How can Males be engaged in Menstrual Health & Sexual and Reproductive Health and Rights?

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MALE ENGAGEMENT IN MENSTRUAL HEALTH & SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

WoMena considers positive social norms as an essential component of menstrual health. Therefore, since its beginnings in 2012, WoMena has included community engagement, in particular male engagement, as part of its theory of change and policy. WoMena has also developed a 10-point strategy and reflected this in its monitoring and evaluation (M&E) framework. 

To further develop programming and curriculum development, including one focused on boys’ puberty, WoMena’s Uganda team requested its Knowledge Management Team to assemble global evidence of best practices to encourage male engagement, how it is assessed and particularly the results. To gain inspiration, lessons from the sexual and reproductive health and rights (SRHR) field were also sought. A scoping of literature was conducted, and the main findings are presented below. 

MALE ENGAGEMENT IN SRHR:

Much of the literature on SRHR draws on comprehensive and systematic analyses performed by the Measure DHS (Demographic and Health Surveys) project, as summarised below:

• • There is no agreed definition of “male engagement” in the literature, but in SRHR it often refers to males being engaged and supportive of female’s choices and needs as well as addressing their own needs and behaviour. In other words, males can be beneficiaries (e.g. of family planning counselling), supportive partners (e.g. as household decision makers, communicating and supporting females during antenatal care) and as agents of change (e.g. educating their family members as well as the wider community, addressing gender inequalities and harmful gender norms) (Measure Evaluation, 2018). 
  • Male attitudes and perceptions have been widely recognised as important contributors to improving outcomes in SRHR. However, there is limited evidence on the effectiveness of interventions. A study of experience to date identified gaps in monitoring and evaluation, including a lack of a standard definition and  indicators as major barriers (Adamou et al., 2017). 
  • Subsequently, a consultation, also conducted by Measure DHS, identified key indicators (e.g. for contraception: male use, support of their partners’ use of modern contraception, trainers commitment to gender sensitivity and inclusion in national policy) (Measure Evaluation, 2018) 
  • A further study identified 100 indicators used to monitor and evaluate male engagement in family planning (Adamou et al. 2019). 
  • Building on the above, the DHS has identified and validated 15 to 20 key indicators on male engagement (DHS Database).
  • Greene et al note that programmes to engage males as beneficiaries are the most straightforward to evaluate, those which address males as partners are a little more challenging, and those addressing males as advocates the most difficult (Greene et al., 2006). 

• The USAID Interagency Gender Group notes that tailoring activities to promote male engagement in health promotion and gender equity can have a positive effect, and has identified do’s and don’ts:

• Do: recognise, acknowledge and ensure males needs are addressed; try to transform harmful gender relations and norms; collect sex-disaggregated data to include males; start early in the lifecourse; include and engage males individually and in groups, as well as together with females. 
• Don’t: involve males at the expense of females; discount the structural barriers faced by males when accessing SRH services; assume that all males are ‘bad actors’; overlook the heterogeneity among men and boys; disregard scale and sustainability to achieve impact (Pulerwitz, 2019).

MALE ENGAGEMENT IN MENSTRUAL HEALTH:

The majority of menstruators are females. Therefore, males as beneficiaries are likely to be less impacted when compared to SRHR in general. However, boys may also need puberty education, both about themselves and that of girls, that includes topics related to menstrual health.

For menstrual health, this scoping review located only a few comprehensive, summative sources and for this reason, additional, more narrow sources are included.

• For M&E indicators, whereas a great deal of efforts have been undertaken to identify and validate indicators for menstrual health as a whole, this review found no agreed or proposed indicators on male engagement in either DHS or other monitoring systems or proposals (e.g. GAMA, 2020). However, UNICEF has produced a monitoring guideline including an extensive list of proposed indicators. These include whether school curriculae include teaching about menstruation for both boys and girls, whether boys (and girls) think menstruation should be kept a secret or is seen as something healthy and normal, whether girls have been teased by boys (or girls), awareness about the relationship between menstrual cycle and pregnancy and whether male and female health care providers/teachers have been taught about menstruation (UNICEF, 2019b).   

The literature identifies a number of challenges, but less on assessments of what programmatic components make a difference (Mahon et al., 2015). 

• Knowledge: Males of all ages may be intentionally kept unaware of menstrual issues, which is often seen as something females should hide (House et al., 2012; UNESCO 2014, Karim n.d.; Mason et al., 2017; Majed, 2020;  Erchull, 2020). 
• Attitudes: Menstruators may be seen as less likeable and competent when menstruating, if they cannot keep their menstruation discreet. Attitudes about menstruation can be a basis for constructing male dominance (Erchull, 2020). 
• Practice: Studies report teasing by boys in school (Benshaul-Tolonen, 2020). Menstruators may be shy to access services if the providers are male. This is particularly so in humanitarian settings, where the males may be unfamiliar, coming  from outside the community (Sohrabizadeh et al., 2018; Majed et al., 2020; Tellier et al., 2020). However,  there are also examples of males becoming ‘champions´, e.g. advocating to their communities to improve knowledge about menstruation and breaking taboos (House et al., 2012).

WoMena’s experience confirms some of these findings. Most of the projects include some of the activities from the 10-point strategy. One challenge is that some communities find it to be culturally inappropriate or embarrassing to discuss menstrual health related matters with males, whose role may be seen only as providing financial support and in some cases do not wish to participate unless they are compensated (CARE International, 2018; Gade et al., 2017; Gade et al., 2020).

“men do not play any role in menstruation … this is because of the culture and cultural setting” – Key Male Informant, Rhino Camp Refugee Settlement Pilot Intervention

The intention is to step up mid-way final evaluation, which is one reason for undertaking this review. Anecdotal evidence has been recorded, which may be helpful when planning interventions and formulating indicators. WoMena’s experience aligns with literature findings that note that men often attribute negative qualities, such as being unintelligent or careless, to females who are unable to manage their menstruation in private (Gade et al., 2017; Nalunga et. al.; 2020). During projects implementation, there is often a notable shift in perceptions surrounding menstruationand comfort in discussing menstruation and other SRH topics, even in the presence of opposite-sex peers (Nalunga et al., 2020).

“I have understood that this [menstruation] is not a disease. Before I used to see it as something very bad, but nowadays, no problem.” – Role Model Man, Rubi Cups Intervention in Imvepi Refugee Settlement

Many males become advocates (and are sometimes described as ‘role model men’). For example, in the Adjumani settlement, schoolboys proposed a Menstrual Health Club, and visits to other schools, encouraging sustainability after the end of the intervention (CARE International, 2018; Hytti, 2019; Nakalema et al., 2020).

“For us boys, a time will come, and we will grow up, so it’s good to know what girls go through. It helps us to learn how to treat women in the future, and it helps us to be good husbands.”- Buikwe District Feasibility Study (Phase 1 Report) 

WoMena’s experience is that males, since they are often expected to pay for materials, appreciate any programmes which can reduce costs for them (Tellier, 2012; CARE International, 2018; Jahangir et al., 2020; Nalunga et al., 2020).

“My husband is positive about [the cup]. He asked me how it works better, he now knows, and I no longer ask for money for pads … I used to spend 5,000 Ugandan shillings for pads, now I can spend it on something else, I am so happy for that.” -Ann, Pilot Study Report (Tellier et al., 2012)

This is particularly relevant since male attitudes towards menstrual management can be discouraging and sometimes violent for females. Beneficiaries have reported that the lack of menstrual hygiene products and male understanding of females’ needs during menstruation have led to school drop-out, early marriages and pregnancies, transactional sex and gender-based and economic violence (Gade et al., 2017, CARE International; 2019). 

Teasing (by boys) often occurs, triggered by odour, seeing the outline of a pad or a stain (as also found by Benshaul-Tolonen et al., 2020). Girls reported feeling ‘free’ and more confident when provided with products, such as the menstrual cup, and training (CARE International, 2018; Nakalema et al., 2020). Including male school teachers in training can have an important impact, e.g. in the Buikwe district, at baseline only 2% of the surveyed girls (2%; 3 out of 168) reported feeling confident talking about their menstruation with both male and female teachers, as compared with 30%; 46 out of 154 in the midline survey (Gade et al., 2020). 

COVID-19 has been widely reported around the world to exacerbate violence against females, mostly due to the dependence on fathers/husbands/breadwinners to purchase menstrual products, as well as reduced privacy. In a rapid assessment of the impact of the pandemic, WoMena found that 12-14% of respondents stated that they had experienced or knew someone who experienced economic or physical violence during the lockdown period, for requiring financial resources to purchase menstrual products (CARE International, 2018, WoMena, 2020).

In conclusion, despite a broad agreement that male engagement in SRHR is important, it has taken several decades to arrive at a good evidence base and a set of key indicators for M&E.  For menstrual health, there is less experience and as yet no agreed list of indicators. WoMena’s experience seems to align with and enrich the limited evidence which does exist, indicating the importance of male engagement, and also encouraging the continuing development of a better evidence base and understanding.

USEFUL RESOURCES FOR PROGRAMMING AND CURRICULUM DEVELOPMENT:

EngenderHealth and United Nations Population Fund (UNFPA). 2017. Engaging men in sexual and reproductive health and rights, including family planning: Why using a gender lens matters. New York. Available at: https://www.engenderhealth.org/pubs/gender/gender-toolkit/.

House, S., Mahon, T & Cavill, S. (2012). Menstrual hygiene matters – a resource for improving menstrual hygiene around the world. WaterAid, First Edition, 2012. Available from: https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/Menstrual%20hygiene%20matters%20low%20resolution.pdf

UNESCO (2014). “Puberty education and menstrual hygiene management”. Paris. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000226792

UNESCO, UNAIDS, UNFPA; UNICEF, UNIFEM, WHO (2018). “International technical guidance on sexuality education: an evidence-informed approach”. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000260770

United Nations Population Fund (UNFPA) (2011). “Engaging men & boys in gender equality.” Available from: https://www.unfpa.org/publications/engaging-men-and-boys-gender-equality

REFERENCES

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Adamou, B. M., Iskarpatyoti, B. S., Agala, C. B., & Mejia, C. (2019). Exploring gaps in monitoring and evaluation of male engagement in family planning. Gates open research, 3, 1114. https://doi.org/10.12688/gatesopenres.12927.1 

Alberda, H. (2020). Menstrual health during COVID-19 times. Hilda Alberda, Director Monitoring, Evaluation and Learning at Simavi. 

Benshaul-Tolonen, A., Aguilar Gomez, S., Batzer, N.H., Cai, R. & Nyanza E.C. (2020). Period Teasing, Stigma and Knowledge: a Survey of Adolescent Boys and Girls In Northern Tanzania. PLOS ONE, 15 (10): e0239914 Available at:  journal.pone.0239914 https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0239914

CARE International, 2018. Ruby Cups: Girls in Imvepi Refugee Settlement Taking Control. Available from: https://womena.dk/wp-content/uploads/2018/12/Ruby-Cups-Girls-in-Imvepi-Refugee-Settlement-Taking-Control-03.12.18-Final-report.pdf

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Erchull, M.  (2020) “You Will Find Out When the Time Is Right”: Boys, Men, and Menstruation. in (eds. Chris Bobel et al., The Palgrave Handbook of Critical Menstruation Studies Palgrave MacMillan Available at: https://library.oapen.org/handle/20.500.12657/41299

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Gade, A., Hytti, L. (2017). Menstrual Health in Rhino Camp Refugee Settlement West Nile, Uganda: Pilot Intervention Report. WoMena & WoMena Uganda. Available from: https://womena.dk/menstrual-health-in-rhino-camp-refugee-settlement-west-nile-uganda/

Gade, A.,  Bustamante Madsen, L. (2020). “Beyond product distribution. A feasibility study of introducing a menstrual health component into four secondary schools in Buikwe District, Uganda (Phase 1)”. WoMena & WoMena Uganda. Available from: https://womena.dk/wp-content/uploads/2020/07/Buikwe-report-phase-1.pdf 

GAMA (2020). Proposed indicators for global adolescent health measurement by the Global Action for Measurement of Adolescent health (GAMA) Advisory Group. Version 20 October 2020. Available at: https://www.who.int/docs/default-source/mca-documents/advisory-groups/gama/gama-list-of-indicators-draft-2-v20201020.pdf?sfvrsn=f6d00176_6

Greene, M.E., Mehta, M., Pulerwitz, J., Wulf, D., Bankole, A. & Singh S. (2006). Involving Men in Reproductive Health Contributions to Development. Background paper to the report Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals. Available from: https://www.faithtoactionetwork.org/resources/pdf/Involving%20Men%20in%20Reproductive%20Health-Contributions%20to%20Development.pdf 

House, S., Mahon, T & Cavill, S. (2012). Menstrual hygiene matters – a resource for improving menstrual hygiene around the world. WaterAid, First Edition, 2012. Available from: https://washmatters.wateraid.org/sites/g/files/jkxoof256/files/Menstrual%20hygiene%20matters%20low%20resolution.pdf

Hytti, L. Simkute S. and Jahangir, A (2019). Menstrual Cup Interventions Follow-up Study Report, Uganda. WoMena & WoMena Uganda. Available from: https://womena.dk/wp-content/uploads/2019/04/Menstrual-Cup-Interventions-Follow-up-Study-Report-March-2019_FINAL-V0.2.pdf

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Majed, R. & Touma, H. (2020). Menstrual Hygiene Management among Syrian Refugee Women in the Bekaa. Oxfam Research Reports – June 2020. Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/rr-menstrual-hygiene-management-syrian-refugee-women-bekaa-180620-en.pdf 

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