IMPLEMENTATION GUIDE

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INTRODUCTION

This Implementation Guide illustrates examples of how to develop, implement, and evaluate reproductive health (RH) programs that involve men with a gender-sensitive perspective - that is, in ways that promote gender equity and improve health outcomes for men and women. These program examples were presented at the conference, Reaching Men to Improve Reproductive Health for All, held in Dulles, Virginia in September 2003.

The primary audience for this guide is in-country reproductive health program managers and technical staff of implementing agencies, government, and non-governmental organizations. Readers of this guide will note that many programs described here engaged multiple stakeholders, demonstrating the need for (and feasibility of) working with men across sectors.

Working with Men is Feasible
Surveys and research suggest that men are willing to change their attitudes, beliefs, and behaviors. Men want to be supportive partners and caring fathers; they want to know about pre and postnatal care. They also want to help their partners avoid unwanted pregnancies, protect themselves from STIs, including HIV/AIDS, and avert violence. Programs with youth confirm that young men are open to considering alternative means of expressing themselves that do not rely on virility and violence. Such expressions and features that in varying degrees make a person a man are often termed "masculinities."

The data in the table below, taken from the Orientation Guide, highlight program areas in which working with men would improve the reproductive health of men and women.

Programs can address such challenges and help improve health outcomes by working with men:

• Men can help reduce maternal-related death by recognizing symptoms that require immediate attention and by assuring their partners get the medical attention they need.
• Programs can inform men about dual protection, no-scalpel vasectomy, female methods and their side effects, and facilitate role playing discussions about contraceptive methods, including withdrawal and periodic abstinence.
• Programs that reach out to adolescent boys and young men teach them how to recognize symptoms of STIs can encourage them to go a clinic if they suspect they are infected.
• Working with men can redress women's disproportionate risk of contracting HIV. Programs with men can encourage them to address common misconceptions about HIV transmission (sex with a virgin can cure HIV infection, for example), and can also encourage delay of sexual debut, reduction in sexual partners, and consistent and correct use of condoms.
  

Working with Men is State of the Art
Male involvement is rooted in the Program of Action that was agreed to at the International Conference on Population and Development (ICPD, Cairo 1994) which included "male responsibilities and participation" as critical aspects for improving reproductive health (RH) outcomes, achieving gender equality, equity, and empowering women (Programme of Action, adopted at the ICPD, Cairo, 5-13 September 1994, paras 4-24 through 4-29). This mandate grounded male involvement programming. It contributed to broadening the concept of gender so that it now includes men.

The conference in Cairo catalyzed programs and studies that confirm the viability of involving men. Men's roles as sexual partners, fathers, decision-makers, actors in preventing sexually transmitted infections (STIs) including HIV/AIDS and as allies in improving reproductive outcomes are summarized in the Orientation Guide that preceded this document.

Working with men can be done in a variety of sectors (e.g., employment, entertainment, community, market place) with a variety of collaborating program partners. For example, Trade unions can inform, educate and incorporate RH into existing health services provided by union benefits. The armed forces can integrate RH information and programs into their health service infrastructure. Schools and military academies can integrate RH education. Theatre groups, television and radio stations can develop dramas that address RH issues. Community members (barbers, taxi drivers, bartenders, coaches, and community, traditional and local leaders, for example) can be trained to become community-based promoters who inform their peers about RH.

GOs and NGOs skilled in specific areas (e.g., education, curriculum and/or development, training, outreach) can work together so that men can become informed consumers and allies in reducing maternal morbidity and mortality, unplanned pregnancies and the spread of STIs.

Working With Men Is Creative
The interventions presented at the Conference reflect an array of innovative approaches, including:

• The socialization of boys and supporting gender equitable boys (Program H, Promundo/Brazil; Peer Advocates for Health, US; Better Life Options Program, CEDPA/India);
• Fostering dialogues across generations and between genders (Intergenerational Dialogue on Gender Roles and Reproductive Health, a GTZ program in West and East Africa);
• Mobilizing communities to counter such harmful practices as female genital cutting (FGC) (Community-Based Education: A Strategy for Engaging Men to Fight Female Genital Cutting (FGC), Mwangaza Action/Burkina Faso; Mobilizing Men against Female Genital Cutting, Center for Development Services/Egypt);
• Alerting men to support women's health to inform men about the actions they can take to promote safe motherhood (An Intervention Study From Zimbabwe; Involving Husbands in Safe Motherhood: The Suami Siaga "Alert Husband" Campaign in Indonesia, Directorate of Medical services; Caring Men? Husbands' Involvement in Maternal Care Among Young Couples in Rural India, ICRW; and several other programs were presented that addressed these issues; and
• Educating young people to respect the human rights of others (Concientizing Nigerian Male Adolescents, CMA, Nigeria).

Not all of the interventions described here have been formally evaluated. However, all of the interventions offer insight into innovative efforts to involve men in institutionalizing social change. Moreover, while intended changes (goals and objectives) may vary significantly, the programs in this guide share many common features that are essential in implementing male involvement programs that promote gender equity. For example, broad involvement of stakeholders is critical to program success. This includes: policymakers from all governmental sectors (e.g., health, education, labor, family law); religious and traditional leaders; health care providers; and the target population and their families.

Other key factors include:

• Needs assessment surveys and formative research completed before designing and implementing the program. The needs assessment shapes the program design while the base line study informs on progress achieved. A survey of men's knowledge, attitudes and practices (KAP) tests are commonly used to collect information about men's needs and are useful tools to assess program achievements by comparing base line studies with post intervention surveys. Demographic and Health Surveys (DHS), which are increasingly surveying men, are other tools that provide programmers with information about unmet needs.
• Program design based on the needs to be addressed. The goal should be quantifiable (e.g., percent reduction in STIs, percent increase in condom use, number of men who are familiar with dual protection after the intervention compared to those who knew about it at baseline). The objectives should define the target population (e.g., in or out of school youth, married men, men in the armed forces), specify what will be achieved (e.g., change in knowledge and behavior, increase in condom use, reduction of violence), and quantify the expected change within a defined period of time (e.g., by the end of the three year project 50 youth peer leaders will have reached 2,000 youth; knowledge about STI prevention will increase by 50% among the 2,000 youth reached by the project).
• Advocacy focused on all stakeholders (e.g., governmental officials for health, education, labor, and family law; religious and traditional leaders; care providers; target population and their families), using various media to target this diverse audience.
• Capacity building to provide theoretical and practical on-going training for care providers, teachers and others who work with intended beneficiaries.
• Evidence-based approaches that contribute to improving the reproductive health of men, women, and children by involving men, e.g., community-based, employment-based, service deliver-based.
• Monitoring and evaluation is an integral part of every program with specific budget allocations reserved for these activities. Ongoing monitoring including supervising staff, trainers, peer educators, etc; tracking the number of clients served and types of services rendered or activities undertaken; tracking the number of boys, young men and/or men who participated; and tracking the requests for and distribution of condoms. Monitoring activities should include feedback from supervisors, clients, and care providers so as to make necessary adjustments. Output indicators should be time bound (short, mid and long-term) and should reflect changes in knowledge and behavior (e.g., 30 providers trained in counseling men and women within the first three months of the project; increase in proportion of men attending counseling sessions either with their partner or alone at the completion of the project).

Working with Men: A New Vision
Abhijit Das, one of the keynote speakers at the conference, eloquently describes what male involvement programs with a gender perspective aim to achieve:

"These programs embrace a vision where men define new roles for themselves, a new vision, where men are not limited to being passive participants or simply facilitative gatekeepers. This vision goes beyond ensuring reproductive health of women. It is a new vision where men can be described as being sensitive, emotional, concerned and creative; a new vision of reproductive health for all, which is based on equality and partnership between women and men. But this partnership goes beyond women and men in the community. It includes service providers, researchers, trainers, communicators and program managers, because we also share the same vision."

Abhijit DAs, Keynote Opening Address, Reaching Men to Improve Reproductive Health for All, Dulles, Virginia, September 2003.

Abbreviations | Chapter 1
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