Background
Family planning (FP) has many societal benefits including reduction of maternal and infant mortality, improved economic development through increased women’s participation in the labor force, and more sustainable use of resources due to reduced population growth [
1‐
4]. However, many women do not practice FP despite their desire to delay or avoid childbearing [
1]. It is estimated that a quarter of women of reproductive age in the developing world want to avoid pregnancy but are not using an effective contraceptive method (in other words, they have an unmet need for FP) [
5]. This translates to an estimated 225 million women in developing countries having an unmet need for modern contraception [
5]. The burden is worse in sub-Saharan Africa where it is estimated that, in 2012 alone, 60 % of women of reproductive age (i.e. ages 15–49) had an unmet need for modern contraception [
6]. According to the most recent Demographic and Health Surveys (DHS) in Kenya (2014), Nigeria (2013), and Senegal (2010/11), the proportions of women in union (i.e. married or cohabiting with a male partner) using a modern contraceptive method are 53, 10, and 12 % respectively [
7‐
9]. These low levels of modern contraceptive prevalence are discouraging, especially in light of the region’s high fertility and high maternal and infant mortality rates. With such low levels of modern contraceptive method use, it is expected that the unmet need for FP will be high. However, only 18, 16, and 30 % of women in union reported having an unmet need for FP in Kenya, Nigeria, and Senegal, respectively [
7,
8,
9]. These low proportions of unmet need for FP indicate that high fertility desires continue to persist in these countries.
Several studies have found that women in sub-Saharan Africa face many sociocultural barriers to use of modern contraceptive methods [
10‐
12]. A common reason for non-use of modern methods is male partner opposition to FP [
12‐
18]. A number of studies show that men’s reproductive intentions (or women’s perceptions of men’s intentions) affect the contraceptive behavior of their female partners [
13,
17,
19,
20]. This is often manifested through men’s disapproval of FP, their desire for more children, and/or lack of spousal communication about FP. Despite men’s key role in sex and reproduction, they are often left out of FP discourses and programs.
Two decades have passed since the 1994 International Conference on Population and Development (ICPD) that led to recommendations to involve men as clients, partners, and agents of change in sexual and reproductive health, including FP [
21]. Male involvement was positioned as essential to the success of FP programs [
21‐
23]. However, not many FP programs have involved men. Among the few studies in sub-Saharan Africa that include men, a majority focus on factors associated with couples’ FP practices within the context of HIV/AIDS [
15,
23,
24] or men’s reported knowledge and use of contraceptive methods [
25‐
28] rather than the impact of reproductive health programs on men’s contraceptive behaviors. Therefore, there remains a dearth of knowledge on the best strategies to engage men in sexual and reproductive health programs and the impact of male involvement on FP adoption and continuation. Scientific evidence exists on the impact of FP programs on increasing contraceptive ideation/approval and use, and reducing fertility among women [
29‐
34]. However, less is known about the impact of such programs on men’s involvement in couples’ use of modern contraceptive methods.
One evaluation study that included married men in northern Ghana found that men who reported being encouraged to use FP by at least one person in their social network were more likely to approve of FP and to discuss contraceptive use with their wives compared to those who did not receive such encouragement [
35]. Men’s increased FP approval and communication were found to be associated with their female partners’ increased use of modern contraceptive methods [
36]. A second study examined a peer-delivered educational FP intervention that targeted married men in Malawi and found increased uptake of modern contraceptive methods (especially male condoms and injections) through improved spousal communication about FP [
37]. A third study, conducted among men in rural Gambia, showed that involving religious leaders in teaching about the connection between Islam, health, and FP resulted in increased knowledge of the different contraceptive methods and a 13 percentage-point increase in couples’ contraceptive use over a one year period [
38]. Further, Terefe and Laron (1993) conducted a field trial in a semi-urban community in Ethiopia on the efficacy of home visitation by health personnel on women’s modern contraceptive use, with or without the husbands’ participation [
39]. They found that involving the husbands during the home visits resulted in increased uptake of contraceptive methods by couples two months following the intervention and was sustained even after 12 months. In addition, there was less discontinuation of the contraceptive methods in the experimental group (husband participation) compared to the control group (wife only) [
38]. Lastly, a 2003 study conducted in Uganda examined the relationship between exposure to behavior change communication (BCC) campaigns in the media (television, radio, posters, and print media) and use of modern contraceptive methods among men and found a positive dose-response effect between media exposure to FP messages and modern contraceptive use, mostly male condoms [
40]. In summary, targeted FP messages delivered by peer educators, health personnel, religious leaders, and multimedia sources seem to have positive associations with men’s FP use and, in some cases, couples’ use of modern contraceptive methods. Many of these studies involved the evaluation of a single-strategy FP program. Thus, little is known about the effect of a multi-strategy FP intervention that includes community education and media campaigns. Implementing a multi-strategy FP intervention may reach a broader audience and possibly have a larger impact on modern contraceptive use.
FP programs may also have heterogeneous effects on pregnancy prevention depending on the geographic context, for example rural versus urban contexts. The high rate of urbanization coupled with little or no change in urban development, especially in sub-Saharan Africa, has led to concentrated poverty in urban areas resulting in an increased number of slums [
11]. The health and development challenges faced in urban slums are likely different from those faced in poor rural areas. Hence, there is a need to understand the effect of FP programs in urban areas especially in those areas with high poverty and fertility rates. Our study helps to fill the gap in information on the effect of a FP program on use of modern contraceptive methods among men in select urban areas in sub-Saharan Africa. We assessed the association between exposure to a multi-strategy FP program implemented in select urban areas in Kenya, Nigeria, and Senegal and the report of modern contraceptive method use by men in the studied areas. Identifying strategies to increase men’s approval and use of modern contraception is relevant to improving FP practice in sub-Saharan Africa.
Discussion
This study demonstrates that targeted FP demand-generation activities can lead to improvements in men’s reported use of modern contraception. The Urban Reproductive Health Initiative (URHI) program in these three countries undertook comprehensive demand-generation activities that included mass media (radio and television), interpersonal communication (meetings, outreach activities, and engaging religious leaders), and branding of program materials. These activities were differentially related to men’s modern method use in the varying study contexts. In particular, in Kenya, community outreach events were associated with greater modern method use among men but were not found to be significant among men from the other two countries. In Nigeria, exposure to NURHI’s English Language slogans was associated with modern method use particularly in Kaduna; this suggests that interventions may need to differ across cities. Finally, in Senegal, there were significant associations between modern method use and exposure to radio advertisements/programs and to religious leaders speaking favorably about FP.
Differences found across countries may reflect the types of FP messages used on the radio, television, and in interpersonal communication activities employed in the various settings. The NURHI team used formative research to design their multi-pronged demand-generation strategy that used local language and English language slogans and messages [
35]. As seen here, these activities were associated with greater use among men in Kaduna (in the North) but not in Ibadan (in the South). This may reflect greater latent demand for modern FP in Kaduna where the use of modern contraceptive methods at baseline was only 20 % among men as compared to 40 % among men in Ibadan [
47]. It may also reflect more effective (or targeted) activities in Kaduna that is a more homogenous city as compared to Ibadan that is very heterogeneous and may require a more diverse set of activities. Further, we found a negative association between exposure to
Tupange television programming and modern method use among men in Kenya; this might reflect the conservative culture of Mombasa and the fact that the media messages were designed for other less conservative urban areas of the country such as Nairobi and Kisumu. Finally, the differences across countries may relate to the program’s focus, or lack thereof, on men. The ISSU program in Senegal had more focus on men as compared to the URHI programs in Nigeria and Kenya.
Our results that show the association between targeted interventions and men’s use of modern FP are similar to the results found for women, but with some notable differences [
31]. Overall, exposure to the program activities was in a similar range between men and women and where there were differences, men were slightly higher on each of the items. Multivariate regression findings demonstrate that for women in Senegal, community outreach activities were significantly associated with modern method use whereas for men in Senegal, it was the exposure to religious leaders speaking favorably about FP that was significant. This distinction may reflect different activity spheres among men and women in urban Senegal but both reflect the role of interpersonal activities as a strategy for influencing FP use in the Senegal. Among women in Nigeria, mass media (radio and television) as well as interpersonal community events were associated with use of modern methods whereas for men, exposure to English language slogans (most likely on the radio) was associated with modern method use. These distinctions between men and women may reflect the need to design activities and messages that better reach men in the varying Nigerian city-level contexts. Among women in Kenya, exposure to Tupange print media and the Tupange radio program was associated with modern method use whereas for men, community events were associated with greater use of modern methods. Community events among men may represent activities targeting men in religious settings in Mombasa, a city that is more Muslim than most cities in Kenya.
This study is not without limitations. First, it is important to note that this study is based on cross-sectional samples of men in three African countries and thus cannot control for time-related changes in population characteristics or directly estimate the causal relationship between exposure to the URHI program and modern method use. Likewise, there is a potential recall bias among respondents as we are asking them to recall their exposure to program activities within the past year. Additionally, these results reflect URHI country-specific program exposure among men only after two years of program implementation. The endline evaluation results may show additional changes and associations between these demand-generation activities and modern contraceptive method use given more time for roll-out of activities and increases in program exposure levels across the study sites. Further, the cities included are not meant to reflect all urban areas within each country. They can only represent the contexts under study, especially in Nigeria and Kenya, where the largest urban areas, Lagos and Nairobi respectively, were not included. In addition, men may over- (or under-) report modern contraceptive method use. This may reflect their desire to give socially desirable responses or a true lack of knowledge of their partner’s contraceptive use. There is also a potential for selection bias for exposure to the URHI demand-generation activities. It is possible that men who have a favorable disposition to FP are able to recall seeing, watching, or participating in any of URHI activities compared to those who do not have this favorable disposition. This bias may also be associated with their probability of practicing FP. In light of these limitations, our study findings should be interpreted with caution.
Despite the limitations, this study provides valuable information. The evidence from prior studies on FP program impacts on men’s contraceptive method use is limited at best. The few studies that examined mass media programs targeted at men’s participation in FP decision-making and use showed positive impacts on contraceptive methods, mainly male condom use [
23,
48,
38]. Less is known about program impacts on use of a wider range of modern methods by men and their female partners. Our study begins to fill this gap. While we demonstrate some associations between program exposure and modern contraceptive method use, the main message is that FP programs likely need to not simply “include” men but actually target the program activities and messages to men. This may involve undertaking activities in places where men congregate and/or through specific medium that men use (e.g. religious leaders, television, radio, and sporting events). Furthermore, messages and strategies need to engage men directly (rather than indirectly) as clients, partners, and agents of change. This approach will likely encourage men to communicate with their partners about fertility desires and the need for FP, accompany their partners to a health facility for reproductive health issues, and gain better understanding and need for safe reproductive health behaviors. Additional qualitative and quantitative research is needed with men in varying contexts to better understand the roles men play and/or want to play in reproductive health such that programs can develop messages appropriate to the different contexts. For example, messages developed for one city in Nigeria may not be applicable to another city that represents different ethnic, religious, and socio-demographic groups. Additional research is also needed to better understand the dynamics of couples’ contraceptive choices within varying sociocultural settings.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ISS is a co-principal investigator of the MLE project; she conceived the idea of this paper and wrote parts of the manuscript. CCO conducted the statistical analyses and wrote parts of the manuscript. MC and AG participated in the data collection and revised all drafts of the manuscript. All authors read and approved the final manuscript.