Engaging the Missing Link: Evidence from FALAH for Involving Men in Family Planning in Pakistan

"When they are directly and effectively engaged, Pakistani men are ready to participate and share responsibility in family planning."

Results from the United States Agency for International Development (USAID)-funded Family Advancement for Life and Health project (FALAH), implemented from 2008-2012, show that the inclusion of men in family planning (FP) efforts is a feasible and effective intervention to help shift attitudes and behaviours in Pakistan and perhaps in other countries in the region and globally as well. This brief presents findings of a case study of FALAH's male engagement component and its contributions to these results. The document describes how the male engagement component was implemented and the outcomes achieved. Assessment of the outcomes is based on baseline and endline surveys conducted by FALAH in 2008-09 and 2011-12, as well as qualitative research in 4 districts of Punjab on community perceptions of male-focused interventions carried out by the Population Council in 2013. In addition, the case study includes relevant findings from external evaluations conducted by Contech International and Gallup Pakistan in 2011.

Implemented by a consortium of non-governmental organisations (NGOs) led by the Population Council, with partners Greenstar–Social Marketing, Health and Nutrition Development Society (HANDS), JHPIEGO, Rural Support Programme Network (RSPN), and Save the Children (USA), FALAH aimed to reduce unmet need (20% of women have unmet need) and improve access to FP services through community-based interventions in 20 districts in Pakistan's 4 major provinces: Punjab, Sindh, Khyber Pakhtunkhwa (KP), and Baluchistan. In Pakistan, husbands' approval is a decisive factor in contraceptive uptake, yet the Pakistan Demographic and Health Survey (PDHS) 2012-13 found that 76% of men (86% urban and 72% rural) disagreed with the idea that contraception is a woman's business and a man should not have to worry about it. In that light, a distinguishing feature of FALAH was the recognition and active involvement of men from the beginning in creating a supportive and conducive environment for FP. In its behaviour change communication (BCC) programme, the project emphasised the role of men as family leaders dedicated to ensuring the health of their wives and children.

The main objectives of FALAH's communication interventions for men, which are described below and illustrated in a pathway of change in figure 3 on page 5, were to: increase men's understanding of the benefits of birth spacing and the World Health Organization (WHO) recommended spacing interval of 24 months; encourage male responsibility in FP; increase interspousal communication on birth spacing, including communication initiated by men and men's responsiveness to communication initiated by women; increase knowledge of correct and effective use of contraceptives, including male methods; minimise fear of side effects from contraceptive use; and create awareness of various sources of contraceptive information, products, and services. The defining trait of its communication, advocacy, and mobilisation strategy was a focus on the practice of healthy timing and spacing of pregnancies (HTSP), with the message "birth spacing saves lives!"

To communicate with men, FALAH from the onset employed 5 types of interventions at the interpersonal, community, and mass communication levels, as follows:

1. "Man Talk": individual counseling through community-based volunteers (CBVs), referred to as falahi workers - "The innovative aspect of this intervention was its equal inclusion of male volunteers to inform, educate, and counsel men in [4 project districts in Sindh, 1 district in KP, and 1 district in Punjab]....This was found to be a strong complement to the more conventional intervention of female workers counseling women." After training and equipped with specially designed information, education, and communication (IEC) materials, each falahi worker conducted mobilisation activities consisting of individual and group sensitisation, education, and counseling sessions separately for men and women. At the end of the 7-month project period, the study found a contraceptive prevalence rate (CPR) of 50% among the women, much higher than the national estimate of 29% at that time, including much higher use of modern than traditional methods. Ninety percent of the women recalled that CBVs provided them with information on sources of FP, and 71% of current users said that CBVs were instrumental in motivating them to practice FP. About half of the women reported that their husbands participated in intervention activities conducted by male falahi workers, as illustrated by a case study of Ranjeet, who decided with his wife Heemi to delay her first pregnancy until she turned 18 based on counseling provided to him by male falahi workers.
2. Men's group meetings at the community level - In each of their assigned communities, the recruited and trained male community mobilisation officers (CMOs), social mobilisers, and village health committee (VHC) members organised men's group meetings (MGMs) every 3 months; approximately 20-25 local men participated in each session. Modern and conventional contraceptive methods were discussed, and myths and misconceptions regarding contraceptive use were clarified. This was done with the help of an audio cassette resource and a pictorial flip chart comparing a positive case of a couple who used contraception and a negative story about a couple who did not. One finding: Compared with a 42% likelihood of contraceptive use among men who did not participate in the meetings, the predicted probability of use of any contraceptive method was 59% among MGM participants.
3. Friday sermons at mosques by sensitised local religious leaders - At the outset, a meeting of ulema (religious scholars) was convened representing the major schools of Islamic thought. Participants agreed that the Quran enjoins mothers to breastfeed their children for 2 years, leading to natural spacing, which indicates that spacing is fully endorsed by the Quran and Sunnah (Islamic teachings). On this basis, they passed a unanimous declaration of unequivocal support for birth spacing in July 2009, which was captured in a 15-minute documentary entitled Farishton Nay Bhi Poocha ("Even the angels dared to ask"). The declaration was a cornerstone in FALAH's curriculum for sensitising religious leaders and communities to birth spacing and the Islamic perspective. A training-of-trainers approach was used to conduct 24 step-down sensitisation sessions for more than 1,500 religious scholars from different sects to become birth-spacing advocates. Religious leaders then propagated the birth-spacing message in Friday sermons, nikkah (marriage) ceremonies, and other religious gatherings attended by men in large numbers. "Of note was the dramatic improvement in...the proportion of men reporting that they would cooperate with their wives if their wives broached the topic of family planning, with the predicted probability of a positive response being 23 percentage points higher among men who attended talks by sensitized religious leaders."
4. Interactive community theatrical performances - Twelve theatre groups from FALAH partners HANDS were formed and trained to perform in underserved rural areas in 5 districts of Sindh where it was previously unacceptable to openly discuss FP and birth spacing. The audience was encouraged to participate in the performance by identifying indigenous solutions to the community problems highlighted. More than 1,000 interactive theatre performances were held, with over 61,000 female and 40,000 male participants in attendance. Community members were offered basic health care, maternal and child healthcare, and FP services through Mobile Service Units of the Sindh Population Welfare Department, which had been specially arranged in the vicinity after the performances. More than 11,600 women obtained FP methods from the Mobile Service Units; a further 617 clients were referred for other FP services.
5. Electronic media - Given the generally low literacy levels in the country, especially in rural areas, mass media was deemed fitting and featured FALAH's key messages such as: "As a responsible husband, talk to your wife about birth spacing for the health of your wife, children, and overall prosperity." The project produced: 4 radio spots; a television jingle; 2 television commercials ("Pauda" (Plant), on the dangers of early pregnancy, and "Waris" (Heir), on the problem of preference for male children; 13 episodes of a television talk show, "Kiyoun Ke Maa Bachay Ki Sehat he Sab se Barh Kar!" (Because mother and child health is most important); and the 15-minute video documentary discussed above, "Farishtoan Nay Bhi Poocha" (Even the angels dared to ask). Gallup Pakistan found that 50 million people were exposed to FALAH messages, at least half of whom were men. Exposure to FALAH messages through both radio and television led to an increase in the predicted probability of men communicating with their wives about FP and also of being approachable if their wives wanted to broach the subject. The television campaign resulted in a far stronger improvement in the predicted probability of men using contraceptives, compared with the radio campaign.

The paper concludes with reflections on these findings, noting that the FALAH approach to male engagement in 20 districts across Pakistan's 4 provinces shows that male engagement can be implemented on a large scale and that it can be synchronised with interventions that reach out to women together with men as is the case with interactive theatre or separately as with the male and female falahi workers. There is strong evidence that exposure to television messages and the men's group meetings have been clearly influential in changing important behavioural aspects of involving men more fully in FP programmes. It is notable that the media campaigns translated into a significant increase in the proportion of men likely to have an actual conversation with their wives about FP in the preceding year. In shifting the focus from fertility limitation to HTSP, obtaining the documented endorsement of religious scholars representing all schools of thought, and involving these scholars in the development of its training and communication activities, FALAH presented the FP message in a new paradigm.

The project's success has been noted by provincial policymakers, and the most recent provincial population policies envisage a greater focus on involving men, including replication of some of FALAH's interventions. To that end, implications for engaging men in future FP interventions in Pakistan include, for example, making men a focus, adopting the HTSP paradigm, obtaining religious endorsement, introducing male health workers and providing peer support to men, and communicating creatively at all levels.