Men are more interested in reproductive health than most people think. Recent surveys and studies seem to contradict popular views about men's participation and involvement in family planning -- for example, that most men know little about contraception, do not want their partners to use it, and are not interested in planning their families.
Individual attitudes and behaviors among men vary enormously, of course. On balance, however, the evidence suggests that many more men would participate if they had more opportunity to do so.
While some family planning programs have been interested in involving men for more than a decade, only recently has men's participation become the focus of substantial attention. Why now? One important reason has been rising global concern over the rapid spread of HIV.1 "The prominence of HIV/AIDS has opened up the discussion of sexual behavior," says Mary Nell Wegner, director of the Men As Partners Initiative at New York-based AVSC International. Programs to prevent HIV have focused on both men and women with nearly equal attention, in contrast to family planning programs, which have focused mainly on women, she and other experts say.
Traditionally, family planning programs have viewed women as their primary clients for three reasons: it is women who become pregnant; most contraceptive methods are designed for women; and reproductive health services can be offered conveniently as part of maternal and child health services.2 Some family planning programs have avoided serving men in the belief that many women need privacy and autonomy in reproductive health matters.
"The assumption of many health-care providers that men are uninterested in taking responsibility for family planning has become a self-fulfilling prophecy," says Dr. Cynthia Green of Washington, a consultant who has studied male participation extensively. Most observers agree that family planning programs have made little effort to consider men's reproductive health needs or to reach men, and that as a result men have few contacts with the reproductive health care system. "In Africa, men are brought up to think that family planning or reproductive health are woman's issues," says Dr. David Awasum, a physician from Cameroon who chairs the Men's Participation Task Force at Johns Hopkins University's Population Communication Services (PCS) in Baltimore, MD, USA. "No wonder they lack information and do not participate actively with their spouses or partners."
The 1994 International Conference on Population and Development (ICPD), held in Cairo, reminded the world audience that good reproductive health is the right of all people, men and women alike, and that together they share responsibility for reproductive matters. By emphasizing gender -- the prescribed roles men and women play in society -- the conference drew attention to the fact that, if men are left out of the reproductive health equation, they are unlikely to be able to exercise responsibility. The consensus reached in Cairo is that neither women nor men are likely to enjoy good reproductive health until couples are able to discuss sexual matters and make reproductive decisions together.3 "For the first time, Cairo established clear policy language about men's participation and provided a foundation for family planning donors and programs to act on," says Wegner.
As interest in men's participation has grown, more attention is being paid to learning how to reach men effectively. "Family planning programs are looking for ways to become more inclusive," says Dr. Green. More surveys are interviewing men, as well as women, and some surveys are interviewing couples. The Demographic and Health Surveys (DHS), for example, now collect comparable data about family planning attitudes and practices from men, in addition to a long-standing practice of interviewing women. Also, more qualitative data are becoming available from focus-group research and in-depth studies. As researchers obtain more information, stereotypes are giving way to a more factual portrait of men.
Similar attitudes
According to recent DHS, men are more likely to approve of family planning and to know about contraception than stereotypes about men suggest. Based on data collected from men in 15 countries -- 11 in sub-Saharan Africa, plus Bangladesh, Egypt, Morocco, and Pakistan -- Alex Ezeh and colleagues at Macro International, Inc., the U.S.-based organization that organizes and helps conduct the DHS, report that in most countries "the reproductive preferences and attitudes of men and women toward family planning are similar."4
The 15 studies reveal a "KAP gap" among men -- a contradiction between the level of "knowledge and attitudes" about family planning compared with "practices" (KAP). Men's contraceptive use is lower than might be expected, given their overall levels of approval and knowledge. Between one-quarter and two-thirds of men surveyed want no more children, yet neither these men nor their partners were using contraception.5 The implication of such findings is that, if programs could find better ways to reach men as individuals and as members of couples, contraceptive use might rise considerably.
While the 15 countries represent only portions of Africa and Asia, there is a striking consistency among them regarding male interest in reproductive health, enough so to suggest a similar level of male interest elsewhere. Only a few DHS have interviewed men in Latin America and the Caribbean (Brazil, Dominican Republic, Haiti and Peru); however, initial results suggest a similar pattern of male interest. For example, in Brazil, men are even more likely than women to say that they do not want to have more children. In Haiti, 92 percent of men surveyed approve of contraceptive use and in Brazil, 86 percent approve.
The 15 African and Asian countries in the Ezeh analysis offer a developing-country portrait of male participation from several perspectives. In addition to measuring sentiments about whether men approve of family planning and men's family size intentions, these surveys gauge male awareness of contraceptive options, their concerns about sexually transmitted diseases and their use of contraception:
Approval -- Most men, like most women, approve of family planning. In seven of 15 surveyed countries, at least 90 percent of men approve of using contraception. Approval is lowest in West Africa. Even in this region, however, men's approval appears to be on the rise. In Ghana, for example, the percentage of men who approve of family planning rose from 77 percent in 1988 to 90 percent in 1993. Within most of the countries men are less likely than women to approve of family planning. This fact in part may explain why men often are pictured as obstacles to contraceptive use. Nevertheless, in some of the countries (Ghana, Malawi and Pakistan) men are more likely than women to approve of family planning. In nearly all countries surveyed, better-educated men express greater approval of family planning than do men with less education.
Family size -- In most surveyed countries, the number of men who want to have another child is only slightly higher than the number of women who want another child. This finding shatters one of the most widespread myths about men -- that men generally want much larger families than do women. In most of the 15 countries, the differences in reproductive intentions between men and women are small. The fact that men are somewhat more likely to want another child, however, helps account for the finding that, even though men tend to know somewhat more about contraception than do women, they are less likely to approve of its use. In Kenya, Morocco and Pakistan, only a minority of men want to have another child, and in Egypt and Bangladesh less than one-third of men want another child. In West Africa, however, men are substantially more likely than women to want another child. In Niger, the extreme case, 93 percent of men want to have another child compared with 82 percent of women.
Awareness -- In almost all 15 countries surveyed, men are more likely than women to know about contraception. Surveys, however, report only whether respondents have heard of the various contraceptive methods. They do not gauge the depth of knowledge, including whether respondents know how to use methods correctly. In all 15 countries, a majority of men know about at least one modern method and one traditional method. In all but one African country (Rwanda is the exception), a higher percentage of men than of women know of a modern method. In Egypt, Morocco, Bangladesh, and Pakistan, men and women report similar levels of awareness. The gap between men's and women's awareness of contraception is greater in countries where overall knowledge is low.
Sexually transmitted diseases -- The spread of HIV and other sexually transmitted diseases has brought an increase in awareness and use of condoms. For example, in Kenya, Tanzania, and Zimbabwe, where HIV and other STDs are widespread, DHS results show that virtually all men have heard of AIDS and most know that sexual intercourse can transmit it. While the surveys also reveal much misinformation about HIV, they show that many people know that using condoms is a means of protection. In Zimbabwe, for example, 57 percent of men cited using condoms as a way to avoid contracting AIDS; and in Tanzania, 55 percent. In Kenya, however, only 36 percent of men who believe that people can protect themselves against AIDS identified using condoms during sex as a means of protection.
In most developing countries prevalence of condom use is typically below 5 percent. So widespread are STDs that programs need to promote and provide condoms for disease protection as well as for family planning. Although there is little information about condom use for STD prevention versus family planning, "family planning service providers need to recognize that many women would benefit greatly from using condoms to prevent STDs, plus another method to prevent pregnancy," says Dr. Green. "For clients who need both pregnancy and STD protection, programs should encourage dual use, even though it raises costs."
Contraceptive use -- Men are more likely than their partners to report using contraception, according to the 15 surveys. One possible explanation is that some men may be reporting condom use outside of marriage. Another possibility is that some women may not acknowledge use of contraception to survey takers, since they are using it without their husbands' knowledge. Whether the explanation lies primarily in men over-reporting contraceptive use or women under-reporting use is unknown. Men's participation in family planning cannot be measured simply on the basis of use of male-oriented methods -- withdrawal, condoms, and vasectomy -- because few satisfactory contraceptive choices have been designed for men.
Experts agree that the more husbands and wives discuss family planning with each other, the higher the level of contraceptive use. It is not clear whether discussion of family planning stimulates its use or whether using family planning invites discussion of the topic -- probably, both statements are true. Remarkably, in six West African countries surveyed, only one couple in every four had discussed family planning during the previous year. Studies also show that when husbands approve of family planning or when wives think that husbands support it, the wives are more likely to use contraception. Yet some wives typically report that their husbands disapprove of family planning, when in fact the husbands themselves report that they approve.
Program implications
Where programs have reached men, male attitudes have changed and contraceptive use has increased. Nevertheless, reaching men with reproductive health care is more difficult than reaching women, for whom maternal and child health services are designed. "Health care programs cannot do the same things to reach men that they do for women," Dr. Green observes. Since many men are reluctant to seek reproductive health care, Wegner says, "you have to take advantage of every available opportunity; you have to go to where men are."
According to Dr. Awasum, "to have an impact you have to reach men in places where they congregate in large numbers." In Africa, for example, because almost all men follow football (soccer), Johns Hopkins University's PCS is reaching men with reproductive health information and services by sponsoring the "Challenge CUP" -- where "CUP" stands for "Caring, Understanding Partners." The CUP football matches bring thousands of men together, often with their wives and children, to watch teams compete and at the same time learn about and receive reproductive health care. To communicate with men effectively through mass media, experts agree that programs need to understand men's views and needs, then use this knowledge to design messages for them.
Men have fewer opportunities than women for receiving counseling about reproductive health care from service providers because so few men are reached by reproductive health care. Family planning counseling usually is offered as part of maternal and child health services and is typically done by women. Programs that have relied entirely on women outreach workers have had difficulty in reaching men. Thus, many family planning clinics need to learn how to welcome men, while service providers need training in how to counsel men about reproductive health.
Particularly urgent is the need to improve sexual responsibility among young men, including more condom use. Sexual activity often begins at a young age and before marriage. Because life-long attitudes and behavior patterns often form during youth, addressing the needs of young men can have a long-term impact.
More emphasis on men's participation in reproductive health could help draw attention to the need to do more for women as well. Increasing men's participation may help improve women's programs because more men would understand and be likely to support better reproductive health care -- for women, as well as for themselves.
-- Bryant Robey and Megan Drennan
Bryant Robey is editor and Megan Drennan is a writer/researcher for Population Reports, published by the Population Information Program, Center for Communication Programs, The Johns Hopkins School of Public Health in Baltimore, MD, USA. Robey prepared this article as a private consultant, while on leave from Johns Hopkins. Drennan, who is writing a Population Reports issue on men's participation, provided editorial and research assistance.
References
Danforth N, Roberts P. Better Together: A Report on the African Regional Conference on Men's Participation in Reproductive Health. Baltimore: Johns Hopkins Center for Communication Programs, 1997; Green CP. Male Reproductive Health Services: A Review of the Literature. New York: AVSC International, 1997.
Green CP, Cohen SI, Belhadj-El Ghouayel H. Male Involvement in Reproductive Health, Including Family Planning and Sexual Health, Technical Report 28. New York: United Nations Population Fund, 1995.
Danforth N, Jezowski T. Beyond Cairo: men, family planning, and reproductive health. Presentation at the American Public Health Association Annual Conference, Washington, October 31, 1994.
Ezeh AC, Seroussi M, Raggers H. Men's Fertility, Contraceptive Use, and Reproductive Preferences, DHS Comparative Studies No. 18. Calverton, MD: Macro International Inc., 1996.
Roudi F, Ashford L. Men and Family Planning in Africa. Washington: Population Reference Bureau, 1996; Ezeh.
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