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Background: The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project integrates gender as part of its work to strengthen health systems and build improvement capacity. Gender integration rests on the understanding that achieving sustained and equitable improvement requires a gender-sensitive approach that takes the different needs, constraints, and opportunities of women, men, girls, and boys into account and responds to them strategically in program design, implementation, and evaluation.
Description: ASSIST partner WI-HER, LLC developed an innovative and effective six-step approach to integrate gender throughout the program cycle to improve health outcomes. The approach has been tested in a variety of programs and improved outcomes. In VMMC programs, it led to female partner involvement in the form of group education, couples HCT, offering health services for women such as HIV testing, counseling and cervical cancer screening, and community mobilization and education. In looking at quality of care, our improvement approach allows for the consideration of cultural and gender norms, and helps to identify unintended negative results from changes introduced.
Lessons learned: In Uganda, ASSIST improvement efforts in VMMC led to adherence to international standards of care and procedures. Integrating gender by involving female partners resulted in increased adherence to the WHO-recommended 48-hour (98%) and 7-day (96%) follow-up and a decrease in adverse events. Our approach led to incorporating gender in VMMC assessment tools at the national level in Uganda and identifying the unintended negative consequences of prioritizing couples at VMMC services to encourage partner involvement (leaving single clients at a disadvantage), and newly circumcised boys dropping out of school (due to their new identity as men).
Conclusions/Next steps: Female involvement should become a standard aspect of VMMC programs, though more research is necessary to determine why we have not seen the same level of improvement for adherence to the 6-week visit or post-operative abstinence. Future improvement work must include consideration and research of long-term consequences like these, as well as issues of consent and coercion; by examining power dynamics and cultural and gender norms that influence circumcision, we can work to ensure the true consent of the client.

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