IMPLEMENTATION GUIDE

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VI. Successful Strategies in Reaching Men

This chapter highlights various strategies for reaching men, particularly young men, and for informing them about a number of reproductive health related topics, such as prevention of unwanted pregnancies, STIs and HIV/AIDS. Including men in information, education and communication (IEC) or behavioral change communication (BCC) programs is an effective way to inform them about their bodies and give them a comfortable environment to talk about their sexuality, to express their concerns, and to ask questions. Community wide awareness-raising campaigns or counseling sessions are other means to encourage men and women to discuss sensitive issues such as family planning and birth spacing.

This chapter is divided into three sections:

• IEC/BCC
• Peer education
• Communication and counseling

Each section is self-contained and summarizes programs that have been implemented using these strategies.

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IEC is evolving into BCC in response to studies that consistently point to the wide gap between knowledge and action. RH programs have succeeded in informing people about how to protect themselves from STIs and avoid unintended pregnancies but have been less successful in turning knowledge into action. The following program aims to address this dilemma by including actions individuals and couples can take to plan their families and avoid STIs.

Men Win with Contests, Reaching Men through Entertainment Education (Jordan)

Implementing agencies: Johns Hopkins Bloomberg School of Public Heath/Center for Communication Programs (JHU/CCP), Idea International Center, and the National Population Commission, Jordan.

1. Background
Jordan's population growth is very high (TFR 3.8), compared with other Arab and Muslim countries (TFR is 3.5 in Egypt, 2.1 in Tunsia, and 2.6 in Indonesia), consequently burdening the economy and social service sector. Frequent multiple births are also taking a toll on the health of mothers and children.

Islam is a crucial force in Jordanian society. It shapes attitudes, impacts behaviors of Jordanians, and directly influences their decisions regarding all aspects of life including those related to FP and RH. Religious leaders are intimately involved as opinion leaders in the social networks that influence the decisions and actions of Jordanians at the local level.

Knowledge, Attitudes and Practices (KAP) survey: The Department of Statistics (DOS) conducted a national population-based study throughout Jordan on a representative sample in which 1,000 married women in reproductive age and 1,000 men married to women in reproductive age were surveyed. The results concluded that a lack of knowledge about Islam's position regarding the use of modern FP methods, their safety, reversibility, and effectiveness are barriers to their use. Furthermore, the study also identified two deeply rooted social norms that influence men's reluctance to use modern contraceptive methods: the preference for male children and large family size (The mean ideal number of children is 3.8).

The survey was crucial in identifying the concepts that the campaign should address and the most appropriate channels for conveying information about RH to men. It also identified geographical locations best suited for initiating such interventions. The first national family planning communication strategy was developed based on these findings. Its aim was to increase the participation of husbands in making RH/FP decisions and using modern contraceptives. The slogan by which the different communication interventions were identified was "Together for a Happy Family."

2. Goals and objectives of the campaign
The main purpose of the campaign was to improve the results of the 1996 KAP survey. In addition, the campaign emphasized the idea that FP improves the quality of life of families and that a female child is as precious as a male child. The messages conveyed to emphasize the latter were: male and female children are god's gift and are of equal value; men are biologically responsible for determining the sex of the child; parents should treat their male and female children equally; and females have important roles to play in society. The objectives of the campaign were to:

• Provide married men with the necessary health, social, and religious information to enable them to make informed FP decisions;
• Encourage men to initiate discussions with their spouses on this issue.

Themes addressed: The following five themes were discussed and promoted during the campaign. Each theme was selected and designed based on the KAP study.

The use of modern FP methods is consistent with Islamic teachings. Clarifying Islam's position regarding the use of modern contraceptive methods is crucial to the acceptance of these methods by the people in Jordan. Furthermore, communicating that Islam allows birth spacing and that it is different from birth limitation was an important part of the message. Birth limitation is not allowed by Islam while spacing is. It was important to stress the fact that the campaign was promoting birth spacing and not limitation. Islam views children as a gift from God and the main reason of happiness in life. Another important reason behind this differentiation is the political situation in the region that makes people in Jordan view children as an asset for the future and an important factor in social positioning of their family in the society.

Modern FP methods are effective, safe and reversible. Health concerns were identified as one of the barriers to using modern FP methods. The campaign recommended couples consult with a health provider before starting to use a method.

Spousal communication on FP. Previous studies demonstrated the percentages of couples that discussed family planning issues was double among users of modern family planning methods compared to non-users.

Female children are as precious as male children. Preference for boys drives couples to have children until they reached their desired number of male children. The male child is considered a continuation of the man's name. A common belief is that the greater the number of male children, the greater the social support and position of the family in society. The messages relayed in the campaign conveyed the ideas that: parents should treat male and female children equally; Islam asks parents to treat their female child with the same respect and love as their male child; and girls have the same intellectual capabilities and rights as boys.

Family planning enhances the quality of life. Approximately 44% of men and 37% of women surveyed mentioned that FP improves the quality of life (representative sample of 1,000 married women in reproductive age and 1,000 men married to women in reproductive stage). Emphasizing the message of planning a family is important to create social norms about the relation of family planning to the quality of life of the Jordanian family. In addition, this message may lay the groundwork to promote the idea of smaller family size in the future

3. Campaign Strategy and Design
The National FP/RH Contest was a part of the "Together for a Happy Family" campaign. The campaign used multiple communication channels and approaches: mass media, community mobilization sessions (CMS), and a national contest.

• Mass Media: Five television and radio spots were specifically designed to convey the different themes of the campaign. They aired during prime time on Jordanian TV and radio. All the campaign themes were integrated into different related TV and radio programs.
• Community Mobilization Sessions: 40 triadic teams conducted community mobilization sessions in five governorates (provinces or states). Each triad team consisted of a social worker, a Moslem religious leader, and either a trained gynecological or obstetric specialist. The Men's Involvement in Reproductive Health Survey (MIRHS) showed that 2% of respondents in these governorates reported having participated in such meetings. This was an achievement considering the challenge of organizing and conducting sessions that reached 20,000 men.
• National RH/FP Contest: In addition to the above-mentioned channels, the National RH/FP Contest was designed using the entertainment-education (enter-educate) approach. This approach uses entertainment to educate people about specific topics and offers many advantages for health communication, as it has been used for educational purposes throughout history. Greek tragedies, parables in the Bible, songs and stories in every religion and culture present the conflicts and values of different societies in vivid, dramatic, and, above all, entertaining terms. Modern mass media carries on this tradition, reaching millions with popular radio and television shows that entertain and educate simultaneously. Johns Hopkins has used this approach for more than a decade to make health messages more appealing. Enter-educate has many advantages in promoting different health messages as it is persuasive, popular, and stirs emotion.

The National RH/FP Contest:

Stakeholders and their roles: The National RH/FP Contest was crafted carefully in partnership with Idea International Center and all the parties involved in the campaign with an endorsement from the Royal Family. Idea International Center is the private advertising agency that developed , conducted and monitored this campaign. Its design, content, and methodology took into account the personality of Jordanians, their sensitivity to these topics, and at that time, the absence of entertainment-educational approaches used in promoting health and social messages.

Themes of the RH/FP contest:

• Male and female children are of equal value;
• Spousal communication is important in making decisions about FP;
• Using modern family planning methods is consistent with Islamic teachings;
• Modern family planning methods are safe, effective, and their effects are reversible;
• Using modern FP methods enhances quality of life for the entire family as:
  • It allows more time for mothers to take care of their children's and their husband's health;
  • Smaller families enhances the economic status of the family, so parents are able to provide better education and care when pregnancies are sufficiently spaced.

In one of the community mobilization sessions, a father of 10 children talked about the problems his family faced in caring for such a large family and advised his peers to think carefully about having so many children.

Strategic design: The contest was designed to enhance and maximize the impact of the campaign and work in synergy with its other components. To participate, entrants had to complete four entry forms; each form included a paragraph with information about one of the campaign themes which were the basis for the answers to the four multiple choice questions contestants had to answer.

The contest distributed messages through four channels: advertisements in four daily local newspapers, mailings to all post office boxes (135,000) in the country, direct distribution through outreach teams, and e-mails.

Several promotional and public relation activities, such as teasers on TV, newspapers, posters, and giveaways contributed to increasing the visibility of the contest. It was launched in a well promoted, highly publicized ceremony attended by representatives of all the sponsors, media professionals, and representatives from other relevant national organizations. Over 100 prizes were awarded in a national ceremony under the patronage of Her Royal Highness Princess Basma. The prizes included 100 household electronics, five accounts at the National Bank of Jordan with an opening balance of 100JD, and two round trip tickets, one from Amman to Vienna and another to the Gulf. The winners' names were advertised in daily newspapers.

Throughout the life span of the contest, various pre-testing, monitoring, and supervision activities and techniques were held to maintain the momentum, to solve problems that might arise, and to analyze results on a regular basis. All the campaigns were field-tested on targeted audiences before an materials were produced. Religious leaders, media professionals, and selected policy makers pre-tested the materials and were consulted to assure that their content was culturally appropriate and religiously acceptable. The management team held weekly meetings to address and resolve problems. Community mobilization sessions were carefully coached and supervised.

The contest was fully sponsored by the private sector. Four private companies donated 107 prizes with a value of approximately US$32,000. Gatekeepers and stakeholders such as religious leaders, media professionals, health and social professionals, and private sector representatives were involved in its planning and implementation. This partnership, combined with endorsements, created the enabling environment required for the contest to achieve its objectives.

4. Results
Two percent of the Jordanian population participated in the contest (around 100,000 contestants). Of the participants 60% were male and 40% were female. The largest age group that participated were 24-38 years olds (43%) followed by youth, those under the age of 24 (32%). More than half of the contestants were married (58%) but a large number of them were single (42%). Three quarters of the participants responded to the direct mailing and 92% of all contestants answered the multiple-choice questions correctly.

Impact of the campaign:
The "Together for a Happy Family" campaign markedly improved the knowledge and attitudes of Jordanian men and women regarding specific modern family planning methods. The 2001 Men's Involvement in Reproductive Health impact assessment Survey (MIRHS) shows that a significantly higher proportion of men considered the use modern family planning methods as safe, effective, reversible, and permitted by Islam. Accordingly, the number of men who cited the use of specific modern methods as forbidden by Islam and those who did not know the religious stance of specific methods decreased from 1996 to 2001.

The proportion of men who used a family planning method and discussed it with their wives significantly increased from 93% to 98% (P < .05) between 1996 and 2001. Among women, however, the difference was not significant.

MIRHS survey respondents received a list of actions taken as a result of exposure to the campaign. Respondents ranked discussing issues with spouses and sharing decision-
making as the top actions taken. Other actions included treating sons and daughters equitably and initiating the use of a family planning method.

Although the campaign did not directly promote smaller family size, it did promote the use of family planning to improve the quality of life of Jordanian families. Nevertheless, a comparison of the KAP survey with the MIRHS data indicate that the ideal family size declined from 4.3 in 1996 to 3.8 in 2001.

Gender preferences: More than 70% of respondents of the MIRHS survey said that the sex did not matter or said they wanted an equal number of boys and girls. However, men tend to prefer male children more than women do: 24% of the men said they wanted more boys than girls, compared to 16% of the women. A very small minority of men and women expressed a stronger preference for girls than for boys.

Youth Contest: The success of the enter-educate approach in promoting different health/social messages within the men's campaign prompted the National Population Council, with technical assistance from JHU/CCP, to offer another contest, on a larger scale, in the National Youth Program (Youth 21). The Youth 21 program provided adolescents and young adults with information on reproductive and sexual health and life planning skills. The contest was designed and implemented by Idea International Center with technical assistance from JHU/CCP.

The enabling environment that was created during the National RH/FP Contest for men broke the culture of silence about such sensitive issues in the Jordanian society. This allowed the new contest targeting youth to be designed and implemented on a larger scale. The youth contest used more innovative channels to promote approximately 15 messages, many more than the four relayed in the men's contest. The youth campaign attracted more private sector involvement and participation (table 1 highlights the differences between the two contests).

LESSONS LEARNED
The findings described above demonstrate that, even in a country with strong traditional and religious beliefs, a well-coordinated large-scale reproductive health communication campaign supported by political and religious leaders, endorsed by the royal family, supported by the private sector, and designed in partnership with all parties can increase knowledge and positively change attitudes.

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Peer education is particularly popular in adolescent RH programs. There are clear indications that youth are more willing to listen and share experiences with peer leaders who speak their language and share a common culture than with adults. The following two programs emphasize peer education.

Addressing Adolescent Males' SRH Needs Through the Creation of Male Peer-educator Groups, Belarus. The lessons learned from this program suggest that such programs could benefit from the participation of health specialists such as psychologists and medical professionals who could meet with young people, alongside their peer leaders, to address specific issues related to physiology, psychology, and sexuality.

Impact of a Peer Education Intervention on Gender and Reproductive Health among Vietnamese Youth

Implementing agencies: Population and Development International, Family Planning Australia, Academy for Educational Development (AED), and Consultation of Investment in Health Promotion (CIHP).

1. Background
The project was conducted in Cualo in the Nghe, a coastal area in central Vietnam during a period of urbanization triggered by tourism. Most of the people in the province are classified as having an average socioeconomic status (49%), another major sector of the population is better off (39.2%), while 7.9% is poor and 3.9% is rich. (Ministry of Labor, Invalid and Social Affairs (MOLISA), Vietnam: people earning less than 10$ per month are classified as poor.)

Boys have a higher level of education: 65.7% finished high school and went on to higher education compared to 52.5% of the girls. The first case of HIV was detected in Vietnam in 1989. By July 2003 there were 63,361 HIV positive cases; 9,802 people living with AIDS, and 5,349 deaths from AIDS. The rate of induced abortions among single women was 21% (about 150,000/year).

2. Project goals
The goal was to reduce the health and social consequences of risk behavior among Vietnamese youth in the intervention area. The two main objectives were to:

• Increase knowledge among youth regarding reproductive health and other health matters, and increase their ability to make positive decisions affecting their health and lives;
• Improve the capacity of the Vietnam Youth's Union (VYU) to manage and implement peer educations RH programs to facilitate expanding the project throughout the national VYU network.

3. Project Design
The needs assessment informed the design, planning, implementation, and evaluation phases of the project. A Participatory Rapid Assessment was used to collect data on the socio-economic situation and reproductive health of young people aged 14 - 25, and identify issues they face and their needs in terms of life skills, reproductive health, and HIV/AIDS prevention. Results of the assessment were the basis for defining young people's roles in community development programs and building an appropriate model of group activities for effective reproductive health communication. Staff of the Youth Union, representatives from different organizations and agencies, and youth participated in the needs assessment.

This project relied on a peer education strategy, using a participatory approach in working with its target audience, in-and-out-of-school youth. The project had four main components: IEC development and training of trainers; training team leaders; life skill team meetings; and life skill teams carrying out their activities (e.g., peer education and IEC campaigns).

Stakeholders and their roles: There were many stakeholders participating in this project and the coordination was not always easy.

• The technical groups worked closely with local Youth's Union to help them implement the project step by step. Youth's Union is a nation wide association centrally organized with networks at the provincial, district, and commune level. Its membership includes youth who are interested in joining and who fulfill the criteria.
• The local People's Committee coordinated different sectors to work with the youth. This is a governmental organization which works at the provincial, district, and commune level.
• The life skill teams, with the support from the health sector, teachers, and parents worked directly with youth in and out of school.

Training: Youth leaders at the commune, district, and provincial level received training on project management, gender issues, IEC development, and training of trainers. Initially, gender issues were addressed as a separate topic in training sessions, but due to limited time and resources, this unit was dropped. This is a common problem not only in this project but in other intervention projects in Vietnam. However, gender issues were mentioned in relation to other topics like FP or prevention of STIs.

Team leaders were trained in ten topics which include: friendships and relationships; love and interaction skills; physical changes at puberty; psychological changes at puberty; conception and unwanted pregnancy; sexuality; safe sex; contraceptive methods; STIs and HIV/AIDS; composing songs and dramas for IEC campaigns; and IEC campaign organizational skills.

Activities: Three main activities are carried out by the life skill teams:

• Educating team members on 10 topics through team meetings;
• Conducting IEC campaigns: outdoor performances with songs, dances and dramas;
• Counseling other youth by team members.

4. Results
The data from pre- and post-surveys show that boys' and girls' knowledge improved across many topics. However, as gender issues (joint decision-making, open communications, and conflict resolution, for example) were not clearly emphasized, the surveys respondents' attitude about some general issues of gender remained unchanged. Though some life skills were taught, both boys and girls continue to be embarrassed about asking for or buying condoms. It is worth noting that there was a slight increase in the percentage of girls who approved of premarital sex. This may be due to the fact that in the first survey--before trust had been completely established--some girls hid their opinions. Other significant results were:

• 14 new cases of HIV were identified in the last year, in comparison to 22 the previous year;
• Local health centres reported that termination of pregnancy among young women decreased by 20% over the past year;
• Effective planning and management systems were established and run by Vietnam Youth's Union, including financial management;
• The project profited from an enabling environment in which the MOH has integrated adolescent RH (ARH) as a component of RH strategies.

LESSONS LEARNED:

• Participatory needs assessment and planning increase the ownership of youth.
• Community support from parents, community leaders, and local agencies is essential to ensure the participation of youth.
• Selecting team leaders is important to maintain the life skills team and its quality of activities.
• Gender issues, such as joint communication, decision-making, and conflict resolution should be explicitly introduced in the training contents.
• Involving the Youth's Union was beneficial for several reasons: a) it has a large network that extends from the central to the commune level; b) its young staff tends to be enthusiastic and is capable in carrying out social activities; c) it is effective in reaching youth and implementing a peer-education strategy due to its familiarity with the skills and needs of its members.
  

COMMUNICATION AND COUNSELING

This section does not include a chart summarizing key actions for projects that focus on communication and counseling as these methods tend to be integral components of IEC and service delivery programs. Please refer to the IEC/BCC chart at the beginning of this chapter.

The studies summarized below conclude that:

• The right to privacy is a major challenge in male involvement programs. Providers should ask the client for consent, privately, before including the client's partner.
• Men will attend counseling sessions regardless of whether they are for men only or for couples.

Addressing Gender Issues with Men and Couples in a Reproductive Health Service in Ecuador: a Case Study in Organizational Change

This case study looks at the program implications of adapting clinic-based services to include men. One of the lessons learned is that the right to privacy is a major challenge in the male involvement strategy. APROFE (Asociacion Pro Bienestar de la Familia Ecuatoriana) achieved universal compliance with procedures that ask, privately, for the female client's consent before including her male partner. Another lesson pertains to the "gendered dynamics that affect health" in that discrimination, power imbalances, and gendered norms about sex are some of the root causes that put men and women at risk of STIs.

Involving the Men: Condom Promotion among Groups of Men vs. Couples: A Randomized Study in Zimbabwe)

Based on a paper presented by Margaret Mlingo, Involving the Men: Condom Promotion among Groups of Men vs. Couples: A Randomized Study in Zimbabwe, September 2003.

Implementing agencies, stakeholders and their roles: University of Zimbabwe and the University of California, San Francisco (UZ-UCSF) Research Program provided the human and material resources needed to design and implement the study; the Chitungwiza and Harare Municipalities, with whom the UZ-UCSF Program has enjoyed a long-standing collaboration, granted permission to recruit participants from their clinics; the Zimbabwe National Family Planning Council (ZNFPC) provided support and a facility where the study was conducted; the UZ-UCSF Community Advisory Boards (CABs) in Harare and Chitungwiza represented the communities where the study was conducted. These CABs were involved in protocol development and implementation, and communicated the concerns of people in the community to the researchers in the UZ-UCSF Program. Family Health International assisted with protocol development, monitoring, data analysis, and preparing reports.

1. Background
The study was conducted in Zimbabwe; the research sites were in the peri-urban and urban communities of Harare and Chitungwiza. The combined population of the two settings is 3.5 million.

According to the latest Zimbabwe Demographic Health Survey (1999), the adult literacy rates are estimated at 91% for males and 82% for females. Maternal mortality rate for Harare is 331/100,000 live births; however, this estimate is not very reliable because of incomplete notification of maternal deaths, especially for women who die at home (Majoko, 2001). The rate of unwanted pregnancies is 86% for youth and 34% for adults (Phiri, 2000; Johnson, 2002).

HIV/AIDS is one of the most serious public health challenges in Sub Saharan Africa. According to the most recent report from UNAIDS on HIV in Zimbabwe, approximately 25% of 18-49 year olds are HIV +; 33% of pregnant women are HIV +; 72% of persons with STIs are HIV +; 65% of hospital admissions are HIV-related. Life expectancy in Zimbabwe is estimated to be 35 (UNDP, 2003); this is down from a life expectancy of 60 in 1998.

As in most cultures, gender norms in Zimbabwe are deeply rooted in Zimbabwean culture. This society is patriarchal and the boy child is considered more important than the girl child as he symbolizes family continuity. The boy child is socialized toward decision-making processes, while the girl child is brought up to be subservient and a conduit of the society's values. Because men are ascribed with power over women, men decide on the size of the family, the method of family planning, and when to have sex. A husband can refuse to have sexual relations without any consequences and yet such refusal by a wife results in divorce. In 1990, the ZNFPC began targeting their campaigns towards men, rather than women (Zimbabwe, 1999), after realizing that men had a greater role to play with regard to contraception and family size (Zimbabwe, 1999).

Culturally, female ignorance of sexual issues is considered a sign of purity, and women are not socialized to discuss sexual issues (Zimbabwe National HIV/AIDS Policy, 1999). Girls should remain virgins until marriage whereas men are expected to enter into marriage with requisite experience acquired through multiple sex partners. Zimbabweans are taught that men should dominate during the sex act, and women should please men sexually and bear children. Women have gone to the extent of using herbs and other products that are meant to dry and tighten their vaginas in order to please men (Braunstein, 2003). In addition, and despite legal prohibitions, women are entrenched in customary practices that have consequences on their sexual freedom, such as pledging a young woman to marriage with a partner not of her choice, offering a young girl as compensatory payment in inter-family disputes, or forcing a widow to marry a late husband's brother.

Violence against women, especially wife beating, is very common in Zimbabwe. Domestic violence accounted for more than 60 % of murder cases tried in the Harare High Court in 1998 and in Zimbabwe, as a whole, one woman in every four suffers some form of violence (Musasa Project, 1997). Some aspects of gender violence are culturally condoned in that they are perceived as within the bounds of what is culturally expected of men (National HIV/AIDS Policy, Republic of Zimbabwe, 1999; 31).

There are also gender inequalities in education. If a family is unable to pay fees, it is most often the female child who does not go to school. According to the 1998 UN Development Programme's Human Development Report, fewer girls than boys attended secondary education.

UZ-UCSF Research Program: The UZ-UCSF Research Program is a collaborative research program between the University of Zimbabwe and the University of California, San Francisco. Researchers from several departments have been collaborating on reproductive health research for the past eight years. The program also collaborates with CABs, in each community where research takes place.

2. Objective
The overall objective of the UZ-UCSF Research Program is to conduct clinic-based and community-based, qualitative, and quantitative research projects on RH and HIV prevention among adult women, men, and adolescents in Zimbabwe.

Rationale and history of the Study: The Condom Promotion and Counseling Study were initially slated to be a microbicide preparedness study for Nonoxynol-9 (N-9). However, following the release of preliminary results indicating that N-9 did not protect against HIV, the N-9 trial was cancelled and converted to a condom promotion study in which 551 HIV-uninfected women were enrolled and counseled to use condoms with their male partners. Participants in the study were followed for 14 months. The female study participants and the CABs requested that the men be involved in the research as it is difficult for a woman to bring up RH issues with a man without threatening his superior status. Male partners of female study participants were added to the ancillary study.

For just under US$28,550, granted by USAID through FHI (Family Health International), UZ-UCSF added this ancillary study on male involvement. The project was implemented in four phases. The four month preparatory phase entailed obtaining regulatory board approvals, sensitizing communities and CAB members, hiring staff, developing data collection forms and counseling materials, and conducting three two-day training workshops for the staff. The second phase involved recruitment and data collection followed by data entry and clearing. The last phase involved data analysis (which is ongoing). The study was monitored internally by study coordinators and externally by FHI study monitors.

Objectives of the Ancillary Study: The ancillary study proposed to evaluate:

• Whether the male partners of the female study participants would come to the clinic for condom counseling if invited by their female partner;
• Whether male-group counseling or couples counseling was more acceptable to the men and women;
• What effect the male-group counseling and couples counseling would have on condom use.

3. Design
343 HIV-uninfected reproductive age women attending postnatal clinics and participating in the Condom Promotion and Counseling Study were enrolled into this ancillary study and randomized to invite their male partner to attend either one male group condom counseling session, or one couples condom counseling session. This number was reduced from 551, in the original study, as some of the women had exited the Condom Promotion and Counseling Study by the time the ancillary study was conducted and 59 women refused to participate. Women received an invitation letter that they took home to their partner.

Male and female participants completed standardized questionnaires before and after the male groups and couples counseling sessions which included information on socio-demographic background, sexual behavior, contraception, pregnancy, STI history, condom use, and attitudes about the counseling session.
Key outcome indicators:

• number of women who thought that their partner would attend the counseling session;
• proportion of invited men who attended a counseling session;
• men's attitudes after the counseling session;
• women's actual condom use, reported before and after the counseling session.

4. Preliminary Results
Socio-demographic and behavioral characteristic at baseline in the two randomization groups were compared to determine if randomization was successful. There were no significant differences between women randomized to the couples counseling session and those randomized to male group counseling. Similarly, the men in each randomization group did not differ.

Demographics and Sexual Behavior
Baseline socio-demographic characteristics and sexual behavior are summarized by sex. The median age among women was 28 years, and among men 32 years. Less than half of the women were employed, compared to over 90% of the men. This included both formal and informal forms of employment. About two-thirds of the men and two-thirds of women reported using condoms during the seven days prior to their baseline interview.

Attendance and Attitudes
Overall attendance by men was surprisingly high, with 141 men, or approximately 41% of invited men, attending a condom promotion session. Researchers expected men to have a preference for one kind of counseling session over another; thus, it was surprising to find that the men were evenly split between their attendance for the male group and the couples' condom counseling sessions. All of the men, regardless of the intervention group, indicated that the counseling would increase their condom use.

Impact of Intervention
Both before and after the male counseling intervention, researchers interviewed women about their condom use over the last seven days and the last time they had sex. Although there was an increase in condom use following the couples counseling session, these increases are statistically non-significant.

CONCLUSIONS and LESSONS LEARNED
Call from community to involve men in research: the community and participants supported the program objectives. The only complaint received was that the ancillary study was based on men's desire to be involved rather than being an integral component of the original study design.

Men want to be involved in HIV prevention efforts: additional research is needed to determine how to increase the involvement of men in reproductive health and HIV prevention efforts.

A flexible schedule is needed to accommodate men and their schedules (e.g., evening and weekend clinics): as men are less available during the weekdays, a varied schedule could potentially improve their participation in reproductive health and HIV prevention programs.

Group assignment did not influence male participation: the study shows that group assignment (male group counseling vs. couples counseling) had little impact on men's interest and involvement. Both groups had similarly high levels of participation.

Couples counseling modestly increased condom us; however, participating in condom counseling and promotion activities did not necessarily equate to increased condom use, which could be due to the small sample size and/or already high baseline rates.

More research is needed to demonstrate impact of increased condom promotion: additional studies are needed to examine ways to harness men's enthusiasm and increase their involvement.

References

Braunstein, S. and van de Wijgert, J. 2003. Cultural Norms and Behaviour Regarding Vaginal Lubrication During Sex: Implications for the Acceptability of Vaginal Microbicides for the prevention of HIV/STI. Robert H. Ebert Program on Critical Issues in Reproductive Health, Population Council.

Johnson, B. R., Ndhlovu, S., Farr, S. L., and Chipato, T. 2002. Reducing Unplanned Pregnancy and Abortion in Zimbabwe Through Postabortion Contraception. Studies In Family Planning, 33(2):195-202

Majoko, F., Chipato, T., and Iliff, T. 2001. Trends in Maternal Mortality for the Greater Harare Maternity, Central Africa Journal of Medicine, 47(8):199-203.

Phiri, A., Erulkar, A. S. 2002. Experiences of Youth In Urban Zimbabwe. Population Council.

UNDP. 2003. Human Development Report.

Zimbabwe Women’s Resource Centre and Networks. 1999. Resource Manual for Gender Training, Harare, Zimbabwe.

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