The Population Council (Hardee); What Works Association (Croce-Galis, Gay)
"Although the range of contraceptives includes methods for men, namely condoms, vasectomy and withdrawal that men use directly, and the Standard Days Method (SDM) that requires their participation, family planning programming has primarily focused on women. What is known about reaching men as contraceptive users?"
This paper draws from a review of 47 interventions that included some focus on men as users of contraception in low- and middle-income countries, augmented with interviews with 36 representatives from institutions involved in relevant programming and research. This paper reviews current programmes and evidence, including those that address gender norms that affect men's use of contraceptive methods, and proposes key considerations to strengthen programmes for men as family planning (FP) users. The analysis takes a broad view of programming to include policies that create an enabling environment, services, and behaviour change interventions to address norms and demand creation.
The literature review included a search strategy for articles and reports from 2010 to 2015, and included selected programming from years prior to 2010 if one or more of four methods of contraceptive methods (male condom, vasectomy, withdrawal, and the SDM) was included. The interventions, which were carried out in 27 countries spanning Africa, Asia, Latin America and the Caribbean, and the Balkans, are grouped under five strategies: 1) Clinic Provision of Information and Services for Men; 2) Outreach with Male Motivators and Peer Educators/Mentors; 3) Community Engagement; 4) Communication Programmes; and 5) Comprehensive Sexuality Education. Two of the strategies, namely communication programmes and community engagement, include sub-strategies. Table 1 in the paper outlines the strategies, the number of interventions found under each strategy, the countries of implementation, and the categorisation of the strategy as proven, promising, or emerging based on the strength of evidence for each strategy adapted from the Family Planning High Impact Practices initiative. (Further details about the 47 interventions are provided in the study available at Related Summaries, below.)
The review of programming shows strategies for reaching men with evidence ranging from proven (social marketing; and outreach with male motivators and peer educators/mentors), to promising (clinic provision of information and services; mass media; promoting community dialogue and comprehensive sexuality education), and emerging (social media; mHealth; hotlines; and engaging religious leaders). Interventions sought to improve men's attitudes toward FP, their knowledge of specific methods of contraception, and their use of FP generally or male methods specifically. Furthermore, most of the interventions sought to address gender norms around FP use - mostly to promote male support for their partner's use but also some to promote male use of methods. When male methods, notably condoms, vasectomy, and SDM, were made available through interventions, uptake generally increased. Finally, a number of the interventions had positive outcomes related to promoting more equitable gender norms related to FP and increasing couple communication on fertility and contraceptive use.
The review leads to the conclusion that men and boys are not particularly well served by FP programmes. "Most programs operate from the perspective that women are contraceptive users and that men should support their partners, with insufficient attention to reaching men as family planning users in their own right. At the same time, the review highlighted that there is sufficient evidence demonstrating men's desire for information and services, as well as men's positive response to existing programming to warrant further programming for men and boys in family planning and contraceptive services."
Based on this analysis, the paper proposes 10 key considerations for strengthening programming for men as contraceptive users, including:
- Provide information and services to men and boys where and when they need it - Reproductive health services are largely seen as spaces for women, with male norms of masculinity often challenged by men's accessing services. Also, there is a large gap in men and adolescent boys’ access to information and services, leading to a disparity between male and female knowledge of and access to contraceptives. However, hotlines are one of the approaches discussed here that are demonstrating promise as platforms to reach men with information about contraceptives and available services. In the Democratic Republic of Congo (DRC), evaluation of use of an FP hotline - Ligne Verte - found that although women were the primary intended audience of the hotline, men represented 80% of the 20,000 calls per year, with men asking for information about contraception and where to obtain it. The vast majority (94%) of calls to a hotline in India were from males, who asked for a range of information.
- Address gender norms that affect men's use of contraceptive methods - Although most programming is based on the perception that gender norms value masculinities that include bragging about sexual encounters, having frequent sex and multiple partners, and leaving the responsibility for unintended pregnancies to women, masculine ideals may also involve showing respect for and protecting their female partners. Where men and boys have been exposed to gender equality programming, they are more likely to report increased contraceptive use, including condom use.
- Improve couple and community communication - When couples have discussed FP, contraceptive use tends to go up, with evidence (cited here) from Kenya, Ethiopia, Nepal, Bangladesh, and Pakistan. Some have noted the need to ensure that couples communication interventions take into account unequal power in relationships - a topic that is explored here.
- Meet men's needs while respecting women's autonomy - Men should be able to exercise their reproductive right to use contraception, but they should not be able to deny their partner's right to use FP.
- Link men's contraceptive use with their desire to support their families - A study of married men in Pakistan found that the perception that a responsible, caring husband uses FP to improve the standard of living of his family and to protect his wife's health made men 1.5 times more likely to intend to use a condom.
- Teach adolescent boys about pregnancy prevention and healthy sexual relationships - Comprehensive sexuality education should talk about parenthood and make the link between sexuality and fatherhood more explicit.
- Develop national policies and guidelines that include men as FP users - Some countries have successfully integrated policies regarding men's involvement in sexual and reproductive health. Cambodia was among the first countries to do so in 2003.
- Scale up programmes for men - "Communications programming in Bangladesh, Ghana, Honduras, Guatemala, Pakistan, India, Vietnam, Burkina Faso, Tanzania, and Nicaragua show that mass media can create national conversations that address the social and cultural barriers to men's contraceptive use. Social media is a rising force that can be harnessed to connect men to information and services as seen in the use of Facebook by WINGS in Guatemala to publicise the availability of vasectomy....Social marketing can challenge social norms and help overcome barriers to acceptability of contraceptive use. Use of male motivators and other trained male peers has repeatedly demonstrated success on a small scale. This programming could be more effective on a large scale if it were linked with other strategies, such as comprehensive sexuality education that includes information on men and boys' contraceptive needs; provider training and information and service provision for men; and gender-responsive programming that improves couple communication and joint decisionmaking. The FALAH Project, implemented between 2008 and 2012 in Pakistan shows that programming for men can reach millions of men. That project...engaged men through multiple strategies including male motivators and peers, mass media, theatre performances, men's groups, and religious leaders. An mHealth solution in India that supports fertility awareness and use of SDM (CycleTel Family Advice and CycleTel Humsafer) has been developed..."
- Fill the gaps through monitoring, evaluation, and implementation science - Regional and country contexts are important in developing this research.
- Create more contraceptive options for men.
"Scaling up successful programming and ensuring that the key considerations for programming are intregated into interventions for men, and continuing to undertake robust implementation research and valuation, will increase men’s knowledge and use of family planning services, reduce barriers, increase gender equality and improve the health and well being of men and women, boys and girls worldwide."
Reproductive Health 14:14 - sourced from Population Council website, March 9 2017. Image credit: Population Council