A long way to go: engagement of men and boys in country family planning commitments and implementation plans

Definition of male engagement

Our definition of male engagement draws on a categorization that was developed by Greene et al. (2006) and adopted by the Interagency Gender Working Group and includes the need to address gender norms. We define male engagement as:

Analytic Framework

Using this definition of male engagement, which encompasses boys and men, as a guide, and drawing on the FP High Impact Practice Initiative strategic planning guide for engaging men and boys in family planning, a framework on best practices for male engagement in family planning programming was developed in order to analyze these documents. We applied this framework to each of the existing standardized domains within the CIPs, assessing the extent to which they incorporated male engagement, and added new dimensions assessing the extent to which they addressed gender norms and promoted use of male methods. This framework included the following areas:

DRC

The DRC made a commitment to FP2020 in 2017, thus its National Multisectoral Strategic Plan for 2014–2020 became its CIP. The plan notes that “men are often considered as an obstacle or a barrier to family planning. In many cases, men believe that authorizing women to use family planning will encourage prostitution”. Yet, the plan also cites the 2007 Demographic and Health Survey statistic that seven in 10 men have never received any information regarding family planning. The plan notes that implementation will “ensure a sustained increase in modern contraceptive use by Congolese women and men who wish to use contraception.” Approaches involving men include increasing access for men and women to services in the public and private sectors, constructing youth-friendly service delivery points in each of country’s 516 health zones, training teachers on comprehensive sexuality education, addressing demand creation by developing programs targeting men, especially young men, and widening access to mobile fertility applications that would empower couples to plan their pregnancies. While these approaches are promising, little detail is provided on how they would be implemented, nor are there any indicators that include males.

Ethiopia

The Costed Implementation Plan for Family Planning in Ethiopia, 2015/6–2020 reveals a strong intention to generate demand for sexual and reproductive health (SRH) by improving knowledge, building skills, and decreasing stigma among adolescents, women and men (Ministry of Health [Ethiopia], 2016). Ethiopia’s CIP notes that SRH is not just a women’s issue:

Furthermore, Ethiopia’s CIP states that “specific demand creation efforts will be targeted at youth (ages 15–19), community and religious leaders, and men as husbands and fathers,” including through special regional Men’s Day events to raise men’s awareness of family planning and using male role models to guide group education and conduct community outreach and mobilization.

Ethiopia’s service delivery improvements focus on decreasing bias and improving provider knowledge and patient interaction, as well as shifting services to become more welcoming to adolescents and improve confidentiality. Ethiopia’s strategies for improving family planning use lack detail about the content of social and behavior change communications to promote FP use, and about how programs engaging men and boys are transformative, i.e. addressing reproductive autonomy and power within relationships. Although the CIP says that FP commodities should be available to both men and women (including youth), male methods (e.g. sterilization and condoms) and male-cooperative methods such as the Standard Days Method (also referred to as Cyclebeads) are not a priority for Ethiopia. Ethiopia’s CIP does not emphasize couples counselling in family planning, and service statistics capture only women’s counseling and service uptake. One process indicator mentions men: “availability of accessible, relevant, and accurate information about SRH, tailored to young men” (p. 36). While Ethiopia’s CIP does note that barriers to contraceptive uptake “include power and gender dynamics that inhibit women from making open decisions about FP use in their households” (p. 15), the CIP is not clear on how these should be addressed.

Kenya

Kenya completed its first CIP (2012–2016) and its second CIP (2017–2020). Kenya’s National Family Planning Costed Implementation Plan 2012–2016 notes that low male involvement has been a traditional barrier to family planning in Kenya and noted the plan to conduct an assessment of male involvement in order to develop a strategy (Ministry of Health [Kenya], 2012). If this assessment was conducted, it was not made available online. In almost identical language, Kenya’s National Family Planning Costed Implementation Plan 2017–2020 describes low male involvement in FP and FH services as a cultural barrier (Ministry of Health [Kenya], 2017). Yet no references to male involvement activities were found in Kenya’s 2017–2020 CIP. Demand generation within underserved groups is central to Kenya’s family planning objectives with particular focus on youth, unmarried sexually active youth, people living in rural areas, and people living with disabilities or HIV/AIDS. The country proposes to reach these groups with in-person mobilization and mass media messaging. However, it is not clear how boys are being targeted differently from girls. Additionally, men are not mentioned in relation to service delivery innovations or any other domains. Nor are there any indicators that specify males.

Niger

Niger’s CIP, Planification Familiale au Niger: Plan d’Action 2012–2020 (Family Planning in Niger: Action Plan 2012–2020) and other family planning documents related to FP2020 focus heavily on engaging gatekeepers who may be opposed to family planning, including members of the government as well as Islamic and traditional leaders (Republique du Niger, 2012). They also show a commitment to using peer educators and engaging husbands to help address the normative barriers to family planning use at a community level. Other efforts, designed to address myths and misconceptions about family planning in public fora, suggest an effort to reach male decision-makers with convincing messages via television and radio. Importantly, all of these programs have a wide focus, aiming to cover the entire country.

While the CIP proposes advocacy to and mobilization of gatekeepers and change agents who are presumably male, there is rarely an explicit mention of engaging men; the words “gender” and “male” are not found in the CIP and “men” is found only three times. There is a lack of detail related to demand creation, including, for example: How are gender and power being incorporated into messaging? Who is delivering the messages, and how are they working in conjunction with women? How are norms being addressed with adolescent boys? Demand generation programs targeting young people and men do not include a complementary effort to conduct training and refreshers on such things as youth-friendly and gender sensitized services. Furthermore, no indicators measure male engagement activities.

Nigeria – national

Nigeria’s CIP, Nigeria Family Planning Blueprint (Scale-Up Plan) 2014–2020, calls for the selection of advocates who will engage at the community, state, and national levels, with particular focus across key sectors in government and in the private sector, to serve as family planning champions and to address the norms that undermine family planning access. Nigeria’s CIP also outlines several demand generation activities, including a national communications campaign and the integration of a comprehensive sexuality curriculum into secondary schools with complementary interventions with peer educators. This demand generation will be met through the bolstering of services to young people through the training of providers as well as the creation of youth-friendly spaces in primary health centers. Lastly, Nigeria will track behavioral and attitudinal changes through several key indicators. Male engagement is nevertheless mentioned only once across all of these activities, namely promoting male engagement during demand generation and awareness raising. Nigeria indicates efforts to install youth-friendly service delivery points in primary health centers, but there is no indication of whether the services address the specific needs of both girls and boys. Furthermore, no indicators relate directly to men.

Nigeria - Gombe State

Very little information that focuses on men and boys is provided in the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013–2018 (Gombe SMoH, 2012). However, the presence of a Brothers for Health initiative shows understanding of the importance of male engagement to some extent, though how this will be carried out gets little attention. Youth family planning is clearly a priority, in policy, demand generation, and service delivery spheres. However, there is no explicit description of how youth activities are targeting boys and girls separately. Lastly, only one target associated with objectives in the CIP refer to men. Objective is to increase the use of FP methods among men, women and young persons of reproductive age in Gombe State by 2018. The second target under this objective is to increase support for FP (family planning) by 50 percent among men, women and young persons of reproductive age in Gombe State by 2018.

Nigeria - Kaduna State

In Kaduna State’s Costed Implementation Plan for Child Spacing, 2016–2018, policy and advocacy activities related to male engagement include activities to institute youth-friendly services at all Kaduna State clinical facilities, and to introduce reproductive rights awareness in various service providers’ training curricula (Kaduna State Government, 2016). Demand generation activities in Kaduna State include outreach to men and customary and religious leaders through traditional and social media, as well as through the availability of posters and fact sheets in places like schools and clinics which focus on dispelling myths and reinforcing the importance of family planning for families and the health of the mother and child. To meet the new demand, Kaduna State proposes several new male engagement activities in the service delivery domain, including the aforementioned training, the creation of job aids for gender-sensitive family planning counseling, purchasing supplies and equipment which is important for the bolstering of all 380 facilities as youth-friendly sites, and enabling midwives to train community extension workers on youth-friendly service provision. Although there are process indicators such as the number of male engagement/community sensitization meetings held, there is little clarity about the content of the demand generation messaging.

Nigeria - Lagos State

The Lagos State Family Planning Costed Implementation Plan, 2016–2018 includes limited male engagement activities (Lagos State Ministry of Health, 2016). There is no evidence of attention to male engagement at policy, financing or governance levels. The stronger focus on engaging men is included within the demand generation activities, which include a new behavior change communication strategy, outreach to cultural and religious leaders, use of male champions, and targeting male adolescents with information. These activities are accompanied by indicators to measure progress. However, the CIP is not specific about what the messaging will be, and how it will challenge inequitable gender norms. Few service delivery improvements are proposed other than strengthening youth-friendly services, although there is no detail about how the services will be gender-responsive. Indicators in Lagos State’s CIP fall short of measuring attitudinal or behavior change among men or couples.

Pakistan – national

As a result of a 2010 national law, the health and population welfare functions in Pakistan underwent devolution and were fully transferred to the provincial level. While Pakistan made a national pledge at the London Summit on Family Planning in 2012, provinces were tasked with developing their own strategies. Of these, four developed CIPs.

Pakistan - Sindh province

The Costed Implementation Plan on Family Planning for Sindh (2015–2020) emphasizes the pairing of bolstered demand and supply-side activities to attain its FP goals. The need to engage men and youth emerged from the process of prioritization that engaged stakeholders in developing the CIP (PWD Sindh, 2015). For the demand-generation activities, Sindh looks to re-envision the role of dormant social institutions like social male mobilizers and also create new cadres of extension workers through male-led community-based organizations and male community elders who can promote health-seeking behaviors among young people and couples. The male mobilization was considered a priority activity for the first year of the CIP. The focus on men in Sindh’s CIP is to encourage them to support women’s use of family planning, with “the primary goal…to make the community aware of available services and motivate MWRA (married women of reproductive age) to obtain services.”

For supply-side activities, Sindh is focusing on provider training, referrals from extension agents, and the creation of youth-only spaces for education and community. The CIP focuses almost primarily on female methods of contraception. While the CIP projects increases in condom use from 8 percent of the method mix in 2011–12 to 10.5 percent in 2020, use of vasectomy as part of the method mix is projected to remain steady at 0.1 percent over the life of the CIP. The CIP projects only 1,012 adopters of vasectomy between 2014–2020, even though the province has invested in developing centers that provide no-scalpel vasectomy. Sindh will measure the effect of such programs with core FP2020 indicators which, to some degree, are male-specific and capture attitudinal as well as behavior change. The Sindh CIP also has a few activity indictors that include men, such as couple’s outreach by community health workers, services to young couples, and elders included in community awareness raising.

Sindh Province’s CIP does not acknowledge the deep and persistent gender norms that explain women’s limited access to family planning. While the CIP explicitly and consistently acknowledges the disadvantages that women live with in Sindhi society, it couches them as “social pressures,” “cultural norms,” or “lack of women’s empowerment” or as influenced by the “supportive outlook of the husband,” while not naming gender norms explicitly. Furthermore, they highlight factors that are symptomatic of patriarchal power structures, such as low mobility, lack of spousal communication, and poor knowledge. The CIP notes:

The lack of acknowledgement of structural gender inequalities are reflected in the CIP: no policy and advocacy, nor financing and governance activities, are included that explicitly focus on men as users of reproductive health services or as partners or advocates for women’s use of reproductive health services.

Senegal

Senegal’s commitment in 2012 mentioned increasing the involvement of men and young people along with leveraging networks leaders and champions to advocate for family planning. Senegal’s 2012–2105 plan, the National Family Planning Action Plan 2012–2015, includes a large-scale communication plan, mainly for men and youth, with tailored behavior change messages in favor of family planning and addressing misconceptions (Republic of Senegal, 2012). Furthermore, the plan called for behavioral studies “to better define profiles and messages adapted to men and young people.” The plan also called for outreach activities “to sensitize [men] to the advantages of FP and widen the scope of FP to include the health of the couple.” Senegal’s 2016–2020 CIP, the Cadre Strategique National de Planification Familiale 2016–2020 (National Strategic Framework for Family Planning 2016–2020) continues to characterize male engagement as a challenge (Republique du Senegal, 2016). In particular, male knowledge is poor and attitudes towards family planning are often negative. Senegal’s 2016–2020 CIP describes men’s attitudes towards family planning as mixed, noting that a report from a communications campaign found that 50% of men ages 25–55 believe that people who use FP end up having health problems. As such, nearly all male engagement activities in Senegal’s FP plans are oriented toward demand generation and social and behavior change. The 2016–2020 plan called for strengthening communication directed towards men, building on earlier campaigns to help reluctant men and religious leaders to understand the benefits of family planning and improve their acceptance of family planning in homes and communities. Senegal employs a wide variety of channels to advance knowledge and perceptions of family planning among men: religious and community leaders, peer educators, grandfathers, science and home economics teachers, as well as mass media. Senegal also employs the Husbands’ Schools model (IRH, 2020). Despite the range of demand generation and behavior change related activities, no service delivery interventions target men or couples. And while Senegal’s FP documents target male knowledge and attitudes towards family planning, there is no articulation of how gender norms will be addressed. The 2016-2020 plan does not include indicators specific to males.

Address harmful gender norms throughout the life-cycle

While the CIPs acknowledged cultural and gender barriers to family planning, some, such as Pakistan’s Sindh province, were indirect while others, such as Ethiopia’s were more direct, noting power and gender dynamics that inhibit women from making open decisions about FP use. Still, no CIP or action plan adequately addressed how it would confront harmful gender norms in its program descriptions. Rigid masculine norms around self-sufficiency impede men from positive health-seeking behaviors, with consequences for themselves, their partners, and gender equality more broadly (Ragonese et al., 2019). Interventions and initiatives throughout the entire life cycle should provide opportunities for reflecting on and challenging narrow gender roles and unequal power relations, and for practicing healthy, caring behaviors. This can be thought of as an ethic, which can be thoughtfully integrated across a country’s FP portfolio, particularly among programs for young people (Blum et al., 2019), and must also not reinforce male hegemony in doing so.

In many of the CIPs and action plans, “gender transformation” was not specifically included. For example, the majority of plans reviewed included commitments to building adolescent-friendly service sites, and still others had planned for training of providers in this approach. While adolescent-friendly services are one way to improve the state of adolescent sexual and reproductive health around the world, it is important that they be gender-responsive, treating boys and girls not as a homogenous population, but as having specific needs. Gender responsiveness means specifically naming boys (as well as girls) as a target group and addressing these concerns through a variety of means, such as ensuring that clinics guarantee anonymity, destigmatize care, and address structural-level factors like discriminatory policies. For example, due to rigid gender norm prescriptions, adolescent boys may require extra motivation to seek advice or visit a health provider and may be highly sensitive (i.e. unfamiliar, afraid) to the clinic environment once there. Importantly, any intervention to comprehensively address boys’ specific sexual and reproductive health concerns must be informed by gender-transformative approaches that deconstruct strict ideas of manhood (Seth et al., 2020). The International Planned Parenthood Federation (IPPF) and UNFPA’s 2017 Global SRH Package for Men and Adolescent Boys (Shand et al., 2017) points to some very specific steps clinics can take to ensure their youth-friendly services are also male-friendly. Other resources, including the Interagency Gender Working Group’s (IGWG’s) Do’s and Don’ts for Engaging Men and Boys (Pulerwitz et al., 2019), and the High Impact Practice’s Engaging Men and Boys in Family Planning: A Strategic Planning Guide (HIP, 2018) will also be of use to programmers.

Address male engagement explicitly through policy, standards and protocols

No CIP or action plan delineated explicit policy or advocacy goals to advance the engagement of men. Efforts targeting individual- and community-level change require supportive structural environments, as attitudes, behaviors, and access are shaped and influenced by institutions, policies, and the ways policies are implemented. Within a broader focus on men’s services and methods, such policies, norms and protocols could include training on vasectomy counseling, operation and post-operation for all family planning strategies, regulations, and policies, and a focus on male engagement in services proximal to family planning like antenatal care, post-partum care, and early childhood protocols and services which offer opportunities to include men at moments when the couple may be interested in discussing family planning. Similarly, male engagement in family planning is also complementary to policies to address the unequal burden of care work on women, and to involve men more deeply in parenting, through parental and paternity leave policies in the public and private sectors. This should complement an acceleration of research into safe, affordable and scalable male-controlled contraception.

Implement couple-centered approaches

Too few demand generation and service delivery innovations in CIPs and action plans address partners together as contraceptive users. The Sindh province in Pakistan takes a couples-centered approach by encouraging health centers to open during evenings and weekends when men are off work. However, the Sindh province and other countries and states considering similar strategies should ensure that providers are trained to interact with and hear from both male and female partners during counseling, and to be aware of how men’s participation in FP counseling may undermine women’s voices, participation or autonomy. In patriarchal contexts, when men are present in such consultations, women may speak less, health care providers may focus more on the men as decision-makers, and show greater respect to men in FP consultations. In such cases, women’s decision-making and autonomy may be reduced by deference to or coercion by the male partner. Therefore, it is essential to ensure that providers address power dynamics within couple relationships to improve communication, while preserving the right of women to make their own SRH decisions at all times.

When conducted sensitively, couples counseling can be an effective means of improving a couple’s communication around family planning, challenging entrenched gender norms which prioritize male decision-making, and improving overall service uptake (Doyle et al., 2018). The 2018 Guttmacher Lancet Commission on Sexual and Reproductive Health and Rights highlights this need for increased attention toward relational approaches to masculine norms and men as partners in sexual and reproductive health and rights (Starrs et al., 2018).

Develop men’s capacity as advocates and change agents for Sexual Reproductive Health and Rights

Too often, the CIPs and action plans were silent about the ways in which men were engaged as advocates. One possibility is that work with men is couched in other terms, such as working in conjunction with religious and community leaders, or youth groups. Explicitly engaging men in critical examinations of constructions of manhood is important to ensuring women’s empowerment and family planning access. Men, and particularly men in influential positions, are uniquely positioned to challenge these inequitable norms for the betterment of themselves and women’s health and equality (Adams et al., 2013; Greene et al., 2014; Singh et al., 2014). Examples of male mobilizer programs, such as in Ethiopia, the Sindh Province in Pakistan, or Lagos State in Nigeria, point to the ways in which countries can train and organize groups of men for positive change. An evaluation of the Husbands’ Schools approach has found that it can contribute to increasing contraceptive use and transforming gender norms (IRH, 2020).

Include attitudinal and behavior change measures for men/boys in assessing program impact

We know that gender inequality undermines women’s family planning access. We also know that supportive, informed and engaged male partners can play an important role in increasing women’s access. As a result, too few CIPs and action plans track attitudinal or behavioral change related to gender norms and male engagement. This is incongruent with the numerous demand generation and social/behavior change programs spelled out in the CIPs and other documents. Expanding our measures of success to capture the gender-equality dividends of engaging men in SRHR can provide valuable data on pathways to increased healthcare utilization and improved health outcomes for women and men. Such measures could capture the benefits of improving couple communication and shared equitable decision-making, preventing gender-based violence, increasing men’s participation in prenatal visits, and expanding men’s involvement in maternal, newborn, and child health and caregiving.

For implementers or donors seeking inspiration on how to measure this, a list of 15 key indicators that family planning program implementers can use for monitoring and evaluating male engagement in FP programs was published by MEASURE Evaluation in 2018 (Adamou et al., 2019). Further measures of male engagement will be useful in yielding additional indicators to add to CIPs.

View men as users of contraceptive services, too

All programs included in this analysis focus contraceptive methods on women, with scant attention to reaching men as contraceptive users. Mentions of youth friendly services do not specify whether young men should be included. Projections of contraceptive use over the life of the plans assume little or no increase in use of male methods or male cooperative methods, other than some attention to condoms. Evidence demonstrates men’s desire for information and services, and their positive response to existing programming (Dorman & Bishai, 2012; Glasier, 2010; Heinemann et al., 2005; Kabagenyi et al., 2014; Lundgren et al., 2012; Shattuck et al., 2016). Hardee et al. (2017) propose 10 considerations for the inclusion of men as FP users: provide information and services to men and boys where and when they need it; address gender norms that affect men’s use of contraceptive methods; meet men’s needs while respecting women’s autonomy; improve couple and community communication; link men’s contraceptive use with their desire to support their families; teach adolescent boys about pregnancy prevention and healthy sexual relationships; develop national policies and guidelines that include men as family planning users; scale up programs for men; fill the gaps through monitoring, evaluation, and implementation science; and create more contraceptive options for men. Research shows that if even 10 percent of men interested in using a new male-controlled method did so, the introduction of a male pill or temporary vas occlusion could have a substantial impact on pregnancy prevention, by 3.5 to 5.2 percent in the United States, 3.2 to 5 percent in South Africa, and as much as 30 to 38 percent in Nigeria (Dorman et al., 2018).

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Open Science Framework: A long way to go: engagement of men and boys in country family planning commitments and implementation plans

https://doi.org/10.17605/OSF.IO/MA6FB (Hook, 2021)

This project contains the following underlying data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).