There is a growing understanding in the international public health community of the role of gender as a fundamental influence; along with decision-making power, access to education and earning power; it affects the health choices available to everyone. This understanding has been instrumental in making reproductive health professionals aware of the need to develop creative strategies to reach men—a need that has become increasingly urgent in the face of the growing worldwide spread of sexually transmitted diseases (STDs), including HIV infection.
Although pilot programs and initiatives for including men in family planning and other reproductive health services have existed for more than 20 years in a number of countries,1 few are well-established, and fewer still have been fully integrated into their country's health care system. Program managers and policymakers in many countries have almost automatically assumed that men are not interested in or supportive of family planning and contraceptive use, even though recent research shows that many men are.2 Moreover, studies and reports from clients and service providers show that many women want men to become more involved. Around the world, women and men have told health care providers and interviewers that they want both partners to be involved in the health care decisions that affect their families' lives.3
In the past, men's involvement has sometimes been opposed by women's health advocates, who understandably fear that adding these services will damage the quality of women's services and create additional competition for already scarce resources. However, adding programs for men can enhance rather than deplete existing programs if the designers of these programs carefully integrate them into the existing health care structure in a way that benefits both women and men. Both the 1994 International Conference on Population and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing endorsed the incorporation of reproductive health services that include men, mandating that men's constructive roles be made part of the broader reproductive health agenda.
In fact, neglecting to provide information and services for men can detract from women's overall health. For example, men who are educated about reproductive health issues are more likely to support their partners in decisions on contraceptive use and family planning,4 support that may be essential if women are to practice safe sex or avoid unwanted pregnancy. Moreover, if men are knowledgeable about reproductive health issues and can communicate about them with their partners, they are more likely to be supportive during pregnancy and may make better health care decisions: for example, by ensuring that their partner receives emergency obstetric services when needed, rather than delaying recourse to such care. The effect of men's attitudes and behavior on women's health is perhaps most obvious in regard to the pandemic of AIDS and other STDs. Programs that educate, test and treat only one partner will not be effective in safeguarding the continued health of both. Men need to share the responsibility of disease prevention, as well as the risks and benefits of contraception.
Therefore, to foster dialogue and to develop strategies to address this issue, 145 men and women from more than one dozen primarily African and Asian countries gathered in Mombasa, Kenya, in May 1997 to share their experiences with, knowledge of and concerns about fostering men's involvement in reproductive health care. The majority of participants made up country teams from Egypt, Eritrea, Ghana, India, Kenya, Pakistan, South Africa, Tanzania and Uganda. Together, these teams developed and presented plans that would create programs for men in their countries and would integrate these programs into existing national reproductive health systems.
The workshop was one of a series of activities undertaken by AVSC International's Men As Partners initiative to encourage men to become better informed, supportive partners in their families' reproductive health and to become active in preventing the spread of STDs.
A Closer Look at Program Issues
Participants found that despite national differences in the wants, needs and realities of women and men, a number of issues were common to all. These included the need to define what is meant by "partnership" in relation to families' reproductive health, to understand the role of "gatekeepers" in controlling and channelling resources and in setting policy goals, to design services hand-in-hand with the local community, to communicate effectively with clients and to ensure that services are not only institutionally and economically sustainable, but also well-integrated into the health care system. Finally, all participants recognized that each country's action plan should articulate strategies to meet youths' special needs.
In exploring the meaning of the word "partner," participants agreed that in the context of reproductive health, the term must take into account differences stemming from socioeconomic and cultural factors, including gender. When developing strategies and designing programs as part of their country plans, the participants found that the goals of reproductive health programs fell into three broad categories previously outlined in AVSC's Men As Partners initiative:
• To increase men's awareness and support of their partners' reproductive health choices;
• To raise men's awareness of the need to safeguard their partners' and their own reproductive health, especially by preventing STDs; and
• To enhance couples' access to male methods of family planning.
Participants also recognized that these broad definitional outlines must be adapted to each country's needs. For example, the Kenya team felt it appropriate to include a reference to improving the health status of the family in their definition.
The Role of Gatekeepers
Workshop participants expressed the strong belief that policymakers, program managers, health care workers and other types of providers can block male involvement. This may occur because of conservative cultural and political values, the conventional wisdom that men are not interested in reproductive health matters or simply the assumption that family planning is a woman's responsibility. The participants suggested that messages developed to reach these groups should be tailored to address cultural and political issues, and as such may not be the same as those designed to reach clients and potential clients.
Health care providers at all levels may deny individuals services or supplies due to biases, arbitrary policies or inadequate attention to clients' needs; clinic personnel are often unaware of their own prejudices. In particular, many health care providers lack adequate information and training to provide care to men. To improve the reproductive health of all individuals, programs must reach out to providers and supply them with the information they need to provide quality care and to assess their own attitudes and biases about methods and clients.
The Young Men's Clinic in New York City provides an example of the role and importance of gatekeepers. The clinic determined where in the neighborhood young men congregated and where services were available to them. The staff then carefully executed a strategy to inform sports coaches, emergency room physicians, teachers and youth club directors about the health services available at the young men's clinic, including sports and work physicals. Staff at this clinic found that once youths were inside the clinic, staff members had many opportunities to teach them about reproductive health issues.
For similar reasons, the Eritrean country team decided to use a multifaceted approach to convince adults in their communities to encourage youths to learn more about reproductive health. Concepts about involving men in reproductive health will be integrated into curricula and training for clinicians and counselors with the National Union of Eritrean Youth and Students, and these curricula will be introduced into junior and secondary schools for teacher training, as well as into medical and nursing schools.
•Integrated vs. separate services. Many participants believed that housing services for men and women in the same facility allowed for the most cost-efficient use of space and staff, but others reported that trying to bring men into facilities that have traditionally served only women presented major practical or social and cultural barriers. While separate services for men and women may be made sustainable, participants agreed that good referral systems and close cooperation between the administrators of such programs are essential, particularly in building programs for the prevention of STDs.
In Colombia, an assessment in the late 1980s and early 1990s of Profamilia's experience of designating separate male-only hours or clinics to provide vasectomy showed that while male-only clinics performed more vasectomies, they did not increase men's satisfaction with services.5 Therefore, if services for men are to be designed from a quality perspective, whether they are provided in separate locations may not be the critical issue.
Some participants believed that men-only clinics are the most appropriate way to generate interest among potential male clients and to ensure that there is space and staff dedicated to meeting their needs. This avenue may be especially appropriate in societies where the sexes often are segregated, as it follows the country's cultural norms. In addition, if a community or region is just beginning to serve men as reproductive health clients, it may be easier to market a facility just to men than to advertise the fact that a previously existing women's clinic is now serving men.6
Still, in some countries, female clients have suggested that men be included in existing programs for women. A participant from Pakistan described his organization's tentative start to a men's program, after some female clients had requested that men be included. A sign that read "Entrance by Males Strictly Forbidden" was removed, and staff members began to encourage women to bring their husbands. As a result, couples now have the opportunity to discuss sensitive issues with a counselor, a service that had not previously been offered. In this particular clinic, the demand for services turned out to be so great that the clinic built a second floor and now houses men's and women's services in the same facility, but separated by floors and hours of operation.
•Mobile services. Workshop participants acknowledged that in most parts of the world, men—unlike women—tend not to seek either preventive health care or information about reproductive health. For this reason, participants agreed, providers must seek men through mobile outreach. Often this outreach is "attached" to an existing clinic, which serves as the home base for picking up commodities and rotating staff.
Mobile services have proven to be an important mechanism—not only in rural areas where there are no existing facilities, but also for urban neighborhoods. One U.S. participant explained that her mobile outreach van has become a trusted source of health care, serving an "at risk" community that includes commercial sex workers and drug users. The van goes to the same part of the city several days a week and serves individuals who otherwise would not have the opportunity to receive health care. As its services have expanded to include primary care for individuals with HIV and AIDS, the van also serves an important function for those who are too sick to transport themselves to a hospital or clinic for care.7
•Workplace programs. Workplace programs have proven successful in many parts of the world.8 Such programs' main benefits include fostering a good relationship between the health care system and the private sector and shifting attention to the importance of preventive health care. The role of marketing in these programs appears to be pivotal to their success, as are assurances that client confidentiality will be respected.
Although taking health care services to the workplace requires an initial investment of staff time and resources, many workplace programs can become self-sustaining. Offering examples from factories in Malawi, Mexico, India and Pakistan, representatives from Marie Stopes International described how such programs were working toward sustainability. Emphasizing that the commitment and support of management are essential for success, they noted that workplace programs must be structured so employees are not indirectly penalized for attending the clinic (having to miss a break or an important meeting, for example). Services must also be designed to fit workers' needs—even if this means that clinic facilities must be open after normal working hours, or even 24 hours a day to treat emergencies. While management may understandably be concerned about cost, the better health of the workforce may save money in the long run.
Participants shared many other examples of workplace programs. For example, representatives from Family Health International described the use of peer educators in Kenya to reach men in the workplace. In Cameroon, information on STDs was incorporated into basic military training. In Kenya, to reach thousands of young men and women, Marie Stopes International included information on reproductive health in the curriculum of the National Youth Service. And a representative of PATH described a project to offer STD self-assessment and counseling to dock workers in the Philippines. All of these programs have learned that their primary purpose may be as much education as service delivery.
A number of participants emphasized the importance of involving the community in both the design and delivery of services. In Uganda, a large part of one project's success was its profound commitment to community participation, investment and ownership. When the organization found that it did not have the funds to build a clinic, the staff asked children to bring a stone or brick to school once a week. As the pile grew, the perception spread that the community would have a clinic one day. As a result, everyone (from local leaders to the school children) actively contributed to the building of the clinic, and indeed now feel that it belongs to them.
The workshop participants also discussed the fact that when an idea, like male involvement in reproductive health, is perceived as "new," community ownership is even more critical to a program's success.
Communication with Clients
Communication was identified as a programming area of particular importance. Participants from all nine country teams included in their plans of action information, education and communication strategies to reach out to policymakers and other influential groups about reproductive health programs for men. In addition, the Egyptian, Eritrean, Indian, Tanzanian and Ugandan teams recognized that working with the mass media was an important strategy.
The participants noted that because reproductive health care has traditionally been geared to women, they have become accustomed to accessing it. Men, in contrast, are often not aware of their own reproductive health needs, let alone those of their partners. In addition, many have not sought access to reproductive health care because they perceived it as being a woman's domain. It is therefore crucial to use a variety of communication strategies to help men gain access both to information and to services.
•Developing messages and materials. One lesson learned from the workshop and from a literature review is that special care is required in the design of information, education and communication messages for men: Messages developed for women or for other groups, such as adolescents, may not work for men.
It is crucial to ascertain from male clients what services they want, learn what information men need and determine what communication approaches are acceptable or appropriate. In addition, men sometimes know less about reproduction, anatomy and contraception than women,9 and often have their own set of misconceptions about these issues. Messages for clients must address the misconceptions of both men and women.
Another important lesson learned about the development of messages for men is that such messages need to be gender-sensitive: Program managers who design messages for men must be careful not to reinforce stereotypes about either men or women.
Sometimes, however, messages developed to reach men are also intended to reach women. For example, in one community-based distribution program in India, program managers realized that they needed to educate men if women were to receive information and services.10
•Counseling. Designing counseling services that meet male clients' needs is essential for successful programs. Although the principles for effective counseling on reproductive health issues are the same for men and women, workshop participants agreed that an effective counselor for men should have special qualities: knowledge about masculinity, about gender roles and values, about men's position in the family and (where appropriate) about polygamy, as well as an ability to put men at ease and to talk frankly about sexuality and sexual behavior.
Some programs are now beginning to design couple-oriented services, including counseling. Although the concept of "couple friendly" care may be gaining currency in the field of reproductive health, workshop participants suggested that programs should proceed with caution in this area, as in some cultural milieus this ideal may shortchange women. For example, if a woman is being abused by her partner and seeks counseling for how to deal with domestic violence, aiming to include her partner may do more harm than good.
•Mass media. Several country teams included in their information, education and communications strategy a plan to work directly with the mass media to develop messages for men and women about male reproductive health. Because they reach such a wide audience, television, radio, newspapers and magazines can be effective mechanisms for communicating about reproductive health issues.
Although mass media can raise awareness, they do not necessarily in themselves lead to behavior change. Mass media messages need to be reinforced through other means of communication, such as one-to-one counseling—by providers or peers—and written materials. A key recommendation from a 1996 conference in Harare for African programs dealing with male reproductive health issues was that communication strategies should address the diverse needs of different groups of men.11
•Satisfied clients. Many participants spoke of the importance of using satisfied clients in outreach activities. For the Family Planning Association of Pakistan, for example, this is one means of reaching other men. In Kenya, a group of satisfied vasectomy clients spontaneously decided to form an outreach group. Together with their wives, they visit throughout the community, sharing their experiences and talking with interested men and their partners to educate them about all kinds of family planning, including vasectomy. They also have volunteered to be "posted" at clinics to talk informally with anyone who is interested in learning more about vasectomy as a contraceptive option.
Workshop participants believed that integrating services for men into a country's existing health care structure is the key to achieving sustainability and to ensuring that programs for men do not compromise existing programs for women. Institutional capacity (including the training and commitment of staff to serving men's reproductive health needs) and cost were seen as critical issues.
•Institutional capacity. Many participants stressed the importance of keeping sustainability in mind when designing men's programs. In one small-group session, participants argued that greater emphasis must be placed on making technical expertise more sustainable, possibly by increasing the effectiveness, efficiency and quality of an array of reproductive health service providers. In this way, technical capacity is not lost if one staff member leaves.
•Cost considerations. The cost of providing services varies considerably, depending on the existing facility, the level of staff training needed and the array of services to be offered. Some clinics have found that they can serve men effectively simply by reorienting staff, reorganizing the facility's structure and remaining open for more hours. Others report that they incurred more significant costs because they hired more staff, printed additional client education material or built an addition onto the existing facility.
While the cost of adding the components necessary to serve men may be great, the cost of not serving men may be greater still—even though these costs may not be immediately apparent. For example, at the Mombasa workshop, a man told of a client who came to his clinic for the treatment of an STD after having been turned away from a clinic that did not serve men. During the intervening eight months, this man had put several partners at risk of infection or reinfection, and had himself risked incurring complications both more serious and more difficult to treat. Thus, the failure to treat the young man at the first clinic ultimately produced higher economic and human costs.
In some settings, providing services for men may even generate income. A representative from Colombia described how her institution's three men's clinics—one each in the three largest cities in the country—operate at a profit, producing income that is then reinvested in work with youths and with men and women who cannot pay for services. The program's ability to produce a profit depends on the program designers' attitude toward services, as well as on the circumstances in each country.
"If your institution has a good name and people come," the Colombian organization's director reported, "you can organize a program that is self-sufficient and even starts bringing in profit...that is if you think from the very beginning that it can be self-sufficient and produce profits."
Of all issues discussed at the workshop, this issue of planning for sustainability generated the most interest and was rated as among the highest of priorities.
Recent research from Kenya indicates that men exposed to family planning and other reproductive health issues when they were young are more likely to have a positive attitude toward, and be supportive of, their partner's family planning use.12 Among the country teams at the workshop that incorporated a focus on youths into their action plans, three issues came to the fore: the role of gatekeepers in facilitating or hindering youths' access to reproductive health services; the attitudes of providers when they serve youths; and the design of services to meet youths' needs.
Once youths have decided to seek reproductive health information, a participant who operates services for youths noted, the providers' skills and attitudes are the most important component of any program. First, providers must feel comfortable working with young people. Secondly, they must be conversant with the social issues youths face, including pressure to use drugs, to have sexual intercourse or to marry. The skills used to counsel youth must include a commitment on the part of the provider not to be judgmental, but to listen openly and honestly to the concerns presented.
The Busoga Diocese Family Life Education Program in Uganda uses respected retired teachers to conduct sexuality education seminars with youths and their parents. These teachers have a long-standing rapport with their students, as well as the respect of the adults in the community. With training, they have been able to create an opportunity for dialogue between generations about sexuality, in a contemporary environment that includes topics like high rates of STD (including HIV) transmission as a potential consequence of sexual activity.
Workshop participants agreed that among the many issues programs must tackle when trying to serve young males is determining a service design that meets clients' needs. Whether urban or rural, married or unmarried, in school or out of school, many youths have similar concerns: that services be confidential, that they be low-cost and that they be delivered by competent, respectful providers.
A Model for Men
There is no model for men's reproductive health services comparable to the existing, well-defined constellation of obstetric and gynecologic services for women. In fact, no one has defined what constitutes men's reproductive health care.
During the workshop, panelists from three countries reviewed a comprehensive model for reproductive health care for men that is intended to address this need, and assessed its feasibility for use in their own countries.13 The model, which was developed by an AVSC-sponsored team of men's service providers in the United States, with review from program designers in Africa and Asia, can be adapted to suit country- and program-specific needs.
The model outlines three categories of services: screening, which includes the information to be obtained from each male using the clinic, as well as the services for meeting their needs; information, education and counseling services; and clinical diagnostic and treatment services.
Although participants agreed with the model's client-centered approach, many felt that its very comprehensiveness might be too daunting for newly developed programs, especially in low-resource settings. Participants from Kenya and Pakistan argued that the model represents an ideal scenario that can serve as a guide for developing their programs, but the relevance of any model must be seen in the context of existing health delivery systems.
From Issues to Action
Throughout the workshop, each country's team members—health care providers and policy makers from the public and private sectors, as well as researchers and journalists—met to discuss the best ways to include men in reproductive health, as partners and as clients. By the end of the workshop, these individuals had formed new partnerships and articulated plans for turning the issues discussed into concrete action plans. Each country team left with a plan that included strategies and activities to be carried out within the next year.
The nine teams were unanimous on three areas that need attention. One was to assess the services currently provided to men, and then expand and integrate those deemed most appropriate and logical, given available resources. The second was to develop information, education and communication strategies that disseminate the message that men's reproductive health must be placed on the agenda if women's health is to be improved. The third was to train health care workers in the issues surrounding the provision of men's reproductive health services, and to review existing materials and revise them as needed. Participants also agreed that gender issues, especially men's and women's influences on each other, should be addressed in all three areas.
Other areas identified by some country teams as important were the need to assess men's needs and roles in reproductive health (Egypt, Kenya, Tanzania and Uganda); to develop programs to reach out to youths (Eritrea, India, Kenya, Tanzania and Uganda); to develop institutional linkages among various sectors to address issues concerning men as partners (Pakistan, Tanzania and Uganda); to advocate for "men as partners" in national plans and review and revise national guidelines, as necessary (Eritrea, India, Kenya, Pakistan, South Africa and Uganda); to lobby for resources—human, financial and material—to support such initiatives (Eritrea, Ghana and South Africa); and to address cost-recovery and sustainability issues at the outset (Ghana and Uganda). Identifying these issues represented only the first step toward addressing them. With assistance from a variety of sources, participants are now beginning to implement strategies for doing so in their respective countries.
Organizations now have the opportunity to examine existing programs and create new ones that reach men as partners, while safeguarding services for women. As the international reproductive health community focuses on developing a more holistic, integrated approach to the design of reproductive health services, pioneering strategies for reaching men as a client population will provide important lessons for those seeking to expand concepts of service delivery beyond traditional family planning approaches.