Men’s involvement in family planning programs: an exploratory study from Karachi, Pakistan

The demographic characteristics of the participants (Table 1) show that most stakeholders are men and belong to the private sector.

Variables

Stakeholders

Service providers

Married men

Age

(Mean age in years)

39.1

44.7

36.7

Gender

Female

Male

37.5%

62.5%

62.5%

37.5

-

100%

Public Sector

8%

16%

-

Private Sector

24%

12%

-

Semi-Private

-

4%

-

Predetermined themes and subthemes were utilized to examine the data. These main themes included the service delivery, governance, health workforce, medicine/technologies, finances, and information. Further details of each theme and sub-theme are provided below:

Service deliveryReorient health services

The theme of men’s engagement in service provision and usage is significant and includes key components, such as men’s participation in service delivery, their accessibility and availability to services, and the existing family planning services aimed at meeting men’s needs. The identified sub-themes were as follows:

Involving men in service delivery is an essential component of the family planning program and was explored during stakeholder interviews. The cultural and societal aspects were dominant when the stakeholders and providers responded to this question, where it was emphasized that:

“men’s involvement in the family planning services provision is not culturally accepted in our society.”

However, there is a cadre of male mobilizers working in the public sector parallel to lady health workers in many parts of the province, but their impact is yet to be observed. As one of the SH_002 mentioned,

"Changing behavior is the responsibility of male mobilizers, but they are significantly rejected by male members of society; they are abused, humiliated, and beaten up by men in the communities”. “Lack of acceptability in the communities for these male mobilizers".

is one of the reasons discussed during the interviews by SH_004. The geographical context was also considered one of the factors associated with cultural acceptance to involve men in family planning service provision. As one of the participants SH_005 mentioned,

“In urban areas, male providers can sit and counsel couples with a female provider, but in semi-urban areas it is difficult for men to visit communities and talk to male members for family planning there”.

The mechanism adopted by the communities to involve men was also explored through interviews with stakeholders and service providers. “Mohalla (communities) meetings” was the only mechanism that was highlighted during these interviews. These meetings were conducted once or twice a month by male mobilizers; however, very few men from the communities attended these meetings. One of the SP_009 said:

"We conduct mohalla meeting twice a month in which 6–7 men come".

Accessibility of male mobilizers or male providers to RHC and BHU clinics was also explored, where it was discussed that these providers never visited these clinics. While inquiring about the accessibility of the programs and availability of door-to-door services one of the MM_003 commented,

“No, these programs are not easily available in the community they are very less”.

While MM_004 said,

“No, they’re not. I have never met any person at my doorstep telling me about reproductive health or informing me about family planning or things of those sorts. So, I have not met them in my 30 years of life”.

All participants were asked about service availability and accessibility for men living in the communities. The stakeholders unanimously mentioned that there was no specific family planning program for changing behavior or addressing men’s need for family planning in the region (specifically Karachi). While SH_005 commented,

“…I have never heard of or seen any program focusing on men’s family planning needs”.

The major argument against this gap is due to the limited availability of male contraceptive methods; SH_007 said,

“Offering men-oriented project would be a waste of time…as there is nothing to tell men to accept vasectomy or condoms in Pakistan”.

A female SP_003 also discussed,

We do not talk to men. There are no specific services available for them.

The shortage of male doctors was also considered one of the reasons for these limited offerings; it was discussed that,

“Vasectomy is only available in those areas where there are male doctors, so if we talk to men about this method, we are not sure where they would avail those services” (SP_005).

SP_003 considered that,

“They needed to involve men if they required consent”.

On the other hand, men from the communities were asked if they knew of any men’s contraceptive services provided at facilities such as RHC or BHU in Karachi. Most participants did not know about family planning facilities. Still, they knew about a few social marketing products such as “green star” (a private organization), or “Khandani mansooba bandi (family planning) program” Khandani mansooba bandi family planning program (public program), as these programs are advertised on media. However, they were questioned about whether anyone approached them in the communities for these services. Most of them mentioned that no one had ever visited them to offer these services. One MM_005 said,

“I have never been visited by any of the workers who visited my home to discuss the family planning program with me”.

While responding to the question about men’s visiting family planning programs, one participant MM_009 said,

“Men don’t go to any such clinics, but those who have some infertility issues or have no children…men don’t go anywhere to prevent unwanted children”.

Another participant MM_007 specifically mentioned,

“I’ve only heard of women going to those clinics; I’ve never known any man to go there.”

Family planning services aim to bridge gender gaps by addressing the specific needs of men in communities. These programs and services are designed to understand and meet individual needs effectively. Stakeholders responded that there are currently no such initiatives. The government is planning to introduce programs to change men’s behavior towards family planning use, but currently, it is difficult to involve them as only female workers are providing services in the communities. An SH_004 discussed,

“It is difficult for female workers to talk to men and discuss family planning with men in the communities. We have a patriarchal society, and it is culturally inappropriate to involve men in such programs”.

This argument was also affirmed by a female family SP_002 who said,

We cannot involve men or change their behavior because we do not interact with them”. Another SP_006 said they “indirectly involve men as they discuss these things with their wives, and we use them to convey family planning messages to men.

Similarly, all male participants said that,

“They were unaware of a program focusing on behavior change or providing male contraception directly to them”.

Medicine/technologiesNeed more locally made products to help with the supply chain of FP items

The theme was explored to understand the availability of family planning commodities to fulfill the needs of men living in communities.

According to stakeholders, the shortage of commodities was attributed to the import of family planning commodities as a major cause. During the COVID pandemic, there has been an increase in the shortage of family planning commodities leading to increased unintended pregnancies, increased spread of sexually transmitted infections (STIs), decreased access to abortion services, and reduced access to reproductive healthcare. The SH_002 mentioned,

“The shortage at the post-covid, and during covid was high, and demand was difficult to meet during this time”.

Providers, on the other hand, affirm the shortage; a provider from the private sector SP_004 said,

We consistently encounter the issue of stock-outs every quarter.

A female SP-005 mentioned,

“Six to eight months back, all health department didn’t have male contraception, so we gave other methods for a long time to the clients”.

The strategy these providers adopted during the stock-out period is “referring clients to other facilities”. However, few providers mentioned that they don’t face such issues, as one SP_003 said,

“We don’t face shortage 75% of the time”.

Male providers don’t provide male condoms to clients at public facilities. An SP_007 male mobilizer mentioned that,

We don’t provide condoms; if anyone wants condoms, they are available with LHW, not with us.

Health workforceDeveloping personal skills

This theme explored participants' perceptions in the domain of the health workforce. Major subthemes emerged. One of them was the scarcity of family planning providers, while the other was the insufficient counseling skills of these providers.

To better understand and meet the needs of men seeking family planning options in their communities, participants' perceptions of the availability of male family planning providers in the communities were explored. During the discussions, SH_001 and SH_004 acknowledged the existence of male providers at the community level. SH_001 expressed that,

“There were male mobilizers, but their number was limited”.

However, the effectiveness and accessibility of these male providers in the communities are uncertain. Conversely, SH_007 stated that,

“There were no male mobilizers in the communities”.

Family planning providers were asked about the availability of male family planning providers in the communities. Almost all the providers denied the presence of male family planning providers in the communities. Two providers SP_001 and SP_002 said that,

“The male workers only provide services for polio or vaccination, but not family planning”.

A provider from the private sector, SP_004, confirmed that they have a male doctor in their team, but for the community worker, she said,

“There is one man who has some knowledge of family planning work in the communities with us”.

The provincial government introduced a male cadre of “Family welfare assistants” in communities, while only one provider SP_005 confirmed that

There are 1500–1700 male mobilizers in the communities providing door-to-door services.

On the other hand, the male interviewee stated that no male family planning providers are working at the community level. An MM_002 said,

I don’t know if any male health workers are in the community. I have seen many females, though.

To address the lack of male family planning providers in local communities, female community health workers were assessed for their ability to counsel couples and individuals for family planning effectively. Almost all health workers mentioned cultural factors as a hindrance to communicating with the men in the communities. Lack of training to discuss family planning matters with men is another factor that demotivates these workers to provide family planning services. A provider SP_002 mentioned,

“We are told to provide services to mother and child only; no training is provided for that”.

Participants who work in non-government organizations are trained to effectively communicate contraception methods to men,

“It was part of our training to communicate with men regarding family planning methods” (SP_004 & SP_005).

In contrast, male service providers confirmed that they receive training to communicate with men about family planning methods.

“Counselling is an important component of our training…training to address myths and misconceptions were also provided”. (SP_007).

InformationFamily planning information and record keeping

The theme aimed to understand the mechanism for recording and sharing information about clients with the authorities.

During a conversation, female workers disclosed that they maintain and exchange records exclusively for female clients. However, for male clients, they keep a separate record that is shared by male mobilizers and is limited to vasectomies,

“We don’t have any record for men specifically” (SP_003),

“Men don’t come to us for getting any information; they go to male mobilizers, we enter data which comes from male mobilizer” (SP_006),

“Man, record maintains just information on vasectomy and referrals” (SP_003).

The male providers mentioned that they keep records for vasectomies.

Finances

It was important to understand the funding mechanism used for family planning programs at the provincial level and the mode of payment people use while availing family planning services.

Program funding was explored with the stakeholders. During the discussion, it was identified that public funding is a dominating financing mechanism for family planning programs. An SH_001 said,

All family planning programs are government-funded, while the private sector has different donors for these programs.

It is also important to consider the financial accessibility of contraception for men. This sub-theme was examined through conversations with both providers and male members of communities. According to providers, condoms are commonly purchased by men at pharmacies, while women can get them at primary care facilities. Community health workers can also provide condoms by going door-to-door and distributing them to households. The distribution of condoms at the household level is free of cost. An SP_008 male counselor mentioned,

At our outpatient facilities, we offer commodities to those in need and assign a focal person to provide services to individuals who live far from the available resources.

The married men affirmed that they buy condoms from pharmacies through out-of-pocket payment. However, few of them mentioned that community workers from the public sector distribute condoms in the communities,

“I have heard that the government and few NGOs distribute condoms, but it is for preventing sexually transmitted diseases” MM_007.

Similarly, other participants discussed that their partners get condoms from health facilities,

“The service providers target women more than men, even for distributing condoms, which is a male method of family planning” MM_003.

Governance/leadership

Although the impact of family planning policies on men living in societies is a broad theme, it was not thoroughly examined in this research as it was not the main focus.

During discussions with stakeholders, the topic of developing and implementing family planning policies was addressed. Several stakeholders expressed their awareness of these policies but also conveyed dissatisfaction with their current implementation. An SH_002 considered the implementation of family planning policies as a,

Furthermore, the focus of policies, according to these stakeholders, is, “female-oriented”, or “women-focused”. SH_008 further elaborated by stating that,

“While government departments are making progress in implementing family planning initiatives at the grassroots level, their efforts will remain ineffective unless they actively engage the community in education and awareness campaigns. Incorporating sex education or life skills-based education (LSBE) into family planning policies, coupled with multisectoral collaboration, is crucial to achieving sustainable and widespread impact. This comprehensive approach will empower individuals to make informed decisions about their reproductive health, fostering responsible family planning practices and improved overall well-being”.

SH_005 highlighted the weak areas of the policies, saying,

“While existing family planning policies are in place, they require revision to adequately address the needs of various population groups. Currently, these policies fall short in catering to the specific requirements of young people, unmarried individuals, men, and adolescents’’.

Fig. 4figure 4

Figure 4 represents the summarized key findings derived by doing data triangulation. The figure illustrates the implementation gaps within the six building blocks identified by WHO for effectively engaging men in family planning programs. Despite the acceptance, knowledge, positive attitudes, and practices observed among male participants in this study, there’s a need to fortify the health system’s ability to engage men not just as decision-makers or a support system, but also as users or clients.

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