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Men are more interested in reproductive health than most people think. Recent surveys and studies seem to contradict popular views about
men's participation and involvement in family planning -- for example, that most men know
little about contraception, do not want their partners to use it, and are not interested
in planning their families.
Individual attitudes and behaviors among men vary enormously, of course. On balance,
however, the evidence suggests that many more men would participate if they had more
opportunity to do so.
While some family planning programs have been interested in involving men for more than
a decade, only recently has men's participation become the focus of substantial attention.
Why now? One important reason has been rising global concern over the rapid spread of HIV.1 "The prominence of HIV/AIDS has opened up the discussion
of sexual behavior," says Mary Nell Wegner, director of the Men As Partners
Initiative at New York-based AVSC International. Programs to prevent HIV have focused on
both men and women with nearly equal attention, in contrast to family planning programs,
which have focused mainly on women, she and other experts say.
Traditionally, family planning programs have viewed women as their primary clients for
three reasons: it is women who become pregnant; most contraceptive methods are designed
for women; and reproductive health services can be offered conveniently as part of
maternal and child health services.2 Some family planning
programs have avoided serving men in the belief that many women need privacy and autonomy
in reproductive health matters.
"The assumption of many health-care providers that men are uninterested in taking
responsibility for family planning has become a self-fulfilling prophecy," says Dr.
Cynthia Green of Washington, a consultant who has studied male participation extensively.
Most observers agree that family planning programs have made little effort to consider
men's reproductive health needs or to reach men, and that as a result men have few
contacts with the reproductive healthcare system. "In Africa, men are brought up to
think that family planning or reproductive health are woman's issues," says Dr. David
Awasum, a physician from Cameroon who chairs the Men's Participation Task Force at Johns
Hopkins University's Population Communication Services (PCS) in Baltimore, MD, USA.
"No wonder they lack information and do not participate actively with their spouses
or partners."
The 1994 International Conference on Population and Development (ICPD), held in Cairo,
reminded the world audience that good reproductive health is the right of all people, men
and women alike, and that together they share responsibility for reproductive matters. By
emphasizing gender -- the prescribed roles men and women play in society -- the conference
drew attention to the fact that, if men are left out of the reproductive health equation,
they are unlikely to be able to exercise responsibility. The consensus reached in Cairo is
that neither women nor men are likely to enjoy good reproductive health until couples are
able to discuss sexual matters and make reproductive decisions together.3
"For the first time, Cairo established clear policy language about men's
participation and provided a foundation for family planning donors and programs to act
on," says Wegner.
As interest in men's participation has grown, more attention is being paid to learning how to reach men effectively. "Family planning programs are
looking for ways to become more inclusive," says Dr. Green. More surveys are
interviewing men, as well as women, and some surveys are interviewing couples. The
Demographic and Health Surveys (DHS), for example, now collect comparable data about
family planning attitudes and practices from men, in addition to a long-standing practice
of interviewing women. Also, more qualitative data are becoming available from focus-group
research and in-depth studies. As researchers obtain more information, stereotypes are
giving way to a more factual portrait of men.
Similar attitudes
According to recent DHS, men are more likely to approve of family planning and to know
about contraception than stereotypes about men suggest. Based on data
collected from men in 15 countries -- 11 in sub-Saharan Africa, plus Bangladesh,
Egypt, Morocco, and Pakistan -- Alex Ezeh and colleagues at Macro International, Inc., the
U.S.-based organization that organizes and helps conduct the DHS, report that in most
countries "the reproductive preferences and attitudes of men and women toward family
planning are similar."4
The 15 studies reveal a "KAP gap" among men -- a contradiction between the
level of "knowledge and attitudes" about family planning compared with
"practices" (KAP). Men's contraceptive use is lower than might be expected,
given their overall levels of approval and knowledge. Between one-quarter and two-thirds
of men surveyed want no more children, yet neither these men nor their partners were using
contraception.5 The implication of such findings is that, if
programs could find better ways to reach men as individuals and as members of couples,
contraceptive use might rise considerably.
While the 15 countries represent only portions of Africa and Asia, there is a striking
consistency among them regarding male interest in reproductive health, enough so to
suggest a similar level of male interest elsewhere. Only a few DHS have interviewed men in
Latin America and the Caribbean (Brazil, Dominican Republic, Haiti and Peru); however,
initial results suggest a similar pattern of male interest. For example, in Brazil, men
are even more likely than women to say that they do not want to have more children. In
Haiti, 92 percent of men surveyed approve of contraceptive use and in Brazil, 86 percent
approve.
The 15 African and Asian countries in the Ezeh analysis offer a developing-country
portrait of male participation from several perspectives. In addition to measuring
sentiments about whether men approve of family planning and men's family size intentions,
these surveys gauge male awareness of contraceptive options, their concerns about sexually
transmitted diseases and their use of contraception:
Approval -- Most men, like most women, approve of family planning. In seven of
15 surveyed countries, at least 90 percent of men approve of using contraception. Approval
is lowest in West Africa. Even in this region, however, men's approval appears to be on
the rise. In Ghana, for example, the percentage of men who approve of family planning rose
from 77 percent in 1988 to 90 percent in 1993. Within most of the countries men are less
likely than women to approve of family planning. This fact in part may explain why men
often are pictured as obstacles to contraceptive use. Nevertheless, in some of the
countries (Ghana, Malawi and Pakistan) men are more likely than women to approve of family
planning. In nearly all countries surveyed, better-educated men express greater approval
of family planning than do men with less education.
Family size -- In most surveyed countries, the number of men who want to have
another child is only slightly higher than the number of women who want another child.
This finding shatters one of the most widespread myths about men -- that men generally
want much larger families than do women. In most of the 15 countries, the differences in
reproductive intentions between men and women are small. The fact that men are somewhat
more likely to want another child, however, helps account for the finding that, even
though men tend to know somewhat more about contraception than do women, they are less
likely to approve of its use. In Kenya, Morocco and Pakistan, only a minority of men want
to have another child, and in Egypt and Bangladesh less than one-third of men want another
child. In West Africa, however, men are substantially more likely than women to want
another child. In Niger, the extreme case, 93 percent of men want to have another child
compared with 82 percent of women.
Awareness -- In almost all 15 countries surveyed, men are more likely than women
to know about contraception. Surveys, however, report only whether respondents have heard
of the various contraceptive methods. They do not gauge the depth of knowledge, including
whether respondents know how to use methods correctly. In all 15 countries, a majority of
men know about at least one modern method and one traditional method. In all but one
African country (Rwanda is the exception), a higher percentage of men than of women know
of a modern method. In Egypt, Morocco, Bangladesh, and Pakistan, men and women report
similar levels of awareness. The gap between men's and women's awareness of contraception
is greater in countries where overall knowledge is low.
Sexually transmitted diseases -- The spread of HIV and other sexually
transmitted diseases has brought an increase in awareness and use of condoms. For example,
in Kenya, Tanzania, and Zimbabwe, where HIV and other STDs are widespread, DHS results
show that virtually all men have heard of AIDS and most know that sexual intercourse can
transmit it. While the surveys also reveal much misinformation about HIV, they show that
many people know that using condoms is a means of protection. In Zimbabwe, for example, 57
percent of men cited using condoms as a way to avoid contracting AIDS; and in Tanzania, 55
percent. In Kenya, however, only 36 percent of men who believe that people can protect
themselves against AIDS identified using condoms during sex as a means of protection.
In most developing countries prevalence of condom use is typically below 5 percent. So
widespread are STDs that programs need to promote and provide condoms for disease
protection as well as for family planning. Although there is little information about
condom use for STD prevention versus family planning, "family planning service
providers need to recognize that many women would benefit greatly from using condoms to
prevent STDs, plus another method to prevent pregnancy," says Dr. Green. "For
clients who need both pregnancy and STD protection, programs should encourage dual use,
even though it raises costs."
Contraceptive use -- Men are more likely than their partners to report using
contraception, according to the 15 surveys. One possible explanation is that some men may
be reporting condom use outside of marriage. Another possibility is that some women may
not acknowledge use of contraception to survey takers, since they are using it without
their husbands' knowledge. Whether the explanation lies primarily in men over-reporting
contraceptive use or women under-reporting use is unknown. Men's participation in family
planning cannot be measured simply on the basis of use of male-oriented methods --
withdrawal, condoms, and vasectomy -- because few satisfactory contraceptive choices have
been designed for men.
Experts agree that the more husbands and wives discuss family planning with each other,
the higher the level of contraceptive use. It is not clear whether discussion of family
planning stimulates its use or whether using family planning invites discussion of the
topic -- probably, both statements are true. Remarkably, in six West African countries
surveyed, only one couple in every four had discussed family planning during the previous
year. Studies also show that when husbands approve of family planning or when wives think
that husbands support it, the wives are more likely to use contraception. Yet some wives
typically report that their husbands disapprove of family planning, when in fact the
husbands themselves report that they approve.
Program implications
Where programs have reached men, male attitudes have changed and contraceptive use has
increased. Nevertheless, reaching men with reproductive healthcare is more difficult than
reaching women, for whom maternal and child health services are designed. "Health
care programs cannot do the same things to reach men that they do for women," Dr.
Green observes. Since many men are reluctant to seek reproductive healthcare, Wegner
says, "you have to take advantage of every available opportunity; you have to go to
where men are."
According to Dr. Awasum, "to have an impact you have to reach men in places where
they congregate in large numbers." In Africa, for example, because almost all men
follow football (soccer), Johns Hopkins University's PCS is reaching men with reproductive
health information and services by sponsoring the "Challenge CUP" -- where
"CUP" stands for "Caring, Understanding Partners." The CUP football
matches bring thousands of men together, often with their wives and children, to watch
teams compete and at the same time learn about and receive reproductive healthcare. To
communicate with men effectively through mass media, experts agree that programs need to
understand men's views and needs, then use this knowledge to design messages for them.
Men have fewer opportunities than women for receiving counseling about reproductive
healthcare from service providers because so few men are reached by reproductive health
care. Family planning counseling usually is offered as part of maternal and child health
services and is typically done by women. Programs that have relied entirely on women
outreach workers have had difficulty in reaching men. Thus, many family planning clinics
need to learn how to welcome men, while service providers need training in how to counsel
men about reproductive health.
Particularly urgent is the need to improve sexual responsibility among young men,
including more condom use. Sexual activity often begins at a young age and before
marriage. Because life-long attitudes and behavior patterns often form during youth,
addressing the needs of young men can have a long-term impact.
More emphasis on men's participation in reproductive health could help draw attention
to the need to do more for women as well. Increasing men's participation may help improve
women's programs because more men would understand and be likely to support better
reproductive healthcare -- for women, as well as for themselves.
-- Bryant Robey and Megan Drennan
Bryant Robey is editor and Megan Drennan is a writer/researcher for Population
Reports, published by the Population Information Program, Center for Communication
Programs, The Johns Hopkins School of Public Health in Baltimore, MD, USA. Robey prepared
this article as a private consultant, while on leave from Johns Hopkins. Drennan, who is
writing a Population Reports issue on men's participation, provided editorial and research
assistance.
References
- Danforth N, Roberts P. Better Together: A Report on
the African Regional Conference on Men's Participation in Reproductive Health. Baltimore:
Johns Hopkins Center for Communication Programs, 1997; Green CP. Male Reproductive
Health Services: A Review of the Literature. New York: AVSC International, 1997.
- Green CP, Cohen SI, Belhadj-El Ghouayel H. Male
Involvement in Reproductive Health, Including Family Planning and Sexual Health, Technical
Report 28. New York: United Nations Population Fund, 1995.
- Danforth N, Jezowski T. Beyond Cairo: men, family
planning, and reproductive health. Presentation at the American Public Health Association
Annual Conference, Washington, October 31, 1994.
- Ezeh AC, Seroussi M, Raggers H. Men's Fertility,
Contraceptive Use, and Reproductive Preferences, DHS Comparative Studies No. 18. Calverton,
MD: Macro International Inc., 1996.
- Roudi F, Ashford L. Men and Family Planning in
Africa. Washington: Population Reference Bureau, 1996; Ezeh.
For more information, visit Family Health International's Website at www.fhi.org
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