IMPLEMENTATION GUIDE

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II. Policy Initiatives and Strategies for Advocating the Involvement of men in Reproductive Health

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Masculinities, Reproductive Rights, and Public Policies, a program initiated by the Municipal Secretary of Health of Rio de Janeiro, Brazil, is an example of a government and a policy program that targets a large and diverse group of people, from policymakers to children. In contrast, Reaching Men to Improve RSH for All, Mexico, is an advocacy program that is directed to highly educated professionals seeking to increase their knowledge and strengthen their skills to implement effective programs. Such initiatives give the issue visibility and encourage networking among local and country-wide organizations.

The third program described in this chapter, Linkages between Democracy and Governance, RH, and GBV, Nigeria, reports on the results of a study that found that women who participated in programs that link FP/RH and democracy and governance activities were more effective in increasing use of FP/RH programs than non-linked programs.

Masculinities, Reproductive Rights and Policies (Brazil)

Implementing agency: Municipal Secretary of Health, Rio de Janeiro in collaboration with Departments of Education, Social Welfare, Sports, Municipal Media, Social Works, and various NGOs.

1. Background
In 2002, there were close to 6 million people living in Rio de Janeiro, 47% male and 53% female. There were almost one million adolescents between the ages of 10 and 19. Adolescent mothers accounted for almost a fifth (19.26%) of all births. HIV/AIDS is spreading rapidly among women.

Rio de Janeiro has 1,040 municipal schools with 700,000 students, 155 municipal health facilities and 10 youth centers with 2,000 trained peer educators.

Identifying which issues to advocate: In 2001, the Municipal Government of Rio de Janeiro created a "Quality of Life" Committee which was coordinated by the Municipal Secretary of Health. The committee includes representatives from the departments of education, social welfare, sports, culture, labor, housing, publicity, communications, security, media and women's rights. Universities and NGOs such as Promundo, NOOS, CEDUS, NESC-UFRJ, Fiocruz, EICOS/UFRJ, and others were welcome to participate as well.

2. Program design
The objective is to raise awareness of the need to improve men's involvement in reproductive health and care of children and adolescents through several strategies, including two seminars on "Challenges of Contemporary Masculinities." One of the most important activities was a "Fatherhood Week," created officially in 2002, and repeated in 2003. This initiative was followed by partnerships with other campaigns such as the "International Breastfeeding Week" and the municipal campaign, "No to violence against women; world peace starts at home."

The health department coordinated these campaigns, and they were run by members of the Quality of Life Committee. During the two "Fatherhood Week" programs (2002 and 2003), committee members implemented activities in their area of expertise. For instance, research-based members conducted surveys about child-parent relationships and men's health needs. NGOs familiar with issues of fatherhood created public displays about fatherhood, identified and reduced institutional barriers to fathers' participation (in schools, community centers, health care facilities, etc.), adapted children's games to include fathers, and trained institutional staff on including issues of fatherhood and masculinities in training curricula. Members of the committee led discussions on diversity, inclusion (men who have sex with men, disabled people, other men, etc.), gender norms, socialization of adolescent boys, involving fathers in childcare, and men in family planning and STI/HIV prevention. Some committee members developed activities to enhance the father-child bond.

The program targeted all sectors of society, including professionals, children, adolescents and youth, men, women and families.

Duration: Initiated in 2001, and on-going. The activities included in this report are those that were carried out in 2002 and 2003. Activities for 2004 are being determined based on available resources.

Stakeholders and their roles: The Department of Health developed educational materials, hosted a web forum, seminars, and in 30 public health centers ran activities such as games, debates, making and distributing posters, conducting surveys, and hosting celebrations.

The Department of Education ran activities in 300-400 schools, similar to those run in the public health clinics. They also developed a newsletter for teachers with information about masculinities and suggested activities.

The Social Welfare Department trained 2,000 peer educators and ran activities in 10 youth centers, similar to those run by the health department. In addition, children of battered women were invited to participate in these activities.

The Sports Department conducted activities in five sports centers and 20 public parks.

The Municipal Media Institution ran eight television programs with themes such as the new man, fatherhood week, father's rights, fatherhood and health services, adolescent fathers, men and care, fatherhood and violence, and fatherhood and the media.

The Social Works Department/UFRJ conducted a survey on "What does it mean to be a father?"

NGOs and other institutions were involved in the activities described above, and ran seminars, lectures, and contributed to the development of educational materials including plays.

Activities planned for the two Fatherhood Week programs helped raise awareness about fatherhood and health services programs by emphasizing the father's role in contraception, pregnancy testing, antenatal care, delivery, pediatrics, school health programs, adolescent and young men's programs, STI/AIDS, clinical care, and care of the elderly.

3. Results
The initiative has strengthened partnerships between 400 different institutions (municipal departments, NGOs and universities) and thereby has fostered creative ideas. Running activities in different sites optimized opportunities and as well as helping to integrate working with men with activities already underway (e.g., a vaccination campaign encouraged the involvement of fathers and schools addressed such issues as the role of families in schools).

The program has led institutions, particularly health facilities, to review their routines to foster the participation of fathers. In other cases, the program gave visibility to activities that were already underway in health facilities but were not receiving the support they needed.

In terms of policy change, municipal departments in the health and education sectors are including masculinities and fatherhood topics in the training programs directed at peer educators, teachers, and health professionals.

Obstacles and strategies to overcome them: It is awkward to talk about fatherhood when many children don't have fathers. This was overcome by discussing "men and care" rather than fatherhood.

It was difficult to involve fathers of malnourished children. Health personnel had to be very careful when trying to involve fathers in group activities in order to avoid having them feel guilty for not being able to support their families.

The problem of discussing fatherhood with children and adolescent with a history of violence was addressed by giving children and adolescents the opportunity to talk among themselves about the fathers they have and the fathers they would like to have.

Remaining challenges include attracting media attention and having sufficient funds to assure the continuity of the program.

LESSONS LEARNED
Working with multiple partners requires careful planning and coordination and an on-going open dialogue among participating organizations.

Not knowing whether funds will be available to continue the program from year to year hampers the ability to do long-term cohesive planning and hinders efforts to scale up this initiative.

Creating a week of activities whose impact can be evaluated is very strategic to promote reflection among men and to mobilize institutions. Working with institutions generates new models of care.

Fatherhood motivates men to reflect about masculinities. However, one must recognize that it is a very sensitive issue, one that requires professionals to consider their own personal experiences.

Reaching Men to Improve Reproductive and Sexual Health for All (Mexico)

This program took a different approach to advocating and promoting men and RH. This project was initiated by two NGOs, MEXFAM and CORIAC, but also involved the public sector and academia.

The partnership between NGOs working on male involvement and academicians interested in male identity issues, in Mexico, is rooted in their close collaboration on this issue from its pioneer days. Theoretical research findings initially informed designs of male involvement programs. As the discipline evolved, with operational research findings indicating that working with men in RH was a viable strategy for addressing some of the countries' public health problems, representatives from the public sector were gradually invited to join meetings where such findings were discussed.

This male involvement advocacy project was designed to promote an interdisciplinary discussion of needs, problems, and ways to promote male involvement in sexual and reproductive health. Its objectives were to promote exchange of research and male involvement experiences in the field of sexual and reproductive health; promote collaboration and operational strategies for working with men and give technical assistance to the state groups; provide interdisciplinary training in gender and in sexual and reproductive health from a male involvement perspective; and to develop action plans.

Implementation: monthly meetings held in five cities: Mexico City, Hermosillo, Jalapa, Morelia, and Oaxaca, with set syllabi and invited speakers. Participants received materials on masculinity and related theories.

LESSONS LEARNED

• Institutional support is critical for implementing ideas developed by program professionals, as are the commitment and leadership skills of the local leader.
• Buy-in from key stakeholders such as the participants themselves and beneficiaries has to be obtained from the beginning of the project. Convincing stakeholders to support advocacy activities may take time and resources. In this case, it took three years and three separate conferences (regional, Oaxaca 1998; national, Mexico 1999; and theme based, NGOs in Mexico that work with men 2000) to convince stakeholders of the need to undertake a national advocacy program.
• Experiential workshops in which participants have a chance to role play or practice other interactive skills were among the activities participants consistently cited as the most useful. Participatory activities helped increase their understanding of male involvement issues and how to change attitudes.

Linkages between Women's Political Participation and Reproductive Health: The Male Influence (Nigeria)

Implementing agency: The Enabling Change for Women's Reproductive Health (ENABLE) Project implemented RH and Democracy and Governance activities. CEDPA evaluated the effectiveness of the integrated intervention.

1. Background
The Church of Christ in Nigeria participated in Democracy and Governance (DG) activities run by the ENABLE project in 1998. In 1999 RH was integrated into the Democracy and Governance project at the request of the Church of Christ.

Activities implemented in Democracy and Governance program:

• Grassroots mobilization for women's participation in political processes
• Formation of coalitions and networks by women-focused organizations
• Advocacy visits to opinion leaders on women's issues
• Women's leadership training

Activities implemented in Reproductive Health program:

• Training community and clinical health workers
• Distribution of family planning commodities and IEC materials

2. Study Design
The hypothesis tested by CEDPA is that women exposed to both DG and RH activities will have more favorable reproductive health practices than those who are not exposed to both, particularly those women whose spouses are supportive of women's empowerment

The experimental study compared the level of women's empowerment, political participation, and use of modern contraception in four local government areas of Plateau State. ENABLE, in partnership with the Church of Christ in Nigeria, implemented both RH and DG activities in only one of the local areas; participants in two of these locations received either RH services alone or DG interventions alone; and the fourth local area was the control group, with no RH or DG activities. Data for the study is from a representative survey of 2,000 reproductive-age women conducted in Plateau State in December 2002 and January 2003.

The information presented focuses on the types of influence that husbands have on women's empowerment, which in turn affects the relationship between women's political participation and contraceptive use. Women's empowerment was measured on four scales: freedom of physical movement, decision-making on household purchases, situations in which a wife can refuse sex, and justification for wife-beating. In this traditional, male-dominated culture, male approval is generally needed for nearly all actions that women take, including going to the market, attending a health clinic or visiting friends.

3. Results
The results of the study indicate that:

• Women in the RH/DG-combined intervention area scored highest on all of the women's empowerment and RH indicators compared with other women.
• Modern contraceptive use was low overall (8.6%), but highest in the RH/DG combined area (12.0%), as is the percentage of women who intend to use contraceptives in the future (45.6%).
• Intention to use family planning was 56% greater among women exposed to DG activities than those not exposed.
• Among women with little or no education, current use of modern contraceptives was 10 times higher among those whose husband approved of FP than among those whose husband did not approve. The intervention only measured the impact of husbands' approval of FP on contraceptive use among women. It did not try to increase husband's approval of FP.
• Similarly, among women with little or no education, those with permissive physical mobility scores were twice as likely to say they intend to use FP compared with women with lower mobility scores. The intervention did not attempt to increase women's physical mobility.
• Group affiliation (e.g., church membership) has a strong independent influence on current contraceptive use, while the effect of political involvement operates through other background characteristics (education, socio-economic status, age).

LESSONS LEARNED
The project demonstrates that linking health programs with non-health programs leads to women's informed and autonomous decision making, particularly for the allocation of women's time and resources. These linkages promote greater acceptance of family planning and the participation of women in the democratic process, particularly if husbands are supportive and permissive. In a traditional, male-dominated society, husbands who permit greater physical mobility faciliatate exposure to new ideas and other social networks that can be conducive to improved reproductive health behavior. A husband's positive attitude on family planning and greater communication on reproductive issues are highly related to his wife's use of modern contraceptives.

The implications of linked programs are that political involvement through group affiliation of women leads to better reproductive health outcomes and is enhanced when men are supportive of the economic, cultural, social, and sexual dimensions of women's empowerment.

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