Involving men: impact of integrated services depends on male cooperation.

KEY POINTS

* Men play a central role in reproductive health decisions.

* Programs are increasing efforts to involve men.

* Some of these programs address expectations about gender roles that compromise the health of women and men.

* Rigorous evaluation of the impact of these programs on reproductive health outcomes is needed.

Family planning programs that have integrated HIV prevention into their services have discovered that the full benefits of their efforts will not be realized if they overlook a group of people they may have been unaccustomed to serving: men.

Reproductive health experts have long recognized that involving men in family planning yields such benefits as client satisfaction and the adoption, continuation, and effectiveness of contraceptive use. (1) But it has also become clear that the cooperation of male partners is necessary for women to act on HIV prevention messages delivered through integrated services. (2)

Recognition of the central role that men play in most decisions about reducing HIV risks--from initiating sex to remaining faithful to one partner to using a condom--has accelerated efforts to involve them in protecting reproductive health.

Focus on gender

Since the mid 1990s, when the Programme of Action adopted at the 1994 International Conference on Population and Development (ICPD) in Cairo called for efforts to "encourage and enable men to take responsibility for their sexual and reproductive behavior"--and linked these efforts to promoting gender equality (3)--a growing number of programs have sought to increase male participation in reproductive health. Many of these programs involve men primarily so they will support partners' use of contraceptives. Some offer reproductive health services specifically for men. Increasingly, programs that work with men also address threats to reproductive health that stem from underlying inequities between men and women, such as those that make it difficult for women to negotiate condom use. (4)

Studies in many countries have documented the connection between health and prevailing attitudes about what it means to be a man or a woman. (5) Societal expectations about what it means to be a man, for example, may give men the power to influence or even determine women's reproductive health choices, (6) which may undermine women's ability to protect themselves from unintended pregnancy or HIV infection. Such expectations also compromise men's health when "manliness" is associated with taking risks, using physical force, and having many sexual partners, while seeking health care or taking precautions to protect their health is considered a sign of weakness. (7)

Dr. Margaret Greene, senior associate at the George Washington University School of Public Health's Center for Global Health, believes that programs promoting gender equity most closely reflect the spirit of ICPD. "What is needed is a clearer focus on how gender roles and inequities constrain health--not a simple shift in what services are offered," she says.

From theory to practice

Staff working on EngenderHealth's Men as Partners (MAP) program, which supports services and education for men to enable them to share responsibility for reproductive health, found that simply doing an exercise on gender and reproductive health during a training workshop had little impact. "As we realized how entrenched these gender issues are, they have become an increasing part of everything we do," says Manisha Mehta, MAP program manager.

In MAP training programs for family planning providers, gender issues are raised as providers learn how to encourage men to support women's reproductive health choices, rather than to make the decisions unilaterally. Trainers also help providers overcome gender-related biases that might affect the way they interact with men and women, such as judgmental attitudes toward unmarried, sexually active women or assumptions that men should speak for their wives when couples are counseled together. In South Africa, where MAP focuses on violence and HIV prevention, men participate in workshops where they are encouraged to question prevailing gender roles and practice new ways of interacting with women. (8)

Program H, designed by the Brazilian nongovernmental organizations Instituto PROMUNDO, Programa PAPAI, and Estudos e Comunicao em Sexualidade e Reproducao Humana (ECOS) and by the Mexico-based Salud y Genero, takes a similar approach with young men in Latin American countries. The program encourages young men to consider the costs of stereotypical definitions of masculinity, as well as the benefits of changing health-threatening behaviors. It also provides skills training, male role models, and support from peers--all factors associated with more equitable attitudes and behaviors in PROMUNDO's previous work with young men in Brazil. (9)

Evaluating projects

A review of reproductive health programs involving men, conducted for the U.S. Agency for International Development (USAID) by the Synergy project of Washington, DC-based TvT Global Health and Development Strategies, identified 14 evaluated projects specifically designed to influence gender norms. But only four of the evaluations--of the New Visions project in Egypt, MAP in South Africa, the Soul City television and radio series in South Africa, and Program H--had experimental designs. The reviewers concluded that strong data on the efficacy of most of the projects was lacking, and they called for more uniform, rigorous evaluation. (10)

An evaluation methodology (see article, page 31) developed as part of Program H is being tested in Brazil and India, and the first randomized controlled trial of an intervention to influence health-threatening gender norms is under way in South Africa, with results expected in 2006. Funded by the U.S. National Institute of Mental Health, the trial will assess the impact of Stepping Stones, a community-based HIV prevention intervention for men and women, on gender-related attitudes, HIV prevention behaviors, and new HIV infections.

Also in South Africa, a prospective study of MAP interventions will assess changes in the attitudes and behaviors of both community members and participants. Because MAP participants report that their efforts to change are not always well received, EngenderHealth and its partners have begun working with those who shape social norms in South African communities, including municipal government leaders, community leaders, and sports and entertainment stars.

"Whatever epiphanies men experience in a workshop, we have to realize that they go back into the communities that socialized them in the first place," says Dean Peacock, who manages EngenderHealth's programs in South Africa. "If programs are not rooted in those communities, then they will just wither away."

References

(1) Fisek NH, Sumbuloglu K. The effects of husband and wife education on family planning in rural Turkey. Stud Fam Plann 1978;9(10-11):280-85; Terefe A, Larson CP. Modern contraceptive use in Ethiopia: does involving husbands make a difference? Am J Public Health 1993;83(11):1567-71; Wang CC, Vittinghoff E, Hua LS, et al. Reducing pregnancy and induced abortion rates in China: family planning with husband participation. Am J Public Health 1998;88(4):646-48.

(2) Nzioka C. Research on men and its implications on policy and programme development in reproductive health. In Programming for Male Involvement in Reproductive Health. Report of the Meeting of WHO Regional Advisors in Reproductive Health, WHO/PAHO, Washington DC, September 5-7, 2001. (Geneva, Switzerland: World Health Organization, 2002)143-52.

(3) Programme of Action. International Conference on Population and Development, Cairo, Egypt, 1994.

(4) Greene ME. Present lessons and future programmatic directions for involving men in reproductive health. In Programming for Male Involvement in Reproductive Health. Report of the Meeting of WHO Regional Advisors in Reproductive Health, WHO/PAHO, Washington DC, September 5-7, 2001. (Geneva, Switzerland: World Health Organization, 2002)159-65.

(5) Mensch B, Bruce J, Greene M. The Uncharted Passage: Girls' Adolescence in the Developing World. New York, NY: Population Council, 1998; World Health Organization (WHO). What About Boys? A Literature Review on the Health and Development of Adolescent Boys. Geneva, Switzerland: WHO, 2000; Mane P, Aggleton P. Gender and HIV/AIDS: what do men have to do with it? Curr Sociol 2001;49(4):23-37; Foreman M, ed. AIDS and Men: Taking Risks or Taking Responsibility. London, England: Panos Institute, 1999.

(6) Gupta GR. Gender, sexuality, and HIV/AIDS: the what, the why, and the how. XIIIth International AIDS Conference, Durban, South Africa, July 9-14, 2000; Mensch.

(7) Barker G. Gender equitable boys in a gender inequitable world: reflections from qualitative research and programme development with young men in Rio de Janeiro, Brazil. Sex Relat Ther 2000;15(3):262-82; Joint United Nations Programme on HIV/AIDS (UNAIDS). Gender and HIV/AIDS: Taking Stock of Research and Programs. Geneva, Switzerland: UNAIDS, 1999.

(8) Levack A. Educating men in South Africa on gender issues. SIECUS Rep 2001;29(5):13-15.

(9) Barker.

(10) White V, Greene M, Murphy E. Men and Reproductive Health Programs: Influencing Gender Norms. Washington, DC: The Synergy Project, 2003. Available: http://www.synergyaids. com/show.asp?id=4065&type=11.

RELATED ARTICLE: Integrating services to appeal to men.

Reaching men requires a holistic approach. Men's concerns about sexual and reproductive health issues that family planning programs rarely address--such as infertility and sexual dysfunction--"give the provider an opportunity to discuss issues related to reproductive health and sexually transmitted infections," says Manisha Mehta, who manages EngenderHealth's Men as Partners program.

For the Mexico-based nongovernmental organization Salud y Genero, appealing to men's pride in fatherhood has proved effective for opening dialogue with men who might feel threatened by topics such as violence, alcohol use, or sexuality. (1) In the Gambia, men agreed to participate in Stepping Stones workshops when the HIV prevention intervention was adapted to emphasize preventing infertility. (2) And in New York City, where the Young Men's Health Clinic attracts male clients by providing physical examinations required for participation in school, sports, or jobs, one out of four young men attending the clinic for a routine exam was also treated for a sexually transmitted infection. (3) treated for a sexually transmitted infection.

Some organizations reach men by incorporating reproductive health messages into other programs for men. The "Seizing the Day" project provides HIV prevention and reproductive health education as part of an adapted traditional circumcision rite for adolescent boys at Chogoria Hospital in Meru, Kenya. (4) Another innovative integration initiative by the San Diego, California-based Project Concern International and the Institute for Reproductive Health at Georgetown University in Washington, DC, incorporated family planning services into a community-based water and sanitation project that had already gained the trust and participation of men in El Salvador. (5)

Programs that seek to address gender roles often involve more than one reproductive health issue. In South Africa, the EngenderHealth Men as Partners program's integration of HIV and violence prevention, reproductive health, parenting, and HIV care and support is a natural result of its emphasis on the connection between health and gender norms, says Dean Peacock, who manages EngenderHealth's programs in South Africa. Dr. Gary Barker, executive director of Instituto PROMUNDO in Brazil, notes that the topics of the manuals that PROMUNDO helped develop for Program H in Latin America (6)--sexuality and reproductive health, fatherhood, violence, mental health issues, and HIV--are linked by the program's efforts to change societal expectations about what it means to be a man.

* Kathleen Henry Shears

References

(1) de Keijzer B, Reyes EM, Aguilar O, et al. Constructing new, gender-equitable identities: Salud y Genero's work in Mexico. Reaching Men to Improve Reproductive Health for All, Dulles, Virginia, September 15-18, 2003.

(2) Paine K, Hart G, Jawo M, et al. "Before we were asleep, now we are awake." Preliminary evaluation of the Stepping Stones sexual health programme in The Gambia. Unpublished paper. Medical Research Council of The Gambia, 2003.

(3) Armstrong B. Involving men in reproductive health: the young men's clinic. Am J Public Health 1999; 89(6):902-5.

(4) Grant W, Brown J, Mecheni K, et al. Seizing the Day--right time, right place, and right message for adolescent RSH. Reaching Men to Improve Reproductive Health for All, Dulles, Virginia, September 15-18, 2003.

(5) Lundgren R. Planificando juntos: consequences of involving men in family planning through water and sanitation programs. Reaching Men to Improve Reproductive Health for All, Dulles, Virginia, September 15-18, 2003.

(6) ECOS, Instituto PROMUNDO, Programa PAPAI, Salud y Genero. Working with Young Men: Program H Manual Series. Rio de Janeiro, Brazil: Instituto PROMUNDO, 2002.

RELATED ARTICLE: Assessing men's attitudes about gender roles.

Use of a new tool to evaluate interventions that seek to change health-threatening attitudes about gender roles is helping to clarify whether more egalitarian gender attitudes are associated with behaviors that ultimately reduce reproductive health risks.

The evaluation tool, called the Gender-Equitable Males (GEM) Scale, was developed by the Washington, DC-based Horizons program of the Population Council and by the Brazilian nongovernmental organization Instituto PROMUNDO. The scale consists of 24 statements about attitudes regarding gender roles in domestic work and child care, sexuality and sexual relationships, reproductive health and disease prevention, and intimate partner violence, as well as attitudes toward homosexuality and close relationships with other men.

A test of the scale in a community-based survey among 749 men in three Rio de Janeiro neighborhoods revealed statistically significant associations between GEM Scale scores and behaviors such as partner violence and contraceptive use. Men ages 15 to 24 years who least supported egalitarian gender attitudes were most likely to report violence against a partner and least likely to report contraceptive use. Among men ages 25 to 59 years, support for more equitable gender norms was associated with condom use. (1)

The scale is being used to evaluate the impact of group education and lifestyle social marketing interventions that promote gender equity among 750 young men in three low-income Rio de Janeiro communities. 2 Preliminary results showed that the interventions were associated with improved GEM scores. Preliminary analyses also revealed statistically significant associations between equitable gender attitudes and reduced reports of symptoms of sexually transmitted infections (STIs) among young men in the intervention communities. Those with higher GEM scores were four to eight times less likely to report STI symptoms during the previous three months. Final results of this two-year evaluation are expected in 2005.

* Kathleen Henry Shears

References

(1) Pulerwitz K, Barker G. Measuring equitable gender norms for HIV/STI and violence prevention with young men: development of the GEM Scale. Unpublished paper. Population Council and Instituto PROMUNDO, 2004.

(2) Barker G, Nascimento M, Segundo M, et al. How do we know if men have changed? Promoting and measuring attitude change with young men. Lessons from Program H in Latin America. In Ruxton S, ed. Gender Equality and Men: Learning from Practice. Oxford, England: Oxfam, 2004.