IMPLEMENTATION GUIDE

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IV. Men's Rights and Empowerment in Improving Women's Reproductive Health

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The programs presented at the conference raised gender awareness within the guiding principles of ICPD (International Conference on Population and Development, Cairo 1994). The ReproSalud (Peru) experience in working with men, Involving Men in a Project Based on Women's Empowerment (Peru), described below, captures the intricate connections between the goal of improving women's RH by empowering women to take control of their health and the numerous actions vital to achieving such a goal - among these the need to reach out to men as informed allies, aware of gender inequities. This project along with others, such as Challenging Inequities: The Story of an Anti-Sexist and Rights-Based Program for Nigerian Adolescent Males and Rights-Based Interventions Are Crucial to Changing Attitudes Toward RH Issues (Malawi) undertake reproductive health programming by embracing men as partners with the understanding that they have been ignored even though they are essential to human reproduction and a key audience to reach in the efforts to stop the spread of AIDS. Such projects teach adolescent boys and men about men and women's reproductive health systems and provide them with alternative gender models that foster more gender- equitable relations. They inform men and women about ways to improve communications about such personal matters as contraceptive use, family planning, and protecting themselves from STIs including HIV. As health providers become increasingly involved in efforts to reduce violence against women, RH programs that include men tend to address gender-based violence by presenting alternative behaviors to resolve conflicts. The program in Nigeria that targets adolescent males was highlighted in Quality/Calidad/Qualité (issue No. 14, 2003); the ReproSalud Project is described in issue No. 10 (2000). Both of these are available from the Population Council.

The session on raising men's awareness about gender, empowerment, and rights was prefaced with an overview of the challenges in collecting RH data on men, Collecting RH Data From Men: A View From the Demographic and Health Surveys (Global). Surveys undertaken in 40 countries found men difficult to reach, a challenge faced by programs that are designed to respond to men's unmet needs. The men were less easily available during the day and the length of the questionnaire was more problematic for them than for women. As a result, men only completed a third to a quarter of the household surveys completed by women.

Involving Men in a Project Based on Women's Empowerment (Peru)

The ReproSalud Project (Brems, 2003; Leau, 2003)

Implementing institution: ReproSalud, a reproductive health project, is being implemented by Movimiento Manuela Ramos Movement, a Peruvian feminist organization with a long and rich history of championing women's rights and gender equity from a participatory, community-based approach and assistance from various CBOs. USAID-Peru provides technical and financial resources.

1. Background

Peru is a South American country characterized by large inequities among urban, peri-urban and rural populations. Many of the targeted social indicators for urban areas have already reached or are close to acceptable levels, while similar indicators for rural areas are currently at the level where urban area indicators were more than 25 years ago. As in many places throughout the world, differences in social indicators between urban and rural women are remarkable because, in addition to socio-economic exclusion and ethnic discrimination, they suffer gender inequities. For example, the illiteracy rate of rural women is 38%. This is 2.6 times higher than that of rural men and almost 5 times higher than that of urban women (ENNIV, 2002).

Rural women are less likely to achieve their fertility preferences. They average almost twice the number of children (4.3) as urban women, even though their desired fertility is very similar (2.5). The national maternal mortality ratio is 185/10,000 live births, one of the highest in Latin America. Only 29% of deliveries in rural areas are assisted by a professional, while 85% of women in urban areas receive professional assistance (ENDES, 2000).

Furthermore, rural and peri-urban women who completed self-assessments identified reproductive tract infections (RTI) as the most important reproductive health problem.

2. Project goals and objectives
The ReproSalud project aims to improve the reproductive health status of low-income, rural, urban, and marginalized women by increasing their use of interventions to protect their reproductive health. These range from adopting health preventive behaviors to increasing their use of health services.

The project aims to establish relationships that are more gender equitable, specifically to enable women to overcome their subordination and reach a more equitable place in their community.

The work with men, introduced two years after the project was designed (1997), aims to increase men's awareness about gender equity and human rights--particularly women's ability to access RH care and live healthier lives--and to involve men in preventing and dealing with reproductive health problems which affect women and men.

Objectives include involving men as partners in preventing sexually transmitted infections, unwanted pregnancies, and maternal mortality and morbidity. Activities implemented by ReproSalud to achieve these objectives include promoting men's reflection (i,e., exploration, analysis, discussion) about gender roles, responsibilities and rights; and giving them the information they need to prevent these health problems. As with the women, the men learn about consistent and correct use of contraceptives, including condoms; the causes of RTIs and STIs, their symptoms and medical treatments; and the importance of antenatal care and the identification of alarm signs during pregnancy or after childbirth.

Duration of program: nine years and six months. The project's duration included a six month pre-project phase to design and test methodologies and strategies that had little precedent in conventional health and population programs, and to train staff to implement them.

PHASE ONE: lasted four years (1996-2000) and involved 2-3 cycles of providing sub-grants to women's community-based organizations in eight regions. Each sub-grant supported participatory educational and community-based interventions addressing specific reproductive-health problems identified by women.

PHASE TWO: extended the project for five additional years (2000 - 2005). This phase focuses on increasing educational activities and strengthening advocacy in local communities. The intent is to scale up and expand the impact of ReproSalud to create a critical mass which will ensure its sustainability.

Needs Assessment: ReproSalud designed its project to address the under-utilization of health services provided by the ministry of health in marginalized urban and remote rural areas. The project design took into account relationships between health care providers and low-income women by focusing on the demand side of the reproductive health equation, and by addressing, at the community level, those structural barriers related to gender, ethnicity, and class that prevent poor and marginalized women from exercising their reproductive and sexual rights.

3. Project Design
Rather than delivering health care, ReproSalud works to empower women and their communities to overcome gender-based, social, cultural, and economic barriers to reproductive health. It aims to enable women to become informed consumers of reproductive health care, to practice healthy behaviors, and to advocate for changes in the health care system to meet their needs. In other words, ReproSalud aims to empower women to reach full citizenship.

Early during the design phase of the first community projects, many community-based organizations (CBO) identified the need to reach out and work with men in their communities. They cited both pragmatic and strategic reasons. Pragmatically, it was necessary to engage men so that they would not oppose women's involvement in ReproSalud's meetings and related activities. Strategically, it was vital to involve men because they were continually identified as an important factor in women's reproductive health problems. In view of the women's sound arguments, ReproSalud decided to respond to their request.

The need for more equitable-gender relations is stressed with male as well as female audiences so that couples, for instance, learn to talk more openly about sexually transmitted infections, family planning, and domestic violence.

Communication Strategies: A radio-based communications program is being implemented to reinforce the face-to-face program and to expand educational contents about reproductive health and gender in places not yet reached by ReproSalud. A radio soap opera was produced based on women's and men's true stories gathered in the field. However, the characters also exhibit alternative gender roles as one of the objectives of these shows is to expose viewers to different types of men's and women's roles and relationships.

Educational Activities: Educational strategies and training modules were adapted to work with men, taking into account the same participatory and reflexive methodology that ReproSalud uses with women. Specific issues or interest for men, like STIs, prostate cancer, and urethritis, were included in the training materials for men.

Men do not participate in the self-assessments, instead they talk about their needs and worries at the beginning of each module, as part of the methodology. Workshop discussions include myths related to sexual performance and concerns about mutual enjoyment and pleasure. These tend to surface toward the end of the sessions on women's and men's anatomy, and birth spacing, and improving their health. Issues of interest and concern to men were concurrently included in training materials that address women's issues so that women could understand and help men with their problems. This promotes communication between men and women on topics that are important to individuals, regardless of gender, and to couples. Finally, this strategy enhanced men and women's ability to recognize the interdependent cause and effect of many sexual and reproductive problems and how they affect the life of the couple and family life in general.

Project staff selected and trained male trainers. The training required self-reflections by the trainers. A Mexican consultant specializing in work with men was in charge of the training process because there were no precedents of working with men, in particular with rural men, in Peru. Following training, project staff led educational activities with male community promoters selected by their communities, and set up educational programs for interested men. Prior to conducting workshops, promoters adapted guidelines and organized educational workshops.

Educational methodology of ReproSalud: Training is based on the processes of self-reflection and building an integrated knowledge base that combines what men know with their experiences and biomedical information.

The curriculum includes an introductory module on gender roles and equity, human rights (focused on sexual and reproductive rights), male and female anatomy, and reproductive physiology. Three modules focus on sexual and reproductive health problems and one addresses violence against women. Rights and violence are covered in all the modules including to the two dedicated to these topics. The curriculum is covered in approximately 48 hours of class time.

Men are encouraged to exercise their right to know and care about their bodies, specifically their sexual organs. In this context, they are encouraged to take care of their own sexual and reproductive health, for example, by practicing hygiene as well as making more use of the government health care facilities for sexually transmitted infections (STIs) and prostate cancer screenings. At the same time they are encouraged to help women to care for their bodies, and prevent and deal with sexual and reproductive problems.

Each module concludes by asking participants to make specific voluntary and spontaneous commitments. For instance, some men have committed to sharing with other men their knowledge and new perspectives; others make it a habit to practice preventive health care to avoid STIs and unwanted pregnancies, thus implementing what they have learned.

Stakeholders and their roles: several key local stakeholders are involved in making ReproSalud successful. There are local ones, such as:

• Women leaders of CBOs--the main actors--manage projects, involve CBO members, advocate, and negotiate with health care providers;
• Local male authorities provide legitimacy to the program and community resources, and help to convene men;
• Health care providers at the local and regional levels incorporate some of the women's needs and carry out agreements negotiated with community leaders and promoters. An example of such agreements is making professional health care providers accessible to women who may want or need them regardless of the fact they give birth at home with the help of traditional birth attendants, as is customary.

Other actors are:

• NGO Coordinators responsible for advocating at national and regional levels in favor of policies and programs that ensure that poor women and men are able to exercise their rights to determine the number of children they want, their spacing, and whether or not they want to engage in sexual relations. Their primary audiences are the Ministry of Health (MOH), the Ministry of Social Development, some sectors of civil society's stakeholders, members of the Medical Association and mass media communication reporters.
• Donors through technical and financial support.

The intended beneficiaries are 290,000 women and 130,000 men of reproductive age, who live in rural and marginalized urban areas of the highlands and jungle. The rural women and men in the regions participating in the project are largely indigenous, approximately 75%-95% speak Quechua or Aymara (in Puno), as a first language.

4. Evaluation of expected outcomes
The evaluation of ReproSalud involves a quantitative impact study and a scaled down ethnographic study to review expected outcomes. These will be carried out before, during, and after the project is implemented. In addition the evaluation includes a cost-effectiveness analysis.

In accordance with the principal goal, the primary expected results are to increase women's use of reproductive health interventions (the strategic objective); increase equity in gender relations; improve women's abilities to access reproductive health programs; and include grass-roots women's organizations in all aspects of RH programming, from developing proposals to adapting and overseeing programs.

The quantitative study seeks to evaluate changes in knowledge, opinions, values, attitudes, and practices relating to the expected results through a survey administered to women and men.

The qualitative study gathers in-depth data on key issues in the results framework of the ReproSalud project, data for which the quantitative impact study is not appropriate. It aims to learn and understand patterns of social relationships (between men and women but also between provider and client and vice versa) and processes relevant to the expected changes. The study also seeks to identify paths toward change and empowerment. The data is collected with different qualitative techniques such as in-depth interviews with each woman and her partner, participant observations, and information gathered on paradigmatic events that are significant to people in the community. For example, the study will look closely at relations between rural women and health service providers by examining a case in which medical assistance was considered successful and one in which it was not. Violence against women and women's empowerment will be used as indicators to assess changes in gender relations.

Examples of indicators: indicators that are used to assess the program's success related to women's reproductive health are:
- % of men who can recognize some alarm signs during pregnancy or after child birth
- % of men who agree that their partners should attend a health care facility for the delivery.

Indicators related to men's sexual health:
- % of men with STI's who went to a health care facility
- % of men who have used the condom in order to protect them and/or their partner against STI's.

Indicators related to enhancing men's awareness about gender equity and women's rights:
- % of men who believe that it is never right to hit a women
- % of men who believe that men are entitled to demand sex even when the woman does not want it.

Monitoring activities: Monitoring activities include supervisory visits of staff trainers to community promoters at least twice per workshop. During these visits, trainers review materials with promoters to refresh their knowledge before the workshop starts, and observe some sessions conducted by promoters to identify strengths and challenges in introducing new knowledge and perspectives or address problems with the training methodology itself. Trainers reinforce the promoters' knowledge and skills based on information gathered through their observations.

At the end of each activity promoters complete a report, taking into account achievements, difficulties, and the number of participants. In addition, they complete a report with information such as an overview of the educational background, age range, and occupations of the participants.

Evaluation: Participants are evaluated at the beginning and at the end of the workshops through a test that is graded by promoters. The levels of achievement and increase in knowledge are registered as indicators of the effectiveness of community educational projects.

Promoters and the steering committee of community-based women's organizations with one or two members of ReproSalud's staff evaluate the community-based projects. The goal is to know if these projects have made the anticipated progress and to reflect on the difficulties and opportunities encountered during the project's implementation. The project is evaluated based on the level of knowledge and it's increase, the number of beneficiaries, and the degree of satisfaction of beneficiaries and authorities, which is measured through a survey conducted by ReproSalud Project's regional staff. The degree of complexity of the next community project depends mostly on the results of the evaluation.

Obstacles and strategies to overcome them: Some obstacles that constrain ReproSalud's ability to achieve their goals are related to MOH policies and health providers' attitudes.
Strategies that Reprosalud has used to overcome them are as follows:

• Advocacy and lobbying to effect changes in MOH policies regarding sexual and reproductive rights;
• Empowering a critical mass of users and raising cultural awareness to achieve more equitable relationships with health providers;
• Sensitizing providers on gender issues and user's rights.

Other constraints are men's negative attitudes about participating in educational activities and difficulties in organizing meetings with them. Strategies to resolve this issue are as follows:

• Reflexive-participatory education, which takes into account fears, rights, benefits for all, to address men's reluctance to sanction women's participation;
• Convening participants through house-to-house visits by a male promoter and community authority;
• Radio programs to reach men (especially young men) who are displaced from their communities in search of work or have no access to higher levels of formal education in better educational institutions.

LESSONS LEARNED

• Before starting a new program, managers should consult the community about their sexual and reproductive health and gender needs and problems. Women in communities with few resources have taught us that we need to work not only with women but also with men. As gender, sexuality, and health are socially constructed, women and men in communities with few resources are more able to identify their needs related to RH than program managers. It is important to consider a "cross analysis" of women's assessments and men's assessments of their reproductive health, taking into account power relations based on gender and a lack of communication about sexual and gender issues.
• Taking into account that power is a key issue in understanding gender relations and many aspects of women's reproductive and sexual health problems, empowering women and involving men simultaneously in reproductive health programs is highly advantageous, and even indispensable, in conditions of marked female inequality for women. This approach avoids the reinforcement of oppressive gender norms that result in oppressive relations between men and women.
• Designers of reproductive health programs need to think more about how to change meanings and values associated with masculinity which are contrary to gender equity. Designers should achieve a balance in power as well as broadening existing social norms attributed to men and women and emphasizing the diverse ways that currently exist or can be created and which are valued in being male and female.
• Men need involvement in community activities to deepen their understanding about their health problems and relations with women and other men. Thus, training workshops help men express their own concerns and discover the importance of relationships and discussions about reproductive health, even when they talk about reproductive health problems identified by women. In addition, men, including community-based promoters, are changing the way they relate to men and women. This in itself is creating and strengthening alternative models of femininity and masculinity.

References

Leau, C. 2003. Involving Men in a Project Based on Women’s Empowerment. Paper presented at 2003 Reaching Men to Improve Reproductive Health for All International Conference, Dulles, Virginia.

ENNIV. 2002. Encuesta Nacional de Hogares Sobre Medición de Vida. National Survey of Levels of Life, Lima, Peru.

ENDES. 2000. Encuesta Nacional de DemografÌa y Salud (National Survey of Demography and Family Health). National Institute of Statistics and Information Science (INEI), DHS, Lima, Peru.

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