Involving Men

Impact of integrated services depends on male cooperation.

Network: 2004, Vol. 23, No. 3

See Also:

Family Planning and the Prevention of Mother-to-Child Transmission of HIV: A Review of the Literature

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 equality³ — 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 Comunição em Sexualidade e Reprodução Humana (ECOS) and by the Mexico-based Salud y Género, 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 Assessing Men's Attitudes About Gender Roles) 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."

— Kathleen Henry Shears

References

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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.
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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 online.