Male Engagement in Reproductive Health Programs

 

Welcome to the programmatic area on male engagement in reproductive health (RH) programs within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the men’s health section of sexual and reproductive health section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. Engaging men in family planning (FP) and RH can be beneficial for their partners and children, as well as for the men themselves. Efforts to expand the vision of strategically engaging men in FP and RH have been slow, but steady (Dunn Gage, 2010). Gender experts agree that men should be encouraged to be supportive partners of women’s RH while also meeting their own RH needs, and engaged as agents of change in families and communities (Greene, et al., 2006). Funds spent on well-designed health programs that seek to promote more gender-equitable behaviors among men and boys can be viewed as an investment in a larger process of gender transformation which will also benefit women and girls. The core indicators selected for this database focus primarily on men’s beliefs and behaviors.  Key indicators to monitor and evaluate male engagement in RH can be found in the links at left.   Full Text Engaging men in family planning (FP) and reproductive health (RH) can be beneficial for their partners and children, as well as, for the men themselves. A number of international partners including IPPF, UNFPA, USAID, Promundo, EngenderHealth and other members of the MenEngage global alliance have programs underway to engage men more fully in FP and RH.  These program outcomes can help achieve Millennium Development Goals: #3. promote gender equality and empower women; #4. reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDS. Although they can be done in isolation, efforts to engage men and boys may have greater benefits for women and men and girls and boys when they are combined with or at least coordinated with efforts to empower women for a synchronized approach to address gender norms, reduce gender inequalities, and improve health.  For example, the Global Health Initiative’s (GHI) first principle, Women, Girls, and Gender Equality (WGGE) specifies a number of gender-related strategies to accomplish these changes, including involving women and girls and men and boys in addressing gender norms and equity; enlisting men to support women's use of FP/RH services and contraception; encouraging men to use sexual RH services themselves; improving training of health providers on gender issues; ensuring meaningful participation of women and girls in decision-making; and engaging civil society in partner countries to address gender equity in health care (GHI, 2010). Background on Male Engagement Programs Initiatives to involve men in RH began with the 1994 Cairo International Conference on Population and Development (ICPD). Mounting concerns for the high numbers of women diseased and dying in low-resource settings, often due to child-bearing related causes, and concurrent infant and child health issues led the ICPD to set a number of goals to improve RH.  Traditionally, RH has been viewed as a woman’s domain and most programs and interventions were targeted for women. Given the gender power imbalances in many regions, all too often men and the dominant cultural norms interfered with practicing FP and women’s attempts to access healthcare resources and services, particularly sexual health services. A leading strategy from the ICPD was to involve men in RH through emphasizing communication and education programs for men about the importance of health care for women and infants.   While some successes were documented in the following decade, the high burden of women’s and children’s health issues persisted, and programs working with male involvement became more aware of how gender norms and inequalities shaped factors that influence demand for FP services (e.g., timing of marriage, fertility intentions), as well as men’s own RH concerns (e.g., use of male-controlled methods, sexually transmitted infections, and HIV/AIDS). The focus shifted toward engaging men more directly and broadly in their own and their partners' healthcare. More attention was also put on in behavior change communication efforts to address gender inequalities. Men seeking care for their own health not only can benefit the men, but may translate into enhanced health knowledge, motivation, and concern for the health of their partners and families. Because men still hold most of the decision-making power in many settings, even with regard to their partners’ health and bodies, there’s an acknowledgement that improving women’s health undoubtedly requires programming targeting male involvement, support, and education.  The most recent trends in programs working with men and RH are to engage both women and men to promote shared responsibility and decision-making with partners and use gender transformative approaches that work to challenge and transform rigid gender norms and relations. An ecological model working at multiple levels to transform gender norms has been developed by Promundo, UNFPA and MenEngage (2010) (for example) and these transformative and partnering approaches have been shown to improve program outcomes.    A concern with the shift toward male engagement has been that the increased attention on men’s health could reduce available resources for women.  However, when synchronized with attempts to empower women, male engagement may have greater gender and health benefits.  Further, this may be an area where cost and benefits do not act necessarily as a ‘zero sum game,’ rather women’s and men’s programs and their impacts can build on each other and many services can be integrated in facilities even if conducted separately. Promundo, UNFPA, and MenEngage (2010) note that funds spent on well-designed health programs that seek to promote more gender-equitable behaviors among men and boys can be viewed as an investment in a larger process of gender transformation which will also benefit women and girls. A framework for monitoring and evaluating (ME) programs engaging men has been developed by UNFPA and partner organizations. A total of 35 output and activity indicators are listed moving from the macro and social level to the micro and individual level. The nine core indicators selected for this database focus primarily on men’s beliefs and behaviors. Several indicators are directly from the UNFPA framework and others have been taken from additional sources, including a compendium of indicators for violence against women and girls (Bloom, 2008) and the Gender-Equitable Men or GEM scale developed by Pulerwitz and Barker (2008).  For a toolkit for ME specific to young men and HIV/AIDS prevention programs, see Promundo and UNFPA (2007). __________ References: Bloom, S., 2008, Violence against Women and Girls: A Compendium of Monitoring and Evaluation Indicators, Chapel Hill, NC: MEASURE Evaluation. Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. Rio de Janeiro, Brazil: Promundo. http://www.unfpa.org/public/site/global/pid/6815 Promundo and UNFPA, Young Men and HIV Prevention: A Toolkit for Action, Rio de Janeiro, Brazil: Promundo.  http://www.xyonline.net/sites/default/files/Instituto%20Promundo,%20Young%20Men%20and%20HIV%20-%20Text.pdf Pulerwitz, Julie and Gary Barker. 2008. "Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale," Men and Masculinities 10:  322–33 UNFPA, 2003, It Takes Two: Partnering with Men in Reproductive and Sexual Health. http://www.unfpa.org/upload/lib_pub_file/153_filename_ItTakes2.pdf USAID, The Global Health Initiative (GHI). 2010. Implementation of the Global Health Initiative: Consultation Document, Washington, DC: USAID. WHO, 2002, Technical Consultation on Sexual Health, Geneva: WHO, January.

Availability of accessible, relevant, and accurate information about sexual and reproductive health tailored to young men

Definition:

Number and types of sources providing accessible, relevant, and accurate information about sexual and reproductive health (SRH) that are designed specifically for adolescent boys and young men ages 10 to 24. 

Sources can include media, health programs and facilities, peer education and mentoring programs, sexuality education programs for schooled and for out-of-school young men, workplace, and community-based reproductive health education and services.    

Accessibility needs to be locally defined, depending on the geographic area and the modes of transportation and communication that are readily available to most of the population.  A geographic or programmatic catchment area needs to be defined. Materials and opportunities for program participation need to be readily available and accessible, ideally in male-focused and/or male welcoming formats and environments.

Relevant and accurate information addresses SRH needs, concerns, and risks for the target population with appropriate educational and motivational guidelines, materials, media messages, training, and educational curricula that have been rigorously researched, designed, and tested for the target age groups.

Data Requirements:

Reviews of programs and service facility training tools, curricula, and information sheets; reviews of media messages (e.g., videos, transcripts, and websites); surveys and interviews on accessibility of facilities, services, training, educational materials, meeting sites, schedules, male gender sensitivity and environment.  

Data can be disaggregated by the type of sources, programs, and media.  If age targeting of materials and messages can be determined, the indicator can be disaggregated by age group (e.g., 10-14, 15-19, 20-24).

Data Sources:

Service and program records, training tools, curricula, counseling guidelines, and information sheets; media messages and websites; surveys and interviews with clients and expert informants, such as, peer and health educators, school teachers, and community leaders.

Purpose:

This indicator measures access to SRH information for adolescent boys and young men, a group at high risk for SRH concerns, who are in need of information tailored for their purposes but are often reluctant to seek it out. This population has been generally underserved. Boys and young men ages 10 to 24 are an important target group for SRH programs since they are at critical ages for gender role formation, have many misconceptions about sexuality (their own and their partners’), may have their own issues of abuse, and tend to not be thinking about family planning, contraception, and STI/HIV prevention.  At the same time they may be more open to considering alternative views about gender roles than their older counterparts (UNFPA, 2003).

Outreach programs can be a successful strategy to target young men, especially out-of-school adolescents and difficult-to-reach youth. In many developing countries, young men drop out of school at an early age, and are often concentrated in specific industries such as transportation, agriculture, fisheries, and construction, where they can be targeted through programs and with various communication strategies and media.  

The indicator can be used to compare information availability across catchment areas and to follow time trends.  A documented increase in sources over time may reflect a number of things, including a growing population of young men and boys, increased funding and focus on their needs, and/or increased attention and awareness within communities.

(Note: See link to UNFPA (2003) pp. 33-40 for lists of outputs and output indicators for programs and activities targeted for young men; See Promundo, UNFPA, MenEngage (2010), pp. 101-104 for a tool kit for monitoring and evaluating programs for engaging men and boys).

Issue(s):

Generating an exhaustive list of sources providing information to young men and boys may be difficult depending on the catchment area. Reviews of the required materials and resources can be subjective and expert informants can be biased in their views of the programs and information disseminated.  The type of information that can be successfully presented may vary by context, cultural and gender norms and by the age for the clients within the relatively wide 10 to 24 year range.  The indicator does not reflect the impact of the information in effecting change in knowledge, attitudes and behaviors.

Gender Implications:

Working with young men can have important benefits for them and for the young women they associate with. Boys tend to have sex earlier than girls, often gain status by having sex, and sometimes have first encounters with sex workers.  Young men may say they are informed about sexual issues but are frequently misinformed. Young men are not likely to seek health services and may view reproductive health solely as a women’s concern. 

References:

UNFPA, 2003, It Takes Two: Partnering with Men in Reproductive and Sexual Health, http://www.unfpa.org/upload/lib_pub_file/153_filename_ItTakes2.pdf

Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. http://www.unfpa.org/public/site/global/pid/6815

Number of visits to male-focused services, by type of service

Definition:

The number of "visits“ refers to each occasion on which an individual seeks assistance from a given health facility (or male-focused service within a larger facility).

The number of visits will be the same or greater than the number of persons using the service (reflecting some repeat visits to the service).

Data Requirements:

Number of visits, by type of visit

Data Sources:

Program service statistics

Purpose:

The indicator reflects the volume of service provided to men for reproductive health problems, as well as the nature of the prob­lems treated. It is useful in justifying the continuation of this type of service if demand remains high. Also, it al­lows program managers to adjust staffing patterns based on the services most in demand.

An alternative indicator is the number of individuals seek­ing information and/or services. This indicator raises the question of possible repeat visitors, which is not an issue with “number of visits.”

Issue(s):

This indicator represents a minimum of information needed to track male use of reproductive health  facilities. Any studies determining client satisfaction with the services will fur­ther enhance the monitoring process.

Percent of men (husbands) who are supportive of their partners' reproductive health practices

Definition:

The percent of males who support their partners‘ repro­ductive health (RH) practices

This indicator is calculated as:

(# of males who support their partners‘ RH practices/Total # of men surveyed) x 100

 

“Supportive” can be operationally defined in several dif­ferent ways, including attitudes toward specific behav­iors (e.g., contraceptive use), responses to hypothetical situations, and reported actions/behaviors.

“RH practices” refers to the behaviors that RH programs promote (e.g., often the objective of the program): contraceptive use, breastfeeding, delivery in the presence of a skilled birth attendant, and so forth.

Data Requirements:

Responses to structured or in-depth interviews

Data Sources:

Surveys among the male clientele at health facilities or other men‘s RH sites (program-based) or among the men in the general public (population-­based). Alternative sources are surveys among the wives of participants in male-focused programs.

Purpose:

One way a man can become “involved” in RH is by supporting his wife/partner in her practice of desirable health behaviors. Although some argue that this type of involvement does not go “far enough,” in societies where males have withheld such support, this involvement can represent an important step forward.

Evaluators can assess men‘s level of support for women‘s RH practices using three types of questions: attitudes, responses to hypothetical situations, and re­ported actions. Illustrative questions of each type are presented below. One expects that these re­sponses will become more favorable as a result of inter­ventions directed toward male involvement.

Illustrative Items for Measuring Men‘s Support of Their Wife‘s/Partner‘s RH Practices

Attitudes:

Do you approve or disapprove of your wife/partner:

(a) Using a contraceptive method to prevent pregnancy?

(b) Receiving antenatal care during pregnancy?

(c) Having a trained birth attendant present at delivery?

(d) Breastfeeding your baby?

Hypothetical situations:

  1. If your wife/partner went into labor and experienced complications but you were away on a trip, should she seek health care on her own or wait for your return?
  2. Suppose a woman suspected that her husband/partner was having sexual relations with several other women. Is she justified or not to suggest using condoms when she and her husband/partner have sex?

Actual behaviors:

  1. Have you ever told (or otherwise let your wife/partner know) that you approve or disapprove of her using contraception?
  2. During your wife‘s/partner‘s last pregnancy, did you have a plan to get her to a hospital or health center if she had complications? (If so, explain).

 

Issue(s):

The answers to this set of questions are subject to bias, especially if men are aware that their attitudes or be­haviors deviate from socially accepted responses. The best solution to this problem is for the interviewers to ask these questions in a matter-of-fact way.  An alter­native approach is to interview women about their hus­bands’ attitudes and behaviors vis-à-vis family planning, safe pregnancy, delivery, STI/HIV risk, and other pre­vention behaviors. However, such accounts may be bi­ased if the wives know that their husbands participate in the male-focused activities and thus “anticipate“ changes in their behavior.

Percent of men who accompany their partner to an antenatal care visit

Definition:

The percent of men who accompany their spouse or partner to at least one antenatal care (ANC) visit.

This indicator is calculated as:

(# of men who accompany their partner to an ANC visit/ Total # of men who report their partner had an antenatal visit) x 100

‘Accompany’ their partner means that the man went with his spouse or partner to the health facility and ideally was ‘present’ in the room during the ANC check-up.

Data Requirements:

Responses to structured or in-depth interviews.  The DHS Male Questionnaire includes a question on whether men were present during any of their partners’ antenatal check-ups.  Where the detail is available, disaggregation of the indicator by men’s age, number of children, education, income, urban/rural status and other relevant factors may contribute to interpretation of findings.

Data Sources:

DHS; surveys among the male clientele at health facilities or among the men in the general public (population based); alternative sources are surveys among the spouses and partners of participants in male-focused programs.

Purpose:

This indicator measures the engagement of the male partner in the couple’s pregnancy care. The extent of men’s support for their spouses’ and partners’ reproductive healthcare can significantly affect outcomes. Men’s knowledge of their partners’ reproductive health needs during pregnancy and delivery, danger signs and how to address them, making delivery and transportation plans, and so forth, can be enhanced through their presence during ANC visits and discussions (UNFPA, 2003; Promundo, UNFPA, MenEngage, 2010).  Burgess (2007) found that male involvement during the prenatal, newborn, and early childhood periods can lead to favorable outcomes for the entire family and increases the likelihood that the father will continue to provide care throughout his children’s lives.

Men’s ability to be present at antenatal care is subject to numerous external constraints, such as, health facility procedures, time and work demands, and even health providers’ and other family members’ attitudes toward men’s involvement.  Younger men appear to be more affected by these constraints than older men and disaggregating the indicator by age is advised.  Programs targeting first time and younger fathers for engaging them in maternal, newborn, and child healthcare (MNCH) can affirm young men’s identity as fathers, encourage participation in MNCH, provide support of developing parenting skills, and address men’s anxieties and concerns about their partners’ pregnancy, childbirth and subsequent parenting (Promundo, UNFPA, MenEngage, 2010).

Issue(s):

The indicator as it stands does not measure the degree of the man’s engagement in the actual ANC visit, whether he was present in the room during the examination and if he participated in discussions about care, nutrition, delivery, danger signs, etc.  It is important to recognize that men’s involvement in their partners’ ANC can also be a product of the male’s intent to control his partner and his presence could further reduce the woman’s autonomy in an area that has traditionally been one where women exercised decision-making. 

References:

Burgess, A. (2007). The costs and benefits of active fatherhood: evidence and insights to inform the development of policy and practice. Fathers Direct.

Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. http://www.unfpa.org/public/site/global/pid/6815

UNFPA, 2007, It Takes Two: Partnering with Men in Reproductive and Sexual Health,  http://www.unfpa.org/news/it-takes-two-men-partners-maternal-health

Percent of men present at the health facility during the birth of last child

Definition:

The percent of men who were at the health facility during the birth of their last child, either in the room with their partners during birth or in a waiting area.

This indicator is calculated as:

(# of men present at health facility during the birth of last child/ Total # of men surveyed who have children) x 100

‘Present’ can be defined as the father is in the room with his partner during the birth or is waiting at the facility.  Some facilities may discourage or disallow men from being in the room during delivery, there may be open delivery wards, and/or religious or cultural practices may dissuade men from being in the room - even if that is the father's intention.

Data Requirements:

Surveys and in-depth interviews. Where the detail is available, disaggregation of the indicator by father’s age, number of children, education, income, urban/rural status and other relevant factors may contribute to interpretation of findings.

Data Sources:

Surveys among the male clientele at health facilities or among the men in the general public (population based);  alternative sources are surveys among the spouses and partners of participants in male-focused programs.

Purpose:

The extent of men’s support for their spouses’ and partners’ reproductive health care can significantly affect outcomes, especially regarding family planning, safe motherhood, and newborn health.  Men’s presence at the health facility during birth can indicate an increased level of support for their spouse or partner.  Burgess (2008) found that a father’s presence (or a close friend or relative) at the birth can help make labor and delivery a more positive experience for the mother.  If there is a need for a procedure, such as a caesarean delivery or follow-up surgery, the men’s presence can help with decision-making and consent.  If the father is able to interact with the mother and newborn immediately after birth, this can time together can improve bonding of the father and infant, as well as, provide support for his partner. 

Research has shown that new fathers often are open to information that can help ensure the health and survival of their babies (Promundo, UNFPA, MenEngage, 2010).  Male engagement during their partners’ pregnancy, birth of the infant, and newborn period improves outcomes for the family as a whole and increases the likelihood the father will continue providing care throughout the children’s lives (Burgess, 2007).

A father’s ability to be present at delivery is subject to numerous external constraints, such as, hospital regulations, time and work demands, and even health providers’ and other family members’ attitudes toward men’s involvement.  Younger men appear to be more affected by these constraints than older men and disaggregating the indicator by age is advised.  Programs targeting first time and younger fathers for engaging them in maternal, newborn, and child healthcare (MNCH) can affirm young men’s identity as fathers, encourage participation in MNCH, provide support of developing parenting skills, and address men’s anxieties and concerns about childbirth and parenting (Promundo, UNFPA, MenEngage, 2010).

Issue(s):

Responses to this question are subject to bias, especially if men are aware that their attitudes or behaviors deviate from socially accepted responses. They may try to respond as they expect will please the interviewer and it is best if the interviewers ask these questions in a neutral matter-of-fact way. An alternative approach is to interview women about their spouses’ or partners’ presence at the facility during the birth of their last child, however, these accounts may be biased if the women know that their partners participate in male-focused programs and that this would have been ‘expected’ behavior.

This indicator does not count fathers' presence at home deliveries.  While the father may be close by, they may be less likely to be in the room during delivery at home, particularly if traditional norms discourage their presence.

It is important to recognize that male involvement is not necessarily a positive and does not ensure favorable outcomes if male behavior is dominant and controlling. 

References:

Burgess, A. (2007). The costs and benefits of active fatherhood: evidence and insights to inform the development of policy and practice. Fathers Direct.

Burgess, A. (2008). Maternal and infant health in the perinatal period: the father’s role. Abergavenny, UK: The Fatherhood Institute.

Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. http://www.unfpa.org/public/site/global/pid/6815

Percent distribution of contraceptive methods currently used by men or their sexual partners

Definition:

Among men ages 15–54 years, the percentage distribution of all men, currently married men, and of sexually active men in this age range, by contraceptive method the man or his sexual partner are currently using. Contraceptive options include the following: not using, pill, intrauterine device, injectable, condom (male and female), female sterilization, male sterilization, implant, lactational amenorrhea, periodic abstinence, and withdrawal. Men are considered to be currently using a contraceptive method only if they report being sexually active in the 12 months prior to the survey.

The indicator is calculated as follows:

(All men, currently married men, or sexually active unmarried men ages 15–54 currently using any contraceptive method, by method / total number of male respondents) x 100

Data Requirements:

Survey data from men on what contraceptive method they are currently using, if at all.

Data can be disaggregated by age, marital status (all men, currently married men, or sexually active unmarried men), and geographic location.

Data Sources:

DHS men’s questionnaire

The men’s questionnaire reports contraceptive use among men through the following question, “Are you currently doing something or using any method with any partner to delay or avoid a pregnancy?” Those who respond with a “yes” are further asked to state the method they are personally using or their partner(s) are using (within the past 12 months).

Data collection may include men ages 15–49, 15–54, or 15–59, depending on the local context.

Purpose:

This indicator measures actual contraceptive use at the time of data collection by men by age and marital status. It is a qualitative outcome measure that can be used to track acceptance and use of modern contraception by men over time. 

Issue(s):

It is not possible, from this indicator, to correctly assess "use" and determine if men or their partners are using the contraceptive method correctly and consistently. 

Percent of men who have ever used any male family planning method or family planning method that requires male cooperation

Definition:

Among men ages 15–54 years, the percentage distribution of all men (currently married men and of sexually active unmarried men) who have ever used any male contraceptive method or family planning (FP) method that requires men’s cooperation, by specific method and age. FP options include male sterilization (vasectomy), withdrawal, standard days method, and male condom.

The indicator is calculated as follows:

(Number of men 15–54 ever used a contraceptive method / Total number of male respondents) x 100

Data Requirements:

Men's self-reporting of FP use

Data can be disaggregated by age, marital status (all men, currently married men, or sexually active unmarried men), geographic location, specific method, and modern versus traditional method

Data Sources:

DHS men’s questionnaire

Special survey among the male clients at health facilities, program-based sexual and reproductive health sites, or among the men in the general public (population based)

Data collection may include men ages 15–49, 15–54, or 15–59, depending on the local context.

Purpose:

This indicator measures ever use of a contraceptive method by men by age and marital status. When disaggregated by modern versus traditional method, it is a quantitative outcome measure that can be used to track acceptance and use of modern contraception by men over time. 

Issue(s):

It is not possible, from this indicator, to correctly assess "use" and determine if men used the contraceptive method (withdrawal, standard days method, or male condom) correctly and consistently. 

One advantage of this indicator is that the data are readily available through routinely collected service statistics or through DHS or RHS surveys. The shortcomings are two-fold. First, male involvement interventions usually target a limited geographical area, in which case these large-scale surveys lack appropriate data for evaluation (although a representative survey of the area will). Sec­ondly, although program-based service statistics are readily avail­able, they fail to capture contraceptive use outside the government or NGO facilities that provide family planning (e.g., pharmacies, which are a major source of supply of condoms).

Men's condom use at last sex

Definition:

The percentage of male respondents who say they used a male condom the last or more recent time they had sex with a female partner, within the last 12 months.

This indicator is calculated as follows:

(Number of respondents who report using a condom the last time they had sex with a female partner / Total number of respondents who report having sex in the past 12 months with a female partner) x 100

Data Requirements:

Self-reported data from respondents of special surveys among the male clients at health facilities, program-based sexual and reproductive health sites, or among the men in the general public (population based)

This indicator can be disaggegrated by age, marital status (all men, currently married men, or sexually active unmarried men), and geographic location.

Data Sources:

Population-based surveys, such as Demographic Health Survey (DHS men's questionnaire), AIDS Indicator Survey, Multiple Indicator Cluster Survey or other representative survey 

Purpose:

Male condoms are one of the few male-controlled contraceptive methods. Tracking this indicator can reveal changes in men taking responsibility for family planning (FP). Because this is also a key HIV indicator, it can also signify changes in HIV prevention behavior. 

Issue(s):

It is not possible, from this indicator, to correctly assess "use" and determine if men used the condom correctly.

Again, because this is also a key HIV indicator, it may be difficult to discern if an increase in this indicator is the result of improvements to FP programming and better engagement of men in FP, or if it is the result of improved HIV initiatives to increase access to and use of male condoms.

The indicator may be subject to reporting bias. Men may feel that reporting use of condoms makes them appear less masculine and underreport use or, in areas where there have been major campaigns promoting condom use, men may be more likely to report use at last sexual intercourse when, in fact, they did not use condoms.

Number of family planning providers trained on male-specific family planning

Definition:

A "family planning (FP) provider" is any health worker (e.g., physician, nurse, or community health extension worker) who provides FP counselling and methods. "Male-specific FP" refers to male-controlled contraceptives (condoms and vasectomy) and FP counselling to men. This includes couples’ counselling, because men who are counselled on FP are often accompanied by their partners. "Training" can refer to any type of male-specific FP training event, regardless of its duration or location. It involves a trainee getting a thorough understanding of the essential knowledge required to perform the job and progressing from either lacking skills or having minimal skills to being proficient.

Data Requirements:

Sex, type of provider, and type of training (pre-service or in-service)

This indicator can be disaggregated by geographic location. If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served. 

Data Sources:

Training attendance rosters from project records and public and private facility records of in-service trainings (usually kept by the training division), which are used both for administrative purposes during the training (e.g., distributing per diem) and for monitoring trainees at a later date.

Purpose:

This indicator serves as a crude measure of activity and provider knowledge of male-specific FP methods. Evaluators can use it for determining whether a program/project meets its target and/or for tracking progress from one year to the next.

Issue(s):

Because this indicator does not assess improved knowledge and/or skills, it should be used in conjunction with the indicator, Number/Percent of trainees who have mastered relevant knowledge, as appropriate.

Number or percent of vasectomy referrals

Definition:

The number or percentage of men of reproductive age (15–54) who received a referral for vasectomy. A referral occurs if the client is advised where he can go to receive a vasectomy, and the referral is documented at the referral source as proof that a referral was made.

This indicator may be a count of the number of men who received a referral for vasectomy. As a percentage, this indicator is calculated as follows:

(Number of male clients who received a referral for vasectomy / Total number of male clients ages 15–54 served at the site during the reporting period) x 100)

Data Requirements:

Number of male clients of reproductive age served at a given clinic during a given period (e.g., annually) as well as the confirmation of how many were referred for vasectomy

This indicator can be disaggregated by age, geographic location, and type of clinic making the referral.

Data Sources:

Service delivery statistics

Purpose:

The focus of this indicator is to help monitor vasectomy service delivery by tracking the number of referrals given. This indicator may be used in conjunction with number of vasectomies performed, to understand service delivery more comprehensively. 

Issue(s):

This indicator assumes that vasectomy counseling has occurred prior to referral. Tracking referrals remains a challenge in many countries and following up on individuals who complete referrals at another service delivery point may be difficult until coordination between services improves and linkages are strengthened.

Number or percent of facilities that offer vasectomy services

Definition:

Among the health facilities in a given area that provide family planning (FP) services, the number or percentage currently offering vasectomy services on-site during a specified time frame (e.g., one year or at the time of data collection). 

As a percent, this indicator is calculated as follows:

(Number of facilities currently offering vasectomy services on-site / Total number of surveyed facilities providing FP services) x 100

Data Requirements:

Facility survey/responses to a facility survey question asking whether a facility offers vasectomy services. Vasectomies can be part of the facility’s routinely offered services, or they can be provided periodically on-site by a visiting provider, in which case the service must have been offered during the specified time frame.

The question or questionnaire should specify that the service must be provided on-site, rather than as client referrals.

Data can be disaggregated by geographic location, type of facility, type of vasectomy (conventional or no-scalpel), or type of service (i.e., routinely offered at a facility or periodically).

Data Sources:

Facility survey or a service provision assessment (SPA)

Purpose:

This indicator determines the extent to which facilities that offer FP are providing a permanent FP method to male clients. It is also a long-term indication of whether a national FP policy that includes permanent methods is being implemented. 

Issue(s):

This indicator does not assess quality of vasectomy services.  To measure quality, it is recommended to use this with a complimentary indicator, “Percent of facilities offering vasectomy services that meet the minimum standards with regard to essential supplies and equipment.”

Number of vasectomies performed

Definition:

The number of male sterilizations, i.e., “vasectomies,” that have been performed within a given time frame. Data should be collected continuously at the facility level and should be aggregated periodically (e.g., monthly or quarterly) for use at the local level.

Data Requirements:

Type of vasectomy (nonscalpel or conventional) and location of procedure (e.g., private facility, public facility, or community-based event) 

This indicator can be also be disaggregated by age (of patient) and geographic location.

Data Sources:

Service delivery statistics and program records

Purpose:

This output indicator tracks vasectomy service delivery. It can be a reliable measure for effectiveness of provider trainings in vasectomy and interventions to improve quality standards at facilities to provide permanent family planning methods.

Issue(s):

This indicator assesses the number of vasectomies recorded in health facilities (versus in informal settings, such as a vasectomy camp), which should be performed according to national standards. However, unless the evaluator is observing the procedures to assess compliance with national standards, the standard of care can only be assumed.

Inclusion of vasectomy in family planning guidelines/strategies, regulations, or policies

Definition:

In countries with formal family planning (FP) or reproductive health guidelines, strategies, regulations or policies, this indicator assesses whether vasectomies are specifically included in these documents, and to what extent. In addition, these documents should be evaluated to make sure they are technically sound, based on scientific evidence, and grounded in informed choice.

The assessment should include the extent to which the national FP strategy or policy has a strategic or long-range plan in place to increase access to and use of long-acting/permanent methods, including vasectomy. To measure changes over time, the indicator should consider only those policies developed or modified during a specific reference period, such as the last calendar year.

Data Requirements:

Document review or policy analysis for evidence that vasectomy services are included in a country’s FP or health policy documents.

This indicator can be disaggregated by stage (proposed, drafted, or adopted).

Data Sources:

Actual guideline, strategy, regulation or policy document with evidence of approval (or submission for approval). They appear in constitutional provisions; legislation; implementing rules and regulations; executive orders; ministerial level decrees, and other measures of a regulatory nature (including related regulations and enforcement mechanisms); official goals and plan programs; statements and other formally documented government directives; standards; guidelines; and decrees.

A content analysis of the documents should include level (e.g., national, provincial, district).

Purpose:

The inclusion of vasectomies in formal policy statements reflects a country’s recognition of and commitment to effective FP options. It also signifies a recognition of male involvement in FP.

Issue(s):

Macro-level policies, laws, councils, and programs do not guarantee vasectomy service availability and quality. Therefore, it is strongly recommended that any policy review include operational policies such as standards of practices, codes, regulations, protocols, etc.

Percent of men who support the use of modern contraception for themselves or their partners

Definition:

The percentage of men who support the use of modern family planning (FP) methods for their own use or for their partners’ use.

"Supportive" can be operationally defined as attitudes toward use of modern FP method, responses to hypothetical situations, and reported actions/behaviors.

Modern methods of contraception are hormonal pills, female and male sterilization, intrauterine device (IUD), injectable, male and female condoms, diaphragm, foam/jelly, and emergency contraception.  In contrast, traditional or ‘non-modern’ methods are periodic abstinence, withdrawal and folk methods.

A proposed question is, “Do you support the use of modern contraception for yourself or your partner?”

This indicator is calculated as:

(Number of men who support their own or partners’ use of modern contraception/ Total number of men surveyed ) x 100

Data Requirements:

Responses to structured or in-depth interviews. Evaluators can assess men’s level of support for their own or partners’ use of modern FP methods using three types of questions: attitudes; responses to hypothetical situations; and reported actions.  Where the detail is available, the indicator can be disaggregated by the specific types of modern FP methods the men support, as well as by relevant socioeconomic and demographic factors, such as, men’s age, education level, income, and urban/rural residence.

Data Sources:

Surveys among the male clientele at health facilities or other men’s reproductive health sites (program-based) or among the men in the general public (population based). Alternative sources are surveys among the spouses and partners of participants in male-focused programs. 

The DHS male questionnaire measures men’s type of method use in parallel with the women’s questionnaire that measures their type of method. The DHS surveys allow categorization of actual use of modern versus non-modern FP methods for men and women as individuals and linked as partners.

Purpose:

Modern methods of contraception are generally recognized as more effective than traditional methods, and men’s support of modern method use for themselves or their partners can facilitate planning and spacing pregnancies with accompanying benefits for maternal and infant health.  Modern method use can also give men and women greater confidence in their ability to make decisions about their fertility and child bearing.  Men can become involved in FP decision-making and method use by supporting their partners in their use of modern methods.  Although some argue that this type of involvement does not go far enough, in societies where males have withheld support, backing their partners in using modern methods can represent an important step forward.

One expects that responses for this indicator will become more favorable as a result of interventions directed toward male involvement. 

Issue(s):

The answers to this question are subject to bias, especially if men are aware that their attitudes or behaviors deviate from socially accepted responses. They may try to respond in a way they expect will please the interviewer, so it is best if the interviewer asks this question in a neutral, matter-of-fact way. An alternative approach is to interview women about their spouses’ and partners’ attitudes and behaviors regarding modern FP. However, such accounts may be biased if the women know that the men participate in male-focused activities and anticipate changes in their behavior.

There may be differences in men’s support for the various kinds of modern FP methods. For example, men may be more supportive of their partners’ using an IUD than hormonal methods or sterilization, or men may support their own use of condoms by not vasectomy.  Disaggregation by the different types of modern FP methods will allow examination of these differences.

References:

Performance Monitoring and Accountability 2020. (n.d.). Glossary of family planning indicators [Adaptation]. Retrieved from http://www.pma2020.org/glossary-familyplanning-
indicators.

Percent of men who share in the decision making of reproductive health issues with their spouse or sexual partner

Definition:

The percent of men who report joint decision-making with their wife or sexual partner about various aspects of their sexual and reproductive health (SRH).

This indicator is calculated as:

(Number of men in target population surveyed/interviewed who report that they share in making SRH decisions/ Total number of men surveyed/interviewed) x 100

SRH decision-making can include the areas of contraceptive use, antenatal care, delivery in the presence of a skilled birth attendant, newborn care and breastfeeding, health, nutrition, and sexually transmitted infection/HIV screenings and treatment.

Data Requirements:

Responses to structured or in-depth interviews. The concept of inter-partner communication is somewhat open-ended and questions on partner communication need to be clear and concrete to foster valid responses. UNFPA (2003) has a list of suggested questions about shared SRH decision-making:

The Gender-Equitable Men (GEM) scale (Pulerwitz and Barker, 2008) includes related questions on family planning decision-making in the equitable norms subscale: #18. ‘A couple should decide together if they want to have children;’ and #23. ‘A man and a woman should decide together what type of contraceptive to use.’ Where the detail is available, the indicator can be disaggregated by the specific types of SRH practices for which there is shared decisions-making, as well as by age, marital status (all men, currently married men, or sexually active unmarried men), and geographic location (urban/rural residence).

Data Sources:

Surveys among the male clients at health facilities, program-based SRH sites, or among men  in the general public (population based).  Alternative sources are surveys among the spouses and partners of male participants in male-focused programs.

Purpose:

Increased sharing in SRH decision-making by male and female partners is generally associated with beneficial outcomes for the health and well-being of women, children, and the entire family (UNFPA, 2003). Male engagement interventions often are designed to increase male awareness of SRH issues and to increase partner communication on these topics. This indicator measures the extent to which husbands and wives or other sexual partners discuss and share decision-making for specific SRH topics.

Gender-related attitudes held and expressed by men directly affect the health and well-being of women and girls, as well as, the men themselves.  In many cases, males in relationships or families hold the decision-making power to deny woman access to their healthcare needs.  Male-focused programs can educate men regarding their SRH needs, the needs of women and girls, and can address gender norms.  Engaging men in questioning and challenging inequalities between men and women can promote more evenly shared decision-making power and improved access to SRH resources for women and girls (Promundo, UNFPA, MenEngage, 2010). 

Issue(s):

The answers to this question or subset of questions about specific SRH topics are subject to bias, especially if men or women are aware that their attitudes or behaviors deviate from socially accepted responses. They may try to respond as they expect will please the interviewer and it is best if the interviewers ask these questions in a neutral matter-of-fact way. Follow-up probes and questions with in-depth interviews may be helpful.  In addition, respondents may consider shared discussions about SRH topics as shared decision-making, when, in fact, one partner made the actual decision.  Again, carefully worded questions, probes, and follow-up questions may assist in clarifying whether the decision-making was ‘shared.’

There may be differences in the types of SRH practices for which men and women are more likely to share decision-making.  Male and female partners may find it easier to share in decision-making on antenatal, maternal and newborn care than decision–making on use of modern FP methods, methods requiring male cooperation, or whether to pursue STI/HIV testing or treatment.  Including a range of SRH practices in the questionnaires or in-depth interviews is important for examining these differences and interpreting the findings. 

References:

UNFPA, 2003, It Takes Two: Partnering with Men in Reproductive and Sexual Health,  http://www.unfpa.org/publications/it-takes-2

Pulerwitz, Julie and Gary Barker. 2008. "Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale," Men and Masculinities 10:  322–338.

Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. http://www.unfpa.org/public/site/global/pid/6815

Percent of men who disagree that contraception is a woman's business and a man should not have to worry about it

Definition:

The percentage of men ages 15–54 years who respond negatively to the statement “contraception is a woman’s concern, and a man should not have to worry about it.”

This indicator is calculated as follows:

(Number of men surveyed/interviewed who report they disagree with the above statement / Total number of men surveyed/interviewed) x 100

Data Requirements:

Survey data from men

This indicator can be disaggregated by age, marital status (all men, currently married men, or sexually active unmarried men), and geographic location.

Data Sources:

DHS men’s questionnaire

Data collection may include men ages 15–49, 15–54, or 15–59, depending on the local context.

Purpose:

This indicator quantitatively measures men’s perceptions of shared responsibility in family planning and contraceptive use. 

References:

DHS men’s questionnaire: http://dhsprogram.com/What-We-Do/Survey-Types/DHS-Questionnaires.cfm

Evidence of engagement of men in family planning incorporated in national health standards or policies

Definition:

Instances in which there is concrete evidence of engagement of men in existing national/subnational policies or strategic plans that promote family planning (FP) services and information. Policy implementation is the process of carrying out and accomplishing a policy, in this case, male engagement in FP. This may require the creation of an implementation plan, policy, or strategy guidelines, and a budget line item to ensure that the policy or strategy is carried out in the manner that was intended by policymakers.

Data Requirements:

National health standards or policies

This indicator can be disaggregated by stage (proposed, drafted, or adopted).

Data Sources:

Directive, resolution, tool to measure policy implementation, meeting minutes providing evidence of dialogue among national and subnational governments on new guidelines, evidence of activity plans or reports that show the policy is being used, or key informant interviews.

Purpose:

The inclusion of men in formal health standards or policy documents reflects a country’s recognition of and commitment to male involvement in FP.

Attitudes towards gender norms (GEM Scale)

Definition:

Attitudes toward gender norms in intimate relationships or differing social expectations for men and women, boys and girls, using the Gender-Equitable Men (GEM) scale.

The GEM scale includes 24 items in two subscales. The 17 items in Subscale 1 measure ‘inequitable’ gender norms (e.g., ‘It is the man who decides what type of sex to have’) and the 7 items in Subscale 2 measure ‘equitable’ gender norms (e.g.,  ‘A couple should decide together if they want to have children’). Responses are scaled as: Agree =1; Partially Agree =2; and Do Not Agree=3 for the inequitable subscale and scores are inverted for the equitable subscale, resulting in a higher score for greater gender equity.

Scores of the inequitable norm and the equitable norm subscales are calculated separately and can be combined or used individually. The inequitable subscale has been found to be more reliable than the equitable subscale in some circumstances. The combined or individual subscale scores can be used as a continuous variable or categorized as: Low Equity = 1-23;  Moderate Equity = 24-47; and High Equity = 48-72. 

For the GEM scale and other gender scales: 

https://www.c-changeprogram.org/content/gender-scales-compendium/about.html 

Data Requirements:

Completed GEM questionnaires/interviews. Where the detail is available, disaggregation of the indicator by men’s age, number of children, education, income, urban/rural status and other relevant factors may contribute to interpretation of findings.

Data Sources:

Interviews and survey questionnaires using the GEM scale.

Purpose:

Social norms that promote gender inequality, such as those that encourage men to maintain control over the behavior of their female partners, can increase both young men and young women’s risk of STIs, HIV, and partner violence, as well as risk for unplanned pregnancies. Transforming inequitable gender norms (i.e., societal messages that dictate appropriate or expected behavior for males and females) is increasingly recognized as an important strategy to counter the spread of HIV and generally improve reproductive health (Promundo, UNFPA, MenEngage, 2010).

The GEM scale and scoring procedures were developed using formative research by Horizons and Promundo in order to measure attitudes toward “gender-equitable” norms. The scale is designed to provide information about the prevailing gender norms in a community, in addition to the effectiveness of programs that seek to influence them (Barker, 2000, 2001; Instituto Promundo and Instituto Noos 2003).

According to Pulerwitz and Barker (2008), the GEM scale is intended to:

  1. be multi-faceted and measure multiple domains within the construct of gender norms, with a focus on support for equitable or inequitable gender norms;
  2. address program goals related to sexual and intimate relationships, and sexual and reproductive health and disease prevention;
  3. be broadly applicable yet culturally sensitive, so indicators can be applied in and compared across varied settings and be sufficiently relevant for specific cultural contexts; and
  4. be easily administered so that a number of actors—including the organizations that are implementing the interventions—can take on this type of evaluation.

During an intervention study conducted with young men in Brazil in 2003–2004, the full GEM Scale was applied in a baseline survey. Based on the responses of the young men, the inequitable norms subscale showed more variability and was used as the gender norms measure for the intervention.  Respondents with a higher GEM Scale score showing greater support for inequitable gender norms were significantly more likely to report sexually transmitted infection symptoms and physical and sexual violence against a partner than respondents with lower GEM Scale scores (Pulerwitz and Barker, 2008).  The GEM Scale is currently being used to assess the impact of programs in India, Mexico, Kenya, the United States, and elsewhere.

Issue(s):

Pulerwitz and Barker (2008) note that additional research to evaluate the validity and reliability of the scale with different populations and in varied contexts will contribute useful information.  Even though the current GEM scale has responded well in a number of ways, it does not explain a substantial portion of the variation in responses given by men. There are additional relevant factors that have not been captured by the items in the scale that could explain men’s responses more completely, and adding items to the scale may be a helpful strategy in the future.

The two groups of scale items (inequitable and equitable) were distributed by the factor analysis into factors largely addressing similar issues (e.g., contraceptive use), but they were positively and negatively worded.  The authors comment on an ongoing debate in the field of psychometrics about the meaningfulness of separating positively and negatively worded items into different factors.

References:

Barker, G. 2000. “Gender equitable boys in a gender inequitable world: reflections from a qualitative research and program development with young men in Rio de Janeiro, Brazil,” Sexual and Relationship Therapy 15(3): 263–282.

Barker, Gary. 2001. “Cool your head, man: preventing gender based violence in favelas,” Development 44(3): 94–98.

Instituto Promundo and Instituto Noos. 2003. Men, gender-based violence and sexual and reproductive health: A study with men in Rio de Janeiro, Brazil. Rio de Janeiro: Insitutito Promundo and Instituto Noos.

Promundo, UNFPA, MenEngage, 2010, Engaging Men and Boys in Gender Equality and Health: A Global Toolkit for Action. http://www.unfpa.org/public/site/global/pid/6815

Pulerwitz, Julie and Gary Barker. 2008. "Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM Scale," Men and Masculinities 10:  322–338.

Compendium of Gender Scales: https://www.c-changeprogram.org/content/gender-scales-compendium/pdfs/4.%20GEM%20Scale,%20Gender%20Scales%20Compendium.pdf

Validation with youth: http://www.jahonline.org/article/S1054-139X(16)30376-7/abstract 

Number of family planning providers trained on gender equity and sensitivity

Definition:

A “provider” is any health worker (e.g., physician, nurse, community health extension worker). “Training” can refer to any type of gender equity and sensitivity training event, regardless of its duration or location. It involves a trainee attaining a thorough understanding of the essential knowledge required to perform the job and progressing from either lacking skills or having minimal skills to being proficient.

"Gender equity" is the equally fair treatment of women and men and girls and boys. To ensure fairness, some societies adopt measures to compensate for historical and social disadvantages that prevent women and men from otherwise operating on a "level playing field." Gender-equity strategies eventually attain gender equality. Equity is the means; equality is the result (Interagency Gender Working Group, 2000).

"Gender sensitivity" is the way service providers treat male or female clients in service delivery facilities and thus affects client willingness to seek services, continue to use services, and carry out the health behaviors advocated by the services. In the context of family planning, gender sensitivity also refers to whether a range of male and female methods are offered.

Data Requirements:

Count of providers trained

This indicator can be disaggregated by sex, type of provider, location, and type of training (pre-service or in-service); If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

Training attendance rosters from project records and public and private facility records of in-service trainings, usually kept by the training division, which are used both for administrative purposes during the training (e.g., distributing per diem) and for monitoring trainees at a later date.

Purpose:

This indicator serves as a crude measure of activity and provider knowledge of gender equity and sensitivity. Evaluators can use it for determining whether a program/project meets its target and/or for tracking progress from one year to the next.

This indicator focuses on gender issues in the client-provider context as a step toward addressing gender bias and promoting a service delivery environment free of gender bias toward female and male clients with the aim of encouraging men to use services for their own health (e.g., voluntary male circumcision, vasectomy, sexually transmitted infections, and HIV/AIDS). 

Issue(s):

Because this indicator does not assess improved knowledge and/or skills, it should be used in conjunction with the indicator, “Number/percent of trainees who have mastered relevant knowledge,” as appropriate.

Number of national-level programs/ policies/advocacy campaigns that address gender equity

Definition:

Number of programs/policies/advocacy campaigns that address gender equality or nondiscrimination for women or girls at the national or sub-national level. For the purposes of this indicator, "policy" is meant broadly to include any official document issued by a government (e.g., law, policy, action plan, constitutional amendment, decree, strategy, or regulation) designed to promote or strengthen gender equality or nondiscrimination based on sex at the national or subnational level.

To be counted, the program/policy/advocacy campaign should have as its objective or intent one or more of the following: reducing an aspect of social, economic, or political inequality between women and men, girls and boys; ensuring that women and men, girls and boys, have equal opportunities to benefit from and contribute to social, political, economic, and cultural development, to realize their human rights, or to have access to/control over resources necessary to survive and thrive; or preventing gender-related discrimination or compensating for past gender-related discrimination or historical disadvantage.

To report against this indicator, provide the number (count) of relevant programs/policies/advocacy campaigns drafted, proposed or adopted during the reporting period. Count only once in each stage (e.g., law drafted, proposed, or adopted); do not report on the same program/policy/advocacy campaign across multiple reporting periods, unless it has advanced to the next stage (e.g., law drafted in one reporting period, law presented for legislative action in the next reporting period, or law passed in the subsequent reporting period). If it is a program (or project or intervention) that is addressing gender equity, it should be counted only one time—the reporting period where program implementation begins. 

Data Requirements:

National and sub-national level policies, programs, and advocacy campaigns. 

This indicator can be disaggregated by program/policy/campaign, stage (drafted/proposed/adopted), or geographic location (for subnational levels).

Data Sources:

Program results data for interventions that aim to strengthen and support the creation of national and subnational level programs/policies/advocacy campaigns

Purpose:

Information generated by this indicator will be used to monitor and report on achievements linked to broader outcomes of gender equality, female empowerment and/or nondiscrimination and will be used for planning and reporting purposes by agency-level, bureau-level, and in-country program managers. Specifically, this indicator will inform required annual reporting or reviews of the USAID Gender Equality and Female Empowerment Policy and the U.S. National Action Plan on Women, Peace, and Security, as well as the Joint Strategic Plan reporting in the APP/APR and Bureau or Office portfolio reviews. Additionally, the information will inform a wide range of gender-related public reporting and communications products and facilitate responses to gender-related inquiries from internal and external stakeholders, such as Congress, nongovernmental organizations, and international organizations.

References:

Adapted from indicator GEN-1; USAID ADS 205: https://www.usaid.gov/sites/default/files/documents/1870/205.pdf