comes to how burdened its people are by old age-related disease and disability.

By comparison, Switzerland ranked 1st, South Korea ranked 3rd, Italy ranked 5th, and China ranked 75th. To compare the relative health of adults among countries, the study adjusted for the wide differences in the proportion of adults in each age group in each country. For example, Italians ages 65 and older make up 23% of the population compared with 16% in the United States, 15% in South Korea, and 12% in China.

Table. Countries Ranked Lowest to Highest by Age-Related Disease Burden, 2017

Why does it matter if older Americans have a relatively high disease burden? As the United States confronts coronavirus, the older population’s level of age-related disease and disability may affect the proportion of older adults who becomes critically ill. Individuals with underlying health conditions are more likely to have severe reactions to the COVID-19 infection, according to the CDC.

Cardiovascular diseases and cancers make up half of the age-related disease burden worldwide, according to Angela Y. Chang, assistant professor at the Danish Institute for Advance Study, who led the research team as a postdoctoral fellow at the University of Washington. Diabetes and chronic obstructive pulmonary disease (COPD, a respiratory disease) are also leading sources of disease and premature death, driving differences among countries.

“Italy’s adults have a relatively lower burden of diseases that we think are related to aging than people in other countries,” she said (see figure). Italy’s population, however, has a larger share of older adults than most other countries, which increases the overall level of age-related diseases, she noted.

Figure. Cardiovascular Diseases, Chronic Respiratory Disease, and Diabetes/Chronic Kidney Disease Burden Rate Per 100,000 People Ages 55 to 69 in Italy, South Korea, and United States, 2017

^{Note: Disease burden rate is based on the level of disability-adjusted life years (DALYS; healthy years lost) per 100,000 adults. CKD is an acronym for chronic kidney disease.
Source: Institute for Health Metrics and Evaluation, University of Washington, Global Burden of Disease Study 2017.}

Supported by the U.S. National Institute on Aging, the study examined the level of age-related burden resulting from 92 diseases and conditions. Researchers used a measure that quantifies premature death and years of life lived in less than full health (disability-adjusted life years, known as DALYS) to calculate the age-related disease burden for each country.

This study is the first of its kind to explore both chronological age and the pace at which aging contributes to health deterioration, using estimates from the 2017 Global Burden of Disease study.

It identified wide variation in how well or poorly people age, showing that a 30-year gap separates countries with the highest and lowest ages at which people experience the health problems of an average 65-year-old worldwide.

Chang and colleagues report that 76-year-olds in Japan and 46-year-olds in Papua New Guinea have the same level of age-related health problems as an average 65-year-old. Americans at age 69, United Kingdom residents at 71, and Italians at age 75 have the same level of age-related health problems as an average 65-year-old globally.

Malgré des progrès, sa mise en œuvre reste difficile, puisque neuf femmes africaines sur dix en âge de procréer vivent dans des pays dotés de lois restrictives concernant l’avortement.

Le PRB a développé cette fiche d’information en tant qu’outil permettant aux décideurs, aux experts médicaux et juridiques ainsi qu’aux défenseurs de communiquer sur les avantages du Protocole de Maputo, dans le cadre du mécanisme de réponse rapide SAFE ENGAGE. La fiche d’information se concentre sur l’article 14 du protocole, qui met en avant la santé et « les droits reproductifs des femmes en autorisant l’avortement médicamenteux en cas d’agression sexuelle, de viol, d’inceste et lorsque la poursuite de la grossesse compromet la santé mentale et physique de la mère ou du fœtus ». Cette fiche utilise des données et des éléments visuels pour expliquer comment ce protocole peut réduire le nombre d’avortements non médicalisés.

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In May, Linda Jacobsen, Lillian Kilduff and I helped organize a conference for nearly 300 American Community Survey (ACS) data users. This is the fourth ACS conference PRB has organized in partnership with the U.S. Census Bureau since 2014. If you missed the conference this year, don’t worry. We posted PDF versions of the conference presentations and recordings of the plenary sessions on the conference website.

Organizing a conference is kind of like organizing a wedding. It involves a lot of preparation, and when the big day finally arrives, you spend a lot time making sure everything is running smoothly. But now that a few weeks have passed, I wanted to take a step back and summarize some of my key takeaways from the event.

The conference began with some Census Bureau updates on ACS activities and operations. Steven Dillingham, the Census Bureau Director, expressed the importance the ACS and said “data users are the key to the continuous improvement” of the flagship survey. Regarding the 2020 Census: Dr. Dillingham said operations are on track, but with more than 26,000 distinct activities, there is still a lot of work to be done.

Jim Treat (Assistant Director for Decennial Census Programs) announced the 2018 ACS data release schedule, which has shifted because of the lapse in federal funding earlier this year. He also provided high-level updates on several ACS Program activities, including a recent Workshop on Improving the American Community Survey,  the new data.census.gov platform, efforts to ensure respondent confidentiality, and updated ACS Data User Handbooks, which include detailed case studies on how ACS data are being used for decisionmaking.

Next, Jennifer Ortman (Assistant Division Chief for Survey Methods and Measures in the American Community Survey Office) summarized the Census Bureau’s ongoing efforts to ensure the quality of ACS data. These efforts include changes to the 2019 ACS questionnaire and plans to use administrative records to reduce respondent burden, increase data reliability, and reduce costs.

Protecting Respondent Privacy

The plenary session on Day 2 began with a Census Bureau update on new “disclosure avoidance” methods that could have long-lasting implications for ACS data users. As computational power has grown, privacy concerns and the risk of someone “re-identifying” ACS respondents has also increased.

Rolando Rodríguez (Research Mathematical Statistician at the Census Bureau) described the Census Bureau’s preliminary plans to ensure respondent confidentiality in the ACS. The bottom line is that the ACS will transition to formal privacy methods, but the Census Bureau is currently focused on protecting confidentiality in 2020 Census data, and it’s too early to say exactly how ACS data might be affected by new disclosure avoidance methods.

The formal privacy methods developed for the 2020 Census will inform ACS methods, but the ACS has additional features—more topic areas, complex survey design and survey weights, and population controls—that need more research. Once developed, the methods will be used to balance data privacy and data accuracy in the ACS data. For now, the Census Bureau plans to release the “standard complement of ACS tables and public-use microdata (PUMS) for 2018,” but is exploring the possibility of expanding the use of synthetic data to protect the PUMS data. Rolando also emphasized the Census Bureau’s commitment to data user involvement and feedback as these new formal privacy methods are adopted for the ACS.

Streamlining Data Dissemination

Zach Whitman (Chief Data Officer at the Census Bureau) began his presentation with this chart, which shows the complex web of data tools currently available through the Census Bureau’s website.

This “forest of applications” is being replaced with a more centralized system (data.census.gov) designed to simplify access to Census Bureau data, including ACS estimates. What does this mean for ACS data users? Starting in June 2019, there will be no new data releases in American FactFinder (AFF). Zach encouraged data users to visit the new site and provide feedback: What you like and don’t like, and what changes you would like to see in future iterations (Email: cedsci.feedback@census.gov).

In her remarks, Connie Citro (Senior Scholar at the Committee on National Statistics) applauded the Census Bureau’s efforts to invite input from ACS data users but encouraged more “systematic, two-way interaction” between data users and Census Bureau staff “to best ensure that new privacy protection techniques and the new platform are implemented with full consideration of alternatives and user needs.”

ACS Data User Insights

The plenary sessions focused on informing data users about Census Bureau activities, but the main purpose of the conference was to showcase the work of ACS data users. The program included more than 50 presentations from data users representing a broad range of government agencies, academic institutions, and private-sector organizations.

Breakout session topics included:

• ACS Resources and Tools
• Using the ACS to Study Racial, Ethnic, and Geographic Variations in Health
• ACS Data for Rural and Tribal Communities
• Combining ACS With Other Survey or Administrative Data
• Developing Estimates and Projections Using ACS Data
• Using the ACS to Analyze Poverty and Income
• Using ACS Data to Measure Disparities in Internet Access
• Using ACS Data in the Classroom
• Measuring ACS Data Quality
• Innovative Uses of the ACS for Housing Analyses
• Lightning Session
• Advanced Tools Using ACS Data
• Aggregating ACS Data for User-Defined Areas
• Innovative Health Applications with ACS Data

During lunch on the first day, many ACS data users participated in informal meetups to discuss various topics and issues related to ACS data, including:

• ACS and Big Tech: Applications of ACS data for tech companies
• ACS PUMS: Techniques and working with margins of error
• Journey to work data: Implications of new allocation process for ACS tables
• Small-area estimation with ACS data
• Undercount of children in the ACS

And during lunch on the second day, Census Bureau staff were on hand to lead product demonstrations and topical roundtables:

• 2020 Census Integrated Partnerships and Communications Program
• About the Data Dissemination Program
• American Community Survey General Information
• Ask Our Subject Matter Experts
• Census Academy
• Creating Custom Tables with PUMS on data.census.gov
• Utilizing OnTheMap for Response and Recovery during a Natural Disaster
• Geography and the American Community Survey
• Hispanic Origin and Race Questions
• Introducing Census Business Builder
• Planning Database and Response Outreach Area Mapper
• Transitioning from AFF to data.census.gov

I want to thank all of the data users and Census Bureau staff who attended the 2019 conference, presented their work, and posted conference updates on Twitter.

A special thanks to members of our ACS Steering Committee and our Census Bureau partners for their help in organizing the conference. Their behind-the-scenes efforts were critical to the success of the event.

Where Are We Now?

Much has changed since 2010 when the Interagency Gender Working Group (IGWG) published the breakthrough report Synchronizing Gender Strategies: A Cooperative Model for Improving Reproductive Health and Transforming Gender Relations. This report introduced a new concept of synchronized gender strategies, defined as working with men and women, boys and girls, in an intentional and mutually reinforcing way, to challenge restrictive gender norms, catalyze the achievement of gender equality, and improve health. The report revealed some of the existing tensions between programs focusing on women’s empowerment or on men’s engagement. In showcasing program examples using a gender-synchronized approach, the report also highlighted some key elements of gender-synchronized health programs. These elements included intentionality in reaching out to men and women to promote mutual understanding, aiming for equalizing power dynamics, preventing and responding to gender-based violence (GBV), promoting flexible gender roles, and advocating for gender equality as measures of program success.

We know that the concept of synchronized gender strategies continues to resonate with colleagues working in health and development. But as many have noted, the field has progressed since 2010, and the report needs updating. Many new examples of gender-synchronized projects have been implemented and evaluated. What have we learned from these programs?

In 2017, the IGWG supported a review of the evidence and experiences of gender-synchronized strategies since the 2010 report was released. The aims were to analyze the findings of numerous new program evaluations and to explore interventions that intentionally consider gender and sexual diversity.1 The effort included a literature review and consultations with a range of experts from a variety of backgrounds within the health and development sectors as well as from the violence prevention community.

Lessons Learned From New Evidence

Many new gender-synchronized health programs with published evaluation findings emerged. Examples of these programs are shown below. Many of the key elements outlined in the original 2010 report were evident in the programs. For example, newly identified programs all intentionally reached out to men and women, and boys and girls, and sought opportunities to promote dialogue about the advantages of loosening rigidly defined gender roles. Many explicitly aimed to prevent GBV, and several included interventions to shift the balance of power and provide men and women opportunities to collaborate for a common cause.

One example is the SASA! Initiative in Uganda from Raising Voices, which aims to prevent HIV/AIDS and domestic violence by focusing on power imbalance in intimate relationships. An evaluation through a four-year randomized control trial (RCT) showed that women in intervention communities were significantly more likely to report joint decisionmaking, open communication, and the ability to refuse sex with their partners. Analysis of the qualitative data revealed the importance of working with women and men together, through modeling collaborative male and female leadership and enhancing exchange of ideas and perspectives of men and women.2 A learning report from Raising Voices shows that the gender-synchronized approach provided deeper understanding about the gender constraints and privileges experienced by others. Including women and men in discussions provided the opportunity to discuss these issues together and led to greater gains and diffusion of new ideas about workloads, decisionmaking, and violence among men and women.3

Like SASA!, the Bandebereho program implemented in Rwanda by Promundo and partners incorporated gender-synchronized elements in group critical reflection and dialogue sessions for couples. The sessions provided a structured space for men and women to question and critically reflect on gender norms and how these shape their lives. In discussion groups, men and women rehearsed equitable attitudes and behaviors with supportive peers. This exchange provided an opportunity for men and women to internalize new gender attitudes and behaviors, and apply them in their own lives and relationships. The intervention also included community activities and campaigns related to fatherhood and care-giving. The project utilized an RCT evaluation design with data on gender roles and domestic violence gathered from male participants and their female partners. Compared to the control group, women in the intervention group reported significantly lower levels of physical and sexual violence and more male accompaniment to antenatal care, while men and women reported significantly less violence against children, greater male participation in household tasks, and less male dominance in decisionmaking.4

The Gender Matters (Gen.M) curriculum implemented in Texas by EngenderHealth also yielded some positive results.5 Boys and girls in the treatment group were significantly more knowledgeable about contraceptive methods and where to obtain them, and were more likely to strongly agree that female birth control should always be used during sexual intercourse than young people in the control group. But there was no evidence that Gen.M affected attitudes toward traditional gender ideologies (in large part because youth in the treatment and control groups held relatively egalitarian attitudes) or in sexual refusal skills.

The Primary-School Action for Better Health program in Kenya showed that a gender-synchronized approach can be effective for primary school ages, utilizing in-service teacher training to improve pupils’ health knowledge, self-efficacy, and condom use.6 The evaluation showed that boys and girls reported significantly more communication with their parents and teachers about HIV and sexuality, greater self-efficacy related to abstinence and condom use, and greater condom use as well as decreased sexual activity. Gains were gender specific, with boys reporting increased condom use while girls were more likely to report decreased or delayed sexual activity. This intervention was operational in 11,000 of the country’s nearly 19,000 primary schools by 2006.

Most of the gender-synchronized programs and evaluations were shaped by heteronormative assumptions. The review was able to identify few examples of gender-synchronized programs that intentionally considered gender and sexual diversity. Programs that address the gaps in services or health of gender and sexual minorities have largely been narrowly focused on HIV prevention or efforts to advocate for their rights rather than integrated into health, development, or violence prevention programs. We noted few resources to engage, support, and enhance gender role expectations with or alongside gender and sexual minorities, and few programs that integrated these concerns into interventions for an entire community. Only one project evaluation report showed evidence of attitudinal shifts among adolescents related to their understanding of gender and sexual diversity.7

The literature review also noted other gaps. There was little analysis of whether or how gender-synchronized strategies contributed to the positive results of the project, whether health or gender-specific outcomes. Most programs focused on people’s attitudes and behaviors, but few included components to shift the gender bias and discrimination in systems and structures such as national policies, health services delivery, or school-based practices. The Primary-School Action for Better Health in Kenya was not specifically focused on gender, but successfully used a systems approach to scale the intervention.

Stakeholder Feedback

The feedback from the stakeholders’ consultations showed that many in the health development field find the concept of synchronized gender strategies a useful frame for designing new programs. Among projects promoting women’s reproductive health, gender synchronization has encouraged project staff to be intentional about the dynamics of (heterosexual) couple communication and decisionmaking about family planning and other reproductive health concerns.

As was true in 2010, some tensions still exist among stakeholders, particularly in the context of GBV mitigation. There are some who feel that in practice some programs lack sufficient critique and emphasis on changing the systems and structures that provide more privilege to males (for example, addressing gaps in transportation systems, school, or work environments that could protect women and girls from sexual harassment and assault).

Reflections

This review has been helpful in understanding how far the field has progressed and illuminating the continued need for evidence of the specific contribution of gender synchronization. While it’s encouraging to see that many of the new evaluations revealed significant improvements in women’s decisionmaking, role sharing in workload in the household, and communication between couples, parents and children, and even teachers and pupils, the causal pathways remain unclear.

The authors noted evidence that highlights how gender-synchronized interventions that fully address power dynamics and privilege can help gain traction in the prevention of intimate partner violence. These exemplars provide insights for how they might support the prevention of GBV in other contexts.

The authors found that conceptually, gender-synchronized strategies remain relevant with a strong logic for implementation. The review confirmed that many of the key elements identified as core to gender synchronization were included in the programming examples reviewed. Yet some gaps were also identified. In practice, programs can sometimes offer and inadvertently reinforce an idealized vision for women and for men that lack examples of diversity outside heterosexual married couples. Just as the review found few examples of programs that intentionally consider gender and sexual diversity, specific populations have been under-represented and opportunities to work with more diverse populations may have been missed. Did the authors overlook these projects? Or are gender-synchronized programs that include a focus on gender or sexual identity missing from the field?

This review affirmed that the space for discussions on gender inequality and power dynamics is still not safe in many communities. People speaking out on issues of gender inequality are often silenced or threatened. In our review we noted a lack of discourse about how to assess safety or how to move the conversation forward in a way that is contextually appropriate.

Recommendations and Next Steps in Gender-Synchronized Programming, Evaluation, and Research

Based on the findings of our analysis, the authors see a need to expand the diversity of voices contributing to the discussions about lessons and challenges in gender-synchronized programming. The review currently lacks key insights from community organizations and advocates for marginalized groups, particularly LGBTI persons about how gender-synchronized strategies might be applied with greater inclusion of diverse populations. Developing a shared conceptual understanding of these issues by diverse groups working on women’s empowerment, men’s engagement, HIV, health, and rights of gender and sexual minorities will promote greater trust and willingness to collaborate. This shared understanding and collaboration could contribute to advance the human rights of marginalized and vulnerable populations and improved health outcomes for everyone.

The authors call for future evaluation designs that can show whether and how gender-synchronized strategies contribute to impact in health and gender equality. The community also needs to consider a refined definition, theory of change, and key program elements of gender-synchronized interventions. Language is important. The community needs to be precise in how it describes the gender-synchronized interventions and project goals to avoid misunderstanding. For example, speaking of “including both women and men,” may unintentionally reinforce the idea that only these two groups exist, and always/only in relation to each other. It is important to frame the work as deconstructing harmful aspects and rigid expectations about masculinity and femininity.

The authors call on organizations implementing gender-synchronized programs to apply more inclusive approaches, and in particular to make sure that programs better reflect and incorporate gender and sexual diversity. Improving conditions for vulnerable groups requires engaging the socially dominant groups in the process of reflection on gender roles, norms, and power dynamics in their own lives. And at the same time, programs must be intentional in incorporating vulnerable groups when they are also working with the people in the socially dominant category. A more inclusive process could help to build consensus around a vision for health and healthy relationships (not just sexual relationships), and to aim for equalizing power dynamics and expanding opportunities within and among the roles that all people play in society.

The authors note that many people face stigma or experience threats for challenging social injustices; this could be more explicitly acknowledged and addressed as a new core element of gender-synchronized approaches. The authors honor the courage of those who have stood up and spoken up to help create positive change towards gender equality in their own communities. It’s time for programs with gender-synchronized approaches to proactively include risk-monitoring systems and ways to better protect those working for change.

The authors believe that gender synchronization has relevance across sectors, with future opportunities for adaptation, implementation, and learning. They call for intentional dialogue and exchange of ideas about gender-synchronized strategies in different programmatic and geographical contexts, so that all can gain clarity about the goals and outcomes of gender-synchronized work.