Despite a growing awareness of the importance of involving male adolescents in pregnancy and sexually transmitted disease (STD) prevention efforts, information is lacking regarding the design and delivery of effective male-specific strategies.1 In this special report, we describe the evolution of a promising program in Philadelphia, Man2Man, instituted through the collaborative efforts of the Family Planning Council (the Title X grantee for southeastern Pennsylvania); the Drexel University School of Public Health; St. Christopher's Hospital for Children; and NorthEast Treatment Centers (NET), a local agency providing mental health, substance abuse treatment and social services.
The Man2Man program grew out of two projects that examined the lack of reproductive health and pregnancy prevention services for young men in North Central Philadelphia: a Family Planning Council project, and a collaboration of the Drexel University School of Public Health and St. Christopher's Hospital for Children. Representatives of the three agencies came together to discuss collaboration and a potential course of action. In 1998, they formed a coalition to design and implement a health education intervention for young men. Part of a grant from the Centers for Disease Control and Prevention (CDC) to the Family Planning Council was used to pilot-test the program. Two years later, the coalition was joined by NET, which also serves as a program site.
The target area for the intervention is an economically disadvantaged section of North Central Philadelphia with high teenage pregnancy and STD rates. According to Census Bureau estimates, 45% of the area's families with children younger than 18 had incomes below the federal poverty leve1 in 2000,2 and 53% of households with children were female-headed.3 In addition, North Central Philadelphia's 1997 school dropout rates were higher than rates in other sections of the city.4 The area's 1996 teenage birthrate of 124 births per 1,000 women aged 15-195 was more than twice the national rate of 54 per 1,0006 and substantially higher than the city rate of 83 per 1,000.7 That same year, 12% of 15-19-year-old women living in the area who underwent chlamydia screening tested positive.8
THEORETICAL FRAMEWORK AND GOALS
A synthesis of Bandura's social learning theory9 and the theory of reasoned action10 represents the theoretical framework for the Man2Man program. A central tenet of social learning theory is that people learn as much by observing the experiences of others (i.e., through observational learning) as they do through direct experience, especially when they are observing a person they respect and perceive as being powerful or similar to themselves. According to the theory of reasoned action, behavioral intent and action are influenced by two important factors: one's attitude toward the positive and negative aspects of a particular behavior, and one's perceptions of social norms, or what important others think about engaging in the behavior. In designing Man2Man, the coalition felt that using adult male facilitators would expose participants to positive role models who would help them recognize the benefits of engaging in responsible behaviors and modify their responses to social pressures to engage in high-risk behaviors.
Four goals have informed the development, implementation and evaluation of Man2Man:
• to improve knowledge and attitudes regarding men's health issues, and strengthen intentions to engage in responsible reproductive health behavior;
• to enhance personal values, life skills, family interactions and self-sufficiency;
• to increase personal responsibility by developing relationships with adult male role models; and
•to expand utilization of, and access to, primary and reproductive health care services.
In designing the program, the coalition took into account that a confluence of psychosocial, environmental and economic factors contributes to poor reproductive health outcomes. It used a holistic approach to address multiple, concurrent risk factors (school dropout, early onset of sex, multiple partners, and lack of contraceptive and condom use), and located Man2Man services in established settings, such as public schools. Principals at two target high schools agreed to support the development of services at their sites.
Program planners held focus groups with male students to gain an understanding of their unique health and psychosocial needs and to elicit their input regarding program design. Participants expressed a need for accurate information and support from adult male role models in the following areas: sexual health, disease prevention, child development, relationships with women and fathering skills. They also indicated a preference for a male-only program that provided an opportunity for their voices to be heard.11
Because curriculum development and validation is a time-consuming and costly endeavor, the coalition adapted an existing curriculum—Fatherhood Development: A Curriculum for Young Fathers,12 developed by Public Private Ventures and distributed by the National Center for Strategic Non-Profit Planning and Community Leadership (NPCL)—to use as the foundation for the Man2Man program. Although designed specifically for young fathers, the curriculum covers topics that are important in the lives of all young men.
The Fatherhood Development curriculum comprises five modules: personal development, life skills, fatherhood, relationships, and health and sexuality. Given the goals of the project, the coalition incorporated a lesson on contraception into the health and sexuality module. The curriculum outlines interactive and discussion-based strategies, such as role-playing and games, designed to actively engage participants and to encourage them to share their personal experiences. Activities are also designed to enhance problem-solving and critical thinking skills, and to assist participants in applying the knowledge and skills they are learning to real-life situations. (See box for detailed session content.)
The Man2Man program consists of 15 weekly, two-hour sessions delivered to groups of 10-12 adolescents by a trained adult male facilitator. Twelve sessions cover substantive content; the remaining three are devoted to orientation and evaluation activities.
The project began in the fall of 1999 with final program planning and preparation for piloting Man2Man as an after-school program in the two high schools that had been involved in the planning phase focus groups. At each school, the principal selected a faculty coordinator for the program. The coordinators, in consultation with the principals, collaborated with the coalition to identify facilitators and develop marketing strategies to engage students. Facilitators were selected on the basis of their interest in and commitment to working with youth and the Man2Man goals. Seven teachers from the two schools and a minister from the local community were recruited and trained to facilitate Man2Man groups. The pilot program was launched in the spring of 2000. During the first year, 44 participants attended the program. These participants named the intervention Man2Man.
|Curriculum session content, Man2Man program|
• Discuss definitions, ideas and perceptions about manhood; diverse male role models and their positive contributions; experiences as sons, men and fathers
• Identify stereotyped beliefs about certain groups; develop personal definitions of manhood
• Discuss qualities of self-sufficiency; conduct personal assessment; develop a one-year plan
• Explore communication, miscommunication and communication styles; assess "poor" and "good" listening skills; practice effective listening skills via role-play
• Explore important or difficult decisions made, and discuss outcomes; play game illustrating potential consequences of poor decision-making
• Reinforce accurate information and dispel myths about a father's influence on his children; identify personal values regarding fatherhood and children; explore best approaches for handling problem behaviors in children
• Play game identifying children's developmental stages; identify tasks and skills involved in caring for children at different ages
• Identify clues to help recognize feelings of anger; practice nonviolent responses to resolving conflict and managing anger • Identify qualities of good relationships; evaluate effectiveness of personal relationships and establish goals for enhancement
|Health and sexuality
• Explore differences in men's and women's health; role-play to illustrate how to communicate with health care providers
• Discuss myths and misperceptions about male sexuality; engage participants in activity exploring responsible sexual decision-making
• Play game illustrating spread of STDs; engage participants in activities to test strength and sensitivity of condoms and learn correct use; describe contraceptive method effectiveness and use
During the second project year (2000-2001), Man2Man served 107 students at the schools. Five of the original facilitators remained active in the program, and 10 new facilitators, including school-based probation and security officers, were trained. In addition to the school sites, the coalition introduced Man2Man at NET, targeting adjudicated young men served by one of the agency's behavioral health programs. To ensure adequate supervision, the coalition recruited and trained two NET case managers to facilitate Man2Man groups. Cofacilitators were used for groups of 15-20 young men. (Groups were larger at NET than in the schools because of the greater potential for attrition in this population.) A total of 79 participants were served over two program cycles at NET in 2000-2001.
In the program's third year (2001-2002), Man2Man served 151 young men at the school sites and 43 at NET. At the school sites, five facilitators from the previous year returned and four new facilitators were trained. Because of internal organizational issues, a new team of facilitators had to be recruited at one school. At NET, two new facilitators became involved in the program.
In 2002-2003, the program's fourth year, Man2Man served a total of 200 young men at one of the original school sites, NET and a new site at an alternative school; because of internal organizational challenges, one original school site was unable to offer Man2Man. At the alternative school, Man2Man was incorporated into the routine school day, rather than being delivered as an after-school program. Four teachers were trained as facilitators to implement the program at this site. At the other school site, seven returning facilitators were joined by one new facilitator; both NET facilitators continued their involvement.
An annual two-day Man2Man training workshop is conducted for new and returning facilitators from all sites. In addition to didactic sessions on the Fatherhood Development curriculum modules, the training covers contraception (i.e., the appropriate use, effectiveness, advantages and disadvantages of various methods) and information regarding local adolescent family planning services and techniques to facilitate access to services.
The workshops provide opportunities for facilitators to develop skills needed to effectively lead group sessions (e.g., active listening and nonjudgmental response techniques) and to use appropriate self-disclosure as a role-modeling strategy. In addition, workshop activities allow returning facilitators to share their Man2Man experiences and expertise with new facilitators.
During the first year, NPCL, the distributor of the Fatherhood Development curriculum, conducted the facilitator workshop. In subsequent years, NPCL-trained local consultants have assumed responsibility for facilitator training, and NPCL has provided consultation regarding workshop design. Although the use of local consultants to conduct the workshop generated some debate, the coalition ultimately agreed it was a more cost-effective approach than using NPCL staff.
PARTICIPANT RECRUITMENT AND ATTENDANCE
Project coordinators and facilitators, along with administrators at each Man2Man site, have worked with the coalition to develop and implement appropriate, site-specific participant recruitment strategies. The original school sites have used a variety of techniques to promote schoolwide awareness of Man2Man. For instance, before a new program cycle begins, daily announcements are made over the loudspeaker, and flyers are posted in classrooms and hallways. In addition, each year, the coalition presents evaluation findings, including participant and facilitator feedback, to faculty and staff, and gives them informational materials to distribute in their classrooms. Word-of-mouth advertising by former participants has become an important recruitment strategy. At the alternative school, where teachers and students are assigned to small "learning communities," facilitators communicate directly with interested young men about the program.
Given the nature of NET's services for adjudicated youth, it was necessary to develop a different set of strategies to maximize recruitment at that site. NET facilitators make bimonthly presentations to probation officers and provide written materials about Man2Man to juvenile court judges. In addition, NET case management staff send letters describing the program and encouraging enrollment to parents and guardians of youth in the behavioral health program.
During the first year of the program, participants received four types of incentives: food provided at each session; gift certificates to movie theaters, music stores or sports stores, provided periodically over the program cycle; course credit upon completion of the program; and a graduation ceremony, at which each participant received a certificate of achievement. At debriefing sessions conducted at the completion of the cycle, participants provided compelling feedback that having "good food, and lots of it" was the most important incentive; course credit was a close second. The gift certificates ranked lowest. Given these responses, Man2Man continues to offer food at each session at the schools and NET, and to provide course credit at the school sites. Gift certificates are distributed to all program participants at graduation ceremonies. NET participants also receive public transportation tokens to ensure access to program activities.
For the two original schools and NET, information is available on attendance during the second and third years of the program. (The attendance tracking system was not in place in the first year, and information for the most recent year is not yet available.) At the school sites, participants attended a median of eight of the 12 substantive sessions. Most (86%) participants attended at least five of these sessions; 50% attended at least nine. At NET, participants attended a median of three substantive sessions; 28% attended at least five. The facilitators report that changes in participants' probation requirements or status and transportation difficulties represent the major barriers to program participation at NET.
FACILITATOR AND PARTICIPANT FEEDBACK
The coalition conducts three focus groups with facilitators during each cycle and a focus group with participants at the end of the cycle to gather their feedback on how the program is doing. Project staff independently review and analyze focus group transcripts to identify themes in the following areas: the program's structure and format, its content and areas needing improvement. While a more rigorous evaluation has not yet been completed, this feedback provides valuable insights that are used in further planning.
Structure and Format
•Appeal of the small group format. Feedback thus far indicates that the small group format is an important facet of the program, as it allows facilitators and participants to discuss sensitive issues. One participant's comment exemplifies the majority of responses regarding the small group format: "It's easier to talk and share in a small group with the facilitator." Similarly, one facilitator described the groups as providing "a safe space" for young men.
Facilitators consistently observe that the small group format helps to build a sense of camaraderie and trust over the course of a program cycle. In addition, the small group setting allows facilitators to focus on issues of particular importance to participants. The following statement illustrates the level of comfort of most young men in regard to sharing their feelings and experiences with the group: "I felt real free, like I could say anything and not feel funny about it." Similarly, one participant observed, "I have been to a lot of programs, but [at] this one I was able to give my feelings out." Young men consistently report that they feel empowered to share their feelings because of the self-disclosure of the facilitators and the other participants.
•Importance of adult male role models. Participants report that using supportive adult men as facilitators is an important aspect of the Man2Man program. In the words of one participant, "[Man2Man] is cool, and I would definitely recommend it. It is an opportunity to spend some quality time with men." Facilitators take a genuine interest in the young men and work to develop an appropriate level of intimacy with them. Because many participants do not have regular opportunities to interact with caring and supportive adult men, the facilitators help them "connect with the program messages." Facilitators find that young men are "proud of coming to Man2Man" and that participation makes them "feel special."
•Relevance to real-life situations. Facilitators say that the curriculum is "working," meaning that the ideas and information shared in the sessions have a positive impact on the participants. In describing one program activity, a facilitator commented that it "assisted the young men in understanding the consequences of poor, uninformed decision processes." In a similar vein, the following statement is representative of participants' attitudes in this area: "I like the session because it really helps me out and makes me think about my life and what I am going to do in my future."
Focus group feedback suggests that participants are able to make meaningful connections between session topics and their own lives. For example, some youth have reported an increase in awareness of the tremendous economic and social implications of fatherhood as a result of participation in Man2Man. One young man commented, "Fatherhood is not just diapers and food; there are lots of responsibilities." Similarly, another young man stated, "It takes money to care for a baby. [The program] woke me up to that and to how much money it costs to live on your own."
•Knowledge about sexual health issues and potential consequences of risky behavior. Facilitators find that participants are very interested in topics concerning sexuality and sexual health. Group discussions provide facilitators with the opportunity to identify and dispel misperceptions that many young men hold about sexuality and sexual health, and to focus on potential consequences of unsafe sexual behavior, such as pregnancy, HIV and other STDs. As one facilitator observed, "One teen was shocked to hear that an STD could be transmitted through oral sex." Similarly, the comment of one young man summarizes perspectives regarding the ways in which Man2Man participation enhances knowledge and awareness: "We were surprised at the different ways to have STDs transmitted." The thoughts of another young man reflect the emphasis that is placed on adopting responsible sexual behaviors: "The world says to be a man is having sex; you can be a man without sex."
Participants consistently suggest one modification to Man2Man: the inclusion of women in a session or sessions to discuss "female perspectives." Many young men have indicated an interest in developing a better understanding of women's point of view on issues that fall into the categories of "relationship expectations" and "manhood and responsibility." The words of one young man reflect the feelings of a number of participants: "We need to find out what women want. How are we going to know what women want if we can't talk to them?"
COSTS AND FUNDING
Using data from the third project year, we have calculated that the direct costs of delivering the Man2Man program at the two original school sites total $413 per student for 15 weekly sessions, or $28 per student for each session. (Direct costs are the project coordinators' and facilitators' salaries, incentives, facilitator training expenses, supplies and administrative expenses.) Level of attendance does not affect program costs because facilitator expenses remain the same, regardless of the number of young men at a session.
Funding thus far has been provided through demonstration and research grants from the CDC and the Department of Health and Human Services, Office of Population Affairs, but long-term sustainability remains a challenge. In an effort to sustain the program, the coalition has leveraged available resources to reduce costs—for instance, by adapting an existing curriculum rather than developing a new one. Costs have also been minimized by implementing Man2Man at public schools and NET: With the ready pool of potential participants at those sites, Man2Man does not need to rely on outreach workers or expensive advertising campaigns to recruit participants. Moreover, school and community sites provide men experienced in working with youth who can serve as Man2Man facilitators, thereby reducing the cost of facilitator recruitment and the need for extensive training other than training in the curriculum. In addition, because the program was integrated into the regular school day at the alternative school, its implementation became part of the regular responsibilities of facilitators, who did not receive an hourly stipend.
Thus far, several key lessons have emerged through the coalition's experience with the Man2Man program: Partnerships such as the Man2Man coalition can enhance adolescent pregnancy and STD prevention efforts; young men are receptive to small group formats that encourage active participation and focus on sensitive sexual health issues; and young men are interested in gaining a greater understanding of female attitudes and expectations regarding relationships with men.
From its earliest stages, Man2Man has been a collaborative effort among community agencies, which have faced several challenges in working together to develop and implement the program. Given each agency's unique mission, program priorities and approaches to working with individuals and communities, the coalition had to build consensus and develop a shared vision for the program. It has had to pay careful attention to roles and responsibilities to ensure that the strengths of each partner are utilized and valued, and has had to keep all partners informed of the program's progress at each site. Collaboration has thus required extensive communication, flexibility and respect for differences among agencies.
While collaboration has presented challenges, it has also enhanced program planning and implementation efforts. The unique perspectives and resources of each coalition member have helped to shape, sustain and enrich Man2Man. For example, the Drexel University School of Public Health provides expertise in developing collaborative public health programs, St. Christopher's Hospital for Children provides medical consultation for contraception training and the Family Planning Council provides expertise in project management. The schools and NET have provided access to young men and insight into their unique needs. At the same time, representatives from the coalition have enhanced the range of services the program can provide. Although collaboration requires additional time and effort, the benefits to Man2Man have apparently far outweighed the costs.
Although a common assumption is that young men are not emotionally expressive, those attending the Man2Man program actively participate and share their feelings and personal experiences during session activities. In fact, participants consistently report that they feel comfortable expressing themselves in the group setting. Our experience suggests that traditional views of emotional expression among young men may partly reflect their lack of opportunity rather than lack of desire. As we have observed in Man2Man, young men are willing and able to be emotionally expressive in a safe environment.
Female perspectives on sexual health and related topics are important to young men. The coalition's decision to develop a male-specific program was based on results of formative research and a review of the literature. Although participants agree that it is easier to talk about some subjects in an all-male group, they have pointed out that a better understanding of the "female perspective" would strengthen their ability to communicate and engage in successful relationships with women.
The Man2Man program has completed its fourth year. Positive feedback from participants and facilitators suggests that it can engage young men in activities regarding reproductive and sexual health issues. Meanwhile, the coalition plans a number of enhancements to strengthen and refine the service model. The curriculum will be enriched by the addition of a number of sexual health skill-based activities drawn from other curricula. In addition, the coalition will determine the ways in which female perspectives can be included (e.g., through a panel of young women or an adult female "guest facilitator"). Because the discussion-based nature of the curriculum topics may lead to variations in session content, facilitator training will be enhanced to foster greater consistency. Finally, the program will be expanded to serve young men in other underserved, high-risk communities in Philadelphia and surrounding counties.
A more extensive and rigorous evaluation is needed to fully determine the cost-effectiveness of the Man2Man program and its impact on behavior change and reproductive health outcomes. The coalition hopes that these enhancements will not only result in better services for young men in the Philadelphia area but also contribute to the design and delivery of effective sexual and reproductive health programs for male youth.
1. Sonenstein F et al., Involving Males in Preventing Teen Pregnancy: A Guide for Program Planners, Washington, DC: Urban Institute, 1998; The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual And Reproductive Health Needs of American Men, New York: AGI, 2002; and Sonenstein F, ed., Young Men's Sexual and Reproductive Health: Towards a National Strategy,Washington, DC: Urban Institute, 2000.
2. U.S. Bureau of the Census, Poverty status in 1999 of families by family type by presence of related children under 18 years by age of related children, American FactFinder Detailed Tables, 2000, <http:// factfinder.census.gov/servlet/DTTable_ts=68043150803>, accessed Mar. 10, 2003.
3. U.S. Bureau of the Census, Family type by presence of own children under 18 years by age of own children, American FactFinder Detailed Tables, 2000, <http://factfinder.census.gov/servlet/DTTable_ ts= 68043809170>, accessed Mar. 10, 2003.
4. Family Planning Council, Semi-annual progress report: community coalition partnership programs for the prevention of teen pregnancy in North Central Philadelphia, Philadelphia: Family Planning Council, 1999.
5. Philadelphia Department of Public Health, unpublished data, Aug. 6, 2003.
7. Pennsylvania Department of Health, Resident live births by single age of mother and county: Pennsylvania 1996, July 2003, <www. dsf.health.state.pa.us/health/lib/health/BRX011T_96.pdf>, accessed Aug. 19, 2003; and U.S Bureau of the Census, Population estimates for counties by age and sex: annual time series July 1, 1990 to July 1, 1999, Aug. 2000, <eire.census.gov/popest/archives/county/cas/cas42.txt>, accessed Aug. 19, 2003.
8. Philadelphia Department of Public Health STD Clinics, Region III Infertility Prevention Project, unpublished data, Aug. 6, 2003.
9. Bandura A, Social Learning Theory, Englewood Cliffs, NJ: Prentice-Hall, 1977.
10. Fishbein M and Ajzen I, Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research, Boston: Addison-Wesley, 1975.
11. Adolescent Male Project: findings from teen male focus groups, Philadelphia: Family Planning Council, 1999.
12. Wilson P and Johnson J, Fatherhood Development: A Curriculum for Young Fathers, Philadelphia: Public Private Ventures, 1995.
Genevieve Sherrow is research associate, Tristan Ruby is manager of adolescent programs, Shawn Gibson is director of adolescent programs, and Linda Hock-Long is director of research&#8212;all at the Family Planning Council, Philadelphia. At the time Man2Man was developed and implemented, Paula K. Braverman was chief of adoles- cent medicine, St. Christopher's Hospital for Children, and associate professor of pediatrics, Drexel University College of Medicine, Philadelphia; she is currently director of community program development, Division of Adolescent Medicine, Cincinnati Children's Hospital, Cincinnati. Nathalie Bartle is associate dean of student affairs and professor of community health and prevention, Drexel University School of Public Health.