IMPLEMENTATION GUIDE

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VII. Successful Approaches in Educating or Changing Men's Attitudes

This chapter describes different approaches to reach men:

• Approaches to reduce gender-based violence among men
• Community-based approaches
• Employment-based approaches
• Military services
• Service delivery-based approaches
• Sports-based and other youth-based delivery approaches
• Media approaches

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

To access a presentation, click on the title of the presentation.

Intergenerational Dialogue on Gender Roles and Reproductive Health

The German Technical Cooperation (GTZ) project is a multi-country program to discourage female genital mutilation that fosters dialogues between older and younger men and in turn catalyzes discussion among men and women on various gender related topics, including violence against women. This presentation describes the GTZ program in Guinea, West Africa.

Implementing agency: Deutsche Gesellschaft für Technische Zusammenarbeit (German Technical Co-operation, GTZ) commissioned by the German Federal Ministry for Economic Cooperation and Development (BMZ)

1. Background
The project started in 1999 in response to requests from several partner countries of the German government in West and East Africa. In Guinea, a small country in West Africa, the intergenerational dialogue was initiated and piloted in 2002 as an innovative approach to open a constructive dialogue on this sensitive issue between the younger and older generations. Here, partner organizations and community groups expressed the need to better take into account the fact that people link female genital cutting (FGC) with other reproductive health matters, such as gender and power issues, the threat of HIV/AIDS, and adolescent sexuality. Slogans like "communication rather than information," "dialogue, not lecturing," "participation rather than confrontation" not only characterize the situation the anti-FGC or anti-HIV/AIDS campaign found itself in, they became guiding principles in the development and design of the intergenerational dialogue. However, this approach does not happen in isolation. It is part of a more comprehensive behavior change communication strategy which addresses community groups at different levels, with different approaches and differing intensity.

Stakeholders and their roles: GTZ NGO partners including Fraternité Medical de Guinée (FMG), the Association des Femmes pour l'Avenir Des Femmes, the Cellule de Coordination sur les Pratique Nefaste (CPTAFE Labé and Faranah) or the Association Aide pour la promotion Des Femmes are grass root initiatives working at the community level to address a broad range of topics around health, education, empowerment, and community participation.

2. Objectives
The multi-country project Promotion of Initiatives to End Female Genital Mutilation (FGM) supports governmental as well as non-governmental organizations working to end FGM in West and East African countries. It provides technical assistance to its partners in implementing their programs and activities. This project also helps identify promising approaches and practices that stimulate a process of rethinking traditional attitudes about this issue and changing relevant behaviors.

3. Project Design
Initial work on FGC in different communities in Guinea found that condemning FGM did not affect attitudes, behaviors, or practices either in communities or among "anti-FGM activists." Thus, it emerged that initiatives that center on public outcries may threaten the long-term measures of efforts to abandon this traditional practice. As a consequence, the community asked for a dialogue-centered, interpersonal approach which would enable them to discuss these sensitive matters in more depth.

The intergenerational dialogue first began with a four-day workshop in Guinea's capital, Conakry, where young and elderly women met together to discuss topics and problems that are important to them. Participants were selected by the organizations that either already knew them from their work or they were recommended by their communities. The young women were unmarried, between the ages of 16-20, whereas the older women were married and were over 60 years old. Some of them were already grandmothers with teenage grandchildren. This criteria for selecting participants was also adopted for the later workshops with young and elderly men. Most of the elderly men had key positions of respect and power in their communities.

Trained local staff members moderated the process and promoted understanding between the two age groups. The generation dialogue was conducted in the local language of a given area. Written training materials were not used, as most of the older women and men cannot read or write and are not used to workshop settings. The dialogues were held in local facilities which were close to the communities and did not isolate participants from the context of everyday life.

The following main steps characterize the method:

"Get to know each other": Similarities and differences between generations are initially identified and discussed in small peer groups. Participants then engage in private, two person talks to stimulate curiosity and give both parties something to think about. In a next step, exchanges between generations--using proverbs, music and songs, religious metaphors, and role-play--facilitate the sharing of information about the course of their lives.

"The road of life": Everyday objects illustrate the life style of the two generations: traditional objects (items used in life-cycle rituals) represent important stages in the life of each generation.

Traditional customs and religion are seen by the older generation as the regulating and stabilizing frame of a life that is intact and value-oriented. In contrast, modern music and dance as well as other items from modern life (e.g., condoms, cigarettes, alcohol) represent the stages of life of the younger generation. These customs and life rituals are used in dramatization and role playing. For example, the use of drugs and alcohol as well as premarital sex, contact with sex workers, or a lack of a perspective for the future lead to the young male hero ultimately dying from AIDS.

As the discussion between the young and the older generation unfolds and controversial subjects arise, moderators and participants work on practicing the new forms of appreciative dialogue and ways of talking to one another. Moderators encourage participants to seek common solutions to resolving conflicts.

"Practicing intergenerational dialogue in the community": Accompanied by the moderators, the participants try out the new forms of dialogue with their families and in their neighborhoods. The older men talk about their experience with the dialogue and the issues covered in school or at the mosque; for instance, a participant reported that HIV/AIDS and condom use was raised at a Friday prayer.

After "trial dialogues" between the generations, the process continues: participants meet again after one month in a two day workshop setting to discuss their experience with their newly-gained information and skills. The issues most commonly addressed are:

• Did they succeed in starting up a dialogue in their own surroundings?
• What problems cropped up in the process?
• What changes have come about for them?

"The gender dialogue": After initial experiences with the intergenerational dialogue, participants feel a strong desire to discuss important issues with the other sex. The second day of the workshop provides men and women of the same age group the opportunity to begin a dialogue. The floor is then open for topics that were discussed in the intergenerational, same sex groups held before. The older women, in particular, question male behavior and insist on a more positive attitude towards women. But the young women also demand that:

• Married older men stop buying young women for sexual services;
• Men cease to exercise violence against women and girls;
• The practice of forced marriage or marriage by abduction be abandoned;
• Young men marry girls who did not undergo excision (FGM);
• Fathers care more about their children and their education;
• Men accept condom use in order to protect their female partners from HIV/AIDS.

By exchanging their views and perspectives, men and women of the two generations experience for the first time the value of appreciative communication across the boundaries of age and sex. Agreement is obtained about the need to further reflect on the issues that were addressed and to continue dialogue within one's family and among peer groups. The "gender dialogue" initiates a process of rethinking gender relations and fosters understanding between men and women of both age groups.

"Continuing the dialogue": same sex intergenerational groups meet again on a regular monthly basis to continue the dialogue and encourage a process of exchange and understanding. The aim of the intergenerational dialogue: increase communication and appreciative dialogue in the families and personal lives of participants on issues around sexuality, gender, and reproductive health.

4. Results
At times, the process emerges the fact that the generations are "worlds apart". For instance, young men depicted their lives in upsetting or dismaying terms which were in sharp contrast to the harmonious pictures presented by the older men. Young men expressed their disappointment and a sense of hopelessness inferring an increase in their risk-taking, fatalism, and violence. They accused the older generation of having "double standards," that is, a "moralist" religious orientation coupled with the practice of extramarital relations with young, unmarried girls. Young women expressed the need for education of the girl child; expressed their disapproval of traditional practices like FGM or arranged or forced marriage; question the high social value attributed to female obedience to the male partner; and resent the pressure they feel when submitting themselves to the sexual demands of their boyfriend in order not to lose him to another girl.

Differences in the thinking of the two generations arose with regard to:

• Premarital and extramarital sexual relationships;
• The threat of HIV/AIDS and the necessity versus condemnation of condom use;
• Polygamy and the sexual desires of old men;
• The role and presence or felt absence of fathers;
• The value of female subjugation to spouse;
• Intra-family, partner violence.

Initial results of this pilot approach are visible in Guinea and indicate that some impact will most likely occur over time. Participants stated that they felt some positive effects right after the first introductory round of the generation dialogue. For example they stated that:

1. Silence in the face of differences and conflict became obvious;
2. Old and young became aware of the need for and benefit of more open communication;
3. Old and young together arrived at possible solutions;
4. Dialogue within one's own family was easier.

As a consequence, further generation dialogues were demanded by the population:

• Participants of the first female intergenerational dialogue, who were enthusiastic about the experience, also wanted their partners or key male family members to undergo the experience. Hence, the male generational dialogue setting was conducted.
• Female participants also stressed the need to discuss sensitive issues with their male counterparts in order to be able to successfully change matters in private and public life. Thus, the gender dialogue came into life.
• Older male participants were especially concerned about the obvious disorientation and frustration of the young men whose perception of life did not at all correspond to their idealistic view of religion or traditional customs as the frame of life. They realized the need for improved and more frequent communication between the age groups.
• Ministries and partner NGOs in Guinea are asking GTZ to integrate this approach of interpersonal, intergenerational communication into the HIV/AIDS campaign and in the education sector.

Preliminary results on the impact of the approach are expected from a survey which was conducted among the families and peer groups of those who participated in the intergenerational dialogues.

LESSONS LEARNED

• This pilot approach developed from an unmet need which was channeled into a demand. The approach was conceptualized, tested, redesigned, and adapted in response to the need for more intimate and personal communication in the sensitization campaign on FGM.
• Crucial to the success of the workshops are the communication skills of the moderator. The moderator must encourage an atmosphere of appreciation and respect, and room for listening and understanding between individuals and between generations even at times of confrontation and dissent. In addition, the moderator attends the monthly groups sessions that are organized as follow-up and as a continuation of the initial moderator-led intergenerational dialogues.
• Ideally, the members of the groups, by their example, become positive role models within their communities, so it is important to not only gain, but keep the momentum going. The newly acquired skills of this intergenerational dialogue will hopefully enable the generations to practice and thereby multiply the new form of appreciative, intergenerational communication.

The intergenerational dialogue method has been documented in a video that is available from the GTZ project in French and German language.

Other programs that work with men on reducing gender-based violence are:

• Giving Men Choices: A Rozen Project with the Police Force in Pakistan, a project that aimed to reduce the ineffectual and insensitive handling of victims of gender-based violence by the police and the violence it commits against women and children. Training workshops focused on understanding of GBV by focusing on self-awareness, expression of feelings, anger management, power and stress management along with raising awareness on gender and sensitizing them to issues of violence against women and children.
• MAVA's Efforts Toward Changing Men's Attitudes (India), MAVA (Men Against Violence and Abuse) is a pioneer organization that advocates against gender-based violence, uses an "enter-educate" approach to raise awareness among youth about gender issues including violence against women, and provides counseling in conflict resolution.
• Taking a Stand for Gender Equity and Positive Male Involvement (South Africa), a program that integrated gender-based violence into its RH program for men after finding the problem so widespread. The challenges or next steps in this program are to "eroticize safe sex workshops," address the silence surrounding HIV and GBV in White, "Colored," and Indian communities, and mobilize communities around these issues.
• Reaching Men: Educating, Mobilizing, and Organizing Men to Confront Sexist Violence and Improve Reproductive Health (USA), uses an IEC/BCC approach to empower and educate men about sexist violence. It motivates men to examine the issues and attitudes of sexist violence and provides them with the knowledge and basic skills to address such violence both personally and politically.
• Mobilizing Men against Female Genital Mutilation (Egypt), a project that informs men about the possible complications from FGC, corrects misconception that FGC is based on religious traditions or is medically warranted and thus works to create a social norm that opposes this harmful practice while emphasizing the role of men in combating it.
• Piloting a Men-Centered Domestic Violence Research Intervention: Strategies and Effects (Philippines), aims to explore men's gender and violence-related knowledge, values, beliefs and behavior, and assists men in changing violent behavior. One of the lessons learned from this study is that men also possess values and beliefs that are useful building blocks to promote personal change and gender equity.
• Addressing Domestic Violence in Northern Jamaica 1999-2000, described in this chapter under "Service Delivery-Based Approached."

To access a presentation, click on the title of the presentation.

Community-based approaches to inform men about reproductive health can be an effective method of reaching men as men are less likely to attend reproductive health programs offered at clinics. Planificando Juntos (Planning Together): Consequences of Involving Men in Family Planning through Water and Sanitation Programs in El Salvador is described at length below as an example of how to integrate reproductive health into economic development programs. In addition, eight other programs listed below focus on this type of approach, a testament to its popularity, effectiveness, and adaptability to reach a wide audience and address diverse topics.

• MAVA's Efforts Toward Changing Men's Attitudes (India), MAVA (Men Against Violence and Abuse) is a pioneer organization that advocates against gender-based violence, uses an "enter-educate" approach to raise awareness among youth about gender issues including violence against women, and provides counseling in conflict resolution.
• Involving Men to Abandon Female Genital Cutting (FGC): A Community-Based Education Program in Burkina Faso, this project underlines the importance of involving community leaders and decision-makers as advocates in projects that disseminate information through public meetings about issues such as FGC in an effort to abandon this ritual.
• The Importance of Male Involvement in Reducing Barriers to Safe Motherhood (Ghana and India), a study conducted in Ghana and India that engages communities in safe motherhood. It uses a participatory learning approach that empowers men to help their partners avoid delays in obtaining prenatal care; assures that they are properly nourished; and encourages men to help reduce women's pre and postpartum workload.
• Addressing Men's Concerns About Reproductive Health Services in a Rural Community Mobilization Program (Ghana), the Navrongo Project in Northern Ghana addresses men's opposition to family planning and gender equality by undertaking dialogues with chiefs, bringing in trusted outsiders as advisors, and reaching out to men and women to talk about these issues. Including RH as a topic openly discussed in community meetings (durbars) mostly attended by men is an important aspect of this project.
• Involving Village Men in Health Issues (Armenia), a dual protection project to empower men to make knowledge-based decisions about reproductive and sexual health which faced such obstacles as: men not wanting to be involved in the educational process because they think they know enough; cultural norms that made it difficult for women providers to train men on topics such as sexual health; local physicians' unwillingness to train project coordinators on a volunteer basis; and fear of sharing personal information, a vestige of the Soviet era.
• Reducing Reproductive Health Vulnerabilities of Male Adolescents Involved With Justice Conflicts in Brazil, this project targeted young men who are in trouble with the law. It aims to increase their knowledge about sexuality and STIs/HIV and change their attitudes by increasing access to RH clinical services and condoms and by strengthening educational activities with parent involvement. One of the outcomes was that Sociedade Civil Bem-Estar Familiar no Brazil (BEMFAM) broadened its range of activities and developed partnerships with organizations knowledgeable about working with troubled youth. Project managers attribute its success to the integration of educational activities and clinic services and the involvement of youth in several phases of the project.
• How to Reach Men With a Gender Perspective of Southeast Asia, Pakistan, a comprehensive program that aims to inform men about RH by reaching out to all sectors of society from political and religious leaders to teachers and health care providers using various approaches including peer education, advocacy, and outreach through the media and places where men tend to congregate (barbers, cafes, factories, etc.) Among some of the valuable lessons learned from this project are a) that the project design needs to include gender-sensitive strategies to ensure program focus on men and b) that strong advocacy helps men realize their strategic role in RH programs.
• Talking Man-to-Man Conversations: Reflexive Group Methodology (Brazil), a project that works with groups of men with diverse backgrounds and various social situations in Rio de Janeiro. Participants include street children, ex-street children, students of public and private institutions, military policemen, residents, leaders and social agents from favelas (slums), universities, liberal professionals, and men who are perpetrators of domestic violence. It aims to reduce violence among its clients.

Planificando Juntos (Planning Together): Consequences of Involving Men in Family Planning through Water and Sanitation Programs

Implementing agencies Project Concern International (PCI), Institute for Reproductive Health at Georgetown University.

1. Background
PCI integrated family planning (FP) into its water and sanitation program as a way to increase male involvement in family planning decision making and use. This activity followed the integration of women into water committees, a domain that had previously been reserved for men. PCI was well positioned to reach out to men, given its "male friendly" culture, especially in comparison to most FP organizations. PCI staff was relatively free of the biases held by many health workers related to men's roles in family planning. PCI staff and volunteers were comfortable and experienced working with men, and about two-thirds of the staff was male. PCI has developed ongoing, positive relationships with men while providing support for building water systems contributed to a male friendly culture.

2. Design
PCI called the model "Planning Together" to emphasize gender equity in decision making. The strategy included integration of FP messages into water and sanitation education; community-based provision of condoms and the Standard Days Method, a fertility-awareness based method the couple can use together; and referrals for other methods. The Standard Days Method (SDM) was introduced to expand family planning options for men.

After obtaining a go-ahead from community development committees, water, and sanitation volunteers were trained to incorporate FP into group talks and home visits. Couples interested in obtaining a FP method were referred to the community volunteer, Ministry of Health promoter, or health center for counseling. The topics discussed in group talks and home visits centered on couples making decisions--as a couple--for the welfare of the family. The key family planning messages included were: 1) the relationship between the protection of natural resources and the protection of family health; 2) gender equity in making decisions about family and community resources; and 3) the availability of a range of family planning methods to meet the particular needs of each couple.

Strategies used to reach men: male and female volunteers provided information and services in their communities. Trained staff and volunteers were monitored and rewarded for their efforts to reach men and couples. The rewards included public recognition in meetings and trainings of staff and volunteers who made an extra effort. In addition, staff who were especially effective in reaching men were extended opportunities to participate in cross-trainings and other meetings, such as, a training of trainers for SDM trainers held in Washington, D.C. and a regional dissemination meeting in Honduras.

Project staff had flexible working hours which allowed them to support volunteers on evenings and weekends, thus, making it possible to plan visits according to men's schedules. In addition, they made surprise or unscheduled home visits and reached men during meetings of community associations, where men tend to be well represented. If men were unavailable, volunteers encouraged wives to share the information with their husbands. The project also used the print media to relay messages on client cards, calendars, and posters.

Evaluation design: The evaluation used several strategies to assess the success of the project. These included baseline and endline community surveys to measure changes in knowledge, attitudes and behavior. PCI also conducted focus groups with men, women, and providers to assess the feasibility and acceptability of the strategy. Men and women using the SDM were interviewed quarterly for up to thirteen cycles to assess satisfaction, correct use, and male participation.

3. Results
Almost half (45%) of men and 51% of women participated in a home visit, group talk, or both. About 27% of the people who had participated in a discussion reported that their partners had also participated in a group talk. Although volunteers tried to conduct the home visits with both members of the couple, only 18% of the respondents reported that they and their partner had both been present during the visit. When asked about the PCI water and sanitation project, almost three quarters (73%) of the respondents knew that it included FP. Almost all of them (92%) stated that including FP in a water and sanitation project is beneficial and even necessary.

Men who used the SDM received instruction from their wives (43%) and from community health workers (48%). Most of them (82%) reported that they discussed when to have sex and were able to reach agreement about whether to abstain or use a condom during the fertile days. Most (83%) of the SDM users were not using any method at they time they began using the method, and the majority were first time users of a modern method. This intervention helped change men's attitudes about decision-making regarding contraceptive methods and male participation in family health, and increased couple communication. FP prevalence increased from 45% to 58%, primarily through use of the Standard Days Method and other methods which involve men, which increased from 20 to 28% of the method mix. Indicators used to measure changes included couple communication, decision-making, and use of contraceptive method involving the man.

The study also concluded that FP is more acceptable when it is discussed in the context of partner communication. Ministry of Health staff reported that PCI's efforts paved the way for continued discussion of family planning use with men and women previously opposed to the topic. Lastly, PCI is scaling up this model and other NGOs are now interested in replicating it.

Obstacles and strategies used to overcome them: The major obstacle to successful implementation of this project was staff overload. Staff found it difficult to balance competing priorities, especially when dealing with natural disasters. Close collaboration with Ministry of Health staff provided ongoing support to newly trained community volunteers which PCI's overcommitted staff sometimes found difficult to provide. Flexible hours were critical to the ability of PCI staff to reach men.

LESSONS LEARNED
Integrating FP into resource programs is feasible, but requires work and changes within the implementing organization. Strategies that insure success include organizing the program plan so that activities happen simultaneously, for instance including FP at the outset of the project. Ongoing coordination with community members and leaders, including the MOH, is also critical. Such programs are effective in reaching men with both information and services and succeed in teaching men about FP. They are also well received by communities.

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As male-involvement programming requires outreach to those places frequented by men, the workplace presents an ideal site of intervention. Increasingly, employer-based health services are integrating reproductive health into their programs. Of the four programs described here, two focused on men in the military and are included in the following section, "Military Services."

Preventing Truck Drivers from Risk Behavior: Observation from an Operations Research in India, the study assesses truckers' knowledge of STIs/AIDS and its preventions, document their sexual behavior, and test the usefulness of an education-cum-service model to promote safe sex among the truckers. The study found that men do not like to use condoms and that condoms are not readily available at truck stops or wherever "the truck is parked and the act is hurriedly done - who would take the trouble to use condom?" During the project period, when condoms were readily available at gas stations where men could receive information about STIs and how to prevent them, the number of condoms dispensed quickly increased. However, once the main interventions --the clinic and counseling session-- were withdrawn the use of condoms declined. The study concludes that simple availability of condoms at petrol pumps is helpful to truckers and many continue to use them even when counseling and clinic services are not available

Male Participation in the Trade Union Way (Philippines)

Implementing agency: Trade Union Congress of the Philippines (TUCP).

1. Background
In the Philippines, trade unions are a force for social, economic, and political change and development. They are increasingly resorting to social and political advocacy, using their infrastructure to reach a large number of men in wide ranging jobs. Unions are also becoming more service oriented and are promoting social development programs by taking active roles in protecting the welfare of their members, by helping them find jobs and affordable housing, and increasing their access to proper health care. It is under its health care services that the TUCP pioneered the project, Enhancing Male Participation among Male Trade Union Members. More recently, it broadened its FP/Family Welfare (FW) program to include RH.

More than 60% of union members are men. They are significant partners in workers' households. Targeting them would significantly increase the client base for family welfare clinics (FWC) and male union members have requested an expansion of FP services to include a wider spectrum of reproductive health services.

Workplaces, the domain of most unions, are a convenient and fertile ground for educating and influencing workers, and RH has become part of the worker's welfare program.

2. Goals and Objectives
The goal is to improve RH care of TUCP union members and their families, thus, enhancing workers' productivity in the workplace. To achieve this, the objectives are to:

• Promote greater male participation in RH care among trade unions by training peer educators/motivators and strengthening IEC activities.
• Improve the provision of gender-responsive quality of RH services and IEC/counseling.
• Integrate RH care as part of the welfare and services benefits package under the collective bargaining agreement.

3. Project Design
Strategies: Seven provinces where the union has a large membership were involved in the project which focused on integrating gender responsive RH services while targeting IEC to male union members. The activities included developing a training guide on men's involvement in RH which used a life cycle approach in addressing such topics as healthy life style, MCH, sexuality, prevention and management of abortion complications, menopause/andropause, violence against women, STIs, FP, and ARH. This guide was used to train a network of male peer educators who in turn lead weekend seminars on RH for union members and workers.

IEC campaign: The project also developed an IEC campaign on male involvement in RH that used posters, stickers, buttons, mugs, and t-shirts. Messages promote and encourage shared responsibility and active male involvement. They frame sexual harassment and domestic violence as unacceptable behaviors that are contrary to the rights of individuals. The campaign also advocated the respect for reproductive health; the ability of men and women to resolve conflicts through non-violence; increased awareness about safer sex practices; and vasectomy as a permanent FP method.

4. Results
Health workers were trained to provide gender responsive services, including violence against women, emergency contraception, and quality of care. Ten of the family welfare clinics scheduled male-only hours. Almost 30,000 clients received RH services; 55% of them were men and 45% were women. The family welfare clinics introduced digital rectal and self testicular examinations. Seven collective bargaining agreements included RH services.

Remaining obstacles:

• Men are still tied to their time sheets and can not devote their time to RH activities as much as they feel they need to;
• Management support for RH programs needs improvement;
• Lack of supportive government policies on RH in the workplace in general and Men's RH in particular;
• Lack of access to resources for men's RH activities;
• Need for more innovative and aggressive social marketing;
• Discomfort of men addressing RH issues with female care providers. This is being addressed by training male peer educators to assist in increasing the comfort level between male clients and female nurses.
• Establish male-only service day in RH clinics or male-only clinics. This addresses the stigma that RH clinics are women-oriented. This strategy was partly responsible for motivating men to come to the clinics on specific hours and days. However, it is premature, at this point, to determine the sustainability of male-only clinics run by the trade union. Moreover, early indications show while it may be worthwhile experimenting with such a model, it may not be feasible as it might further contribute to widening the gender gap.

LESSONS LEARNED

• Trade unions are effective networks and partners in providing information and education on population, RH, and sustainable development.
• Informing union members about RH increased the demand for RH services and union members' interest in having these included in their benefit package.
• Peer educators/motivators are effective agents for expanding men's understanding of RH.
• Union leaders and workers' communities need to be engaged in advocating for RH, particularly FP, prostate cancer, gender-based violence, and MCH.
• Men's RH services and issues need to be addressed in a more collaborative manner involving their partners and even their children.

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Many countries have planned or are implementing projects targeting men in the military as a way to promote HIV prevention, engage men as partners in gender equity, reduce gender-based violence, improve their own and their partners' reproductive health status, and protect their rights.

Men in the military are a captive audience, as this is a predominantly male workplace. Furthermore, military leaders are quite interested in collaborating on reproductive health issues, particularly HIV/AIDS prevention, followed by family planning. This commitment is somewhat self-serving, as HIV has become a security issue, but also stems from the military elites' sense of social responsibility for the health of their workforce and a desire to assist civilian populations in crisis. In any case, these serve as valuable entry points for collaborating in reproductive and sexual health and for introducing gender perspectives (UNFPA, Enlisting the Armed Forces to Protect Reproductive Health and Rights: Lessons from Nine Countries, 2003).

The two military-based programs vary from each other: Enlisting the Military to Protect Reproductive Health and Rights: Lessons from Nine Countries, as its title suggests, looks at the challenges of working with the military; while, Establishing Reproductive Health Counseling in Military Services: The Turkish Model illustrates how UNFPA introduced RH counseling in the military in Turkey.

Enlisting the Military to Protect Reproductive Health and Rights: Lessons from Nine Countries, this comparative study of country experiences across regions was undertaken as part of a United Nations Population Fund (UNFPA) interregional project 'Improving Gender Perspective, Reproductive Health and HIV/AIDS Prevention through Stronger Partnership with the Military.'

Some of the most interesting lessons learned from the nine case studies deal with the challenge of integrating gender-sensitive RH into the health service delivery system of a hierarchical, highly structured organization whose mission is to teach young recruits, the target audience of many of these programs, to follow orders without questioning their superiors, usually older men who foster traditional models of masculinity. This, in addition to the vertical approaches to health, particularly HIV, deters interest from adopting more comprehensive and sustainable approaches to RH and gender mainstreaming.

Among the militaries studied, most of them enlisted women, yet the health service system assumed that women do not need STI testing and treatment, or other RH services. Other examples of unmet gender-equity needs in RH programs illustrated in the case studies include:

• Changing risky behaviors with "risk groups" only;
• Exploiting traditional gender roles to promote condom use;
• Explaining HIV transmission but not gender relations;
• Working with men in isolation from women's groups, on base or civilians;
• Staffing policies, including those of service providers;
• Absence of women's participation in shaping training curricula;
• Codes of conducts do not include issues of GBV;
• No easy and equal access to RH services;
• No counseling services;
• Unequal access to in-service training.

The entire study finds that gender perspectives need to be better integrated into project design and monitoring. The study concludes that in codes of conduct the defence sector offers a captive audience with cohesive codes of conduct, strong human resources and skills, training, and health and communication infrastructures. Furthermore, the armed forces have a multiplier effect of socializing young male recruits as gender-equitable sexual partners and fathers and they offer access to RSH education and services to people who live in isolated communities near military bases. Finally, the military is strongly interested in STI and HIV but has competing interests regarding RH, specifically regarding gender and rights-based perspectives.

Challenges specific to working with the Armed Forces include:

• Working in a highly structured hierarchy;
• Introducing comprehensive health care services into a health system that uses a vertical approach (in most militaries STI/HIV/AIDS prevention is disconnected from RH).
• Introducing programs with a gender perspective in an institution that exploits traditional gender roles to promote condom use, and uses a medical model to address HIV prevention and neglects to include the gender dynamic.
• Collecting data. In many countries the military is not accountable and thus is not in the habit of collecting and reporting service statistics.

The full study, Enlisting the Armed Forces to Protect Reproductive Health and Rights: Lessons from Nine Countries, has been compiled onto a CD-ROM

Establishing Reproductive Health Counseling in Military Services: The Turkish Model

Implementing organization: Gulhane Military Medical Academy (GMMA) provided the military medical personnel including physicians, nurses, and non-commissioned officer.

1. Background
The modern contraceptive prevalence rate in Turkey is 37.7%, and the median age of marriage for men is 24 with 80% of the men getting married after the age of 20. Unfortunately, there is no reliable statistical data on HIV/AIDS or other STIs either for the Armed Forces or the general population. The service statistics of the RH/FP branch of the MOH indicate that few men (below 5 % of all clients) receive counseling or medical services. Currently, there are no other initiatives targeting men to increase their involvement in RH/FP.

Every Turkish male citizen between the ages of 18 and 45 is required to serve in the armed forces for an average of 15 months. Over 450,000 new conscripts are recruited annually.

2. Goal and objectives
The project aims to provide basic RH information and programs, including counseling to all members of the armed forces. The short term objectives are to:

• Develop capacity for RH training and services in the Armed Forces;
• Establish mechanism for providing RH information to all soldiers;
• Develop specific IEC materials for personnel in Armed Forces.

The long-term objective is to have a sustainable RH training and service provision system within the Turkish Armed Forces.

3. Project Design
The activities undertaken to achieve this goal are to:

• Establish a RH training center in the Gulhane Military Medical Academy (GMMA);
• Train GMMA staff as RH trainers;
• Train newly graduated military physicians, nurses, and medical noncommissioned officers;
• Train military medical staff from the field and establish RH training rooms in military installations;
• Provide RH information to all new conscripts; and
• Provide RH counseling and services in military clinics.

Training took place in dedicated RH training rooms through interactive workshops. IEC materials were developed. The clinics provided condoms for condom-use training and after counseling sessions. Female condoms are not currently available.

The medical staff provided individual counseling and services in clinics in the field. In addition, Turkish troops that join international peacekeeping forces received HIV/AIDS focused training. Plans are to emphasize gender equity/equality and gender-based violence in the next phase of the project.

Monitoring: Trainers received follow-up visits from personnel at the military medical academy. Such visits were integrated as part of the ongoing supervisory scheme the military has in place. Trainees participated in pre- and post-testing. After a couple of years UNFPA will design and implement an external evaluation.

Stakeholders and their roles: The command level of the armed services, chief of staff and force commanders, fully supported the project. Currently, the command structure of the Armed Forces is supporting the project by creating a positive policy environment. The general staff of command issued general orders to initiate the training of trainers, establish training rooms, etc. Although no specific funds are allocated for the project, the travel and accommodation expenses of nearly 2,500 trainees, which came to almost
USD 100,000, were covered by Armed Forces. The positive policy environment generated by top level commanders enables RH training center directors to call on their support for contacting all lower level commanders, to facilitate the establishment of centers, get commitment of others, etc. Other stakeholders are the ministry of health, MCH and FP departments which provide trainers and training materials.

Obstacles and strategies used to overcome them: The project needs support for at least three more years, whiled UNFPA's funding is decreasing. The armed forces do not have a budget for contraceptives and training materials and the education level of the soldier is low. The project addressed the last point by preparing training and IEC materials (poster, brochures, etc.) in view of the educational level of the soldiers.

The armed forces are exploring the possibility of co-financing with condom manufacturers. The European Union has recently supported RH programs in Turkey and the program with the military may be eligible to receive funds from this source.

LESSONS LEARNED:

• The armed forces are the best venue for reaching the largest male population in Turkey;
• Large-scale interventions work best, however, working with the military is challenging for NGOs;
• Donor interest is not high due to a false assumption that all militaries are well funded;
• Partnership between the armed forces and MOH has to be formed for project sustainability.

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As the following programs illustrate, clinics have succeeded in integrating RH services for men. Substantive literature is available on how to convert traditional women-centered clinics into spaces where men are comfortable, feel welcome, and receive the services they need. Similarly, Addressing Gender Issues with Men and Couples in a Reproductive Health Service in Ecuador: A Case Study in Organizational Change informs about the challenges of integrating RH services for men.

Working with Men in the Clinic and Community: MAP Experiences from Four Countries (Bolivia, Guinea, Nepal, and Pakistan) provided an overview of its introduction of the Men's RH Curriculum in four countries. This three-part training curriculum aims to strengthen the skills and improve the comfort level of health workers who provide services to men. The curriculum is rooted in a holistic approach to RH, so provider training workshops are dynamic and interactive. Topics addressed include the importance of working with men, characteristics of male-friendly services, male sexual and reproductive health issues, service provider values, gender roles, the role of men in FP and RH, and communicating with and counseling men. The tool is available in hard copy; the PDF files are going to be put on the EngenderHealth home page by February 2004. Some of the key lesson learned from introducing men as partners (MAP) programs in several countries is that:

• Building strategic alliances are essential for program success. Stakeholders can include public (MOH) and private (NGOs) entities, peer educators (youth and adults), religious leaders, and community members.
• Men and RH programs should be integrated into existing RH services and to do this successfully support and advocacy is critical from top managers.
• Effective outreach to men requires communications and marketing strategies designed to target men.

Addressing Domestic Violence in Northern Jamaica 1999-2000, One of the objectives of the Jamaica Family Planning Association (JFPA) is to increase awareness of gender dynamics and gender-based violence, and to contribute to the reduction of violence in Jamaica. To achieve this goal, the Association builds its staff's capacity, increases awareness of RH, gender dynamics, and GBV issues among 40 perpetrators of GBV and strengthens collaboration with other agencies to address violence against women. The program had trouble attracting men, and keeping men enrolled in the program. Lessons learned from its experience are:

• More time is needed at the start of the project for planning, preparation, and building collaboration, including judges and magistrates.
• Build a cadre of probation officers dedicated to this task, rather than have it infused in the work of several officers.
• It is essential that resources be dedicated to work with partners and families of the perpetrators.
• Men were accepting of female facilitators.
• More resources needed for monitoring and evaluation.
• Program benefits increase with greater active collaboration with partners.

Integration of Reproductive Health Services for Men: Experience from Bangladesh

Implementing agency: National Institute for Population Research and Training (NIPORT), Directorate of Family Planning, which provides RH services through 3,700 family welfare clinics, and the Population Council.

1. Background
Bangladesh has achieved remarkable success in containing its population growth. The current annual growth rate is 1.5% and the total population size is 132 million with less than one-fourth of the total population residing in urban areas. The literacy rate is still less than 50%. However, the national FP program is a success story. Despite the lack of improvements in socio-economic conditions the program has managed to motivate more than 55% of couples to use contraceptives. Approximately 43% of contraceptive users rely on the oral pill, the most popular modern contraceptive method. Half of the acceptors stop using their chosen methods within a year. The total fertility rate has remained the same for the past 10 years. In terms of HIV/AIDS, Bangladesh is a high risk but low prevalence country. HIV prevalence is less than one percent among high risk groups except for intravenous drugs users which is at nearly four percent.

Studies indicated that men suffer from various reproductive health problems but do not use the services provided by the government service delivery system. Men mostly seek services from unqualified service providers or are self medicated. They even postpone treatment when acutely ill. In Bangladesh, the community-level service delivery points are female-focused. RTI/STIs are quite common among rural women in Bangladesh and the high incidence of STIs among women is an indirect indicator of the high prevalence of these diseases in men. Service providers lack knowledge about RTIs/STIs and their inadequate management contributes to increasing the suffering of men and women. Lack of BCC materials that target men is another major obstacle in addressing male sexual health.

2. Goals and Objectives
The overall objective of the study was to increase access to and acceptability of RH services for men at health and family welfare clinics (HFWCs). The specific objectives were:

• Increase male access to RH services;
• Modify existing BCC materials to increase male awareness about the RTI/STI issues;
• Include male RH services at HFWC and train service providers on syndromic approach and sexual health counseling;
• Assess management, technical, and financial implications of integrating male RH services into the existing service delivery.

3. Study Design and Project Duration
The study used a quasi-experimental non-equivalent control group design with eight service delivery points as intervention sites and four as control sites. The intervention activities were carried out in the experiment sites for 12 months; the duration of the project was 20 months.

Activities undertaken were:

• Theoretical and practical training of service providers on RTIs/STIs;
• Promotion of awareness about male RTIs/STIs and availability of services from HFWCs by group discussion and by developing and distributing BCC materials;
• Inclusion of syndromic approach and provision of RTI/STI services;
• Distribution of condoms;
• Mobilization of resources from the existing government allocation.

4. Results
Outcomes of the study were measured by the following indicators:

• Number of male clients motivated by the BCC activities and the number of men that received services;
• Number of males using RTI/STI services;
• Increase in provider's knowledge on STI/RTI and syndromic approach;
• Number of male clients satisfied with the services;
• Number of males who came for FP methods.

Inventory surveys informed researchers about the availability of medicine for RTIs/STIs and equipment used to prevent infections. Pre- and post-intervention interviews were conducted with 127 and 163 service providers and field workers respectively. Seven focus group discussions (FGDs) were conducted before the intervention and sixteen FGDs were conducted after the intervention. Service statistics were collected from all HFWCs before and after the intervention to estimate the total number of clients who received the services. In addition, 286 male and 300 female client exit interviews were conducted during the intervention period.

Findings indicate that the knowledge of the service providers significantly improved due to the intervention. As expected, knowledge of the service providers in the control areas did not change significantly. Like service providers, knowledge of field workers also improved in the experimental area. Before the intervention took place a test was performed to inquire whether or not a significant difference existed in the knowledge about signs and symptoms of RTIs/STIs among service providers and field workers in the experimental and control areas. The results found no difference in the knowledge of service providers.

Service statistics were complied to calculate the numbers of clients receiving services from the selected HFWCs before and after the intervention. Findings indicate that the quarterly average number of clients in each center from January 2001 to June 2001 was almost the same in both experimental and control areas. The average number of male clients increased three-fold in the experimental area after the intervention. Also, researchers found that before the intervention these centers were treating, averaged less than one male RTIs/STI client per month and this figure increased to more than 5 after the intervention. There was no report of RTI/STI clients in the control areas before or after the intervention period although their register had provisions to record this information.

Obstacles and strategies used to overcome them: As expected, a shortage of medicines was the main obstacle encountered by the services providers. To overcome this, service providers and project staff deliberately involved district and local level program mangers from the outset of the project. They were able to redirect some of the medicines to the participating HFWCs. Similarly, involving district level managers helped reduce the transfer of staff significantly. Another obstacle was the non-availability of RTI/STI clients during the practical training of the service providers. To overcome the problems, training was conducted at the medical college hospitals.

LESSONS LEARNED

• Integrating RTI/STI services for men is possible;
• Grassroot service providers can be trained in RTI/STI management;
• Service providers need theoretical & practical hands-on training;
• Targeted BCC increases the number of male clients;
• Increase in total number of clients helps to increase utilization of services.

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The two programs that focus on reaching adolescents through youth based approaches,
Adolescents and Soccer: Promoting Health and Emerging Masculinities (Chile) (Spanish) and Youth Participation in HIV/AIDS and Reproductive Health Activities (Malawi) reach out to young men in two different settings and aim to achieve different objectives, although they target the same age group.

Adolescents and Soccer: Promoting Health and Emerging Masculinities (Chile) (Spanish) uses soccer coaches as change agents, capitalizing on their role as mentors and on the fact that soccer teams are an accessible venue for reaching a large number of young men. The Chilean program challenges the traditional model of masculinity and aims to promote alternative models to empower young men to prevent disease and improve their health and human development. In contrast the program in Malawi, described below, is driven by the AIDS pandemic in a country where approximately 250 people a day are contracting HIV.

The soccer-based program developed a training manual for coaches that addresses identity and health issues within the context of soccer. Coaches go through a certified training process where they become familiar with the modules that they then teach to their teams in nine formal training sessions.

The lessons learned from this project are to keep the content simple and focus on a few messages to make sure not to overload coaches and team members. Carefully chose the coaches that will participate in such sports-based programming by inquiring about their motivation, interest in the construct of identity, flexibility, commitment, and teaching skills.

Youth Participation in HIV/AIDS and Reproductive Health Activities (Malawi)

Implementing agency: National Association for People Living with HIV/AIDS in Malawi (NAPHAM) was formed in 1993 to deal with issues concerning people living with HIV/AIDS.

1. Background
In Malawi, a country with 10 million people, over half are under the age of 15 and over 70% live in rural areas. One out of five children fails to reach their fifth birthday. Over 16% of the population between 15 and 45 years of age is HIV positive and there are over a million people living with AIDS. Stigma and discrimination surrounding HIV status discourages people from openly acknowledge their status and thus get the services they need.

Baseline survey: A baseline survey conducted prior to the project's initiation indicated that youth had misconceptions around issues related to sexuality and HIV. For instance, HIV positive school boys could see no reason of continuing their education after testing positive.

2. Project Design
To address these misconceptions, 6,200 youth were identified in 20 communities and informed about the importance of participating in activities that informed about safe sex and how to prevent STIs/HIV/AIDS. Twenty-four youth were trained in peer education and interactive drama. The project also formed 40 soccer and 30 basketball teams while training 100 peer educators in HIV/AIDS and sexual education from among the members of these teams.

The peer educators met with youth twice a week in communities and schools to share their knowledge about HIV/AIDS and safer sex behaviors. They led focus group discussions, participated in theatre productions, shared personal testimonies, and used pictures to tell their stories. These youth-friendly tools were used to inform their peers and motivate them to change their behaviors.

Every week, before playing, team members discussed sexuality issues including issues related to HIV/AIDS and learned where they could get access to RH information. The discussions included ethical, spiritual, cultural, and moral factors such as fidelity, honesty, and communicating with partners.

Monitoring: Health educators from NAPHAM monitored peer leaders' work with follow-up visits to observe the implementation of activities. After three months, a competition was held among the different teams that included a quiz on HIV/AIDS, STIs and RH. The winning team received prizes and members who scored well on the quiz attained special recognition.

Field supervisors monitored activities on a weekly basis using data forms and questionnaires to collect data. Quarterly review meetings provided guidance and helped NAPPHAM modify activities. Data collected from monitoring activities was shared with donors, partners, and some beneficiaries.

NAPHAM held sensitization days every three months in communities that participated in the project which included car floats and marching by community members, particularly youth and their peer educators. These occasions also served to refer youth to VCT centers for testing. Clients who tested positive were encouraged to join support groups with people living with HIV/AIDS or post-test clubs. These clubs provide safe spaces for people living with AIDS to talk about their concerns.

Stakeholders and their roles: Malawi Network of People Living with HIV/AIDS (MANET) advocated for the project. Malawi Network of AIDS Service Organizations (MANASCO) helped with networking. The National AIDS commission (NAC) provided technical support, and the Malawi AIDS Counseling and Resource Organization (MACRO) provided VCT and referrals. NAPHAM works closely with District AIDS Coordinating Committees (DACC) and thus has a good partnership at the district level so that its volunteers provide counseling services in several hospitals throughout the country.

UNAIDS, working with a local partner, recruits people living with HIV/AIDS and places them in host institutions to break the silence and promote positive living. NAPHAM supplied most of the volunteers who worked with the different organizations, thus publicizing NAPHAM's work at the national level.

3. Results
The project succeeded in reaching large numbers of youth, more than 35,000 out of school youths and over 131,000 in-school youth. It established 22 out-of-school youth clubs and 14 posttest clubs that attracted youth who were tested for HIV. Over 100 HIV positive youth joined NAPHPAM centers for counseling and supportive care services.

Challenges and strategies used to overcome them: the project addressed negative attitudes toward condoms among school youth by intensifying education on condom use and emphasizing its advantages.

It addressed youth's reluctance to disclose their status by providing supportive counseling. The counseling outlined the benefits of disclosure and discussing such confidential issues as the pros and cons of getting married while living with HIV.

Stigma and discrimination campaigns targeted schools, companies, and communities and were found to be highly effective.

LESSONS LEARNED

• One of the best strategies to involve youth in HIV/AIDS and RH activities is through sports.
• People living with HIV/AIDS are the best educators. The experiences they share with others enrich the learning experience of their students and help them accept their situation.
• NGOs should involve local people in RH and HIV activities. This will reduce preaching and get to the underlying issues that prevent people from changing their behaviors.
• When implementing VCT programs, supportive structures should be in place to care for those who test positive.

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"Enter-educate," a behavioral change communication strategy, combines entertainment and education and has been successful in raising awareness and informing men, women, and adolescents about RH. Typically, enter-educate programs use dramas and films to relay a message about a reproductive health issue. Often the performances or plots target a specific audience and address topics that people face in their daily lives. These performances demystify myths and correct fallacies but also break through the taboo of talking about sexual issues by leading discussions with the audience about topics addressed in the show. Directed discussions are integral components to media approaches that aim to change behaviors.

Two media approaches aimed at involving men in MCH: The Suami SIAGA (Alert Husband) Campaign in Indonesia and the Safe Motherhood Media Campaign (Mongolia). These two approaches relied on television and radio to relay RH messages and supplement this with other related activities. For instance, the program in Indonesia held national public relations events including radio talks shows, roundtable discussions with health officials and political leaders, and interviews with print and broadcast news reporters that generated extensive coverage of the campaign. The program in Mongolia included short TV programs, which were supplemented with radio programs, newspaper articles, a RH newsletter, and informational pamphlets and posters that were distributed nationally.

An independent evaluation of the Suami SIAGA campaign attributed the campaign to helping men and women change their behaviors during pregnancy. The evaluation revealed that more men accompanied their wives during delivery and to prenatal check ups, an indicator of increased involvement. In the case of Mongolia, evidence that the campaign was a success was an increase of telephone calls to a hotline service and frequent requests for repeats of the television and radio programs. One of the lessons learned in Mongolia is the importance of producing films in settings that resemble those of the targeted audience. Broadcasts were in rural settings and realistically conveyed the needs and challenges faced by a rural population.

A film-based program for adolescents in South Asia is described below.

"Growing Up" Toward Gender Sensitization and RSH for Young People in South Asia

The summary below is based on a paper submitted by Venu Arora, Towards Gender Sensitization and RSH for Young People in South Asia, Ideosync Meida Combine, New Delhi, India, September 2003.

Implementing organization: Ideosync Media Combine

1. Background
"Growing Up" is a film-based sex education module designed for an in-school facilitated intervention with adolescent boys and girls. Though it has been produced and designed through a participatory process with young people in India, the module is designed in a manner that is relevant to many other South Asian countries.

Country context: With a population of over a billion people, and an extremely high percentage of young people, India is a country where the reproductive and sexual health of young people continues to remain a challenge, largely because the national health policy framework has not made it a priority. This is somewhat surprising, considering that HIV/AIDS receives a fair amount of government and media attention. The media and those working in the health sector repeatedly stress that the most vulnerable segment is the sexually active young population. HIV prevalence levels are on the rise; and current estimates suggest that more than 4.5 million people in the country might be affected by the virus. The first National Behavioral Surveillance Survey conducted in 2001 shows a large number of people have heard about the virus and the fast spreading epidemic; but simultaneously reflects an extremely poor understanding of safer sexual practices and vulnerability issues.

Taboos around discussing sex and the gender bias against women compound the complexity of addressing issues of sexual health, reproductive care and HIV/AIDS prevention. This then becomes fertile ground for myths and misinformation to spread - and a happy hunting ground for quacks offering a variety of pseudo-scientific sexual therapies.

There are no safe spaces for adolescents experiencing their first sexual urges and thoughts about sexuality to discuss their fears and anxieties. Young boys, especially, are under tremendous peer pressure to prove their masculinity. Gender constructs make it difficult for young people to ask questions, especially about the opposite sex. Understanding of basic human biology, reproductive anatomy and the sexual organs are poor. A service delivery system to offer sexual health care for adolescents is completely missing. Parents and teachers, while acknowledging the HIV/AIDS epidemic and the
need to disseminate more information dissemination, find it difficult to approve of interventions that directly talk about sex and explain condom use.

Some brave but isolated efforts in the face of much opposition have led to small and short-term initiatives in private schools. Unfortunately, these initiatives are limited in many cases to a single interaction with a doctor (usually with 14-15 year old girls to discuss menstruation and menstrual hygiene). Ironically, many of the girls involved are already menstruating by this time, and have already crossed the moment of fear, isolation, and guilt. Indeed, none of these interventions link the physical and psychological changes brought on by puberty to preparing young girls for sexual activity; therefore, most young girls do not know why they menstruate.

Boys, on the other hand, are not considered worthy of even this level of discussion and are often left completely out of these kinds of sessions. There is no discussion of their feelings of guilt about masturbation or nocturnal emission, or their anxieties regarding the size of their penis, for example.

The "Growing Up" project evolved in a context where fledgling efforts towards a sustained reproductive health awareness process were being made by private schools catering to the English-speaking urban Indian middle class. These schools were struggling with life-skill initiatives that started in the wake of the growing fear of the HIV epidemic; but the school-based interventions were still not meeting the challenges of answering young peoples' questions in a sustained manner, or addressing issues surrounding safer sex within the larger context of physical, psycho-social,and sexual changes during puberty and adolescence.

2. Design
The "Growing Up"module was developed as a kit to be used in schools in a sustained fashion, starting with 9-10 year olds and going up through 16-18 year olds. It has been designed as a series of video-based modules, for use in workshops headed by a facilitator or a teacher. The basic informational and empathetic content of the videos are designed to be supplemented by discussions, games and role-plays, some of which are suggested in the facilitators' handbook that accompanies each set of films.

Preliminary workshops were designed to assess the level of information and the kinds of questions asked of young people between the ages of 10 - 14. Within the first few months of conducting the workshops, designers of the tool found that teachers and parents had incorrectly assessed the students; adolescents had many questions and were very willing to talk about these issues. Through sustained interaction, the developers of the tool found that students were not only keen to talk about issues relating to their changing bodies, they were also visibly relieved to find someone with whom they could share their thoughts and ask questions without the fear of being judged from a moral standpoint. It is from such sustained interactions with groups of students that the overall design of the module was developed.

The modules are not meant to be encyclopedic; rather they have been designed to facilitate the flow of questions and answers between the facilitator and the young people. The films are meant as tools to assist facilitators to:

• Break the ice and begin discussions with young people;
• Approach the subject in a coherent and systematic manner;
• Discuss physical anatomy as a foundation towards understanding bodily changes during puberty;
• Discuss adolescence, self image, peer pressure, changing relationships with parents and other adults, and the feelings of young adolescents in the face of authority.

In addition, information regarding feelings of attraction towards the opposite sex, and conception and safe sexual practices are provided in the films through discussions between groups of young people.

An accompanying handbook follows each segment of the films closely, expanding on the issues addressed, and providing suggestions for discussion topics, interactive games, and additional information relevant to each segment. The films themselves are structured around multiple elements, including puppets, animation, songs, and dramatized sequences.

While the first "Growing Up"module set was developed in English, it has now been adapted for use by Hindi-speaking schools. The information package for the Hindi set was slightly modified to appeal to the concerns, economic, and social indicators of the Hindi-speaking youth. The films have been remade with young people from the appropriate socioeconomic/cultural milieu to accurately reflect their concerns and influences. Attention to the minutiae of socio-cultural-economic context distinguishes the "Growing Up" initiative; it allows the targeted audience to strongly identify with the characters portrayed and the dilemmas they face.

The English modules in the next set targets 14 - 18 year olds and are currently under production. They will address issues around pregnancy, contraception, and sexual and reproductive care; STIs, HIV/AIDS, and safer sexual practices; and sexual choices and rights. The completion of the parallel set in Hindi will complete the "Growing Up"module package for schools.

Formative research: The "Growing Up" film-based sex education modules have been designed using results from an extensive formative research process.

The methodology for this research process was largely dependent on qualitative tools which were developed keeping in mind the sensitivity of South Asian school systems and parental resistance to discussing issues around safer sex and sexual and reproductive health with young people.

A key element of the research methodology was a three-tiered interactive workshop program with young people of two distinct age groups: 10-13 years and 14 - 17 years. These workshops were conducted with a fairly large sample of randomly selected participants from a variety of Indian schools.

The first tier of workshops with both groups included:

• Rapport building between the facilitators and workshop participants;
• Delineating issues of concern to the participants, and prioritizing the issues on the basis of a majority vote;
• Creating sub-categories and topics within these issues for further exploration and comprehension.

The second tier of the workshop program included team exercises that were designed for young people to learn about sexual and reproductive health issues and understand social attitudes through group work. These team exercises included, team debates, team role plays, and team problem-solving exercises.

The third (and final) tier of workshops were designed to directly feed into the video modules in the sense that they involved the finalization and rehearsal of role plays that became part of the films; as well as group discussions and reenactments of past events from the participants' lives that were also included in the films.

An additional component of the workshop program was a basic questionnaire on puberty and sexual health issues that all participants had to answer. This questionnaire provided the project team with a quantitative baseline on information levels, knowledge, understanding and attitudes.

Development of Indicators: These three-tiered workshops elicited some of the following indicators that were used to design the films and the accompanying handbook to best respond to the needs of the adolescents:

Examples of indicators for 10 - 14 year old school going adolescents in metropolitan cities in India:

• Knowledge of at least three changes that a human body goes through as it grows;
• Understanding of (and ability to articulate) the biological differences between boys and girls;
• Understanding of menstruation, and the biological reasons for it;
• Explaining the health implications of sexual intercourse;
• Myths and misconceptions around masturbation, nocturnal emissions, menstruation, and pregnancy;
• Understanding of the terms HIV and AIDS;
• Acknowledgment of emotional confusion and awkwardness especially with regard to physical changes like the appearance of facial hair in boys, growth of breasts in girls, and the sudden increase in height or weight in both sexes;
• Understanding and ability to articulate the importance of hygiene during menstruation;
• Understanding of gender as a concept;

Examples of indicators for 15-17 year old school going adolescents in metropolitan cities in India:
All the indicators for 10-14 year olds were applicable to the older age group. Additionally, the following indicators were included:

• Adequate comprehension of the consequences of sexual intercourse;
• Knowledge regarding at least four sexually transmitted infections;
• Knowledge and understanding of HIV/AIDS and modes of transmission;
• Misconceptions around HIV and STIs and biases against HIV positive people;
• Understanding of homosexuality as a concept and biases against homosexuality and homosexuals;
• Level of approval/disapproval regarding sexual activity before marriage;
• Understanding of issues surrounding sexual abuse;
• Gender biases related to pregnancy, child-rearing and contraceptive responsibility;
• Influence of media on attitudes/role models.

The quantitative and qualitative data gathered during the workshop and questionnaire process served as direct inputs to the "Growing Up"video modules, as follows:

1. Where the original project design called for a set of modules in English and a parallel set in Hindi, research data gathered highlighted the existence of distinct sub-groups within the English medium and Hindi-medium schools which would comprise the user audience. The subgroups were defined along economic, social and educational family backgrounds, and required sharply differing structural and thematic adjustments to the modules. Thus, while the original project design envisaged dubbing of the English version of the modules into Hindi, the emergence of these subgroups created a need for a separate set of the modules with a similar informational content, but a markedly different treatment of the subject.
2. The research data defined the principal themes to be addressed by the modules; and more importantly, the thematic spread of issues across the three video films that comprise the set. Additionally, it defined how many of these issues would be expanded upon (a task defined in the facilitators' handbook that accompanies the films).
3. The data also suggested a structural/stylistic/thematic treatment for the films, in that factual data was eventually included in the form of animated and diagrammatic content; and attitudinal and social behavior-related information was presented through role plays, dramatized sections and puppetry. Since there was a marked acceptance for information passed on by peer role models, representative peer figures also became an important part of the films.

Pretesting: various design options for the featured muppet characters were pre-tested with a sample of the target audience, to identify preferences and character detail. The featured songs and their lyrics were also pre-tested before production, and the dramatic sequences included in the films actually evolved from the skits and role plays that emerged from the many interactive workshops conducted as part of the pre-production work on the films.

Safe spaces to address myths: the experience of sustained interaction with groups of students contributes to the conclusion that it is the lack of a supportive environment that is the primary factor inhibiting young people from discussing issues around their sexual and reproductive health. Given a supportive and safe space, both boys and girls are open to understanding and learning about their bodies, and voicing their fears regarding sexual and physical interactions, and abuse. There are numerous myths regarding masturbation, pregnancy, conception and HIV/AIDS intertwined with strong feelings of guilt and moral self castigation in both boys and girls. For instance, beliefs that:

• HIV can infect an individual only after he or she is 18 years old;
• kissing or holding hands with a boy can make a girl pregnant.
• masturbation leads to infertility; that the loss of semen is like the loss of blood;

"Growing Up"is designed to provide the fostering atmosphere of respect, openness and frank discussion where these concepts can be clarified and such myths dispelled.

3. Results
Preliminary experience with young pe