Community-based distribution (CBD) of contraceptives can be helped or hindered by gender norms. Community-based services that bring contraception counseling and information into people's homes can help women obtain control over their fertility, and thereby enhance their autonomy and self-esteem. CBD programs can compensate for the lack of health-care facilities available to men. And, community-based programs can improve the status of female workers, who may have limited opportunities for employment.
However, CBD programs that exclude men can perpetuate the notion that family planning is solely a woman's responsibility. Programs that focus on women alone ignore men's reproductive health needs. And by bringing services into the home, CBD programs can encourage women's seclusion and discourage their movement outside the community.1
"Gender affects decisions about family size, sexual relationships and prevention of sexually transmitted infections," says Dr. Jane Chege, program associate with the Population Council's Frontiers Project in Nairobi, Kenya. "Considering gender concerns from the program design stage will assist managers in determining how to exploit positive gender issues and overcome constraints imposed by gender norms. In view of the fact that CBD agents provide services at the household level, they are in an ideal position to address some gender concerns."
Because there are distinct societal roles for men and women, as well as rules about appropriate behavior, CBD programs can affect women and men differently. An FHI study in rural Mali illustrates this contrast.
The study, in collaboration with Save the Children/Mali, compared the impact of community-based programs on three groups of people: those who received family planning education alone, those who received education and contraceptive methods (condoms and spermicides), and those who received neither. Each group included some 500 participants. In the group that received methods and education, 10 percent of the women knew of one or more modern contraceptive methods prior to the study. After the study, the percentage increased to 99. Among the men, 43 percent knew of modern methods before the study, while 91 percent knew of methods afterward. The gap between male and female knowledge prior to the study may be explained by gender norms.
"One possible explanation for men's greater knowledge of modern methods at pretest is that men had greater access to information," FHI scientists wrote. "While both women and men have access to radio, men generally spend more time listening to it and are, therefore, more likely to hear messages about family planning." In addition, researchers noted, men are more likely than women to travel to the cities, where information about family planning is more readily available. Men are also likely to learn about methods from male friends or family members.
And while men may learn about contraceptives, they typically do not share that information with their wives. In Mali, it is considered inappropriate for women to discuss sexuality issues with men or men to discuss such issues with women. However, the FHI study found that these gender norms can be changed and spousal communication can be improved. Among the three study groups, those who received both education and methods reported the largest increase in spousal communications -- from 17 percent of women to 67 percent of women and from 14 percent to 77 percent of men.2
Gender norms can create barriers to contraceptive use, especially when adolescents are the clients. In many cultures, sexual activity for young unmarried women is frowned upon, while sexual activity among young men is an accepted sign of manhood. This discrepancy was evident in Kenya, where CBD workers were more willing to serve adolescent boys than girls.
Although most workers (81 percent) said they would provide services to an unmarried boy with no children, only 26 percent would provide contraception to an unmarried girl who had not yet had a child.3 "This probably reflects a general societal bias against unmarried women being sexually active and the fact that there are often myths that contraceptives inhibit fertility, so a woman should prove her fertility first," says Dr. Ian Askew, director of operations research in the Population Council's Nairobi office.
Men or women workers?
A central question is whether the sex of community workers affects clients' willingness to use a method and their access to services.
A 1993 study in the Democratic Republic of Congo, conducted by Tulane University in the United States, looked at the characteristics of successful community-based workers. Age was a factor, with older workers providing more contraceptive protection than younger workers. However, sex was not a factor. Four out of five study sites employed male and female CBD workers, and researchers found no significant difference in their performance.4 CBD workers should be selected primarily on their willingness to work, researchers concluded.
Population Council researchers observed that community-based programs in Peru were an important source of information and methods for couples. However, more oral contraceptives were distributed than condoms, and part of the reason was that the majority of workers were women.
To learn how effective men would be as CBD workers, the Population Council conducted a study with two family planning agencies, Promoción de Labores Educativas y Asistenciales en Favor de la Salud (PROFAMILIA) in Lima and Centro Nor-Peruano de Capacitación y Promoción Familiar (CENPROF) in Trujillo.5 One of the first lessons learned was that men were more difficult to recruit as CBD workers than women, possibly because many were already working when approached.
In addition, female CBD supervisors were reluctant to involve men in what they considered "women's work." Among their comments: "Men only want to sell contraceptives. They don't want to keep records and give talks." "Men have less free time to do the work." "Many are too embarrassed."
In analyzing contraceptive distribution figures among male and female CBD workers, researchers found that men and women served approximately the same number of new clients each month. Researchers concluded that, in spite of difficulties in recruiting, men can be effective CBD workers, CBD programs can influence method mix by recruiting more men, and programs should recruit and train more male workers.
The sex of providers has other implications. A review of data collected by the International Centre for Diarrhoeal Disease Research, Bangladesh found that women who had had recent contact (within 90 days) with a community worker were more likely to use contraception, regardless of the worker's sex. However, women who spoke with female workers were 2.8 times more likely to use a method, while those who had contact with a male worker were only 1.4 times more likely. Gender roles, which discourage women from discussing sexual issues with men, may be responsible for the difference.6
Reaching men
Community-based programs offer an opportunity to reach men, who are typically left out of family planning programs. By providing services in the home, CBD programs can help men maintain privacy for themselves and their spouses, and men can avoid the embarrassment of attending clinics that are designed to serve women. In addition, home visits can increase access to other services, such as screening or treatment for sexually transmitted diseases.
In Kenya, contraceptive use increased when men were included in CBD programs -- both as workers and as clients. In the Kilifi District along the coast, the Family Planning Association of Kenya and the Population Council established three teams of community workers -- one with 10 women, one with 10 men, and one with five men and five women. Workers were encouraged to work in places where men typically congregate -- community meetings, sporting events, work places and drinking places -- and to include men in discussions during home visits.
Communication between spouses increased for clients of all three teams, with the percentage of men who reported discussing family planning with their wives nearly doubling during the 18-month study. The greatest increase took place among clients served by the team with both male and female workers.7
"We found from service statistics that male agents tend to provide more condoms whereas female agents tend to provide more pills, suggesting that the sex of the agent is important in determining who they are best able to serve," says Dr. Askew of the Population Council's Nairobi office. "However, we did not find that one sex was more productive than the other. They seem to serve different groups."
Women's status
Some community-based contraceptive programs are offered as part of larger efforts to improve women's status. The primary purpose of Maendaleo Ya Wanawake Organization, one of Kenya's largest women's organization, is to help women earn income. In addition to helping women improve income-producing skills, its 1,200 community workers also provide family planning services. "We found that women needed to do income-generating activities to sustain themselves, but they kept on having children, sometimes every year," says Dorcas Amolo, project director for reproductive health services, explaining how the two activities are related.
Other programs seek to give women control over fertility while accommodating existing gender norms. In Ethiopia, the Gargaar Relief and Development Association started a CBD program in an area where women were too embarrassed to travel to clinics. Health workers came to their homes under the guise of neighborly visits. In Bangladesh, community-based distribution was begun to accommodate the custom of purdah, seclusion inside the home or family compound. While these efforts give women more control over their reproductive lives, they may also discourage women from traveling outside their homes. Visiting clinics could increase women's mobility and self-confidence.
Community-based programs can influence the status of female workers, as well as clients. In India, women volunteers in the city of Hyderabad take responsibility for providing family planning services to 20 homes within their communities. Volunteers undergo extensive training and help identify community health problems, in addition to providing family planning services. Many of the nearly 5,000 volunteers have become respected community leaders.8
In a study of field workers conducted by the Matlab Family Planning and Maternal-Child Health Project in Bangladesh, female employees said their family planning work had helped them gain self-confidence and respect within the community. Village workers are viewed as sources of information on family planning but also provide advice on marriage arrangements, children's education, household spending, conflicts between spouses, and conflicts between women and mothers-in-law. Workers have persuaded fathers to let daughters attend school, intervened when husbands beat their wives, and referred families to health centers for treatment when needed.9
-- Barbara Barnett
References
- Schuler SR, Hashemi SM, Jenkins AH. Bangladesh's family planning success story: a gender perspective. Int Fam Plann Perspect 1995;21(4):132-37,166; Schuler SR, Hashemi SM, Cullum A, et al. The advent of family planning as a social norm in Bangladesh: women's experiences. Repro Health Matters 1996;7:66-78.
- Katz KR, West CG, Doumbia F, et al. Increasing access to family planning services in rural Mali through community-based distribution. Int Fam Plann Perspect 1998;24(3):104-10.
- Chege JN, Askew I. An Assessment of Community-based Family Planning Programmes in Kenya. Nairobi: The Population Council, 1997.
- Bertrand JT, McBride ME, Mangani N, et al. Community-based distribution of contraceptives in Zaire. Int Fam Plann Perspect 1993; 19(3):84-91.
- Foreit JR, Garate MR, Brazzoduro A, et al. A comparison of the performance of male and female CBD distributors in Peru. Stud Fam Plann 1992;23(1):58-62.
- Phillips JF, Hossain MB, Simon R, et al. Worker-client exchanges and contraceptive use in rural Bangladesh. Stud Fam Plann 1993; 24(6):329-42.
- Miller RA. Country watch: Kenya. Sexual Health Exchange 1998:3;5-6.
- Robboy R. Healthier in Hyderabad: innovative partnership improving family health services in urban slums. Working With Us/India. (Washington: World Bank, nd) Http://www.worldbank.org.
- Simmons R, Mita R, Koenig M. Employment in family planning and women's status in Bangladesh. Stud Fam Plann 1992;23(2):97-109; Mita R, Simmons R. Diffusion of the culture of contraception: program effects on young women in rural Bangladesh. Stud Fam Plann 1995; 26(1):1-13.
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