Male Engagement in Family Planning: Reducing Unmet Need for Family Planning by Addressing Gender Norms

With funding from USAID, the Tékponon Jikuagou Project of the Institute for Reproductive Health (IRH), Georgetown University, United States, conducted an initial review of recent literature and programmes on male engagement in sexual and reproductive health, resulting in the conclusion that "the practice of engaging men in sexual and reproductive health programs is not yet clearly defined, and evidence of its effectiveness is still accumulating." This brief resulted from the preliminary review and a subsequent technical consultation to define male engagement practices, discuss evaluation of male engagement programmes, and consider feasibility of scaling-up successful approaches. It includes four case studies of interventions which used gender-transformative approaches to engage men in family planning programmes.

Among the research results:

• Men can and should be engaged in family planning both as clients and as women’s partners to create educated consumers - particularly in light of gender norms - as well as in recognition of men's influence of women partners. 
• Involving men can "enhance spousal communication, improve gender equitable attitudes and increase family planning use."
• On page 2, the document illustrates and defines the gender equality continuum from "exploitative" - in which stereotypes are exploited in pursuit of health outcomes - to "accommodating" - in which gender differences are accommodated - to "transformative" - in which projects seek equality as a means to reach health outcomes. "Family planning programming that falls toward the transformative end of the gender equality continuum seeks to increase family planning use by addressing gender norms and equality among women and men."
• "[A]ddressing gender-related vulnerabilities for men as well as women is increasingly recognized as an imperative in sexual and reproductive health programming."
• "Viewing men as gendered individuals, rather than oppressors or obstacles to women’s health, can create a more lasting impact on family planning and sexual and reproductive health. However, programs that appeal to men for their involvement in family planning because of their role as decision-makers may reinforce harmful norms." 

In answer to how programmes engage men, the brief describes 4 case studies with successful short- or long-term intervention results. "One aim of this brief is to more clearly define gender transformative family planning initiatives and highlight the need for rigorous research to provide evidence on the cost, scalability and value of such approaches."

1. Promoting Gender Equity and Family Planning through Interactive Workshops - FHI360, APROFAM, APAES (Guatemala), Marie Stopes/Tanzania, PEMconsult East Africa, Ltd (Tanzania)

"This short-duration intervention used interactive workshops to promote gender equality and family planning [in Guatemala and Tanzania." The workshop series for couples, breaking into single gender groups during the series, "...consisted of games, discussions and role-plays to raise awareness about gender inequality and norms that function as barriers to family planning [FP] and to encourage gender equitable attitudes and openness to family planning." Trained male facilitators for men, women for women, were linked to mobile clinics for FP supplies and referrals. Results showed " more positive gender attitudes, particularly among men, as measured by the Gender and Family Planning Equity (GAFPE) Scale [FHI360]", greater knowledge of contraception, and limited or no evidence of increased use.

2. Using Male Motivators to Increase Family Planning Use - Save the Children (Malawi and Mozambique), FHI360 (India), and JHPIEGO (Nigeria) 

"This program utilized male peer educators, referred to as male motivators, to increase FP use among couples in a rural Malawi province." Using a randomised design, baseline and post-intervention surveys and in-depth interviews of the participants who engaged in 5 one-on-one sessions with male motivators, the study found that 78% of those who met with the male motivators and 59% of those in the control group reported using family planning methods with their wives. "Qualitative data found that men reported better overall communication with their wives or girlfriends." The programme, with modifications, was adopted in India and in Nigeria.

3. Promoting Male-Centered Methods through Health Services, Media & Community Outreach - HealthBridge Foundation of Canada, HealthBridge Vietnam Office, and Evangelical Social Action Forum (India)

"This multi-pronged program focused on promoting access to and greater use of male-centered methods -specifically condoms and vasectomy..." Carried out in Vietnam and India, it consisted of "several distinct yet complementary components: research, media engagement, government engagement, capacity building, and networking." Based on surveys, mass media materials were developed to promote positive male responsibility for family planning. Working with government-provided health services to raise awareness and build capacity, trainings "on gender, sex, social inequality and couple communication were designed and implemented for multiple stakeholders, including government groups, media, NGOs [non-governmental organisations], farmers unions, and health providers. Additionally, in order to foster community engagement, community information sessions for men and women were carried out with a particular focus on men’s group counseling and discussions." In Vietnam, radio broadcasts also promoted couple communication and male engagement in family planning, as well as condom use. "The abortion rate declined, condom use increased by almost 50%, young women attended more gynaecological appointments than they had previously attended, and domestic violence declined." In India, links with journalists and media outlets led to television broadcast of gender awareness messaging; a local distributor was supplied with condoms; and community trust was built by filling the need for child birth registration. Local governments hired more male outreach workers, increased non-surgical vasectomy, and banned sex-selective abortion. "Evaluation results suggest that this project contributed to increases in men’s reported use of contraception and more positive attitudes towards men’s sense of shared responsibility for family planning. Qualitative results showed that participants involved in the programs came away with a better understanding of gender inequity and changed their behavior as a result. "

4. Integrating the Standard Days Method® (SDM) into Family Planning Programs as an Approach to Involve Men in Family Planning - Institute for Reproductive Health, Georgetown University and B’elejeb B’atz (Guatemala), Project Concern (El Salvador), Kaanib Foundation (Philippines), CARE (India) and Ministries of Health and other local partners (Guatemala, Rwanda, Democratic Republic of Congo, India and Mali)

Scale-up of SDM integration into FP programmes in five countries followed research on facilitating factors involving couples in this FP method. "Media materials included images of couples, rather than women alone. Radio programs that specifically [focused on] men in India, Guatemala and Rwanda focused on male characters discussing the advantages of communicating with spouses, the disadvantages of having too many children or closely spaced pregnancies, and the impact that family planning use can have on women’s health and the family budget." Men's groups, street theatre drama at taxi hubs, and FP information and SDM counselling at farmer initiatives (Philippines), water and sanitation initiatives (El Salvador), and microfinance programmes (Guatemala) were additional efforts to reach men. Study results showed that engaging men led to improved attitudes, enhanced couple communication, improved SDM use, and increased recognition of men's support.

The brief concludes with 10 ways to engage men in FP:

1. "Provide a ‘comfort zone’ for discussion.
2. Foster a sense of shared responsibility.
3. Promote couple communication.
4. Create opportunities to redefine inequitable gender norms.
5. Provide models of positive male behavior and positive consequences of engagement.
6. Create male-targeted, positive messaging.
7. Focus on both men and women.
8. Integrate into other programming.
9. Be flexible and adaptable.
10. Use long-term, coordinated efforts.”

It lists factors contributing to failure:

• "Exploiting rigid gender norms and power imbalances to achieve program goals.
• Not providing ongoing support or follow up for program participants.
• Focusing solely on men or solely on women.
• Ignoring provider biases about men.
• Poor messaging."