A few large-scale sample surveys—such as the Caribbean Contraceptive Prevalence Surveys, conducted in the early 1980s, the 1980 Egyptian Fertility Survey, and the 1975 Thailand Fertility Survey—questioned men directly about family planning (90). Based on evidence from these surveys, Moira Gallen and colleagues concluded in 1986 that men generally favored family planning (90). Most of the men surveyed as part of the World Fertility Survey in the 1970s and the Contraceptive Prevalence Surveys in the early 1980s wanted to share responsibility for making family planning decisions. They knew of at least one family planning method, but many did not know where to get family planning services or supplies. Men tended to know male-oriented methods but not female-oriented methods. Surveys in the Dominican Republic and Thailand suggested that men and women wanted about the same number of children (90).

Recent surveys of men confirm these earlier findings. Since 1987, when the first of the Demographic and Health Surveys (DHS) of married men was conducted in Burundi, about 40 DHS have interviewed more than 45,000 men in East Africa, West Africa, North Africa, and Asia (147). Most DHS data on men are from sub-Saharan Africa. The DHS, which at first interviewed only the husbands of women also being interviewed, now also interview single men. Also, the US Centers for Disease Control and Prevention in collaboration with national institutions have conducted representative surveys of adult men in Honduras and Jamaica.

Alex Ezeh and colleagues analyzed DHS findings on men's contraceptive knowledge, attitudes, and practices in 15 countries, where more than 21,000 married men were interviewed between 1987 and 1993 (76). Ezeh's study is one of the first to present comparable data on men in different countries (147).

In addition, for this issue, Population Reports has analyzed DHS data from 11 other men's surveys: Bangladesh (1996-97), Brazil (1996), Central African Republic (1994-95), Côte d'Ivoire (1994), Haiti (1994-95), Malawi (1996), Mali (1995-96), Senegal (1997), Tanzania (1996), Uganda (1995), and Zimbabwe (1994). Findings from these data are similar to those of Ezeh and colleagues. (See Chapter 3)

With these large-scale surveys, as well as smaller studies, men's family planning and other reproductive health knowledge, attitudes, and practices are more clearly understood than a decade ago. Nevertheless, the picture is still incomplete and offers only a broad look at a group that is far more complex than survey statistics alone can suggest (46 , 118, 157 , 262). More in-depth, qualitative studies could help to probe such issues as men's reproductive decision-making, men's unmet need for family planning, the gap between men's approval and use of contraception, and how different groups of men regard reproductive health issues.

A new men's questionnaire being developed for inclusion in 1999 DHS+ surveys will attempt to fill in many of the gaps in knowledge. The earlier men's DHS questionnaire was modeled on the women's questionnaire. The new men's module is part of the Monitoring and Evaluation to Assess and Use Results Project (MEASURE), which, like the earlier surveys, receives support from the US Agency for International Development.

Some of the research areas under consideration in the new surveys include: the role men play in the adoption of contraception; men's health-related behavior, such as drinking and smoking; and the participation of husbands in the health care of their children (220). More information about the new men's survey is available from the MEASURE website: http://www.measureprogram.org/.

In Jordan the communication campaign Together for a Happy Family put new perspectives on men into practice to increase men's participation in reproductive health. The campaign was carried out by the Jordanian National Population Commission with assistance from Johns Hopkins Population Communication Services and funding from the United States Agency for International Development.

Men's Roles and Attitudes

A survey in 1996 found that, among couples who had never used contraception, only 40% had discussed family planning compared with 86% of current contraceptive users (249). Almost 20% of women who had never used contraception reported that the main reason was their husband's opposition. Also, 40% of men said that couples should continue having children until they have a son (78).

Since 1946 Jordan's population has been one of the fastest growing in the world, increasing an average of 4.3% annually. If the current high rate of population growth remains unchanged, the country's population will double in 28 years.

While a large percentage of Jordanian men believe that the spacing of births is sanctioned by Islam, they are uncertain about specific contraceptive methods. Many think that modern methods are unnatural, have undesirable side effects, or have adverse long-term health implications and thus are not compatible with Islam. These findings suggest that efforts to improve men's knowledge, attitudes, and practices would have positive effects on family health and well-being (120).

Reaching Men, Improving Health

• Spousal communication,
• Equal value of the girl child,
• Safety, effectiveness, and reversibility of modern methods, and their concordance with Islam,
• Improved quality of life through family planning.

As part of the campaign national television and radio spots featured men in their role as family planning decision-makers. Each spot focused on one of the four themes of the campaign. Also, four short docu-dramas aired on prime-time national television, and 60 press articles, news columns, and reports were released throughout the campaign. The mass-media component of the campaign is estimated to have reached 1.5 million men nationwide (120).

Informing Opinion Leaders

Participants in the community meetings discussed family planning and Islam and how to motivate men to discuss family health issues and to use health services. Participants agreed to return to their communities and use their new knowledge to encourage support for family planning and contraceptive use among their social networks—for a ripple effect that could reach as many as 50,000 people (120).

Although it is too early to evaluate the full campaign, preliminary data suggest reason for optimism. Even though the men at the community meetings were older and more conservative than the general population, their attitudes changed signi- cantly. For example, after the meetings the percentage of participants who believe that family size should be discussed with their wives rose from 61% to 69%. The percentage of participants who thought that having at least one male child is very important decreased from 52% to 44%. Participants' approval of the use of contraceptive methods rose from 74% to 84%, and, among nonusers, the percentage intending to use contraceptive methods rose from 25% to 38% (128).

Such findings suggest that reaching men can make a difference. As more men are exposed to campaigns based on new perspectives on men's participation, men's attitudes can continue to change, and contraceptive use may increase.