As the new thinking has evolved, a consensus is forming. To improve women's and men's reproductive health, policies and programs must:

• Encourage men to take more responsibility for their sexual behavior;
• Increase men's access to reproductive health information and services;
• Help men to communicate with their partners and make contraceptive choices together; and
• Address the reproductive health care needs of couples (27, 32, 60, 61, 100, 157, 209, 210, 221, 222, 259, 276).

Men Make A Difference

Men's participation is a promising strategy for addressing some of the world's most pressing reproductive health problems. Men can help slow the spread of human immunodefiency virus/acquired immune deficiency syndrome (HIV/AIDS ) and other sexually transmitted diseases (STDs); prevent unintended pregnancies and reduce unmet need for family planning; foster safe motherhood and practice responsible fatherhood; and stop abusing women (45, 58, 59, 100, 108, 251).

The HIV/AIDS epidemic. By the end of 1997 more than 30 million adults worldwide were estimated to be infected with HIV, the virus that causes AIDS, a usually fatal condition that has no cure. Of these, about 17 million are men and 12 million are women. The majority of these cases are in the developing world. India has the greatest number of people infected with HIV—more than 4 million (124).

In many developing countries HIV/AIDS is devastating families and communities, striking mostly people in the prime of adulthood. In some sub-Saharan African countries—for example, Burkina Faso and Côte d'Ivoire—AIDS has reduced average life expectancy at birth by more than a decade (286). In Zimbabwe life expectancy is expected to decrease by 25 years by 2010 because of deaths related to AIDS (255).

An estimated 1 million children in developing countries also are infected with HIV or have AIDS. The epidemic is spreading so rapidly and so widely that it jeopardizes many previous gains in child survival, warns Peter Piot, executive director of the Joint United Nations Program on HIV/AIDS (256). Currently, according to the United Nations Children's Fund (UNICEF), about 1,000 children die from AIDS every day. Millions more are left without support when their parents die of AIDS, or they suffer because their parents have AIDS-related diseases, such as tuberculosis, and cannot properly care for their children.

The HIV/AIDS epidemic has put men's sexual behavior in the spotlight (56, 61, 63, 143, 268, 286). Prevention is the only solution. Yet too many men still engage in risky sexual practices, such as having multiple sex partners, including other men, and not using condoms consistently. In some countries, such as Thailand, many married men frequent commercial sex workers and do not use condoms, either with the prostitutes or with their wives (135, 216,243 ). In several Asian and African countries, some older men seek out virgin girls, known as cherry girls, whom they believe to be safe from HIV (42, 234).

Men's sexual behavior puts women at risk. In some countries, including the US and several sub-Saharan African nations, HIV is now spreading faster among women than men (124, 149, 201). In India a study of married and monogamous women at STD clinics found a high rate of HIV and other STDs in this apparently low-risk group (5). The strongest predictor for HIV infection among these women was having a husband who had been diagnosed with an STD.

HIV and other STDs have been described as showing "biological sexism" (107). That is, women are more susceptible physiologically to the viral and bacterial agents that cause them (56, 125, 149). As a result, men transmit infections to women more efficiently than women do to men. For example, men are eight times more likely to transmit HIV to a female partner through repeated, unprotected sexual intercourse than women are to transmit the virus to men (185).

Other STDs. The resurgence in some other STDs also underscores the need for men to practice safe sex. The World Health Organization (WHO) estimates that each year there are more than 330 million cases of curable STDs among adults worldwide (261). This figure includes 89 million new cases of chlamydia infection, 62 million new cases of gonorrhea, and 12 million new cases of syphilis (56). The vast majority of these cases, as with HIV/AIDS cases, occur in the developing world, particularly sub-Saharan Africa.

STDs are more difficult to detect in women, making accurate diagnosis harder (139, 261). Women are less likely than men to receive timely treatment because they may have no symptoms at first, they are embarrassed, or they cannot get to a clinic. As a result, sexually transmitted infections can progress to more serious medical conditions before women seek treatment (56, 139, 261). Thus women suffer more long-term and more painful consequences from STDs, such as ectopic pregnancy, pelvic inflammatory disease, and infertility (125, 261, 280).

Each year an estimated 500,000 women worldwide get cervical cancer (177). It is the leading cancer killer of women in developing countries (186, 245). Cervical cancer is caused by several human papilloma viruses (HPV) that are transmitted through sexual intercourse (50, 175, 177). This type of cancer is entirely preventable and, if caught early, treatable. Early diagnosis, which can be done with a Pap smear of the cervix, can detect the infection at a precancerous stage. Cervical cancer remains a major killer, however, because so few women have access to early diagnosis and treatment (191).

STDs such as gonorrhea and chlamydia can cause infertility in men and women, if left untreated. Often, however, women are blamed for infertility when, in fact, the man may be infertile (16, 56, 72, 287). WHO estimates that 8% to 22% of infertility worldwide is due to male causes (291). Treating men's STDs early and correctly diagnosing fertility problems would help to reduce the social stigma and abuse some women receive when they do not conceive (56).

An estimated 100 million married women have unmet need for family planning (208). There is probably much unmet need among unmarried women as well, although estimates based on surveys exist only for married women. Women are considered to have unmet need if they are sexually active, fecund, and do not want to become pregnant, but they are not using either modern or traditional contraception (279).

While most husbands and wives agree about using contraception, couples who disagree (or in which the wife thinks that her husband disapproves) make up a substantial share of couples with unmet need. Many married women who want to avoid pregnancy are not using contraception because their husbands object, according to the Demographic and Health Surveys (DHS) (37, 208, 261, 278). On average, in the DHS 9% of married women with unmet need cite husband's disapproval as the principal reason that they do not use contraception (37). When interviewed in-depth, women with unmet need are even more likely to cite their husbands' opposition as a reason for not using contraception than is apparent from survey responses (208).

Qualitative studies among married women with unmet need for family planning demonstrate the powerful role that their husbands play in determining whether they use contraception. In Uttar Pradesh, India, 87% of women with unmet need said that the decision to use contraception ultimately rests with the husband. More than one-quarter agreed with the statement: "My husband would get very angry if I talked to him about family planning methods" (296).

In urban Guatemala women with unmet need told interviewers that they often deferred to their husbands' wishes despite their own preferences. For example, a woman who had been pregnant 11 times and had six living children said that, while both she and her husband wanted to space future pregnancies, she was waiting for her husband to take the initiative and decide which method they would use. If her husband decided not to use any method, she would be too embarrassed to do or say anything (296).

Husbands' objections reflect a variety of reasons, including not only desire for more children or opposition to family planning but also worries about their wives' health, side effects of contraception, lack of information, and little discussion of family planning—reasons that women with unmet need also cite. As well as husbands' opposition, other factors that explain women's unmet need for family planning include family and social opposition, lack of access to appropriate contraceptives, health concerns, worries about side effects, lack of information, and little spousal communication about family planning.

Most women with unmet need probably have a number of reasons for not using contraception, and these reasons may not be well formed and may change over time (49, 208). In Manila and several rural areas of the Philippines, for example, women's fears of side effects, together with their husbands' fears, explained much of the unmet need (49). In a rural area of Kenya many women used contraception tentatively, ready to discontinue should they change their minds, experience side effects, or face opposition from their husbands (215). In Nepal many women with unmet need expressed concerns about their health and also said that their husbands opposed family planning (237).

Sometimes, women do not use contraception because they think that their husbands object, when in fact their husbands approve (see Communication Is Key to Accurate Perceptions). For example, among couples surveyed in the 1991-92 Tanzania DHS, 63% of wives reported that their husbands disapproved of family planning when this was not so. In fact, in 59% of the cases both husband and wife approved (208). Often, a wife does not know her husband's views about reproductive matters because the couple rarely or never discusses family planning.

Pregnancy-related complications cause one-quarter to one-half of deaths among women of reproductive age in developing countries. In some countries pregnancy-related complications are the leading cause of death for reproductive-age women (87, 214, 288). Many thousands of women in developing countries suffer serious illnesses and disabilities, including chronic pelvic pain, pelvic inflammatory disease, incontinence, and infertility, caused by pregnancy or its complications (86).

WHO defines a maternal death as a death occurring within 42 days after pregnancy, irrespective of the duration or the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management (288). Five direct causes—hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and complications of unsafe abortion—account for more than 80% of maternal deaths (218).

Safe motherhood consists of ensuring good health for women and their babies during pregnancy, delivery, and in the postpartum period. Men play many key roles during women's pregnancy and delivery and after the baby is born. Their decisions and actions often make the difference between illness and health, life and death (6, 229, 244).

Planning their families. The first step that men can take to promote safe motherhood is to plan their families (6). Limiting births and spacing them at least two years apart are good for maternal and child health. Every pregnancy carries potential health risks for women, even for women who appear healthy and at low risk (6, 217, 229). Unintended pregnancies are particularly likely to be risky because they are more likely to end in abortion. Complications of unsafe abortion cause 50,000 to 100,000 deaths each year (218, 288).

Supporting contraceptive use. Men can accompany their partners to meet with a family planning counselor or health worker. Together, they can learn about the available contraceptive methods and choose the one that best meets their needs. A man can help his partner use modern methods correctly (for example, he can help her remember to take her pill each day), he can use a male method himself, or the couple can practice periodic abstinence. Men can encourage their partners to seek help from a health care provider if side effects occur. They also can endorse trying another method if one method proves unsatisfactory.

Helping pregnant women stay healthy. When his partner becomes pregnant, a man can make sure that she gets proper antenatal care, which may entail providing transportation or funds to pay for her visits. He can also accompany her on the antenatal visits, where he can learn about the symptoms of pregnancy complications.

Good nutrition and plenty of rest also are important during pregnancy. Men can help women have safe pregnancies and healthy babies by ensuring that they receive nutritious food, especially food strong in iron and fortified with vitamin A (6, 227, 229, 257, 277). Anemia, while not a direct cause of maternal deaths, is a factor in almost all such deaths. An anemic woman is five times more likely to die of pregnancy-related causes than a woman who is not anemic (267).

Vitamin A is important to the health of both the mother and the fetus (227, 257). Women need to have enough vitamin A both to support the healthy development of their baby and to protect their own health, particularly their eyesight and immune system. Night blindness among pregnant women is a symptom of vitamin A deficiency. Antenatal vitamin A supplements, often provided in pill form, can greatly reduce maternal and child deaths (257). A study of pregnant women in southern Nepal found that low-dose vitamin A or supplements of beta-carotene, the nutritional precursor of vitamin A, reduced maternal deaths by an average of 44% (277).

Arranging for skilled care during delivery. In developing countries the majority of women deliver their babies without skilled assistance, helped only by untrained traditional birth attendants or family members. A trained attendant present during childbirth can mean the difference between life and death. Men can help by arranging for a trained attendant to be available for the delivery and by paying for the services. They also can arrange ahead of time for transportation and can buy supplies, if necessary.

Avoiding delays in seeking care. Delay often contributes to maternal deaths when complications of pregnancy occur (244). Three types of delay put mothers' health at risk—delay in deciding to seek care; delay in getting to a health care facility; and delay in receiving adequate care at the facility. Men and other family members play crucial roles in assuring prompt care (41, 244). Men are often the ones who decide when a woman's condition is serious enough to seek medical care. They also decide how a woman will be transported to the clinic. Men can avoid delays by learning the symptoms of imminent delivery and of delivery complications.

Helping after the baby is born. Most maternal deaths occur within three days after delivery, due to infection or hemorrhage, new research suggests (212). To prevent deaths, men can learn about potential postpartum complications and be ready to seek help if they occur. Men also can make sure that women get good nutrition. While they are breastfeeding, women continue to need extra vitamin A to ensure that they pass enough of the vitamin on to their infants.

During the postpartum period men can help with heavy housework, such as gathering wood and water and taking care of other children. They can encourage breastfeeding, which helps the uterus contract. Finally, they can begin using contraception, either a temporary method to space the next birth or possibly a vasectomy if no more children are desired (6, 182, 229).

Being responsible fathers. The roles that men play as fathers and the ways in which they affect their children's health have been gaining attention (44, 58, 70, 96). Men can become more involved in helping their children's healthy development—for example, ensuring that their children receive all of the needed immunizations. In Ghana a study found that the more education fathers have, the greater their role in deciding to immunize their children (40).

In the US, Baltimore's Urban Fatherhood Program helps young men become responsible fathers by promoting positive male role models. Program staff members, many of whom were teenage fathers themselves, encourage other young men to be good fathers through support groups, counseling sessions, and life skills classes. They also teach young men about fertility, reproduction, the menstrual cycle, pregnancy, and infant nutrition and care (127). In Newark, New Jersey, a similar program also teaches young fathers about contraception, including correct condom use (70).

Fathers, as role models, help to socialize their children (256). In particular, fathers can teach their sons to respect women and treat them as equals, support their daughters' school attend-ance, and encourage their daughters to play an active role in the family. In these ways, fathers can help to improve women's status and make a better future for their daughters (256).

In countries around the world many women report that men have abused them. For example, a study of women in La Paz and El Alto, Bolivia, found that 37% had suffered either physical or verbal abuse at one time or another. Of these, 42% said violence occurred often (298). In Colombia about 20% of women report that they have been beaten. In Papua New Guinea more than half of all rural and urban women report physical abuse. In one Kenyan district 42% of wives said their husbands beat them regularly. In the US an estimated 21% to 30% of women are beaten by a male partner at least once during their lives (261).

Men play many roles in society that place them in positions to discourage the abuse of women. As fathers, judges, police officers, and community leaders, as well as husbands and sex partners, men have the status and power to help change social and behavioral norms to end the abuse of women (261). Men can play critical roles in ending abusive traditional practices, too, such as female genital cutting, or female genital mutilation (FGM) (48). (See Female Genital Mutilation: A Reproductive Health Concern, Supplement to Population Reports, Series J, No. 41, October 1995.)

Recently, for example, two men in Senegal, an imam and a village leader, helped village women to begin eliminating FGM. After learning about the dangers of FGM in an educational program, these two men visited 10 neighboring villages to talk with elders and community members. As a result, the 8,000 villagers promised to stop FGM in their communities. Their efforts encouraged the president of Senegal to call for a law against female circumcision (166).

New Survey Findings About Men

New surveys of men show that many know and approve of family planning—in marked contrast to the stereotype of men as uncooperative and uninterested in family planning or reproductive health (76, 207, 213). While many men use contraception or support their partners' use of it, survey results suggest that most men need more family planning information, education, and services.

Almost all Demographic and Health Surveys (DHS) of men have been conducted in Africa. Thus findings are not representative of men everywhere. Other, smaller studies come from other regions. In the DHS most information is about family planning, but some data cover other reproductive health issues, such as HIV/AIDS.

When nonusers are asked by the DHS why they do not intend to use contraception, many say they would like more children. Throughout the surveyed countries of West Africa, this is the main reason that men give. For example, in Cameroon more than 70% of these men say they want more children. Desire for more children is also the main reason for nonuse in Morocco, Pakistan, and Tanzania (76).

Men who do not use contraception cite a number of other reasons for not intending to do so. In countries where Islam is strong, men often cite religion—even though, in fact, Islamic teachings do not prohibit family planning. For example, in Senegal 35% of nonusers cite this reason, and in Bangladesh and Egypt, 23% (76). Other reasons for not intending to use family planning include lack of communication between spouses, lack of access to contraceptives, the belief that women are responsible for fertility control, and the need for more family planning information (118).

Many men have fears or misconceptions about contraception (30, 100). Men may worry that certain contraceptive methods, such as the Pill or IUD, will have serious side effects and make their wives sick. Also, some men fear that, if a woman is not at risk of pregnancy, she will be promiscuous (100, 118).

Millions of men, like millions of women, have unmet need for family planning (100, 178, 208, 213) (see Avoiding Unintended Pregnancies, Meeting Unmet Need, Chapter 2.2). While there is no generally agreed-upon formulation of unmet need among men comparable to that among women, men's surveys could provide the basis for it. One such formulation, for example, defines men as having unmet need for family planning if they are sexually active, their partners are fecund and not pregnant, and they do not want their partners to become pregnant, but neither they nor their partners use contraception (160, 208).

While DHS data do not yield estimates of unmet need among men, one indication of unmet need is that, in 8 of 13 countries surveyed, there are more married men who do not want any more children than there are married men who are using contraception (including use by their wives) (76). Also, the Population Reference Bureau used DHS data on men in six African countries to estimate that one-quarter to two-thirds of husbands do not want more children but are not using contraception (213).

Young men today comprise half of the largest generation in history to enter adulthood—a generation of one billion boys and girls ages 10 to 19, or about one-sixth of the world's population. When they marry and begin to raise families, these young people will have an enormous impact on worldwide health, fertility, and population growth (4).

Most sexual activity of young people takes place within marriage (159). In the developing world the majority of young unmarried people, especially young women, are not sexually active. Nevertheless, millions of young men are sexually active before marriage. Among young adults who are sexually active, sex is usually episodic, averaging a few times a month (95, 168).

Almost everywhere, the average age at first marriage has been rising, while the average age of sexual initiation is getting progressively younger (159, 168). As this gap widens, young people have more sexual partners before marriage, putting themselves at greater risk for pregnancy and STDs, including HIV/AIDS (51, 148, 159). Earlier sexual initiation may be explained partly by the decline in the age at which puberty begins in boys and girls. For boys, puberty now begins between the ages of 9 and 14 (224).

The influence of testosterone, a hormone that motivates people to engage in sex, is an important and often overlooked factor in the sexual behavior of young men. During men's adolescence and into their early 20s, testosterone levels are very high and account for much of their strong sexual urge (145, 247).

Social pressures as well as physiologic changes encourage young men and boys to take sexual risks, often to the detriment of their own health and especially their partners' (95, 159). Young men are more likely than young women to be sexually active, to have multiple partners, and to have intercourse with casual acquaintances. Their sexual behavior reflects a double standard that exists in most societies—accepting premarital sexual activity by young men while punishing such behavior by young women (159).

Unmarried men generally become sexually active at a younger age than unmarried women do, and these young men have sex more often (24, 159, 168). The average age of first sexual activity varies by country, but most young men have had sex well before age 20. According to Young Adult Reproductive Health Surveys (YARHS) conducted in Latin America, the mean age of young men's first intercourse ranged from 13.9 years in Jamaica to 16 years in Santiago, Chile (170). In these surveys sexually active young men report having sex two to five times per month, although these self-reports may be exaggerated (168).

A 1995 study of unmarried, urban youth in Guinea found the mean age of first intercourse for males was 15.6 years (95). About half of the sexually active young men reported having sex one to three times in the previous month, and the other half, more frequently (95). In Thailand more than half of the boys surveyed reported having sex by age 18, often first with a prostitute (293).

Limited knowledge, limited protection. Most young men have a lot to learn before they can become responsible sex partners. Millions of young, unmarried men are having sexual relations but know little about the consequences. Few young men, for example, understand fertility or the menstrual cycle (95, 168). Many think, mistakenly, that pregnancy cannot occur if their partner is a virgin (95) or that a woman is most fertile during menstruation (168). Furthermore, many young men do not know about modern contraceptives or where to get information and services (159). Even if they do know of contraceptive methods, many believe common misconceptions—for example, that contraception causes infertility (95).

In the YARHS the percentage of young men reporting use of contraception at first premarital intercourse ranged from 11% in Jamaica to 33% in Costa Rica. Condoms were the most common choice of men in the 14 surveys as a whole. In Guatemala City, Rio de Janeiro, and São Paulo, the Pill was the most commonly used method. In Santiago and Mexico City the rhythm method was used most often (168). In Romania 35% of all sexually experienced young men used some contraception at first premarital intercourse. Condoms and withdrawal were the most common methods (226). In the Romania, Jamaica, and Mexico City YARHS, young men's most common reasons for not using contraception at first intercourse were that sex was unexpected and that they did not know about any method (169, 170, 226).

In Guinea, among sexually active young men ages 15 to 19 who were in school, 31% said they had used contraception at first intercourse. Among similar men not in school, 22% had used a method. Condoms were the most common method for both groups (95).

Contraceptive failure is common among young adults because they do not understand how contraceptives work or do not have the skills and practice to use them effectively (4). Even if young adults do seek to learn about contraception and to use it correctly, they are often discouraged by unfriendly, even rude, treatment from providers who disapprove of sexual activity among unmarried youth (4).

Exposure to HIV/AIDS and other STDs. About half of all people infected with HIV are younger than age 25 (4). Given the slow progression from initial HIV infection to AIDS, the high incidence of AIDS among men in their 20s indicates that many contracted HIV before age 20 (159). The younger that people are when they become sexually active, the more likely they are to have multiple sexual partners. Thus they face greater risk of exposure to STDs, including HIV (4, 159). Most sexually active young men know little about STDs or how to prevent them (159).

Even when young men do know about STDs, inexperience or denial as well as cultural pressures can make them take unnecessary risks. For example, in Brazil, Ecuador, and Chile, almost all the young men surveyed reported that they had heard of HIV/AIDS. About 80% knew that a person can be infected with HIV but show no symptoms. Despite this knowledge, most did not think that they faced much risk for HIV infection, even though they were sexually active (168).

Gender and Reproductive Behavior

Understanding gender provides insights into men's and women's behavior, relationships, and reproductive decisions (251, 262, 263). These insights are crucial to communicating with and serving both men and women effectively (53, 67, 106, 187).

"Gender" refers to the different roles that men and women play in society and also to the rights and responsibilities that come with these roles (39, 53, 202, 283). "Gender" differs from "sex," which refers to the biological and physical differences between men and women (53, 104, 154, 171).

So strong are gender roles that they usually are taken for granted. They are reflected in virtually every social institution, including family structures, household responsibilities, labor markets, schools, health care systems, laws, and public policies. The influence of gender is similar in strength to that of religion, race, social status, and wealth (53, 171, 202).

Worldwide, health care providers, policy-makers, and donors are recognizing the direct connection between men's and women's gender roles and their reproductive health (53, 106, 110, 157, 254, 261, 262). In particular, they are concerned about the effect that inequities in gender roles have on women's well-being. The ICPD Program of Action recognizes the importance of gender in stating: "In all parts of the world, women are facing threats to their lives, health, and well-being as a result of being overburdened with work and of their lack of power and influence" (251).

In many countries traditional male and female gender roles deter couples from discussing sexual matters, condone risky sexual behavior, and ultimately contribute to poor reproductive health among both men and women. Programs can encourage men to adopt positive gender roles, such as being supportive husbands and caring fathers (see Use Communication to Promote Behavior Change).

The term "power" is often used when describing gender differences. "Power" is a broad concept that describes the ability or freedom of individuals to make decisions and behave as they choose (52, 53, 115, 187, 202). It also can describe a person's access to resources and ability to control them. When the term "power" is associated with gender, it usually refers to inequities between men and women.

Two types of power help to describe the inequities in male and female gender roles—"power to" and "power over." "Power to" describes the ability of individuals to control their own lives and to use resources for their own benefit. For instance, a man is more likely than a woman to have the power to go where he wants, find a good job, and earn money. "Power over" means that individuals can assert their wishes, even in the face of opposition, and force others to act in ways that they may not want to (115, 202). In many cultures, for example, men make reproductive decisions, such as how many children their wives will have, that can have consequences for women's health and well-being (72, 73, 106,157).

Differences in power between men and women are not absolute or universal. Some men, especially those who are poor, illiterate, unemployed, or homosexual, usually have little power and few resources (20, 25). Also, especially among younger men and women in some cultures, gender roles are changing toward more equality.

Women's gender roles do give them some power. Usually, however, it is much more limited in scope than men's (15, 89). Like a man's power, a woman's power is influenced by such factors as her culture, age, income, and education. Some studies have found that women's power increases as their status in the community improves (36, 164). In Nigeria, for example, Yoruba women who have many children, especially sons, have more say than their husbands about whether or not they will have more children. Among Yoruba women with few or no children, however, their husbands' fertility desires usually prevail (17).

Type of marriage also can affect a woman's power. If a woman can choose her husband, she usually has more influence within her marriage than if her family chooses her husband (89, 138, 140). A woman's power to make decisions sometimes increases with her level of education and also with her husband's level of education. It may also depend on her age. Generally, younger women who marry much older men have less power than women who marry someone closer in age (15, 65, 89).

Gender roles begin at birth and span a lifetime. At very young ages boys and girls learn from their families and peers how they are expected to act around people of the same sex and of the opposite sex (39, 283). Almost universally, adolescent males experience more sexual freedom than adolescent females. Potentially harmful sexual attitudes and behavior that can develop during youth are often difficult to change during adulthood.

Because gender lies at the heart of social organization and the distribution of power, calls for changes in gender roles, and hence behavior, often touch emotional and political nerves. Some people see such change as threatening, while others see it as part of the global trend toward equality and justice (262). However sensitive the topic, taking a fresh look at how gender affects reproductive behavior is a necessary step toward improving reproductive health for all (53, 104, 110, 187, 262).

Little is known about the dynamics of couples' sexual and reproductive decision-making or about how gender roles affect these decisions. Such decisions can include whether to practice family planning, choosing when and how to have sexual relations, engaging in extramarital sexual relations, using condoms to prevent STDs, breastfeeding, and seeking prenatal care (28, 36, 117, 126, 148).

Gender is just one of many factors that influence couples and affect their reproductive decisions. Education level, family pressures, social expectations, socioeconomic status, exposure to mass media, personal experience, expectations for the future, and religion also shape such decisions (28, 115, 117). Consequently, no two couples' "decision-making environments" are identical (117). Some researchers have suggested that personal reproductive decisions result from many smaller, incremental decisions (35, 174, 281). Other researchers suggest that in fertility decisions social and cultural norms and expectations often prevail over individual preferences (117). In some traditional societies many couples say that the number of children they expect to have is not up to them at all, but rather up to God or to fate.

In some developing countries husbands dominate reproductive decision-making, whether regarding contraceptive use, family size, birth spacing, or extramarital sexual partners (73, 79, 85, 138, 142, 148, 188, 238). In Ghana, for example, some men in focus-group discussions claimed to make all family decisions. As one man asserted:

...We control them from the initial stage. When she comes to the house and maybe she thinks she is now the lady of the house and does something contrary to your regulations, you warn her. We don't allow our women to have influence on us (73).

A study of the fertility decisions made by five generations of one South Indian family also found that the men tended to control contraceptive use and to make fertility decisions. The men in the older generations chose to limit their own fertility by getting vasectomies, usually without telling their wives. The men said that economic pressures were their main motivation to limit the number of children. A survey of all five generations in this family revealed that more than half of the men thought the decision-making was mutual, but only 38% of their wives saw it that way (129).

Men's control over reproductive decision-making may be weakening, particularly among younger generations and in certain cultures. In many societies, as social, economic, and educational opportunities for women increase, traditional gender roles are starting to change. As a result, power is being redistributed between men and women. Evidence from several countries demonstrates that, increasingly, reproductive decisions are being made jointly by couples, not by men alone (96, 180, 200).

In Peru, Argentina, and Brazil, for example, research by Gary Barker has identified a group of young men who, contrary to the widespread machisto image, negotiate sexual and reproductive decisions with their partners and are willing to initiate contraceptive use (23). In Sri Lanka, where women's levels of education and literacy are high, a study among couples currently using contraception reported that more than half of the wives and about two-thirds of the husbands said that decisions about family planning were made jointly (65). Also, Japan's patriarchal culture has been changing away from decision-making primarily by husbands and parents toward decisions made jointly by couples (180).

Because of their gender roles, many women around the world have trouble talking about sex or mentioning reproductive health concerns (36, 92, 248, 264). They may not be able to ask their partners to use condoms or to refuse sex, even when they know they risk getting pregnant or being infected with an STD, including HIV (36, 79, 106, 110, 154, 202, 248, 292). In Uganda research found that one person in every four believes that a woman cannot refuse sex, even if she knows her partner has AIDS (36).

Women may submit to men because they are afraid of retaliation, such as being beaten or divorced, and because their gender roles place them in subordinate positions in society (24, 36, 67, 248). For women worldwide, the impact of gender inequality is apparent in many of their reproductive health problems (4, 24, 106, 157, 158, 218, 248, 251, 264, 292).

Male gender roles harm men's health as well women's. A mix of cultural norms, social expectations, and men's sex drive encourages men's risky sexual behavior (21, 53, 58, 236). Some societies, as in Haiti and Thailand, accept that married men will have extramarital sex, either with girlfriends or prostitutes (243, 248). Similarly, in many Latin American and Caribbean cultures, the concept of machismo encourages men to be promiscuous to prove their masculinity (21). Such male gender roles can contribute to their contracting STDs and passing them on to their wives or girlfriends. Male gender roles prompt some men to live recklessly in other ways, a fact that is evident in many national health statistics. In Mexico, for example, the top three causes of death for men are accidents, homicides, and cirrhosis of the liver (21).

Couple Communication

Couple, or spousal, communication can be a crucial step toward increasing men's participation in reproductive health (26, 33, 141, 151, 181, 239). Since men, as well as women, play key roles in reproductive health, communication is necessary for making responsible, healthy decisions.

Communication enables husbands and wives to know each other's attitudes toward family planning and contraceptive use. It allows them to voice their concerns about reproductive health issues, such as worries about undesired pregnancies or STDs. Communication also can encourage shared decision-making and more equitable gender roles.

Research over more than 40 years consistently demonstrates that men and women who discuss family planning are more likely to use contraception, to use it effectively, and to have fewer children (28, 65, 113, 122, 126, 141, 167, 239). In contrast, when men and women do not know their partners' fertility desires, attitudes about family planning, or contraceptive preferences, the consequences can include unintended pregnancies, transmission of STDs, and unsafe abortions (33, 106, 114, 161, 219).

Sometimes, however, communication between partners may not be desirable. For example, a woman may use contraception covertly because it would be unwise and even dangerous for her to inform or try to involve her partner. Counselors need to assess carefully the reasons for covert contraceptive use and the appropriateness of encouraging spousal communication (34).

The DHS and other studies that have interviewed husbands and wives about fertility and family planning offer insight into the extent of their communication on these topics (36, 54, 72, 76). Using surveys to assess spousal communication is difficult, however (28, 33, 103). Communication is an ongoing process, but surveys capture information from only a single point in time. They do not chart the progression of a couple's discussion or decision-making. Further, surveys alone cannot determine to what extent communication between partners promotes contraceptive use and to what extent the use of contraception leads to spousal communication (28, 141, 183, 219).

The DHS report two aspects of couple communication about family planning, occurrence and frequency. First, the DHS ask husbands and wives whether or not they discussed family planning with their partner in the preceding year (76). Of husbands and wives who report discussing family planning at all, the DHS then ask how often they did so—once or twice, or more often (76).

In West African countries only a minority of married men surveyed reported discussing family planning with their wives in the past year from 23% in Niger and Senegal to 43% in Mali (see Figure 3). In East African countries surveyed men were more likely to have discussed family planning—from 49% in Burundi to 68% in Kenya.

In Egypt, Morocco, and Bangladesh, couples were even more likely to have discussed family planning in the past year (76). In Pakistan, however, just 25% of men reported doing so (151).

Among couples who discussed family planning, husbands and wives reported similar frequencies of discussion. Most said that they discussed it more than twice within the past year. Couples in East Africa were most likely to report frequent discussions, with men reporting more frequent discussions than women. Couples in Mali, Niger, and Pakistan reported the lowest frequencies of discussion (76).

Studies in other regions also find that spousal communication about family planning is uncommon (78, 161, 188). For example, qualitative studies in the Central Asian Republics of Kazakhstan, Kyrgyzstan, Turkmenistan, and Uzbekistan reveal that married couples rarely discuss matters related to sex or reproductive health. In focus-group discussions men and women said they were too embarrassed to talk about these subjects. Most men said that they leave family planning decisions to their wives, but they expect their wives to ask for approval to use contraception. Rarely, however, do they reject the wife's choice of method (238).

Similarly, in urban Peru women said in focus-group discussions that husbands and wives rarely talk about the number of children they want to have. Women said that they must have children soon after marriage to please their husbands (85). A study of Bolivian couples found that most men and women have positive attitudes toward family planning, but only half said that they discussed with their partner the number of children they desired (298).

In Uganda researchers found that fewer than half of respondents had ever discussed family size with their spouses. On average, only about one-third of men or women reported ever talking with their partners about the number of children they would like to have. Couples in urban areas were more likely to talk about childbearing than rural couples (36).

Partners may communicate their reproductive desires or concerns through nonverbal or indirect means, if they do so at all (36, 85, 117). In Uganda, for example, most communication between men and women regarding reproductive issues took the form of suggestions, hints, and talking to friends or relatives in the hope that they would convey the information to the sex partner (36).

As with decision-making in general, women's inferior status and lack of power limit couple communication (66, 67, 71, 74, 88, 106, 164, 219, 292). For many women traditional female gender roles mean they have little say in sexual matters and lack the status to influence their partners' behavior ( 67, 85, 164, 248, 264, 292). Even when men and women discuss reproductive health issues, it is usually not on equal terms (64).

Traditional cultures often discourage married women from starting discussions about contraception. For their part, men may feel there is nothing to discuss or no need to take account of their wives' feelings and opinions. In countries such as India, Kenya, and Nigeria, traditional male dominance is a major obstacle to spousal communication about family planning ( 72, 119, 181). Also, a husband might consider his wife promiscuous or unfaithful if she tries to discuss contraception with him (85). In some cultures it is easier for unmarried women and prostitutes to negotiate sexual activity with men, including condom use, than for married women to do so with their husbands (248).

In focus groups Haitian women described a situation that many women face. They said they were afraid of contracting HIV from their husbands but found it hard to discuss the subject with them. Few women thought that their men were faithful, but most felt powerless to change their husbands' sexual behavior. They feared being beaten or raped if they raised the issue of contraception or resisted a husband's sexual advances. They also feared that, if they refused to have sex, their husbands would turn even more to prostitutes or other women (248).

Women's status and communication. As women's equality with men increases, so does their ability to communicate about reproductive matters and to participate in reproductive decisions (28, 164). When a woman shares decision-making power, she is better able to bring up and discuss family planning and sexual relations with her sex partner.

In particular, better-educated women can communicate more easily with their husbands (54, 89, 164, 200). More educated women are better informed, better able to gather information from newspapers and other media, and usually more articulate (203). Education may also increase a woman's earning capacity—and thus her leverage in household decision-making—and raise her self-esteem (164).

The closer a man and woman are in their levels of education, and the more education they have, the more likely they are to discuss and use family planning (54, 65, 164). A study of Nigerian couples found that, when both husband and wife have secondary or higher education, 61% of couples reported discussing family planning. When neither spouse was educated, only 15% reported discussion (164).

A woman who has some economic power also may be more likely to discuss family planning with her husband (89). In Togo women who worked for cash and invested some of it in credit or savings plans reported the highest levels of communication with their husbands about family planning. The level was substantially higher than among women who worked for cash but did not invest or who did not work for cash at all (89).

The type of marriage—whether free choice, arranged, or polygynous—also affects the relative power a woman has and thus the extent that the couple communicates (89, 138, 140, 164). In Togo, for example, women who chose their husbands without any family advice reported the highest levels of discussion with their husbands about family planning. Those in marriages arranged by their families reported the lowest levels of communication (89). Women in polygynous marriage often have low status and report little communication.

Also, the age of a woman at first marriage relates to her ability to communicate. The younger the woman, especially if she is much younger than her husband, the less communication there is about family planning (73, 89).

DHS consistently show that, especially in sub-Saharan Africa, many women mistakenly assume their husbands disapprove of family planning ( 33, 141, 161, 219). Data from matched husband and wife surveys illustrate the extent of wives' misperceptions. In the Dominican Republic, for instance, 14% of women think their husbands disapprove when, in fact, they approve. Another 8% do not know their husbands' attitudes, but the husbands actually approve (see Figure 4). Such findings suggest that women's unmet need for family planning could by reduced by better communication between husbands and wives.

In Burkina Faso, focus-group discussions with men and women separately found that communication between the sexes about family planning was almost nonexistent. Their lack of communication meant that they frequently misperceived each other's views. "The men thought the women were largely ignorant of family planning, generally opposed to it and in need of education.... The women said the same thing about the men" (161).

A woman's perception of her husband's attitude toward family planning strongly influences whether she will use family planning (33, 141, 219). If a woman thinks that her husband approves of family planning, she is much more likely to use it. In an analysis of DHS data from Kenya, for example, a wife's perception of her husband's approval was more significant in explaining whether or not she used contraception than two other communication variables—discussion between partners about family planning and agreement between spouses about approval of family planning (141). One of the oldest studies on couple communication, done in the 1950s in Puerto Rico, found the same pattern. One-third of the women who did not use family planning said it was because they thought that their husbands disapproved (113).

Lessons Learned and
      Program Implications

The question today is no longer whether to involve men, but rather how to involve them (61). How can reproductive health care providers best increase men's participation? How can programs communicate effectively with men? How can they reach more men and meet men's needs? How can programs encourage more men to care about reproductive health?

The number of reproductive health activities that address and include men has increased in the past several years (59, 98). The challenge for these expanding activities is to incorporate new perspectives on men's participation into the design and implementation of reproductive health communication and services.

Program experience with men's participation yields many lessons. Population Reports has identified nine major lessons that can help guide program managers and policy-makers. These lessons can be grouped as follows:

• Reach Male Audiences with Appropriate Messages
  Lesson 1. Build on men's approval of family planning.
  Lesson 2. Use the mass media to communicate with men.
  Lesson 3. Reach out to young and unmarried men.

• Use Communication to Promote Behavior Change
  Lesson 4. Understand the influence of gender.
  Lesson 5. Encourage couple communication.
  Lesson 6. Bring information to where men gather.

• Offer Information and Services That Men Want
  Lesson 7. Inform men about condoms and vasectomy.
  Lesson 8. Counsel men with respect and sensitivity.
  Lesson 9. Offer men a range of health services.

• Recalls family planning and other reproductive health messages
• Understands what messages mean
• Can name products, methods, or other practices and/or sources of services/supplies

• Responds favorably to reproductive health messages
• Discusses messages or issues with members of personal networks (family, friends)
• Thinks family, friends, and community approve of practice
• Approves of practice

• Recognizes that specific health practices can meet a personal need
• Intends to consult a provider
• Intends to practice at some time

• Goes to a provider of information/supplies/services
• Chooses a method or practice and begins use
• Continues use

• Experiences and acknowledges benefits of practice
• Advocates the practice to others
• Supports community programs

Many men appear ready to change their reproductive health behavior and willing to participate more in reproductive health activities. In changing their behavior, people generally pass through five steps: knowledge, approval, intention, practice, and advocacy (121, 190) (see model at above).

Surveys and other studies suggest that many men have already gone through the stages of knowledge and approval and are now ready to adopt healthier practices. Hundreds of millions of men and their partners are using family planning. Millions more know and approve of contraception but are not using it (see Avoiding Unintended Pregnancies, Meeting Unmet Need and The Gap Between Approval and Use). Unmet need for family planning is substantial. Even where contraceptive prevalence is low, as in West Africa, many men say that they want to learn about family planning and to improve their own reproductive health and that of their families (10, 12, 60, 207, 276).

More men probably would take better care of their own reproductive health and that of their partners if programs reached out to them with appropriate information. A number of programs are finding ways to do that. Concerned about the spread of HIV/AIDS, the Transport Corporation of India, in collaboration with the AIDS Control and Prevention Project (AIDSCAP), started the Bhoruka AIDS Prevention Project (BAP) in 1995 (7). Thousands of truck drivers spend days waiting to cross the Nepal-India border. Separated from their wives or girlfriends, the men often turn to commercial sex workers. Social workers educate the truck drivers about HIV/AIDS and refer them to the BAP clinic in Raxaul, a checkpost city on the Indian side of the border. Collaboration with outreach workers in Nepal helps to ensure that truck drivers on the Nepali side also are referred to the clinic. At the clinic male and female doctors offer the men medical services, particularly counseling and treatment of STDs.

During the first year of the program, the number of people seeking counseling and testing for HIV increased from 136 to 2,431. Requests for condoms rose from 630 to 26,290. The BAP project adopted a condom logo, which it pretested to ensure its appeal to both Indian and Nepali truck drivers. It uses the logo on posters, leaflets, and counter displays urging the truck drivers to practice safe sex (7).

In Mardan, Pakistan, outreach workers with the Urban Community Development Council, an all-male organization founded 20 years ago, found that there was much higher demand for family planning information and contraception among men than assumed (195). Although most people in Mardan have conservative attitudes, husbands responded positively when male field workers approached them with information about reproductive health services. Demand for contraceptives exceeded expectations. The project now includes five clinics, and over 200 male Community Educators provide family planning information, distribute condoms, resupply oral contraceptives, and refer men to clinics (195).

The media can impart different messages depending on the needs of the specific audiences and their stage in the process of behavior change. For instance, men need accurate information about contraceptive methods, women's menstrual and fertility cycles, transmission and prevention of STDs, pregnancy, child health, and their own reproductive health. They also need to know where to go for services, counseling, and answers to their questions.

Radio, television, video, and newspapers all may be used in strategic ways to give men important information about reproductive health. A successful campaign is based on audience analysis and research. It follows a proven model of behavior change to design the campaign, pretest messages and materials, monitor progress, and evaluate results (190). In Uganda, for example, the Busoga Diocese's Family Life Education Program reached men with information about reproductive health through short radio dramas that addressed questions such as, "What does an STD look like?" (13).

In Bolivia the Las Manitos National Reproductive Health Campaign reached about 500,000 potential family planning users through radio and television spots and also through in-clinic videos, audio cassettes played on public buses, and posters. The percentage of men who said they intended to seek reproductive health services increased from 25% in the baseline survey to 60% in the follow-up survey after the campaign (122).

In Swaziland the national Family Planning Association (SFPA) joined forces with The Times newspaper to educate citizens about HIV/AIDS. More than 21,000 condoms were inserted into newspapers and distributed by SFPA one Saturday in March 1998 (294).

The mass media also can depict men in positive new roles. Depictions of men in the mass media can influence social norms and expectations of male behavior—for example, by showing men how to become better husbands and fathers. In Egypt a series of television spots encouraging male responsibility featured men in unconventional roles, such as ironing clothes, helping a daughter with school work, and talking with their wives about family planning (136). Also, in Jordan the communication campaign Together for a Happy Family depicts positive male roles in television and radio spots and involves religious leaders as advocates for contraceptive use (see sidebar, Applying Lessons in Jordan: Together for a Happy Family).

Providing information. To help prepare boys and young men to become more responsible sexual partners and spouses, programs can offer relevant information about sexuality and reproductive health, including the risks of STDs and how to avoid them (159). Young men also need encouragement to delay sexual activity until they are better prepared to cope with their own and their partners' emotional and health needs. Influencing young men to delay sexual initiation requires changing social norms and how young men perceive themselves. It may also mean changing how parents, friends, teachers, and girlfriends define masculinity. Training in interpersonal communication skills can help young men talk honestly with girlfriends about reproductive health issues.

Entertainment formats and the mass media can be powerful ways to reach youth with reproductive health information (123, 159, 198). In Uganda, for example, a national music competition called "Hits for Hope" formed the centerpiece of the government's HIV/AIDS prevention effort (123). Young artists performed original songs with AIDS-prevention messages. The winners recorded their song, Ray of Hope, in a professional studio, and it aired on national radio as part of a 6-month mass media campaign in 1995 (123).

Also in Uganda, Straight Talk, a monthly insert in a daily newspaper, provides young people with information and advice about sex, sexuality, STDs, and HIV/AIDS (112). Much of the information comes in the form of answers from a sociologist and physician to readers' letters asking for advice. Straight Talk also features quizzes, contests, and readers surveys to engage its audience (112).

Young men can be a particularly challenging audience to reach. Because young men and their health needs vary considerably, programs often cannot reach them as a single, homogenous group (80). For example, young men who have dropped out of school are usually much more likely to be involved in risky sexual behavior than are students. They are also harder to reach (297).

Some youth programs have found that peer educators can reach groups of adolescents with reproductive health information (80, 97, 165). In Botswana, for example, as part of the Tsa Banana Reproductive Health Program, peer educators talked to secondary school students about pregnancy, AIDS, HIV transmission, and condoms. They demonstrated correct condom use and taught sexual negotiation skills, including how to refuse sex and how to ask a partner to use a condom (165).

In 1990 UNICEF launched a multimedia campaign in Asia to promote girls' potential for achievement when they receive equal education and support. Meena, the young heroine of an animated cartoon series, confronts problems that many girls face: son preference, early marriage, lack of educational opportunity, and poverty. The Meena series has been broadcast in 14 languages on both television and radio, reaching about 57 million people. Recently, UNICEF began 13 new episodes in Bangladesh, India, Nepal, and Pakistan.

The series is changing people's attitudes. As one father of four daughters said after watching Meena, "I will make sure my daughters get more opportunities than my wife or mother ever received" (146, 258). Building on the success of the Meena campaign in Asia, a similar character, named Sara, has been developed for Africa. Researchers drew on discussions with over 5,000 people from Eritrea to South Africa to create a realistic girl that Africans will relate to and learn from (163).

Important lessons about gender awareness have also been learned from unintended consequences of programs designed to increase men's participation. For example, during the 1970s and early 1980s, Profamilia in Colombia used the Latino machisto image to promote vasectomies. As Executive Director Maria Isabel Plata explains, that was a mistake because it reinforced negative stereotypes, such as sexual promiscuity and male dominance in decision-making. The number of vasectomies remained low. In 1985 Profamilia adopted a new strategy that emphasized male responsibility. "For the first time, men were being told that they could also participate. By (our) being gender sensitive, the number of vasectomies doubled and tripled," says Plata (192).

As another example, in Zimbabwe a multimedia campaign in 1993-94 to promote men's use of family planning relied on prominent sports players to tell men about the importance of practicing family planning (122). The campaign succeeded in reaching men and encouraging their participation. As an unintended consequence, however, some men exposed to the campaign were more likely to believe that they alone should make family planning decisions.

One possible explanation is that the campaign unintentionally reinforced stereotypes about male-dominated decision- making (122, 133). Another explanation is that men interpreted the campaign's primary message "Family Planning: It's Your Choice" to mean they should make such decisions by themselves. Subsequent men's participation campaigns in Africa, such as the Challenge CUP Initiative (see Lesson 6), have pretested messages to ensure that the audience correctly understands the intended reproductive health behavior.

Practical needs, strategic interests. In approaching gender issues, programs often face a difficult decision—how much to accept a society's gender roles and work within their confines to make health gains in the short term, and how much to devote attention to the long-term task of changing gender roles to promote gender equity. These different goals have been described as "practical needs" and "strategic interests" (53). For example, increasing condom use for HIV prevention through social marketing is a practical need. Changing social norms so that men and women feel comfortable discussing sexual relations is a strategic interest.

In Jamaica a new condom called Slam, designed to appeal to young men, is prompting a debate about practical needs versus strategic interests (285). The condom is named after the title of a popular song about a sexy dance hall queen, but it also implies violent sex. No Glove, No Love Ltd., the company marketing the condom, argues that condom promotion needs to be realistic in order to appeal to the male audience. By promoting a condom that will enhance sex and make it safer, the company contends, it can help to reduce STD rates, prevent unwanted pregnancies, and save lives.

While supporting these health goals, critics of the campaign worry that the campaign demeans women and encourages men to treat them badly. They argue that the name of the condom sends out a dangerously mixed message that condones or encourages sexual violence against women.

Long-term social change can seem threatening to men who see power distribution as a zero sum game, in which women can gain only if men lose (262). Practical needs and strategic interests need not conflict, however. In fact, addressing the practical needs of women can be an "entry point" to working for longer-term gender equity or fairer power distribution (53). Therefore programs need to address strategic interests with an eye to minimizing opposition and gaining support from male leaders.

Recently, several projects have increased use of contraception by facilitating communication between husbands and wives. In Bangladesh, for example, the Jiggasha project uses existing rural communication networks to make discussion about reproductive health more culturally acceptable and to foster more communication among men and women (190). Jiggasha is the Bangla word for "to inquire."

Jiggashas are village discussion groups composed of either men or women; they meet separately. The jiggashas create a comfortable place for men and women to ask questions about family planning, contraceptive methods, and reproductive health (122). Specially trained field workers collaborate with male and female opinion leaders in the village to teach about contraceptive methods, answer questions, distribute contraceptives, and make referrals. They also encourage both men and women to talk with their spouses about family planning. Men's participation in the jiggashas helps to create an environment of approval for family planning.

Follow-up survey results suggest that the jiggasha approach complemented existing family planning efforts by field workers. In villages with family planning field workers as well as jiggashas, the contraceptive prevalence rate (CPR) increased from 38% to 56%. In villages with field workers but without jiggashas, the CPR rose from 26% to 32% (122).

In rural Honduras an agricultural extension program offers an example of a low-cost way to involve men in reproductive health and to increase couple communication about family planning (194). While meeting with farmers, paid extension workers used an interactive manual to talk about reproductive health. In some areas couples also were given a booklet designed to help husbands and wives plan their long-term family goals. In both areas communication between spouses improved. The percentage of women who reported discussing family planning with their husbands increased from 36% to 50%. The percentage of couples discussing STDs and HIV rose from 42% to 54% (194).

There are many different ways to find men. In southern India more than 250,000 barbers have been trained as community health workers. They talk about condoms and distribute them to clients in their shops. Village men say they feel more comfortable talking with their barbers than to clinic workers (11).

In 1995 the Family Planning Association of Kenya (FPAK) began an ambitious 5-year project to involve men in family planning and reproductive health (122). The Male Involvement Project reaches men through a variety of channels, including going to their workplaces. John Karanja is a typical workplace motivator. Employed at the Nakuru blanket factory, he teaches his fellow employees at lunch-time and at after-work seminars about contraception, birth spacing, and HIV/AIDS. He sells contraceptives, such as the Pill and condoms, to men after work. He bicycles to the houses of employees in the factory compound to answer men's questions and to encourage couples to make reproductive decisions together. On these home visits, he also refers clients to the FPAK clinics for vasectomy or tubal ligation, if the couple has decided they want permanent contraception.

To reach other working men in the Nakuru district, male staff members of the FPAK clinic put on puppet shows in the local park during the lunch hour. The puppets are an entertaining, nonthreatening way to educate men and women about contraceptive methods, STD/HIV prevention, and available reproductive health services. At the end of each show the puppeteers invite questions from the audience (93).

All over the world, sports events attract many men. In Africa, as elsewhere, football is a passion among men and boys. Tapping this natural audience, Johns Hopkins Population Communication Services launched the Challenge CUP Initiative in 1997 in Ghana, Kenya, Uganda, and Zambia. CUP stands for "Caring, Understanding Partners." The Challenge CUP Initiative encourages men who attend the football matches to become more sexually responsible, to prevent STDs, to learn more about reproductive health, and to discuss it with their wives or other sex partners. To reach the large crowds attending the games, a variety of materials featuring key reproductive health messages are given away, including trading cards of football stars, T-shirts, sun visors, bumper stickers, and informative pamphlets (207). At the same time, coaches and football players are counseled about positive reproductive health behavior. Several star players serve as spokesmen and role models, speaking about spousal communication and STD prevention at half-time during matches and also on radio and television.

In the developing world, excluding China, the prevalence of condom and vasectomy use among married couples averages just 4% and 3%, respectively. Use is slight partly because men do not know enough about these methods and may believe rumors. Men need clear, factual information from reliable, trusted sources.

Condoms. Condom promotion and sales have increased in response to the HIV/AIDS epidemic, but use of condoms falls far short of the need for them (81, 139, 144). For sexually active people with multiple partners, using condoms is the only way to protect against HIV/AIDS. Many men do not like condoms, however, because they interrupt sex and diminish pleasure. Others do not trust condoms. Many men and women think mistakenly that condoms often break or that tiny, invisible holes allow sperm and HIV to pass through (77).

In many countries social marketing helps to make condoms widely available. Worldwide, social marketing programs sold 937 million condoms in 1997, 20% more than the year before (299). Social marketing programs promote condoms both for family planning and for STD prevention (81, 144, 197). In Vietnam, for example, social marketing has focused on condoms for family planning (94). Cambodia's Condom Social Marketing Program has helped to promote safer sexual behavior as well as to increase demand for condoms for family planning. Before Population Services International (PSI) started a social marketing program in 1993, condom sales in Cambodia averaged about 2 to 3 million annually. In 1997 sales were estimated at 10.5 million (197).

In addition to more promotion and better availability, another approach to increasing condom use is developing new condoms that allow more sexual pleasure and convenience (263). A new, looser condom has been launched in Europe to appeal to men who are skeptical of condoms. The condom is designed to be more comfortable and easier to put on. It is made of polyurethane, not the usual latex, and is about half as thick as a conventional condom (184).

Vasectomy. While many men do not choose vasectomy because they desire more children, others shun vasectomy because they believe incorrectly that it will lower sex drive, cause impotence, and be inconvenient. Several communication campaigns have used the mass media to get facts to men about the safety and ease of vasectomy. For example, a 1994 vasectomy promotion project in Kenya aired spots on a private television station to improve men's attitudes toward vasectomy. Advertisements in newspapers motivated men to request more information about vasectomy and told men about clinics that perform vasectomies (122). As a result, 835 men in the Nairobi area requested information about vasectomy, more than double pre-campaign requests. After six months of the campaign, the number of vasectomies had increased by 125% (134).

An IEC campaign in Dar es Salaam, Tanzania, sought to dispel rumors about vasectomy and to promote its benefits. During 1995 and 1996 the Vasectomy Promotion Project used radio, newspapers, and satisfied client testimonials to give men and women the facts about vasectomy and to provide information about available services. Addressing a common misperception of men, the campaign stressed that vasectomy differs from castration. It sought to allay men's fears of side effects such as loss of sex drive, obesity, and impotence. The campaign, which reached more than 60% of its intended audience, concluded that men are willing to choose vasectomy if providers educate them and inform them of its availability (173).

In Brazil a multimedia campaign promoted vasectomy as "an act of love." The central image of the campaign was a cartoon of two hearts, one male and one female, who playfully depicted the advantages of vasectomy. The animated cartoon aired on television, and the hearts were featured in pamphlets, magazine advertisements, and billboards. During and after the campaign, requests to clinics for information about vasectomies increased substantially (122, 134). Years after the campaign, family planning clients still referred to the two hearts (63).

Potential family planning clients consider information from friends and relatives to be reliable and trustworthy. Thus satisfied vasectomy clients often can recruit new clients (13, 266, 282). The Family Planning Association of Pakistan, for instance, asks its clients in Faisalabad who have had vasectomies to recommend the procedure to friends and relatives interested in permanent contraception. Also in Brazil, Colombia, and Mexico, vasectomized men have been especially influential in helping other men decide to have vasectomies (266).

In Colombia Profamilia opened its first clinics for men in 1985, performing 1,241 vasectomies that year. Its male clientele has increased steadily since then. A decade later Profamilia performed 6,825 vasectomies in a year (14).