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

doi:10.21203/rs.3.rs-3402672/v1

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Research Article

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

https://doi.org/10.21203/rs.3.rs-3402672/v1

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Background:

In Pakistan, family planning has traditionally been perceived as primarily a women's concern, resulting in the exclusion of men from relevant initiatives. This situation is further exacerbated by cultural and social barriers that hinder men's access to family planning services. This study addresses a significant research gap by assessing the extent of family planning service provision for men in urban areas of Karachi. It delves into the exploration of men’s involvement in family planning service delivery, identifies existing gaps in services catering to men, records men’s perceptions of accessibility and acceptability of these services, and ultimately offers recommendations to enhance men's involvement and strengthen service provision to better meet their needs.

Methods:

We employed a qualitative exploratory research design using semi-structured interviews to investigate perceptions regarding family planning service provision to men. This approach involved 25 interviews, comprising eight key informant interviews with stakeholders, eight with service providers, and nine in-depth interviews with married men.

Results:

This study highlights the limited engagement of men in family planning programs, primarily due to entrenched sociocultural norms that confine female healthcare providers to serving women, hindering men's involvement. While national and provisional policies endorse men’s participation, they lack defined roles for male providers. Behavioral and information-sharing barriers at the community level discourage male healthcare providers from collaborating with females. Family planning programs, except for NGO-led vasectomy projects, fail to adequately address men's needs. Despite policy recognition, implementation remains inadequate. Bridging the men’s involvement gap necessitates more male providers and improved contraceptive stigma combat training. Further research is vital to explore effective methods for involving men in community and service delivery in family planning.

Conclusion:

There is a need to change the perception of contraception that it is solely the responsibility of women, as men’s participation in family planning in Karachi is limited. Engaging men can yield positive health and non-health outcomes. Culturally sensitive services, developed with community input using a couple-centered approach, are crucial for equitable family planning. Further research is needed to explore men's inclusion strategies in service provision and utilization.

Family planning

men involvement

reproductive health

low- and middle-income.

Many family planning efforts focus solely on women, leaving out men, especially in Pakistan, due to cultural and social barriers. This study aimed to explore men’s involvement in family planning programs in Karachi. We talked to 25 different people, like those who run family planning programs, provide services, and married men. We found that men aren't much involved in these programs. Female health providers usually help women, and this stops men from joining or getting involved in such programs. Even though there have been policies to include men since 2002, they don't have specific roles defined. Men don't talk much about family planning with women providers due to behavior differences and not sharing information. Men mostly prefer condoms, and apart from a small NGO-run vasectomy project, there aren't many programs for them. Although policies exist, they're not fully in practice. To change this, we need more male providers and better training to remove the stigma around contraception. Future research should find ways to include men better in family planning, both in communities and services. Overall, getting men involved in family planning is important, and services need to be made with input from communities and couples to make things fair. More research is needed to figure out the best ways to do this.

The approach to family planning provisions that prioritize human rights, involves giving men and women equal opportunities to make decisions about the number and timing of their children. The International Conference on Population and Development (ICPD) has supported this approach, encouraging equal access to family planning information, products, and services for both men and women (1). International organizations and global conferences have further reinforced this rights-based principle (2). Recent agendas for family planning such as FP 2030 and sustainable developmental goals (SDGs) also reinforce the importance of men's involvement in family planning programs and work towards fostering a supportive environment that engages men as partners in reproductive health decision-making. By building on each other's principles and commitments, they emphasize creating more inclusive and effective family planning programs that involve and support men as partners in reproductive health decisions. High-income countries have already adopted a couple-centered approach to promote family planning services by involving men in reproductive health decision-making (3) (4) (5), and many low and middle-income countries (LMICs) are also working to promote equality in family planning by revising or implementing family planning programs and services that involve men (6). For example, Nigeria, Malawi, and Ethiopia are exploring ways to understand men's perceptions and attitudes regarding family use (7) (8) (9). Other countries include men as providers of family planning services to fulfill men’s need for family planning services at the community level. Efforts are also being made to remodel community health programs and policies to ensure men’s involvement in family planning. However, cultural, and social segregation continues to pose obstacles (10) (11) (12).

As a signatory of international agendas, including FP2030, Pakistan acknowledges the significance of engaging men in family planning programs (13). Family planning, along with health, are both provincial subjects post-devolution under the 18th amendment and the Government of Sindh is also a signatory to FP 2030 commitments (14).

To accomplish the 2030 family planning (FP) targets, the following goals are set for Sindh province after the Pakistan Demographic and Health Survey (PDHS) report 2017–2018.

Increase the contraception prevalence rate (CPR) to 43% by 2025 and 50% by 2030.

Reduce the total fertility rate (TFR) to 3.0% by 2025 and 2.6% by 2030.

Decrease Annual population growth rate to 1.5% by 2025 and 1.3% by 2030 (15).

The Sindh Population Welfare Department (PWD) owns the primary mandate for delivering family planning services in Sindh, supported by the Department of Health (DoH). Both departments fall under the Ministry of Health and Population Welfare and deliver family planning services through public sector facilities across Sindh province, including through public-private partnerships.

Limited men involvement in reproductive health and family planning initiatives in Pakistan persists despite well-intentioned efforts, such as the introduction of social male mobilizers working alongside community health workers. These initiatives aim to raise awareness about fatherhood, catalyze social change, and guide men within communities toward embracing their roles and responsibilities (16). However, the full implementation of these initiatives is hindered by a lack of evidence to inform meaningful engagement of men in family planning initiatives beyond just awareness raising which does little to counter barriers due to deeply entrenched cultural and gender norms, men's lack of awareness of their essential role in family planning, and the persistent stigma around contraception. The dearth of male-friendly family planning services, coupled with the broader weaknesses in healthcare infrastructure, including the shortage of trained personnel and inconsistent contraceptive supply, also contribute to this. Moreover, the absence of carefully tailored strategies to engage men in family planning efforts, alongside a lack of supportive policies and guidelines to integrate meaningful involvement of men, presents a significant stumbling block (17).

Resistance from various stakeholders, including healthcare providers, community leaders, and even men themselves, further obstructs the shift in attitudes and practices necessary to enhance men’s participation in family planning (18). Another pivotal factor is the historical framing of family planning as predominantly a female concern, leading to the disproportionate targeting of women in family planning programs. Insufficient emphasis has been placed on crafting strategies to actively involve men and cultivate their engagement in reproductive health initiatives. This unbalanced approach failed to reflect the evolving needs of both men and women resulting in stagnant contraceptive prevalence over the past decade. Urgent attention is needed to reshape the narratives around family planning and create a more inclusive and comprehensive approach that acknowledges the crucial role men play in family planning and reproductive health. This study addresses the gap in research on men’s involvement in family planning programs in Karachi, Pakistan, and aims to explore the extent of men's engagement, identify barriers and gaps in current programs, and suggest strategies for improved men’s participation. Examining men's perspectives, knowledge, and challenges contributes to understanding how they perceive their role in family planning, informing interventions for gender equity and reproductive health improvements. Such insights are critical for policymakers, healthcare providers, and researchers working in LMICs and South Asia, where involving men can address unmet needs and promote gender equality.

We conducted an exploratory, descriptive, qualitative approach to gain an understanding of the health systems and their ability to offer services to men within communities. Purposive sampling was done to identify our stakeholders. This study utilized in-depth and key informant interviews to understand participants’ perceptions of the provision and reception of family planning services perspectives of service providers, policymakers, and married men on the services directed towards men. We developed three interview guides with open-ended questions. The key informant interviews were conducted with a group of eight stakeholders, including directors, high-level managers, and program coordinators employed in the province's public and private sectors of family planning programs in Sindh province. The second group of key informant interviews included eight family planning service providers, including Lady Health Workers, Community Health Workers, Male Social Mobilizers, and medical doctors. These providers serve various sectors and areas in Karachi. In addition, in-depth interviews were conducted with nine married men. The participants were educated, married, and were currently residing with their spouses. All interviews were conducted until the point of saturation. The interview guidelines were prepared in English language and translated into Urdu language, and a pilot test was conducted to detect any changes in the meaning of the content lost during translations. The interviews were transcribed verbatim in the Urdu language and then translated into the English language for analysis. The interviews were conducted from May to September 2022, and the study got ethical approval from Aga Khan University Karachi (ERC # 2022-7136-21536).

Conceptual Framework of the Study:

To understand men’s involvement in family planning for both the provision and utilization of services, this study used World Health Organization (WHO) Health System Building Blocks as the guiding framework. In multiple ways, the six building blocks support the improvement of health systems. The foundation for the general policy and regulation of all the other building blocks of the health system is provided by several cross-cutting elements, such as leadership/governance and health information systems. Finance and the health workforce are two examples of important input components for the healthcare system. A third category includes the delivery of medical services and goods, representing how the health system ensures accessibility and distribution of treatment (19). This framework allowed for the establishment of indicators and measurement methodologies for tracking progress toward the involvement of men and helped focus on these distinct elements and set limits around this complicated construct.

In this study, a deductive approach was used to describe findings under each of the six building blocks as major themes. This paradigm aided the researcher in thoroughly examining stakeholders, service providers, and men beneficiaries' perceptions of men's participation in family planning programs. Governance and information blocks provided limited information in this study. The researcher modified the framework to emphasize the importance of men's involvement in family planning programs. Figure one defines the conceptual framework developed around those blocks. This helped in identifying patterns, responses, or meanings within these themes (20).

Study procedure:

Before conducting interviews, we provided participants with a brief overview of the study and assured them of confidentiality. Informed consent was obtained in writing from each participant. Interviews were conducted in private settings to maintain privacy, and participants explicitly consented to audio recording and then transcribed and translated. The duration of each interview ranged from 30 to 45 minutes.

Data Analysis:

The data were analyzed using NVivo 15, using predefined themes. The analysis followed a deductive approach (top-down approach) where the researcher begins with a broad hypothesis and then evaluates it using detailed observations. Deductive analysis is frequently used to verify a theory or examine a well-established notion. Deductive research is frequently used by researchers to evaluate a well-established theory or hypothesis and either prove or refute it. When a researcher has a specific study question, this strategy performs well (21). The deductive approach helped to identify the patterns, responses, and experiences of participants related to the phenomenon. This involved organizing and categorizing the data, aligning it with the research question, and utilizing a theoretical framework to develop codes for sorting the data into predetermined categories (22). The process described in the figure below was used to analyze the data.

The trustworthiness of the data was maintained using four criteria.

Credibility: To ensure internal validity, we used triangulation, in-depth analysis, and a thick description of the phenomenon. Credibility was established by conducting in-depth interviews, asking open-ended questions to facilitate detailed descriptions, searching for meaningful insights, and asking questions in an organized manner to help the participants give more profound and richer responses.
Transferability: This study ensured external validity by providing detailed and contextual descriptions of the sample, setting, and results. This allows for the study’s findings to be applied to similar settings and contexts.
Dependability: To ensure reliability, each transcription was verified to resolve discrepancies. The preliminary categories were refined and merged to facilitate the analysis.
Conformability: The categories discovered in the study were confirmed and validated by participants’ words and quotes. The findings and codes were checked for accuracy and categories were established.

The findings were reported using 32 items listed in the COREQ checklist (22). The study was triangulated using two out of four types of triangulations suggested by Denzin (23); data and methodological triangulation. Figure 2 below comprehensively shows the trustworthiness and rigor of the study.

The demographic characteristics of the participants (Table 1) showed that most stakeholders were men and belonged 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 availability and accessibility of family planning information, products, and services (including services for male contraception), governance and leadership, the health workforce, logistics and supplies, and program finances. Further details of each theme and sub-theme are provided below:

Availability and accessibility of family planning information, products, and 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 has been explored during stakeholder interviews. The cultural aspect was dominant when the stakeholders and providers responded to this question, where it was emphasized that “men's involvement in 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 stakeholders 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” (SH_002). “Lack of acceptability in the communities for these male mobilizers” is one of the reasons discussed during the interviews. 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.

Accessibility and availability of family planning services for men: 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). One stakeholder (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; One stakeholder (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 service provider (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 will avail those services” (SP_005). A service provider (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 question whether anyone approaches them in the communities for these services. Most of them mentioned that no one had ever visited them to offer these services. One participant (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 any such clinics, but those who have some infertility issues or have no children…men don’t go anywhere to prevent unwanted children”.

Family planning services are filling gender gaps, which aim to understand how the current program or services address the specific needs of men in communities. 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. A stakeholder (SH_004) discussed, “It is difficult for female workers to talk to men and discuss family planning in the communities. We have a patriarchal society, and culturally inappropriate to involve men in such programs”. This argument was also affirmed by a female family planning provider (SP_002) who said, “We cannot involve men or change their behavior because we do not interact with them”. Another provider (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.

It is important to also 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. A male counselor (SP_008) 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”.

Family planning commodities and preferred method:

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 these as a major cause. During the COVID pandemic, there has been an increase in the shortage of family planning commodities. The stakeholder (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 service provider (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. A male mobilizer (SP_007) mentioned that “we don’t provide condoms; if anyone wants condoms, they are available with LHW, not with us.”

Health workforce

This theme explored the perceptions of participants 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, the perceptions of the availability of male family planning providers in the communities were explored. During the discussions, two stakeholders (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 SH_001 in these 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 providers in the communities. Almost all the providers denied the presence of male family planning providers in the communities. One (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, with only one provider (SP_005) confirming 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. A married man (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”.

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).

Family planning information and record keeping:

The theme was 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 men clients, 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 mobilizer, we enter data which comes from male mobilizer” (SP_006), “man record maintains just information on vasectomy and referrals”. The male providers mentioned that they keep records for vasectomies.

Financing:

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. A stakeholder (SH_001) said, “All family planning programs are government-funded, while the private sector has different donors for these programs.”

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. A stakeholder (SH_002) considered the implementation of family planning policies as a “question mark”. Further the focus of policies, according to these stakeholders are, “female-oriented”, or “women-focused”.

Traditionally, family planning programs have focused on women, leading to a lack of men’s involvement in these initiatives. The purpose of this exploratory inquiry was to investigate the participation of men in family planning initiatives in Pakistan, with a particular focus on Urban Karachi. This study explored the extent to which current family planning initiatives fulfill the needs of men living in communities. Through a qualitative study, it was determined that there are various gaps in the family planning program regarding meeting men’s needs. These gaps include a lack of men’s involvement, a lack of providers' clinical and behavioral competence to address men’s needs, and cultural barriers preventing person-centered service delivery.

Our study identified several reasons for men not being able to fulfill their need for family planning. The study identified a significant lack of involvement in addressing men's family planning needs. A study from Uganda also found that men’s participation in family planning provisions had a high impact on family planning uptake (24). Due to the widespread unfavourable opinions among the respondents, the majority of them had never participated in family planning with their wives. Without any other outside influences, the cultural barrier alone discouraged men from participating in the family planning project. To promote the adoption of family planning approaches in their communities by the government, it was also necessary to include the opinions of leaders and community members. Studies from the same cultural context have indicated that educating men and including them in counseling sessions can increase their willingness to support the use of contraception and their understanding of shared decision-making (24). Another study from Nigeria revealed that Men are primarily thought of to increase the prevalence of contraception. Men's varied decision-making responsibilities in family planning and reproductive health have a significant impact on women's health (25).

This study found that cultural barriers are preventing the family planning program from meeting the needs of men. The results identified that men face challenges when it comes to accessing services alongside women. This obstacle has also been encountered in other regions of the globe but has been surmounted by enhancing training programs that address cultural differences (26). According to another Kenyan study, facilities offering family planning services are insufficient; there are not enough of them, and the ones that are offered are not user-friendly for men and have a female predominance, which reduces men's engagement (27). Another study from Cameroon discussed barriers to male involvement in family planning, including the lack of men-friendly services, the attitude of service providers, long waiting times at family planning clinics, and finances (28). In addition to cultural barriers, a lack of counseling among providers is another obstacle that needs improvement. This gap can be filled by providing appropriate training to these providers. An example from Bangladesh has shown that the program in the country meets the needs of the male population as it has been specifically tailored to address their requirements (29). A qualitative study from Southern Ghana also highlighted a lack of skilled reproductive healthcare professionals and poor counseling abilities, thereby affecting the quality of service and resulting in clients not obtaining proper information about family planning procedures or recommendations for other methods when they encounter negative effects. The misconceptions about the use of contraceptives among community members may have been fuelled by the inadequate understanding of lower-level care providers in family planning. The need for better human resource capacity for both the technical and human components of reproductive health and family planning counseling is highlighted in this topic (30).

In a separate study conducted in Kenya, a noteworthy observation еmеrgеd, emphasizing the potential necessity for tailored informational resources and enhanced providеr training whеn involving malеs in family planning counseling (31). As pеr thе insights glеanеd from our study's participants, a valuablе recommendation surfacеd: еquipping womеn with thе training nееdеd to offеr counsеling and support to men could significantly augmеnt thе provision of family planning sеrvicеs. This invеstigation brought to light specific inadеquaciеs within program management and documentation, as well as challеngеs associatеd with surmounting cultural barriers and fostеring requisite skills. Consequently, this research highlights gaps in information regarding men who avail of family planning services. This suggests a weakness in existing health information systems such as the District Health Information System (DHIS). Thе еxisting litеraturе also undеrscorеs thе absеncе of standardizеd mеtrics for еffеctivеly monitoring and assеssing malе еngagеmеnt across numеrous countriеs (32). There is a need to incorporate relevant indicators into policies and programs to improve family planning outcomes specific to men’s needs. A qualitative study conducted in Rural India suggested that healthcare professionals' insufficient knowledge of federal and state regulations that emphasize the value of men's engagement may prevent clinicians from taking action to increase men's involvement (33). A review of public policies focused on gaps in health policies, among other sectoral policies, to advance gender equality in Mexico, South Africa, Chile, India, and Brazil. It also highlights the need for policies that encourage men to use male contraceptives while also encouraging men to support their partners' use of contraceptives (34). Some nations have effectively included men's engagement in sexual and reproductive health in their policies. Cambodia was one of the first nations to accomplish this goal in 2003. The National Strategic Framework for Reproductive and Sexual Health in Cambodia, which was developed from 2006 to 2010, incorporates these recommendations, which include encouraging men to utilize family planning methods (35).

In addition, family planning services in Pakistan must be more intentional about how and when to engage men. This includes making couple counseling available at facilities and ensuring that men are treated with respect. Over the past ten years, a study from India has launched several initiatives to promote men's awareness of and support for family planning practices and the reproductive health of their partners. Over two years, women, and couples at Delhi's six high-volume clinics received antenatal and postpartum family planning counseling from the gender-transformative Men in Maternity (MiM) program in India. The findings show that regular counseling increased both men's and women's knowledge of condoms' dual protection, that both sexes were significantly more likely to use family planning between six and nine months after childbirth, and that among non-users, women who received counseling were more likely to report intending to use contraception than those in the control group. Moreover, in the intervention group, spouses were notably more active throughout pregnancy, family planning, and postpartum care, and were present at the mother’s consultations (36). A total of 194 peer educators were educated by Nepal's gender-transformative Men as Partners program to talk to men and women of reproductive age about reproductive health. Peer educators participated in seminars to expand their understanding of family planning and to develop their communication abilities. Men's accountability for safe sexual practices has also been emphasized. The intervention was successful in raising family planning awareness among both men and women in four villages in Nepal, according to the program's 2004 mid-year review (37). One Kenyan study highlighted a significant relationship between the ease of availability of family planning services and the level of men’s involvement in family planning (27).

The study could obtain a broader perception through focus group discussions instead of in-depth interviews. Due to severe weather conditions, this study was limited to conducting in-depth interviews with healthcare providers. Due to heavy rain and flooding, the study was limited to urban areas instead of including perceptions from providers and communities in rural areas.

Men’s involvement in family planning programs and services is limited in Karachi. Service providers, policymakers, and users of contraception and family planning services should not view them as solely a female responsibility. Involving men in family planning programs can have a positive impact on both health and non-health-related outcomes. It is important to provide culturally appropriate services that are developed in consultation with stakeholders within the community. These services should utilize a couple-centered approach and involve male members of society to further enhance equity in family planning programs. There is a need for further exploration of men’s involvement and strategies to include men in both the provision and availing the family planning services.

ICPD: The International Conference on Population and Development

SDGs: Sustainable Developmental Goals

LMICs: low and middle-income countries

PWD: Population Welfare Department

SRHR: Sexual and Reproductive Health and Rights

FP: family planning

PDHS: Pakistan Demographic & Health Survey

CPR: contraception prevalence rate

TFR: total fertility rate

WHO: World Health Organization

COREQ: Consolidated criteria for reporting qualitative research

SH: Stakeholder

SP: Service Provider

MM: Married Man

RHC: Rural Health Centers

BHU: Basic Health Units

NGO: Non-Governmental Organization

ERC: Ethical Review Committee

MiM: Men in Maternity

Ethical approval and consent to participate:

This study received ethical approval from the Aga Khan University Karachi having ERC # 2022-7136-21536. The research was conducted in accordance with the ethical guidelines outlined by the Aga Khan University Karachi. Before participation, all study participants were provided with detailed information about the study's purpose, procedures, potential risks, and benefits. Written informed consent was obtained from each participant before their inclusion in the study. Participants were assured of their right to withdraw from the study at any point without consequence.

Consent for Publication:

Participants were informed that the collected data would be used for research purposes and may be included in publications. To protect their privacy, all data and responses used for publication were anonymized and stripped of any personally identifiable information.

Availability of data and materials:

Data and materials relevant to this study are not publicly available but available upon reasonable request. However, it should be noted that certain restrictions may apply due to privacy and confidentiality concerns.

Competing Interest:

The authors declare no competing interests that could influence the interpretation of the study's findings.

Funding:

This research was supported by the WHO regional hub for the EM region in collaboration with the Aga Khan University Community Health Sciences Department for awarding a thesis grant for this study.

Author’s Contributions:

Each author contributed significantly to the conception, design, implementation, and interpretation of the study. Dr. Jawaria Mukhtar Ahmed played a key role in the study's conceptualization and design, as well as data collection and analysis. Ms. Farina Gul Abrejo contributed to the development of the research methodology, and data analysis, and played a critical role in drafting the manuscript. Dr. Sarah Saleem provided valuable insights during the interpretation of findings, contributed to the literature review, and aided in manuscript revisions. Dr. Xaher Gul was actively involved in data collection, analysis, and coordination of the study. All authors participated in reviewing and approving the final manuscript, ensuring its accuracy and integrity. The collaborative efforts of all authors enriched the quality and rigor of the study, and their combined expertise facilitated the comprehensive exploration of “Men’s Involvement in Current Family Planning Programs: An Exploratory Study from Karachi, Pakistan”.

Acknowledgments:

We would like to express our sincere gratitude to the Population Welfare Department, Greenstar Social Marketing, Willows iNGO, Pathfinder, iNGO, Aga Khan University, and Aga Khan Health Services for Pakistan for their valuable contributions and support throughout this research. Their effective liaison and linkages greatly enriched the quality and depth of our study. We extend our thanks to Mr. Areesh Jumani for his assistance in data collection, which played a vital role in the successful execution of this research.

Furthermore, we acknowledge Dr. Tahani Zaidi for providing her technical assistance in writing, which was essential for the completion of our study. We are also thankful to Sir Waqas Hameed and Dr. Sana Hayat for linking us with the public sector service providers. We would like to thank our study participants for their participation, their input and time were indispensable to our research endeavors.

Lastly, we would like to express our appreciation to our colleagues, mentors, and friends who provided ongoing encouragement, insightful discussions, and constructive feedback during various stages of this study. Their support significantly contributed to shaping the direction and outcome of our research. This work was made possible by the collective efforts of numerous individuals, and we are truly grateful for their contributions.

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No competing interests reported.

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

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Abstract

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Background

Methods

Conceptual Framework of the Study:

Study procedure:

Data Analysis:

Results

Availability and accessibility of family planning information, products, and services:

Family planning commodities and preferred method:

Health workforce

Family planning information and record keeping:

Financing:

Governance/leadership:

Discussion

Conclusion

Abbreviations

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References

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