HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
DEBATE |
Evaluating men's involvement as a strategy in sexual and reproductive health promotion
1Winona State University, MN, USA and 2Leeds Metropolitan University, Leeds, UK SUMMARY
Nearly 10 years has passed since the 1994 International Conference on Population and Development recognized men as legitimate targets for sexual and reproductive health promotion. This recognition was born of the experience of many health promoting agencies in the 1980s and 1990s who realized that without working with men, change would be very difficult or impossible. It was proposed that men should be involved because their active participation was crucial to the success of programs and to the empowerment of women. However, the idea that men should play an active role in health promotion has not been without its critics, who have posed serious questions about the efficacy of involving men and the effects their involvement would have on women and children. In an effort to examine the lessons learned from men's involvement, this paper reviews published evaluations of interventions that have targeted heterosexual men. Twenty-four studies that met the criteria for inclusion (reported on interventions in areas of sexual and reproductive health that targeted heterosexual men and contained evaluation data) were found. From their review of these studies, the authors suggest that there is some evidence that the use of media approaches may be a successful strategy and that there may be some problems with the application of some cognitive behavior change approaches. However, the fact that few interventions have targeted heterosexual men and have been the subject for detailed evaluation suggests that there is a need for more interventions and better evaluations, which would examine not only the process of men's involvement, but also their impact on the lives of both the men themselves and their families. The reality is that although perhaps no longer regarded as part of the problem, men have yet to be seen as part of the solution.
Key words: evaluation; men; participation; reproductive health; sexual health
INTRODUCTION
During the 1980s there was a tacit, if gradual, recognition within health promotion that men were an important factor in the health of women and children. Research showed that men not only acted as ‘gatekeepers’, restricting women and children's access to health services, but also through abuse or neglect, men's actions had direct bearing on the health of their partners and their children (Gallen et al., 1986
). Initially, the way to deal with what increasingly had come to be regarded as ‘the problem of men’ was thought to be to foster women's empowerment through working directly with women. Men, often identified as uncaring, unconcerned victimizers, were regarded as the enemy to be controlled and dealt with (Stycos, 1996). Many health promoters began to see their role as being to protect women from the impact of men's behavior on their lives by working directly with the women to empower them. This strategy was focused most particularly in the area of sexual and reproductive health.
By the end of the 1980s, the women's empowerment approach became an important driving force within health promotion and, more particularly, within sexual health promotion (Stein, 1997). The approach continues to create useful debate about issues especially in relation to reproductive health promotion and HIV prevention [see, for example (Richardson, 1996)]. However, as a strategy the empowerment of women without the involvement of men is at best a partial solution and at worst could create more conflict and result in more problems by increasing men's feelings of alienation.
These fears, coupled to a more sophisticated understanding of gender power relationships, which grew out of the reorientation of women in development (WID) programs into gender and development (GAD) programs, caused a revolution in thought about the participation of men in health promotion (Drennon, 1998; Cornwall and White, 2000). This revolution eventually resulted in official recognition during the International Conference on Population and Development, which took place in Cairo in 1994, that men had a useful or even ‘crucial’ role in sexual and reproductive health promotion. Ideas about how men could be brought in and what the agenda should be for their involvement were incorporated in the platform of the Cairo Conference. These ideas were extended and refined at the Fourth Women's International Conference, which took place in Beijing the following year. In 1997, the United Nations Population Fund (UNFPA) published a booklet that proposed that the agenda for men's involvement post-Cairo and post-Beijing should be to change men so that they could play a proactive role in the empowerment of women (UNFPA, 1997). The UNFPA booklet was the culmination on an international stage of a decade of rhetoric about male involvement in sexual and reproductive health.
Although few would now disagree that men's involvement is important, the introduction of programs that aim to involve men pose some serious questions about the effects of involving men in areas that have traditionally been considered the preserve of women, such as childcare, pregnancy and fertility control (Berer, 1996; Helzner, 1996). Moreover, there is a fundamental question, as far as the strategy is concerned, about whether men's involvement actually increases men's power over their female partners or whether it will help to empower women.
In the growing literature that surrounds men's involvement, there are a large number of articles that were written as justifications for involving men [see, for example (Green et al., 1995; Mbizvo and Bassett, 1996; Best, 1998; Drennon, 1998; Wegner et al., 1998)]. There is a need to look, as an Oxfam-sponsored conference in 2001 attempted to do, ‘beyond the rhetoric’ and to begin to answer these very serious questions. In an effort to continue the process of looking beyond the rhetoric, which Oxfam began, this paper examines the effects of men's involvement by evaluating the evidence from practical experiences of using the strategy. The paper attempts a meta-analysis of published evaluations of sexual and reproductive health interventions that have targeted adult heterosexual men and have taken place since the early 1990s.
METHODS
A literature search of online databases including Medline and Popline was conducted. When this search failed to yield more than a handful of published accounts, the search strategy was widened to include The Leeds Health Education Database (available online at http://www.hubley.co.uk). The search was based on a series of search terms and topics suggested by the substantial literature around men's involvement in sexual and reproductive health. These terms and topics included men's role in HIV/STI prevention, men's role in the avoidance of unwanted pregnancies, men's role in the promotion of safe motherhood, men's involvement with children (fatherhood) and men's role in stopping violence against women.
In order to be included in the study, reports of interventions had to be published in a book or peer-reviewed journal and be targeted at adult men as a distinct group. Studies that reported interventions were included only if they contained evaluation data. However, in several cases, because of the lack of studies, reports were included that contained only descriptive information because they illustrated an area that was a particular focus for work with men.
RESULTS
Twenty-four intervention studies that fit the evaluation criteria were identified. A further two studies were also included because they gave some information about programs that could usefully be evaluated in the future. The results of the search appear below, categorized under the following headings: men and HIV/STI prevention; men's involvement in the avoidance of unwanted pregnancy; men's involvement in women's reproductive health; men and violence prevention; and men and the promotion of responsible fatherhood.
Men and HIV/STI prevention
There have been comparatively few HIV prevention interventions that target adult heterosexual men as a distinct client group. HIV prevention initiatives for men at their worksites seem to be the most common site and focus for interventions targeting men. Worksites that have been targeted include trucking companies (Jackson et al., 1997; Witte et al., 1998; Laukmann-Josten et al., 2000; Leonard et al., 2000), mines (Campbell and Williams, 1999), the military (Brook et al., 1994; Celentano et al., 1998) and fishing boats (Wilson et al., 1994).
Celentano et al. reported the success of the Thai ‘100% Condom Program’, which educated young male Thai military conscripts about condom use using a series of education sessions and a leaflet/poster campaign (Celentano et al., 1998). In their cohort study, they found that the incidence of HIV and STI amongst their cohort declined dramatically between 1991 and 1995. This study would seem to suggest that it is indeed possible for men to alter their high risk behaviors in a way that has a real impact on infection rates.
A study by Brook et al. contained descriptions of a number of workplace programs from different countries that targeted men, but unfortunately contained little in the way of evaluation (Brook et al., 1994). Similarly, Wilson et al. reported on a prevention program aimed at Kenyan fishermen, but the report was descriptive and contained little information about the impact of the program they described (Wilson et al., 1994). Witte et al. (Witte et al., 1998) studied truck drivers' reactions to posters and leaflets, but did not provide any consideration of their impact. Laukamm-Josten et al.'s study evaluated a peer education program that targeted Tanzanian truck drivers (Laukamm-Josten et al., 2000). Trends shown by surveys done during an 18-month intensive phase of peer education about condom use followed by a 24-month maintenance phase showed that reported condom use increased from 56 to 74% amongst men.
It may be that peer education amongst men is an effective strategy for HIV prevention and increased condom use. Leonard et al. (Leonard et al., 2000) reported on a peer education program of HIV prevention and condom promotion, which involved a 2-year longitudinal study of Senegalese transport workers. They found significant increases in men's HIV-related knowledge and use of condoms. Post-intervention interviews with sex workers indicated that a greater proportion of clients used condoms following the intervention and that fewer men offered money for unprotected sex. They concluded that peer education may be an effective way to promote safer sex amongst the clients of sex workers and proposed that more efforts be made to focus interventions on men.
One target group that has been of considerable interest to HIV researchers is migrant laborers and especially miners in South Africa, but most of the published literature is epidemiological or KAP (Knowledge, Attitudes, Practices) studies. However, Campbell and Williams observed that while many South African mining companies made substantial efforts to initiate HIV prevention programs, these seemed to have had little impact (Campbell and Williams, 1999). Unfortunately, they did not go into detail about the methodologies these programs employed.
Jackson et al.'s study of trucking company workers in Kenya found increases in condom use and a decrease in the percentage of men who had had extramarital sex as well as a decline in the numbers of men who had had sex with a sex worker following their cognitive behavioral intervention (Jackson et al., 1997). On the other hand, Kalichman et al. (Kalichman et al., 1997), in one of the few interventions aimed at heterosexual men outside of their workplaces, found little success with their use of a cognitive-behavioral approach to HIV prevention. They reported that following an intervention that consisted of four cognitive-behavioral skills training sessions (which had already been proved to be successful with other groups), the 81 African-American men who took part at baseline, intermediate and 3-month follow-up showed no significant differences at 3-month follow-up. In their comments, they observed that although their sample was small, there was a need to be very cautious about using interventions that had been successful with other groups of heterosexual African-American men.
Men's involvement in the avoidance of unwanted pregnancy
Many of the reports available in the literature are less about the effectiveness of men's involvement than about evaluating family planning services and making suggestions about the ways services might change to involve more men. Reports in this genre include Schehl and Green's report of AVSC International's (now Engenderhealth) ‘Men as Partners Initiative’ (Schehl and Green, 1997), Clift's (Clift, 1997) and Wells' (Wells, 1997) reviews on reproductive and sexual health services for men, and the Johns Hopkins University review of 20 men's family planning programs from Africa, Asia and Latin America (Johns Hopkins School of Public Health, 1997). These reports found that, contrary to what some supposed, many men wanted to be involved in family planning programs and that those programs in which men were viewed as caring partners rather than as irresponsible adversaries were successful in involving men.
There are a number of reports of interventions that have involved men in family planning programs. AVSC International presented findings from the eight family planning clinics that they had run in Colombia since 1985 (AVSC International, 1997a). The study found that the clinics were successful in attracting male clients. AVSC attributed this success to their policy of offering a brief counseling session to help men articulate their needs and talk about their doubts before they attended medical consultations. Another important element cited by the report was the policy of encouraging couples to seek services together.
In Pakistan, AVSC carried out six case studies to evaluate affiliated projects that aimed to increase men's involvement in family planning (AVSC, 1997b). The study found that the projects were successful at reaching out to and involving men through a combination of extensive outreach work, the introduction of ‘no-scalpel’ vasectomies, and regular meetings with the press, religious and political leaders aimed at promoting changes in the women's status and a reduction in family size.
The Population Council reported on a program in Honduras designed to increase men's knowledge of family planning and to facilitate their role in reproductive decision making (Population Council, 1998). Two strategies were used: one involved agricultural extension workers who were trained to give health education sessions based on a training manual, and the second extended an agricultural program, the ‘Farm Management Plan’, into areas of family planning through the use of a ‘family management’ booklet. The program managed to involve men through low-cost strategies that were incorporated into already existing structures.
There are several reports of interventions that successfully used interpersonal methods to increase men's knowledge of contraception and communication. These included: involving Muslim religious leaders in Gambia (Turner, 1992) and in Bangladesh (Neaz, 1996) in a program to teach about the connections between family planning and Islam; a peer education program amongst Tanzanian men (Popoola, 1999); seminars for health staff and a child-spacing club based around a Malawi hospital (Mason and Lynam, 1992); and the training of agricultural extension workers to provide family planning information to men (Population Council, 1998).
There are also several reports of mass media approaches that have targeted men's participation in family planning. Both Piotrow et al. (Piotrow et al., 1992) and Kim and Marangwanda (Kim and Marangwanda, 1997) evaluated the Zimbabwean Family Planning Council's ‘Male Motivation Project’. The project used a wide variety of media: TV, radio, newspaper advertisements and articles, and a television soap opera. It also used language and images from competitive sport. Both studies found that men exposed to the campaign were significantly more likely to use condoms than men who were not.
In one of the very few studies to test the efficacy of health education theory against the realities of men's involvement, Ha et al. reported on an intervention that targeted Vietnamese men's involvement in contraceptive decisions using the transtheoretical model (‘stages of change’ model) (Ha et al., 2003). The study, which involved 201 men from rural Vietnam, suggested that using a stages of change analysis might be an effective approach to targeting men and helping to promote their involvement in contraceptive decisions, with an emphasis on IUD (intrauterine device) acceptance by their partners.
Actual evidence in the literature about the impact of men's involvement in the prevention of unwanted pregnancy, including increasing their own use of contraception and facilitating their partners' use, is generally sparse. Terefe and Larson's report of a project for Ethiopian men is one of the very few studies to be actually concerned with evaluating the effectiveness of men's involvement as a health-promoting strategy (Terefe and Larson, 1993). It was designed to test whether involving men in family planning discussions with their wives made a difference to the use and uptake of modern contraception methods. An experimental group, which included 266 couples, was compared with a control group of 261 women. Both groups received home visits by female health assistants and traditional birth attendants. Subjects were questioned at baseline and at 2 and 12 months. At 12 months, almost twice as many experimental subjects were using a modern contraception method as controls. The fact that men were participating did seem to make an important difference to contraceptive uptake by their spouses.
Men's involvement in women's reproductive health
If there are few evaluated reports about men's involvement in family planning, there are even fewer about men's involvement in the maintenance of women's reproductive health. Dev reported on an Indian program that aimed to involve husbands in antenatal care checkups (Dev, 1998) and Toubia reported on a program in Mali, which aimed to encourage men to accompany their spouses to family planning and gynecological services (Toubia, 1995). During the Indian program, men were given information about antenatal care services, information about diet, nutrition and weight gain during pregnancy, and information about contraception. Using information gleaned from 113 structured interviews and 13 in-depth interviews, the study compared an intervention group with a non-intervention group. Men from the intervention group had a greater knowledge of the importance of antenatal care services, and their partners made more visits to antenatal care clinics. Toubia's study did not include information about the impact of the intervention.
Men and violence prevention
Although the literature contains a number of studies that have investigated the prevalence and etiology of violence against women, there are very few reports of interventions that have involved men in violence reduction.
Cervantes Islas (Cervantes Islas, 1997) reported on the work of CORIAC (the Men's Collective of Egalitarian Relationships) with violent men in Mexico City. The CORIAC model, designed and facilitated by men, emphasizes men's participation in redefining their masculinity. The intervention helped participants to visualize and question competition, violence and the abuse of power. The CORIAC ‘retraining’ program places an emphasis on the expression of emotion and the non-violent exploration of emotion, flexibility with respect to sexual roles, and the problem-solving skills of abusive men. Cervantes Islas' paper is not an evaluation, but was included in this study because it provides some information about one of the few interventions that have incorporated an understanding of gender and power into a program for violence prevention with men's participation.
Welsh evaluated a Nicaraguan intervention based on the methodology of Popular Education (reflection/action) (Welsh, 2001). A total of 300 Nicaraguan men participated in four 3-day workshops. During the workshops, participants reflected on the ways that their gender and sexual identities led them as individuals to be violent against women, and went on to consider what actions they could take to become less violent. In a post hoc evaluation, carried out some 3 months after the last workshop, Welsh reported positive changes, which included more participation in domestic chores, fewer incidents of physical and psychological violence, and more involvement with children. However, limitations of the study design (lack of baseline study and controls) make it difficult to assess if these changes were indeed the result of the intervention.
Men and the promotion of responsible fatherhood
Although there have been a number of recent ethnographic studies that have examined aspects of fatherhood in various developing countries, there were only two reports of an intervention in a developing country that aimed to foster men's involvement with their children. Both Chevannes (Chevannes, 1992) and Johnston-Pitt and Jiji (Johnston-Pitt and Jiji, 1996) reported on a Jamaican initiative, ‘Fathers Incorporated’. Fathers Incorporated was a club for men that was set up to promote a positive image of responsible fatherhood. Both reports were descriptive, rather than analytical, but were included because they gave details about the only program documented in the literature that was specifically set up to promote responsible fatherhood.
DISCUSSION
Despite the substantial rhetoric around men's involvement in sexual and reproductive health, the reality is that there have been few published evaluations of interventions. From the information from these interventions, it is possible to show that men's involvement may lead, for example, to increased uptake of contraception, but is this necessarily empowering for women? In a newsletter report, Cornwall cited evidence from Middle Eastern family planning programs that men's involvement had actually increased men's power over the fertility of women, rather than resulting in women having more choice (Cornwall, 1998). There is a need for evaluations that examine the impact of the strategy and ask the question, does men's involvement in sexual and reproductive health promotion empower women? Does ‘involvement’ help men achieve the capability to resist social norms of male dominance? These rather important questions have yet to be answered.
Another important question, also as yet unanswered, is what is the impact of men's involvement in programs on the lives of the men involved? The effects of interventions on men need to be evaluated. How are ‘involved’ men coping with issues such as losing control over families if family size is negotiated with wives? How do ‘involved’ men respond to the contradiction inherent in their involvement when social norms dictate that men sire large families, yet they are involved in interventions whose aim is to restrict family size? What is the effect, if any, of men's involvement in their own gender identity? Are new, caring, sharing models of masculinity being formed or are men learning more sophisticated ways to assert their dominance over women?
While it is difficult with the current information available from published sources to evaluate impact, it is possible to begin to evaluate the process of men's involvement. A theme of many of the evaluations that appear in the literature are the interventions' abilities to reach men and engage them in their programs. It is possible to identify certain strategies that seem particularly effective: these include peer education programs, large-scale media campaigns, workplace health programs and community outreach through religious leaders and agricultural extension workers. It is notable that the mere provision of family planning services for men does not seem, in itself, to be enough to attract them into programs. This may be a result of the modus operandi of many services, i.e. that they remain, for the most part, designed to meet the needs of women.
Most of the studies cited above report that men have responded positively to being involved in interventions and that they do in fact care about the welfare of their families. Critics of men's involvement have argued that persuading men to view sexual and reproductive health as important and not just women's responsibility will be very difficult. Some fear that resources earmarked for projects targeting women will be reallocated into projects that target men [see, for example (Berer, 1996; Helzner, 1996)]. These fears however, seem unfounded for two reasons. First, the evidence from interventions is that many men approve, care about family planning and are interested in the welfare of their families [a finding also mentioned by (Ezeh et al., 1996; Drennon, 1998; Baylies and Bujra, 2000)]. Secondly, the evidence from interventions is that men do actually want to be involved and that many respond positively to efforts to involve them.
Despite all the rhetoric about the importance of men's involvement, worldwide funds remain dedicated to programs that directly support women and children's health (Sonfield, 2002). This is probably one of the reasons why this study found so few published interventions. As Sonfield points out, where funding decisions have to be made, it is normally at the expense of men's programs for the very reason that men are seen as a difficult group to target.
Generally, it is difficult to make inferences about the efficacy of one theoretical approach over another because there is a lack of detailed information in the evaluation reports about the theoretical basis of the interventions they report on. The evidence from interventions based on cognitive behavioral change models is equivocal, suggesting that there may be some problems using the model with some men. Possibly these different findings have their roots in differing cultural beliefs and values. In his overview of HIV prevention amongst men who have sex with men in developing countries, McKenna (McKenna, 1996) makes the point that interventions that target this group should be based on an historical political assessment of the sexual culture, which is able to contextualize sexual behavior. While cultural understandings of sexuality and gender fairly obviously have a large bearing on sexual and reproductive health, it seems that very little operationally based research has been done that incorporates such understandings in interventions that target men's involvement.
It is interesting to note that Ha et al. did find some success using the transtheoretical model to stratify a group of men and provide them with targeted interventions with a consideration of their ‘stage of change’ (Ha et al., 2003). It also seems that well targeted mass media campaigns, particularly those that use an ‘ENTED’ (entertainment/education) focus, such as the Zimbabwe Male Motivation Project, have some success with groups of men (Piotrow et al., 1992; Kim and Marangwanda, 1997).
This paper represents a starting point in what should be a large and crucially important project within sexual and reproductive health promotion. There is a need for more research to look not just at the process and immediate outcomes of men's involvement, but also to have a longer term impact on the lives of both women and men. The reality is that despite the considerable rhetoric surrounding men's involvement, men are still seldom targeted and there are very few evaluations of interventions in sexual and reproductive health that address issues from a focal point of masculinity, or even an understanding of men's needs. The inescapable conclusion is that in sexual and reproductive health promotion, although perhaps no longer seen just as part of the problem, men have yet to be regarded seriously as part of the solution.
ACKNOWLEDGEMENTS
The authors wish to acknowledge the help and support of Dr Alan White (Leeds Metropolitan University) and the Catholic Institute for International Relations (CIIR).
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B. C. Mullany, S Becker, and M. Hindin The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial Health Educ. Res., April 1, 2007; 22(2): 166 - 176. [Abstract] [Full Text] [PDF]
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