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RHO archives : Topics : Men and Reproductive Health

IGWG Men and Reproductive Health Subcommittee

Meeting Minutes: November 15, 2001

Attendance and logistics

The meeting was held at the Academy for Educational Development (AED), from 9 am to 5 pm. Attending were: Erin Anastasi (IRH/Georgetown), Mark Austin (USAID), Suzanna Banwell (CHANGE), Anna Benton (CHANGE), Michèle Burger (Consultant), Sam Clark (PATH), Laurette Cucuzza (CEDPA), Mary Ellsberg (PATH), Paul Feldblum (FHI), Jill Gay (Consultant), Meg Greene (PAI), Jay Gribble (IRH/Georgetown), Sarah Heaton (CHANGE), Lori Heise (PATH), Victoria Jennings (IRH/Georgetown), Daniel Kabira (Africa Bureau), Mihira Karra (USAID), Tabitha Keener (USAID), Jim McMahan (INTRAH), Manisha Mehta (EngenderHealth), Diana Prieto (USAID), Julie Pulerwitz (Population Council), Karin Ringheim (PATH), Debbie Rogow (Population Council), Diana Santana (JSI), Diana Santillan (JSI), Jeff Spieler (USAID), Mary Nell Wegner (EngenderHealth), Amy Weissman (Save the Children), Alfred Yassa (JHUCCP).

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Report of the working teams to the committee

Communications Working Team

Mary Nell Wegner, outgoing Chair reported for this team.

New Chair. Jim McMahan agreed to be the next Chair of the Communications Working Team, pending approval from INTRAH.

Proposal: "Dissemination Strategy for State of the Art Lessons on Gender, Men and Reproductive Health". The communications team reviewed the proposal and suggested that the budget include funds for commissioning papers in advance of the State of the Art (SOTA) Conference, which will provide the content for the Implementation Guide, a follow-up to the Orientation Guide, the primary intended output of this conference.

Speakers Series. Lorie Heisi and Mary Ellsberg will be kicking off the Speakers Series today. Plans are to continue to bring experts to speak to the Subcommittee through June 2002.

Research and Evaluation Working Team

Julie Pulerwitz, the new Chair of this working team reported on this teams meeting.

Attendance: Debbie Rogow, Julie Pulerwitz, Karin Ringheim, Amy Weissman, Sam Clark, Meg Greene, Jeff Spieler, Manisha Mehta, Daniel Kabira, Laurette Cucuzza, Paul Feldblum, Erin Anastasi, Anna Benton, Jay Gribble, Tabitha Keener.

Meg Greene, the current coordinator of the Research Group will be stepping down, with Julie Pulerwitz replacing her. Everyone agreed that Meg has done a marvelous job.

The case studies will have final editing by PRB and be published together as one unit. The three case studies are: Salud y Genero; Stepping Stones; Society for Integrated Development of the Himalayas (SIDH) Meg Greene will write the introduction and make the first edits on the drafts. A reduced draft will be available soon and will be sent to the co-chairs for further revision. USAID will review this draft as well. Comments on the draft should be completed by December, before Meg submits it to PRB. The full draft is available to whoever wants to review it as a longer document as long as they do not cite it. It was suggested that there be an executive summary in the beginning. The audience for these case studies is program designers, managers and researchers.

Power in Sexual Relationships monograph is now complete.

Evaluation of the CD-Rom—Dr. Yassa will be using the original evaluation with one additional question. A random sample of those who were sent the CD Rom will receive the evaluation. JHUCCP sought suggestions for possible incentives to get people to participate in the evaluation. A scope of work has been written, but funding issues need to be resolved.

Theme Statements—The gender-based violence and dual protection statements are now on the RHO website. Amy Weissman has been working on the adolescent statement, incorporating various comments and concerns. Meg Greene has concerns that there is not enough of a focus on gender equity. Karin Ringheim and Julie Pulerwitz will review the statement to include more language on social equity and socialization.

There was a question as to whether there has been any feedback regarding the theme statements from the website. Sam will get updates on the numbers of hits the site is receiving. The WHO has received copies of the theme statements.

Partnerships newsletter—Debbie Rogow from the Pop Council is now managing this newsletter, but its fate is in limbo. Its role may change to become an electronic clearinghouse of new documents. The Pop Council may not want it on their web site, because it is not considered a research document. The follow up question as to whether this should be included in the dissemination strategy was raised. There is also interest in having it on the RHO website.

Bellagio Report on Men and Gender Based Violence—Jeff Spieler noted from the report that there is an absence of attention to research on men and gender violence. The field is replete with anecdotal evidence, but not studied well.

RHO website—Karin Ringheim reminded people to send information to the RHO website.

Dominican Republic Positive Deviance Study: The following update was received from Sandy Garcia of the Pop Council: "In brief, we have yet to make our first site visit (these past few months were extremely difficult for coordinating travel, especially due to the Sept. 11 events). At the October EC meetings in NY, I spoke with Vivian Brache once again (as well as Suellen Miller who is doing some work in the DR for her ECC project) and we discussed meeting with Vivian and interested members of her staff in early February. Yes, we're running a little behind, but in the meantime have concentrated our efforts on drafting up instruments (both for the DR and the Mexico site, since the projects are very similar), and Suellen has also sent me a description of her DR project so that we can coordinate efforts better (if it makes sense to do so) and to help us establish more local contacts. I'm sorry I don't have much else to report at this time, but I promise that we'll kick things off very soon in the new year."

Future plans include the possibility of evaluating some of the GBV programs presented at the recent Bellagio meeting. Other initiatives funded by the Subcommittee that are in need evaluation include: the HIM CD ROM (in progress), the "Young Men's Journey" Version of the Safari of Life game that PATH has developed, and Margaret Sanger Internationals Men and RH teaching tool.

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Workplan discussion and budget update

Debbie Rogow suggested that the Subcommittee might want to help disseminate the Population Councils newsletter Toward a New Partnership by posting it on its web site and translating it. Tabitha Keener reported that PATH has expended the funds it was holding for the Subcommittee. IPPF/WHR still has some funds. There are $28,000 remaining unrestricted funds available for the Speakers Series and consultants. The status of the funds held by JHUCCP available for printing a revised Orientation Guide will be clarified by the end of the day.

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Update on IGWG meeting and M&RH subcommittee proposal endorsements and submissions

Diana Prieto provided an update of the IGWGs TAG meeting of September 25. The TAG is comprised of 19 members: 7 USAID PHN representatives, a representative from each of the Regional Bureaus and the WID Office, and 7 technical experts from outside USAID (5 CA and 2 non-CA). The TAG serves as the strategic planning and advising body of the IGWG and guides the work on the IGWG by providing insights into trends and needs in the field. Specifically, the TAG: 1) recommends priority areas and technical themes for each funding year, 2) reviews proposals and makes recommendations to USAID for funding, and 3) reviews progress and products of funded activities. The TAG identified four priority areas—young people, GBV, male involvement, and HIV/AIDS—for the IGWG in the coming year. These areas served as the focus in the call for proposals sent out by the IGWG. The deadline for the proposals is tomorrow, November 16. The proposals will be reviewed by the TAG in the next month and a half; notification of whether or not the proposals are recommended for funding is scheduled for mid-January 2002.

"Lessons Learned Forum on Men and RH" proposal

Victoria Jennings summarized the proposal, which will be amended to indicate funds leveraged. Under the restructuring of the IGWG, the Subcommittee is proposing to evolve into a think tank, a generator and disseminator of ideas. This proposal, along with seven others that the Subcommittee endorsed, including the Dissemination Strategy, will be submitted to the IGWG TAG. Jeff Spieler urged that the proposal include adequate compensation for the time co-chairs spend working on the Subcommittee/Forum.

Endorsed proposals

The Subcommittee had expected to endorse three proposals but, in the end, agreed to endorse seven. Ten proposals were not endorsed because they did not fit into the Subcommittees framework or address its major themes. These proposals can, however, be submitted directly to the IGWG. Mihira Karra clarified the TAGs preference for funding short-term discrete activities. Funds for approved proposals will be obligated in July and must be expended within the proposed time-line.

Transparency

Sam Clark expressed his sincere hope that members of the Subcommittee were clear about the funding process, had enough information and time to submit proposals and urged members to provide feedback about the process. He explained that PATH would be submitting the Lessons Learned Forum proposal because the IGWG requires that grant agreements pass through a co-chairs agency, which must be a cooperating agency (CA). Karin Ringheim addressed the issue of inequality within the Subcommittee due to the fact that some peoples work is compensated while others is not. She cited the example of Meg Greene, outgoing chair of the Monitoring and Evaluation Working Team, employed by an organization that is not a CA. Ringheim also suggested that some organizations received funds for a discreet project under the IGWG that could have been funded under their regular CA agreement.

Management issues

Sam Clark informed members that his term expires in July 2002. Ideally his successor should be male and rules mandate that co-chairs be employed by a CA. Given the restructuring and uncertainty of the future of this subcommittee, Clark indicated that he would be willing to consider extending his term as co-chair if this would be helpful in providing continuity. Jeff Spieler supported this offer.

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IGWG Men and RH Speaker Series presentation on gender-based violence (GBV)—Lori Heise and Mary Ellsberg (PATH)

"Coercion and Abuse: Implications for Health Programs" by Lori Heise

Lori Heise, Senior Program Officer at PATH, began the joint presentation on GBV by discussing the prevalence of abuse worldwide. Lifetime rates of physical abuse by a partner range from 10-50% of women, depending on the country. Rates of sexual abuse during childhood are estimated at between 11 and 25% of women (with lower rates reported among men). However, these figures tend to be underreported, so actual rates are likely to be higher.

One common type of abuse discussed was forced sex. Studies around the world indicate that "refusing a man sex" is one of the most commonly cited reasons for wife beating. (In addition, an ICRW 15-country study of womens HIV risk found that many women have been forced to have sex or participate in sexual activities against their wishes.) Heise also noted that, in many countries around the world, wife beating is the norm.

Addressing the health consequences of abuse, Heise detailed the fatal and non-fatal outcomes resulting from such violence. Fatal outcomes include: homicide; suicide; maternal deaths; and AIDS-related deaths. Non-fatal outcomes include physical and mental suffering, injurious health behaviors, and reproductive health problems, such as: unwanted pregnancy; chronic pain syndrome; injury; depression; alcohol/drug use; STDs/HIV; irritable bowel syndrome; gynecological disorders, etc.

Examining the link between violence and health outcomes, Heise suggested that violence is best conceptualized as a risk factor. For example, women who have experienced abuse generally have reduced physical functioning, increased physical symptoms, worse health, more life-time diagnoses, and higher utilization of health care. Further, the severity of abuse is correlated with the severity of symptoms.

More specifically, the impact of violence and abuse on reproductive health is equally damaging, with consequences including: reduced sexual autonomy, lower contraceptive use, higher parity, earlier age at first intercourse, more risky sexual behavior, unwanted or mistimed pregnancies, adverse pregnancy outcomes, and gynecological problems such as PID, chronic pelvic pain, and vaginal bleeding.

Violence during pregnancy is another serious problem around the world. It is associated with adverse outcomes such as: late entry into prenatal care, increased smoking and substance abuse, vaginal and cervical infections, premature labor, miscarriages/ abortions, bleeding during pregnancy, and low birth weight.

In addition, violence increases ones risk of contracting STIs and HIV. Sexual abuse in childhood is also linked with HIV/STD risk, as those abused in their youth are more likely to engage in unprotected sex, have multiple sexual partners, and trade sex for money or drugs.

Heise advocated for a "graduated response to violence", including the following: first, do no harm (making sure that RH programs do not "re-victimize" women, compromise their safety, undermine their autonomy, or reinforce male entitlement or violent imagery). Next, integrate issues of gender, coercion, and abuse horizontally into existing RH initiatives (into existing training programs for providers, IEC and BCC programs). Finally, undertake efforts to address coercion/abuse (implement pilot projects that address abuse directly).

Finally, Heise discussed involving men in efforts to prevent and eliminate GBV. Batterer treatment programs were reviewed and evaluated. The need and possibility to break the cycle of violence was underscored, and it was noted that, while men who were abused as children are at higher risk of becoming abusers as adults, the majority of boys experiencing violence as children do not grow into abusers. Selected international and domestic projects were highlighted as examples of successful programming.

"Innovative approaches to monitoring and evaluating violence prevention programs" by Mary Ellsberg

Mary Ellsberg, of PATH, began by describing the challenge of evaluating the impact of GBV interventions. Specifically, how to define success, who defines success, and how success is to be measured.

Ellsberg outlined and discussed four different approaches to measuring impact, including: 1) prevalence and incidence indicators; 2) quantitative indicators of quality of care; 3) participatory assessments; and 4) measuring changing norms.

First, Ellsberg examined measurement by national victimization statistics. She detailed problems with this indicator, including the facts that it is not representative of the population, is not "interpretable", and sets the bar too high.

Regarding population-based data on prevalence of violence, Ellsberg pointed out that they are very sensitive to methodological issues, making it hard to compare between settings. They also involve safety and ethical concerns. Further, it is unrealistic to expect to see a reduction in the prevalence of violence over the short or medium term. While population-based data may not be ideal for program monitoring and evaluation, they are useful in advocacy and program design, in order to understand the magnitude and characteristics of violence, as well as the health burden of violence, and both risk and protective factors.

Another approach, quantitative program level indicators, such as those used by IPPF, involves measuring institutional changes (staff training, physical space, etc.), changes of attitudes of staff (pre/post training), and implementation of screening (% of clients screened and identified as victims of violence). These types of data may be useful in identifying clinics that are not implementing program activities, identifying "pockets of resistance" to the program, and identifying possible "bottlenecks" in the system. However, they do not offer information on how women define success and whether or not intervention programs meet their needs.

Participatory approaches were also examined. By examining examples of IPPF and PAHO programs which used this approach, the following lessons were learned: the approach incorporates the perspectives of all stakeholders and allows for comparisons between groups and countries. Criteria for successful intervention included: providers listening with empathy and women feeling empowered to make their own decisions.

Finally, as an illustration of the approach of measuring shifting norms, a mass media campaign ("Puntos de Encuentro") directed toward men in Nicaragua was evaluated. First, a qualitative study on "non-violent" men was conducted to determine what factors influenced them to reject violence, what they perceived as the benefits of being non-violent, what costs were entailed, and what their expectations for a good relationship were. These data were compared with "average" men from workshops on masculinity. Results revealed that non-violent men perceived benefits to their behavior, such as improved communication with their partners and children. However, they also had different expectations for their relationship, so the benefits they perceived may not be meaningful to other men.

The multi-media campaign involved such activities as television commercials, posters, bumper stickers, pamphlets, caps, bill boards, calendars, methodological guidelines, and trained promoters. To evaluate its impact, surveys of 2,000 men before and after the campaign were conducted (with support from FHI), 660 women were surveyed post-campaign, and focus groups were held among participating organizations. Results of the survey indicated that 60% of men surveyed knew of the campaign and that men who had heard the campaign were more likely to believe that men can avoid violence and to see the damaging effects of violence on women and the community. The campaign also encouraged men to talk about violence; 50% of men who heard a message talked about it with someone, and 88% believed the campaign had made a difference in mens behavior.

In closing, the following lessons learned were highlighted: there is a need for stronger links between research and interventions for program design and monitoring; both qualitative and quantitative methods are useful; GBV intervention programs should strive to develop client-centered indicators for success.

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Discussion on men and GBV: What role for M & RH SC?

Victoria Jennings facilitated this "brainstorming session" in which all M/RH participants, as well as the two guest speakers (Mary Ellsberg and Lori Heise) had the opportunity to offer ideas as to what course of action the M/RH SC might take to actively address the issue of GBV. Ideas/comments expressed included the following:

  • Lobby for RFA that focuses on GBV.
  • Lobby for including GBV in other projects (by adding evaluation points, for example).
  • What impact data do we have?
  • Sensitize, educate AID regarding the importance of addressing GBV to reproductive health outcomes.
  • Conduct research in other countries to show causal (not just associative) risk of GBV to RH outcomes (i.e. violence as a precursor to early, unwanted pregnancy).
  • Develop a conceptual framework on the overlaps between M & RH and men and violence (to this end, the report of the Bellagio conference included recommendations, which are being developed into a proposal for IGWG funding).
  • Identify entry points in key regions and countries.
  • Identify sites to pre-test English version of 5 workbooks for boys and adolescent males (which include a module on violence) developed by IPPF.
  • Bring together master trainers with all their best tools and materials and make one consolidated workbook, to be disseminated to program implementers.
  • Inventory of existing programs addressing GBV (CHANGE is already working on this and plans to hold a brown bag on the topic on January 9, 2002.)
  • Identify theoretical and intellectual gaps.
  • Share what is already known.
  • Review existing projects to determine how they can integrate men and GBV (i.e. YouthNet project, others).
  • Develop a tool to help AID program and policy managers integrate GBV into programs (Proposal is being submitted to IGWG for funding and will include development of conceptual framework, literature review, measurement methodologies, etc.).
  • Guest speaker Lori Heise recommended focusing on changing social norms in the general population.
  • Emphasize importance of couple communication as M/RH SC niche (through research, dissemination, etc.).

Other issues raised during the discussion included what should be the role of the M/RH SC? To collect data? To implement programs? Some felt that GBV should be integrated into projects rather than being a separate project. Some cited a need to focus on the "so what?"—demonstrating improved outcomes. Do we have enough definitive data to show the impact of reducing GBV on RH outcomes? Additional resources mentioned included Emily Rothman, who is working on a Ph.D. with WHO on RH, violence, and men. She is conducting phone interviews with programs working with men who are perpetrators of violence. In addition, a study was cited, "Scared in School", about violence and intimidation/coercion in schools.

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Updates regarding selected M/RH and related CA activities/other business

  • CHANGE (Suzanna Banwell, Anna Benton, Sarah Heaton)—Change is in the process of mapping RH programs worldwide and developing a theoretical framework for follow up.
  • IGWG Gender and HIV/AIDS Task Force Update (by Mark Austin)—Activities include: a) A rapid assessment of AIDS programs integrating gender (total of 55 interviews), examining program objectives, gender issues addressed, TA, lessons learned, etc. Initial qualitative analysis to begin in December; compilation of preliminary analysis to be presented to TAG members for feedback. Workshops on best practices will subsequently be designed and conducted; b) EngenderHealth is spearheading the development of guidelines for integrating FP and HIV, and is seeking gender activities to contribute to the document.
  • Population Council, NY (Debbie Rogow)—Qualite journal to focus on masculinity. A program to be highlighted will be chosen in January 2002. (Dissemination date TBD.)
  • PATH (Karen Ringheim)—"Young Mens Journey" board game, adapted from "Safari of Life" includes a new set of cards which have been tested in the U.S. and overseas. Pretesting will continue domestically and in Kenya. A proposal is being submitted for additional funding to do an evaluation. Dissemination planned for next year.
  • Jill Gay (consultant)—Jill, in collaboration with Karen Hardee at Futures, is compiling evidence of what works in RH. (Topics include STDs/HIV, safe motherhood, FP; GBV; all aspects of RH; also gathering data on impact of gender and on impact of men). There is a call for resources on impact evaluations re outcomes. Please submit to Jill or Karen.
  • EngenderHealth (Manisha Mehta)—EngenderHealth is a) Implementing a project on young mens gender roles and socialization and its impact on their and their partners RH in the Philippines. Includes qualitative, participatory, research as well as quantitative data collection. An intervention will be designed to improve RH of young men and their partners; b) Men and GBV project in South Africa—examining role men can play in supporting their partners testing for cervical cancer and following treatment regime. Treatment often involves abstinence for 4-6 weeks, which is often a time of GBV. The project works with adult and young men to sensitize them. Educators have already been trained. Quantitative baseline will begin in January 2002. Post-evaluation and 6-month follow on evaluation planned. (Project also includes clinical arm.); c) Mens RH curriculum being tested in Philippines. Qualitative findings indicate changes in attitudes and knowledge. Results included setting up "mens nights" to discuss issues of relevance to men, as well as hiring of male providers. Curriculum will be available in future (date TBD).
  • IGWG Technical Advisory Group (TAG) (Diana Prieto)—a) The TAG met in September 2001 and identified the priority areas of adolescence, GBV, HIV/AIDS, and male involvement. These themes guided the call for proposals. Recommendations for funding of proposals will be made in mid-January 2002; b) The TAG also plans to do more training within USAID on the IGWGs function and on gender in general; c) a TOT is to be conducted Dec. 18 and 19 to build a cadre of trainers to train their own CAs and be available to train others in the future on gender issues. (This effort is being spearheaded by Mary Kincaid and the Policy Project at Futures); d) TAG plans to publish the indicators paper and the gender perspectives paper in January 2002. Case studies and a manual on designing gender-sensitive training should be released in February.
  • Michele Burger (consultant)—a) Michele is working with UNFPA to integrate RH services into the armed forces health services in 3 countries in Africa (Botswana, Namibia, and Madagascar) and 3 Latin American countries (Ecuador, Paraguay, and Nicaragua); b) the Orientation Guide will be available by the end of 2001/early 2002. The M/RH SC needs to clarify the dissemination plan for this document. Suggestions can be sent to Michèle. (A decision was taken to allow for dissemination without prior modeling, but modeling is encouraged.)
  • CEDPA (Laurette Cucuzza)—CEDPA is developing a project proposal on Skills for Sexuality Education, Negotiation, and Gender Awareness. This OR project, to be conducted in Uganda, is designed for females 10-19 years old. Women (aunts) will be trained in negotiation skills, sexuality, gender, dealing with violence, etc. The women will then pass the information on to their nieces. Outreach will also be conducted to men through faith-based organizations to try to achieve normative change in attitudes toward respecting women and preventing violence. Situation analysis, baseline, and endline analyses will be conducted at the individual, community, and policy levels.
  • JHU/CCP (Alfred Yassa)—a) The evaluation of HIM CD-ROM is set to proceed; b) completed evaluation of "Together for a Happy Family" campaign in Jordan; in process of writing final report. Results may be presented at a future M/RH meeting.
  • INTRAH (Jim McMahan)—developed a gender sensitivity self-assessment tool for providers (field-tested in Bangladesh).
  • IPPF (Judith Helzner)—a) report of March 2001 meeting on "Power in Sexual Relations" available from Population Council; b) M/RH panels conducted at APHA.
  • PATH (Sam Clark)—a) paper sessions at APHA on M & RH. (Sam sent out summary of presentations and may be able to obtain full presentations); b) shared theme materials from UNAIDS (Men and AIDS, etc.)
  • Population Council, DC (Julie Pulerwitz)—a) Report on a second gender and power in sexual relations presentation at APHA (conceptual framework developed, Julies scale for power in sexual relationships used, etc.); b) Judith Helzer pointed out that Julie Pulerwitz received the APHA Population, Family Planning and RH Section Young Professional Award and the group congratulated Julie.

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Next meeting/plus-delta exercise

Sam Clark agreed to follow up with Subcommittee members about their preference for the next meeting. [The next meeting is set for March 12, 2001.]

Plus (to do again next meeting)

  • Master stroke—AM working groups—good structure
  • Good amount of time for discussion of presentations
  • 2 excellent presentations
  • PPT worked
  • J. Helzner good focus management for discussion.
  • Organized
  • "Blue" Background Sheet
  • "in-house" access to food
  • Venue—thanks CEDPA
  • Food was good.
  • Sam's attention to detail/preparation.
  • Finishing on time!

Delta (to change)

  • Lose people by the PM inevitable.
  • Increase time for discussion by PPT ? working teams.
  • Have examples of some of the products we have produced, especially for newcomers.
  • Expand on acronyms list
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    To do in the interim

    Conference calls for working teams to work on tasks that remain. (Co-chairs will conference with working team leaders).

    For more information

    For more information, please review the minutes of other past Subcommittee meetings.

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