Introduction

Sexual and reproductive health (SRH) affects, and is affected by the intersectionality of people’s personal experiences and relationships and by the broader structural context of their lives which shapes their overall health and well-being. This context includes gender inequality as a determinant on its own and in combination with other social and economic inequalities including: unequal power dynamics in interpersonal relationships, harmful gender and other socio-cultural norms and practices, limited economic circumstances, lack of access to education, limited employment opportunities, poor living conditions, disability, ethnicity, as well as the challenging political and legal environments where they live[1]. Studies have shown that harmful gender norms that promote male dominance over women prevent women from practicing safer sex, limit their use of contraceptives, and increase their risk of STIs, including HIV[2]. Similarly, research has also shown a relationship between violation and neglect of human rights and negative health outcomes and emphasizes the need to better integrate human rights approaches into interventions, particularly with attention to provider training, service delivery, raising awareness and capacity building[3, 4].

In the past two decades, great strides have been made in the development of norms and standards related to gender equality and human rights pertaining to SRH and the interpretation and application of existing standards to different areas of SRH programming and policy making. This is true at the level of international policy, as well as at policy and programmatic levels within countries. The centrality of addressing interconnections between gender equality, human rights, and SRH, was recognized in the Cairo and Beijing agreements, the World Health Organization’s Reproductive Health Strategy[5], and most recently the 2030 Agenda for Sustainable Development and the accompanying Sustainable Development Goals (SDGs). Not only is the achievement of gender equality a goal in itself (i.e. Goal 5), but there is a specific target within that goal on universal access to SRH and rights (i.e. target 5.6), in addition to the target(i.e. target 3.7) on sexual and reproductive health in the health goal (i.e. Goal 3).[6]

The achievement of the highest attainable standard of SRH is thus closely linked with the extent to which gender equality and people’s human rights–such as the rights to non-discrimination, to privacy and confidentiality, to life, liberty, and security, as well as the rights to education, information and health–are respected, protected and fulfilled. In its recently adopted General Comment on the right to sexual and reproductive health, the UN Committee on Economic, Social and Cultural Rights, emphasizes that this includes, a “set of freedoms and entitlements”. The freedoms, according to the Committee, include the right to make free and responsible decisions and choices, free of violence, coercion and discrimination, over matters concerning one’s body and sexual and reproductive health. The entitlements, the Committee explains, include unhindered access to a whole range of health facilities, goods, services and information, which ensure all people full enjoyment of sexual and reproductive health.[6]

While progress has been made in understanding how some dimensions of gender inequalities and violations of human rights shape SRH outcomes, as well as in developing and evaluating interventions that promote gender equality in the context of some SRH programmes and policies, much remains to be done to address these issues systematically. Research has a critical role to play in effectively identifying and addressing gender inequalities and human rights by developing an understanding of what’s been done and what remains to be done. As a first step to determine what is known, a systematic literature review of reviews was conducted to address the following question: what do we know about how research in context of SRH programmes and policies has addressed gender equality and human rights and what are the current gaps in research? This review was conducted to inform a larger research priority setting exercise that is being undertaken to identify what research should be prioritized to strengthen the integration of effective gender equality interventions and human rights approaches in SRH programmes and policies. This paper summarizes the results of the review.

Methods

The systematic literature review of reviews was guided by a protocol (See S1 Protocol) that identified the search strategy including search terms, inclusion and exclusion criteria, and a data abstraction process. The choice of conducting a review of reviews rather than primary intervention studies was guided by the necessity of including the broad scope of topics covered within the field of SRH.

Search strategy

An automated search strategy was undertaken in 2014 to identify literature reviews, systematic reviews and meta-analyses. Three priority databases that typically index most systematic and other types of literature reviews were searched—Scopus, PubMed, and Cochrane—using a list of preliminary search terms related to gender equality, human rights, and SRH that included terms such as gender, gender norms, equality, equity, and sexual health. The preliminary search yielded a very large number of review articles). Therefore, some of the search terms were revised to minimize/remove duplicate terms (e.g., empowerment vs. women’s empowerment). Key words capturing important human rights concepts such as human rights, reproductive rights, and accountability were retained. Table 1, below, lists the initial terms used, as well as the revised terms.

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Table 1. Search key words.

https://doi.org/10.1371/journal.pone.0167542.t001

Finally, in addition to database searches, we consulted participants of an expert meeting that was convened in January 2015 to identify additional reviews from the grey literature that may have been missed in the databases[7].

Results

Literature Review and Search Process

In total, we reviewed 3,073 abstracts from our peer-review literature search. We shortlisted 42 abstracts as either meeting (Y) or possibly meeting (M) the inclusion criteria for the review. These articles were retrieved for a full text review. Following a full text review 19 of the 42 articles were excluded as they did not meet the inclusion criteria. The 23 remaining articles were abstracted as per the process outlined above. In addition, ten reviews from the grey literature were reviewed and abstracted. Fig 1, below, outlines the search and screening process and reasons for article exclusion.

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Fig 1. Search and screening process and results.

https://doi.org/10.1371/journal.pone.0167542.g001

Discussion

Nearly 20 years after ICPD Programme of Action (1994) and the Beijing Platform for Action (1995) highlighted the importance of addressing gender equality and human rights in health and specifically SRH programmes, there has been an accumulation of interventions, programming and evaluations that have enabled researchers to review bodies of evidence. This review of reviews provides an overview of that body of evidence, highlighting what the focus and subsequent gaps have been across topics, population and geographic focus, and methodological approaches.

While interventions addressing gender equality and human rights were recognized as important more than a decade ago, our review found that research on gender equality has received more attention than human rights. This is reflected in the relative paucity of peer reviewed reviews on human rights, particularly in the public health literature. A myriad of factors, including limited funding and limited understanding of human rights, may contribute to this finding. As a result, this body of evidence suffers from additional challenges including selective or ad hoc application of some elements (e.g. non-discrimination, participation) of a human rights based approach as against a comprehensive application; data considerations; and lastly implicit integration of what are called human rights considerations, instead of explicit and comprehensive integration of human rights as internationally understood which impairs study design and evaluations.[1, 8]

Although the reviews on gender equality provide a much wider body of evidence than human rights, it’s still challenged by gaps that impede our ability to understand the effectiveness of these interventions. Not surprisingly, given women’s often socially prescribed lower status in communities worldwide, the interventions included in the reviews primarily focused on women and women’s SRH outcomes. While interventions have clearly targeted gender equality for women from multiple levels ranging from the interpersonal to the structural, understanding and measuring change from both women and men’s perspectives is still inadequately done. Specifically, in line with recent ethical and safety recommendations on VAW intervention research[37], evaluations of interventions should measure potential harms or unintended consequences, as well as outcomes in terms of the individual and in relation to social norms. Moreover, there is a need to better understand whether and what types of interventions lead to resistance to prevailing inequitable gender norms among men and how resistance to norms impacts men for the sake of their own SRH (as partners, fathers, and community members). The latter is of particular importance given both, the challenge of engaging men in these issues and the need to engage them to address their contribution to maintaining existing gender inequalities that inhibit women’s health. While much remains to be learned on effective male engagement, motivating men based on the contributions they can make, as well as their own benefits has been highlighted as an important approach and as such, reliable and valid measurement of these outcomes needs to be incorporated.[21, 28, 32]

Finally, several gaps identified by this review, including the short timeframes of research studies, the limited geographical spread of research, the minimal inclusion of a wider variety of populations, and the missing focus on policy research and on cost, replicability and scale of interventions hinder the field’s ability to progress in integrating gender equality and equal human rights in SRH programmes and policies. For example, shorter timeframes for measuring research outcomes inhibit our ability to understand longer term change–a challenge of great importance for issues such as these, where interventions must support intensive changes in social norms and sustain changes in SRH behaviours. Without longer term research frameworks and funding support to measure and evaluate impact of gender equality and human rights interventions in SRH programmes and policies, we will continue to rely on shorter term outcome measures that can only capture shifts in more proximate knowledge and attitudes, rather than truly understanding what is required to change social, cultural and other norms and behaviours. As another example, the limited attention to replicability of interventions included in the reviews prevent us from understanding how different socio-cultural and economic context would affect whether or not a particular gender equality intervention or human rights approach would work across settings. Similarly, the pilot nature of interventions or studies included in the reviews makes it difficult to know and understand whether these would work or not if implemented on a larger scale. Funding agencies have an important role to play in shaping where, how, and for how long research projects occur in order to allow for measuring longer term, community-wide and larger scale impacts across different settings

This review of reviews has several limitations. One limitation was the search focused on databases that primarily capture the public health literature. Although we did identify articles from disciplines other than public health (e.g. legal, policy), all articles meeting review criteria ultimately came from public health journals. This may have somewhat limited the scope of which gender and human rights interventions were considered. However, given the need to identify articles measuring SRH outcomes, we expect that this limitation should be minimized. Another limitation was the restriction of inclusion criteria of reviews published in English and Spanish. This was due to the language capabilities of the authors; yet, given that the inclusion of Spanish reviews identified no additional reviews meeting criteria, it’s likely that the addition of other languages would have yielded similarly low returns. Additionally, although a large number of potential search terms (key words) were initially identified, we were compelled to revise the search strategy due to the volume of results. This, in addition to our focus on review of reviews, contributed to the varied nature of interventions captured under the broad categories of gender equality and human rights and as such, our inability to make nuanced observations about the research gaps within specific gender equality or human rights intervention approaches. For example, among human rights interventions, we were unable to review interventions at the individual, community, health care, or national level or across identified principles such as non-discrimination, availability, accessibility, acceptability, quality of care, decision-making, or participation[4]. Without explicit search terms reflecting the many levels of intervention, we cannot be certain that the exclusion of certain topics is reflective of an actual lack of research across these many areas. On the other hand, the broad search terms used should have captured research framed as gender equality or human rights, thus pointing again to a lack of conceptualization of principles of non-discrimination, availability, participation etc., as part of a human rights framework.

Conclusion

This review highlights that progress has been made over the last fifteen years on research related to inclusion of gender equality and human rights interventions in SRH policies and programming, but fundamental gaps remain. Much more has been published on gender equality interventions than human rights-based interventions in the SRH literature. Research relating to both gender equality and human rights based interventions has been published on topics such as HIV/AIDS, SRH, more broadly, and to a limited extent on FP. There is a need to strengthen research methods and measurement of outcomes to capture long-term sustained changes in SRH behaviours and biological health outcomes[21, 22]. Attention to human rights in intervention research although limited and ad hoc in nature is increasing, although here too publication has been greatest in relation to HIV and FP. Further investment, documentation, research and development of methodologies is needed in order to capture a) the pathways by which gender equality and human rights interventions can improve SRH outcomes; and b) how we address intersecting forms of inequalities and discrimination along with gender and human rights concerns faced by specific sub-populations and marginalized groups in relation to their SRH. Increased coordination between gender and human rights focused actors could improve their ability to more holistically incorporate human rights and gender into intervention design, implementation, and evaluation thereby strengthening the evidence base.

Supporting Information

Acknowledgments

The authors would like to acknowledge participants of the expert review meeting who provided feedback on the initial results of the review search and who aided in the identification of relevant grey literature. The review was conceptualized by RK, AA, and SK. All authors (MH, SK, RK, AA, SG, AG) provided inputs into the scope of the review and the search strategy. MH conducted the search, screened citations, read and appraised the literature, and summarized findings. MH and SK led the content analysis and wrote the first draft of the manuscript. MH constructed the figures and tables. All authors participated in revision, including the present manuscript version. All authors read and approved the final manuscript.