Abstract
Sexual and reproductive health care (SRH) and family planning (FP) services have been primarily female centered. In recent decades, international groups have advocated for men’s involvement in SRH and FP, yet related research remains limited and implementation not fully realized in many countries. This systematic review of literature seeks to summarize the barriers and facilitators to men’s involvement in SRH/FP services in the Philippines. It is limited to publications in English from 1994 to 2021 regarding studies conducted in the Philippines whose research questions focused on men’s involvement in SRH/FP. Eligible studies were assessed for methodological quality using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Evidence Rating Scale. The Ecological Model for Health Promotion was used as the guiding theoretical framework for analysis and to report findings. Barriers and facilitators were identified at every ecological level except that of policy. The most common barrier identified was men’s deficit in knowledge about SRH/FP; the most common facilitator was the positive influence of their social network on men’s attitudes, beliefs, and practices pertaining to SRH/FP. A range of factors from the individual to the community level influenced men’s involvement, including religious beliefs, economic means, and cultural gender roles. More studies are needed to provide a fuller understanding of the multilevel ecological factors influencing men’s involvement in SRH/FP and inform interventions with men that can positively affect their behavior related to SRH/FP decision making.
Introduction
In developing countries, sexual and reproductive health care (SRH) services are primarily female centered, and the presence of men in SRH clinics, especially those offering specifically family planning (FP), is negligible (Porche, 2012), and various barriers to access and accept SRH services exist for men. Gender dynamics and men’s disapproval of FP methods have a significant negative impact on levels of contraceptive use in many countries (Hossain et al., 2007; Islam et al., 2006; Withers et al., 2015). Although there is increased recognition that men often want to be involved in FP services, the focus on integrating them into SRH/FP programs has been limited (Sternberg & Hubley, 2004).
The Philippines is the 13th most populated country in the world, with a population predicted to reach 125 million by 2030 (World Population Prospects, 2022). As of 2013, one in 10 Filipino women aged 15 to 19 were mothers or bearing children, and 78% of youth who were participating in premarital sex were not using protection (GALANG Philippines, 2016). In the Philippines, men’s involvement in SRH/FP has faced challenges, despite international advocacy for the involvement of men, as equal partners, in reproductive decision making (Asian-Pacific Resource and Research Centre for Women [ARROW], 2022). The Filipino government introduced women-focused FP services in the 1970s through the Philippine Population Program with the primary objective of achieving population control and subsequent poverty alleviation (Lee, 1999). In 1978, national-level policy efforts began to focus on men’s involvement, but opposition to modern FP methods by powerful Catholic groups diminished those efforts throughout the 1980s (Genilo, 2014). In 1994, the International Conference on Population and Development (ICPD) working group comprising representatives from more than 180 countries (including the Philippines) developed the ICPD Programme of Action, which formally acknowledged the importance of men’s involvement in women’s and men’s reproductive health and advocated for a holistic approach to SRH that would include men by focusing on partners (Ketting, 1996). These ICPD goals remain unmet as most Filipino programs and services have been directed at women’s engagement (ARROW, 2005), including the Reproductive Health Bill of 2012, which concentrated on expanding women’s reproductive health rights and women-centered services (Philippine Commission on Women, 2012). Although the need for men’s involvement in SRH/FP has been acknowledged within policies that advocate for men’s inclusion, as of the writing of this article, men’s full involvement in and shared responsibility for FP decision making has not been realized within the Philippines (Clark et al., 2010; Hardee et al., 2017).
Despite challenges, there has been a positive shift in attitudes in developing countries throughout Asia toward engaging men in FP methods (Bietsch, 2015; Kaida et al., 2005). This shift provides an opportunity to develop evidenced-based approaches to improve the integration of men into FP services by addressing care delivery from a family-focused perspective. Men’s participation in comprehensive FP services is crucial to ensuring successful FP programs that promote women’s empowerment and positive outcomes in reproductive health (Kassa et al., 2014). Cultural changes in perception of FP can influence assumptions about traditional masculine roles and encourage initiatives focused on promoting more equitable SRH/FP decision making between men and women (Helzner, 1996). Although there are many contextual factors (e.g., gender roles, moral beliefs, social influences) that must be understood to develop robust and well-received FP programs that more actively engage Filipino men (Medina, 2001; Gipson et al., 2012; Lee, 1999), there is a dearth of research that investigates these various influences and factors within the Philippines (Porche, 2012). The objective of this systematic review, therefore, is to determine from existing relevant literature the multidimensional influences (barriers and facilitators) of men’s involvement in sexual/reproductive health care services and decision making within the Philippines.
Method
Search Strategy and Selection Criteria
The protocol for this review was registered with the International prospective register of systematic reviews (PROSPERO) record CRD42019132696. We completed a comprehensive electronic search of four electronic databases: PubMed, EMBASE, CINAHL (via EBSCO), and Global Health (via EBSCO). Our search was limited to studies published in English from 1994 to January 2021; date limitations were intentionally chosen to reflect Filipino government policy changes about contraception in 1994. Editorials, letters, comments, case reports, and conference abstracts were excluded from the search. The following search terms and their MeSH (medical subject heading) equivalents were used in varying combinations to search the different databases: Philippines, Filipinos, contraception, FP, pregnancy, sexually transmitted diseases, men, males, fathers, and husbands. See Appendices A and B for the full search strategy for each database. The first search was run on December 9, 2019. An updated search was run on January 7, 2021, which was limited to studies published between the first and second search dates.
Study Inclusion Criteria
Studies were included whose research questions focused on men’s involvement in SRH within the Philippines, with no predetermined specific interventions as part of the study design. We screened and removed duplicates, then reviewed all potentially eligible abstracts. In the first search, study inclusion decisions were made independently by two members of the research team (ES, CB) and confirmed by a third (AL). In the updated search, an additional research member (MR) used the same search strategy. Decisions regarding eligibility were made separately by two research team members (MR, ES), then agreed upon jointly. The full texts of eligible studies in both searches were assessed for methodological quality using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Evidence Rating Scale (Newhouse et al., 2007). Discrepancies were resolved by discussion with a third member of the research team (AL).
Theoretical Framework for Analysis
We used the Ecological Model for Health Promotion as the guiding theoretical framework to understand men’s involvement in FP within the Philippines (McLeroy et al., 1988). In this model, an adaptation of Bronfenbrenner’s ecological systems theory, health behavior is seen as the outcome of five levels of the environment in which an individual lives, visually depicted by interconnected relationships between individual, interpersonal, and environmental systems. A systems orientation approach understands that individuals influence and are influenced by other people, local organizations, available resources and institutions, and social norms and policy. The ecological system levels include (1) individual factors (e.g., knowledge, attitudes, skills); (2) interpersonal factors (social networks); (3) organizational factors (environmental rules and regulations for operation); (4) community factors (relationships among organizations, cultural values, norms); and (5) public policy factors (local, state, and national laws and policies).
Results
Results of the Search
The selection process for study inclusion for both searches is presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram in Figure 1. In the first search, applying the described search terms to the four selected academic databases resulted in 624 potentially relevant sources. A review of the abstracts using inclusion criteria resulted in 14 included studies. In the second search, applying the identical described search terms to the same four academic databases resulted in 158 new potentially relevant sources. A review of the abstract using the prior inclusion criteria resulted in the inclusion of one additional study to provide a total of 15 included studies.
(A) PRISMA Flow Diagram—First Search; (B) PRISMA Flow Diagram—Updated Search.
Included Studies
A total of 15 studies related to men’s reproductive decision making in the Philippines were included. Five of the studies included multiple sites throughout the country (Abada & Tenkorang, 2012; de Irala et al., 2009; Lee, 1999; Morisky et al., 2004; Yoshioka et al., 2020), and one disclosed only that the location was an urban area of the Philippines (Hirz et al., 2017). A majority of the studies took place in large urban cities, including Manila (de Irala et al., 2009; Guevara et al., 2010; Lucea et al., 2012; Mason & Smith, 2000), Cebu City (Lee, 1999; Lucea et al., 2012, 2013; Morisky et al., 2004), Lapu-Lapu (Morisky et al., 2005), Mandaue City (Morisky et al., 2005), Cagayan de Oro City (Lee, 1999; Morisky et al., 2004), Davao (de Irala et al., 2009; Lee, 1999), and Iloilo (Lee, 1999). Other studies were conducted in rural locations including Ifugao (Kadomoto et al., 2011), Tagaytay (d’Arcangues et al., 2001), Bukidnon province (Lundgren et al., 2012), and Eastern Samar (Cuaton, 2019).
Most of the studies (eight) used quantitative methods, five used qualitative methods, and two were mixed methods (Lee, 1999; Mason & Smith, 2000). The quantitative research designs used included four cross-sectional (de Irala et al., 2009; Guevara et al., 2010; Lucea et al., 2012; Yoshioka et al., 2020), three quasi-experimental (Abada & Tenkorang, 2012; Kadomoto et al., 2011; Morisky et al., 2004), and one crossover study design (Morisky et al., 2005). The qualitative study designs primarily used focus groups and interviews (Cuaton, 2019; d’Arcangues et al., 2001; Hirz et al., 2017; Lucea et al., 2013), but one method consisted of a case study (Lundgren et al., 2012). The characteristics of the included studies can be seen in Table 1. A summary of the barriers and facilitators to men’s involvement at each ecological level discussed below can be found in Tables 2 and 3, respectively.
Characteristics and Quality Rating of Included Studies.
Note. FP = family planning; RH = reproductive health; STI = sexually transmitted infection; STDs = sexually transmitted diseases.
Summary Table of Barriers to Male FP Involvement.
Note. FP = family planning; STI = sexually transmitted infection; SRH = sexual and reproductive health care; IPV = intimate partner violence; STDs = sexually transmitted diseases; IUDs = intrauterine devices; LOC = locus of control.
Summary Table of Barriers to Male FP Involvement.
Note. FP = family planning; STI = sexually transmitted infection; CSWs = commercial sex workers.
Individual-Level Factors
Barriers to Men’s Involvement With SRH Care Services and/or FP Decision Making
Men’s personal sexual preferences and lack of correct information were common individual-level barriers to their involvement in SRH services and FP decision making. Lack of knowledge and belief in misinformation about reproductive health, especially regarding contraceptive use, were the most prominent barriers to men’s involvement with SRH services and FP decision making. Two studies reported that a low perceived risk of sexually transmitted disease (STD) infection resulting from misinformation (e.g., that sexually transmitted infections [STIs] do not occur in the mouth) was associated with rejection of condoms during sexual encounters (Guevara et al., 2010; Lee, 1999). Three other studies with Filipino men reported low knowledge scores regarding a variety of reproductive health topics, including contraception methods, STIs, and pregnancy, often coupled with lack of condom use (d’Arcangues et al., 2001; de Irala et al., 2009; Morisky et al., 2004). Condom use was reduced by lack of trust in effectiveness and fear of side effects; in two studies, men and women reported hesitancy due to misinformation from peers, partners, and media about condom flaws (d’Arcangues et al., 2001; Lucea et al., 2013). Resistance to acquiring information about modern contraceptives and SRH served as an additional barrier to men’s involvement. One study evaluating men’s participation in women’s health programs reported that men expressed disinterest in learning new information about their health (Lee, 1999); another intervention reported that men’s disinterest in health information resulted in participant disengagement and large dropout rates, especially among men who had lower SRH knowledge scores at enrollment (Kadomoto et al., 2011). Many Filipino men and women who reported using the calendar method lacked a basic understanding of the fertility cycle, which resulted in inconsistent implementation of the method to manage FP effectively (d’Arcangues et al., 2001).
Personal preferences and perceptions regarding sexual practice and condom use were factors influencing men’s SRH and FP decision making. In several studies, respondents who were men reported high libido or low perception of risk as validations of sexual promiscuity and nonuse of condoms. For example, Filipino seafarers in one study expressed that (a) the male libido validated their engagement with sex workers while abroad, (b) the gratification of their sexual needs was inevitable and necessary, and (c) no risk of harm to their primary committed relationships resulted from such engagements (Guevara et al., 2010). Personal preference was another factor influencing condom use. In two studies, men in the Philippines frequently reported that condoms reduced pleasure and decreased sensation during sex (Guevara et al., 2010; Lee, 1999). In one study, men reported experiencing desire for skin-on-skin sensation as well as discomfort, pain, or itchiness with condom use (Lucea et al., 2013).
Facilitators to Men’s Involvement With SRH Care Services and/or FP Decision Making
At the individual level, some studies found that men were motivated to engage in FP and SRH decision making, considering participation a moral and personal responsibility. Although some men in a seafarer study considered condom use uncomfortable, 83% of participants (a) agreed that commercial sex workers (CSWs) should not bear sole responsibility for ensuring that condoms were used during sex; (b) agreed or strongly agreed that all seafarers should be tested for STIs before boarding the ship and inform their sexual partners if they had an STI; and (c) expressed a moral responsibility to report an STI to a committed partner to protect the “sacredness” of sex within marriage (Guevara et al., 2010). In another study, men expressed motivation to engage in SRH and FP decision making with a partner experiencing an unintended pregnancy due to the belief that they were morally and financially responsible to provide for a child they had fathered (Hirz et al., 2017).
Interpersonal Level
Barriers to Men’s Involvement With SRH Care Services and/or FP Decision Making
Male dominance in partner decision making was a common interpersonal-level barrier across included studies. Abada and Tenkorang (2012) discussed men’s dominance in determining desired family size as a key factor in reproductive decisions. Although 66% of married women surveyed in their study reported consensus with their husbands regarding family size, nearly half the pregnancies were reported to be unintended. Of note, in cases in which the husband wanted more children than their wife, there was a 22.8% increased likelihood of the woman experiencing an unwanted pregnancy. The rate of mistimed births was lower for women who had the final say in household matters or reported attitudes that indicated greater sexual autonomy with their husband.
Men’s dominance and partner power dynamics can limit a woman’s power to negotiate sex and condom use or put her at risk for with intimate partner violence (IPV). In one study, women with less autonomy were less likely to share their partner’s fertility preference (Mason & Smith, 2000). Another study reported a significant association between IPV and women’s inability to negotiate contraception use with their partners (Yoshioka et al., 2020). Women’s lack of power to negotiate with men who held decision-making dominance in sexual relationships was directly associated with IPV toward young women which contributed to their risk for unwanted pregnancy or HIV (Lucea et al., 2012; Yoshioka et al., 2020). Eighty-one percent of respondents in a study within the Cebu province reported having experiencing some amount of unwanted sexual pressure, physical violence, or psychological abuse, and almost two thirds of participants reported at least one act of pressured or unwanted sex (Lucea et al., 2012). In a study of men’s perceptions of the male role in pregnancy and abortion, Filipino men reported feeling afraid and resentful of unintended pregnancy yet disparaged women who decided to terminate an unwanted pregnancy without the father’s knowledge, expressing that abortion was a sin from which they wished to distance themselves; the authors indicated that these women were at risk for partner abandonment and loss of support (Hirz et al., 2017).
Facilitators of Men’s Involvement With SRH Care Services and/or FP Decision Making
Common facilitators of men’s involvement at the interpersonal level were social network influences and partner communication. In a study in which peer educators were used to instruct participants who were men on material related to reproductive health, FP, and STDs/AIDS, participants reported post intervention that they were more motivated to use condoms and become peer educators themselves as a result of the intervention (Lee, 1999). A similar HIV/STI intervention program for high-risk men in the Philippines reported that the use of peer counselors played a crucial role in increasing HIV/AIDS knowledge, resulting in significant knowledge increases as well as improved condom use at both posttest and a 6-month follow-up compared with the control group (Morisky et al., 2004, 2005). Study results indicated that a strong element of trust in the peer-led program and its confidentiality was an important facilitating factor (Morisky et al., 2005).
Communication between partners or couples was a prominent theme for facilitating improved men’s involvement in reproductive health decision making between partners. One study reported significant improvement in men’s attitudes about reproductive health after an intervention aimed at strengthening husband–wife communication (Lundgren et al., 2012); another identified a positive association between partner communication regarding condom use and condom use uptake (Lucea et al., 2013). A cross-sectional study in several Filipino communities reported that (a) couples who engaged more frequently in communication demonstrated greater alignment in fertility preferences and less dominance of the husband’s preferences over the wife’s, and (b) increased discussion of fertility-related issues among couples was associated with increased likelihood of contraception use (Mason & Smith, 2000).
Organizational Level
Barriers to Men’s Involvement With SRH Care Services and/or FP Decision Making
Common barriers to men’s involvement identified at the organizational level included religious teachings, national laws, and economic means. The Philippines is a nation consisting primarily of religiously devout Roman Catholics. Several studies reported that the Catholic Church’s positions on SRH and FP, including the teaching that contraceptive use is sinful and should be replaced with natural FP, guided many respondents’ decisions (Hirz et al., 2017; Lucea et al., 2013; Mason & Smith, 2000). Religious beliefs that pregnancies are “the will of God” affected men’s involvement in SRH and FP decisions regarding abortion. According to one study, the belief that abortion is immoral influenced men to distance themselves from SRH activities related to abortion and to disparage women who sought to terminate an unexpected or unwanted pregnancy (Hirz et al., 2017). Abortion in the Philippines has legal consequences, and this factor affected men’s motivation to become involved in SRH services associated with pregnancy termination. In one study, men acknowledged that many women used illegal methods to induce abortion, and that they feared being associated with a woman who terminated a pregnancy due to possible legal ramifications (Hirz et al., 2017).
Men expressed reluctance to become involved in SRH/FP due to economic costs (e.g., purchasing contraception, supporting additional children). In a study by d’Arcanguesc and Kennedy (2001), couples preferred to use the calendar method or periodic abstinence because it has no associated costs, unlike other contraceptive methods. Mason and Smith (2000) similarly noted that cost and availability of products and services influenced contraceptive use among their respondents. Hirz et al. (2017) reported that young Filipino men who participated in their study feared undertaking responsibility for an unintended pregnancy in part due to the cost of a pregnancy and subsequent family support given their limited material and social resources. In one study, respondents who were men considered SRH and FP decision-making complex, involving engagement in population control, current resources, and the overall economy (Lucea et al., 2013).
Facilitators to Men’s Involvement With SRH Care Services and/or FP Decision Making
Common facilitators at the organizational level included employer investment in SRH/FP accessibility and economic means. In some high-risk employment areas (e.g., seafaring, taxi/ tricycle driving), sexual health intervention partnerships have been created between employers and employees which have facilitated male participation in SRH/FP activities. The employers in one study made it possible for nearly all of their employees to participate in a peer-based training seminar intervention and sometimes assume an active role such as distributing educational materials (Morisky et al., 2004). Economic means served as a facilitator for men’s awareness of and involvement in SRH and FP issues, as economic difficulties that participants faced motivated these men to control their family size and engage in FP. One study reported that men’s awareness of their limited finances and resources motivated them to assume a more pronounced role in reproductive decision making, and some married participants’ personal financial awareness and decision to reduce their family size was influenced by the country’s limited resources as well (Lucea et al., 2013).
Community Level
Barriers to Men’s Involvement With SRH Care Services and/or FP Decision Making
Cultural gender norms and stigma surrounding sex and condom use were identified in studies as common barriers to men’s involvement at the community level. Filipino cultural norms separate gender responsibilities: women are viewed as primary caretakers and men as economic providers (Cuaton, 2019). Some studies reported that these gender-specific perceptions caused men to believe that SRH/FP issues fell outside their roles as men (Hirz et al., 2017; Kadomoto et al., 2011; Lee, 1999). Men in one study of Ifugao males in the Philippines reported SRH/FP issues to be a women’s responsibility (Kadomoto et al., 2011). In another study, men reported that they depended on their partners to track their menstrual cycle rather than using modern contraceptive methods to manage FP, thus avoiding responsibility for unintended pregnancies (d’Arcangues et al., 2001). Cultural expectations of sexual behavior across genders fueled men’s disengagement from SRH/FP. Men reported that although premarital/extramarital sex and unintended pregnancy was condemned in women, premarital or extramarital sex was acceptable if not inevitable for men during long separations from a female partner (Guevara et al., 2010; Hirz et al., 2017; Lucea et al., 2013). Perceptions of the dominance of the men’s preference affected FP by undermining women’s ability to negotiate condom use to prevent pregnancy (Lee, 1999; Lundgren et al., 2012; Mason & Smith, 2000). In one study, women reported relenting on their insistence that a condom be used during sex to avoid trouble or prevent the realistic threat of their partner “walking out” (Lucea et al., 2013).
Cultural stigma surrounding the topic of sex and condom use served as a barrier to men’s engagement with SRH. Some studies suggested that negative connotations attached to condom use, such as infidelity or STIs for both men and women, led to sexually active men’s reluctance to use condoms for fear of raising suspicion (Guevara et al., 2010; Lee, 1999). In addition, in the unmarried demographic, condom use was perceived as a sign that the man did not wish to marry the woman with whom he was engaging in sex (Lee, 1999; Lucea et al., 2013). Men are vulnerable to stigma due to the location of condoms, which are usually sold in small local pharmacies commonly crowded with neighbors (Lucea et al., 2013). The lack of privacy and anonymity deters both men and women from purchasing condoms to avoid incurring stigma within their communities by publicly conveying their intent to engage in sexual relations by purchasing condoms (Lucea et al., 2013). Cultural stigma toward sex limits opportunities for young men and adolescents to learn about SRH and FP from family and community. In one study, Filipino high school students who were men reported having had few conversations about sex or sexuality with their parents (de Irala et al., 2009).
Facilitators to Men’s Involvement With SRH Care Services and/or FP Decision Making
Although there were many barriers to men’s participation in women’s reproductive health programs, the cultural value of men’s leadership and involvement served as a facilitator of their involvement in SRH/FP at the community level. One article reported that women in the Philippines sought information regarding the calendar method as a form of contraception from family elders who were men, such as a grandfather (d’Arcangues et al., 2001). A study by Lee (1999) reported that both women and men believed that men’s involvement was important for women’s reproductive health (Lee, 1999). Managers of identified studies and programs which provide SRH for women overwhelmingly supported the inclusion of men in interventions, specifically because of their role in making major decisions for SRH/FP issues. Surveyed program managers believed that including men and directing attention at couples would allow heath issues to be better addressed. Participants in reproductive health programs reported increases in knowledge about various health topics, which influenced their value systems related to SRH/FP (Lee, 1999).
Discussion
In our systematic review of the literature, we sought to identify the multidimensional factors impacting the involvement of Filipino men in SRH/FP. Only 15 studies were identified that addressed these factors within the Philippines from 1994 to 2021. We used the ecological model, and the reviewed studies identified barriers and facilitators at every ecological level except that of policy, which is the outermost level. Factors such as religious views, power dynamics, economic means, and individual knowledge impacted identified barriers and facilitators. In our discussion, we describe how the overarching factors we identified in studies conducted around the world can provide a deeper understanding of the multilevel influences on men’s involvement. Our review demonstrates that the amount of research surrounding men’s involvement in SRH/FP services remains insufficient, especially in regard to political influences, and that more research is needed to realize the goal of men’s full involvement in and shared responsibility for FP decision making in the Philippines.
Policy Gaps With SRH/FP
None of the included literature examined the influence of SRH/FP law or policies at local, regional, or national levels on men’s involvement. A number of laws focus on SRH/FP in the Philippines, but the strong influence of the Catholic Church in Filipino culture has made the government reluctant to enact comprehensive FP laws in violation of church doctrine (Ruiz Austria, 2004). Although policy efforts in 2012 sought to guarantee universal access to SRH/FP services through the Responsible Parenthood Law (Republic Act No. 10354), resistance from religious pro-life groups led the Supreme Court to place the proposed law under a Temporary Restraining Order until it was lifted in 2017 by President Rodrigo Duterte (Finch, 2013; Gulland, 2014; Ozaki et al., 2017). This slow and complex legal process to increase access to modern methods has meant that attention to men’s role in SRH/FP is nearly absent on a national policy level. As research seeks to include men in SRH/FP initiatives, it is imperative to consider key decision makers at the policy level to address these gaps, including tailoring advocacy methods and messaging to impact how decision makers perceive SRH/FP initiatives (Smith et al., 2015).
Religious Significance in SRH/FP
Religious teachings and community beliefs have a powerful impact on SRH/FP behavior in the Philippines. Studies reported that moral teachings often informed men’s resistance to contraceptive use and abortion, resulting in their disengagement from SRH/FP decision making and disparagement of women’s FP decision making. In a culture where power dynamics tend to prioritize men’s preferences, it is important to recognize that men’s religious views impact SRH/FP decision making within the family unit (Hirz et al., 2017; Lucea et al., 2013; Mason & Smith, 2000). Religious beliefs have been identified as a primary reason for low utilization of FP services in developing counties (Kassa et al., 2014). In addition, a culture’s moral and religious beliefs surrounding FP may support a husband’s fertility desires in opposition to practices meant to improve women’s SRH, such as birth spacing and contraception use (Kabagenyi et al., 2014). It is important that SRH/FP initiatives in the Philippines engage with religious groups to harness support for men’s involvement. Collaboration with religious leaders has been successful in other places. In a study conducted in Africa, collaboration with religious groups as FP advocates resulted in improved men’s involvement and positive changes in attitudes (Adelekan et al., 2014).
Economic Influences on SRH/FP
Financial means and the economy were identified as driving organizational-level barriers to and facilitators of men’s decision making in FP. As the cultural “bread winners” of the family, men face pressure to provide sufficient daily income; restricted income and free time can prevent men from attending FP visits. Restricted access to contraceptives due to location or time often result in men’s disengagement with SRH/FP and preference for a natural FP method (d’Arcangues et al., 2001). Studies have identified that economic barriers to SRH/FP use, such as lower socioeconomic status and logistical barriers to services, negatively affect contraception use (Mukasa et al., 2017; Najafi-Sharjabad et al., 2013). In low- and middle-income countries and rural areas particularly, there is a need for inadequate infrastructure to be strengthened and organized supply chain systems to be better funded to address the economic and logistical barriers to SRH/FP access that many men face (Mukasa et al., 2017).
Economics facilitated the promotion of FP in some ways. For example, when individuals perceived that by controlling family size, they ensured their personal financial stability and their family’s security. In early 2018, the Filipino government projected that the nation’s population would increase by 1.8 million by the end of 2018, with a growth rate of 1.69% (Republic of the Philippines Commission on Population and Development, 2018). As of 2019, the average family size nationally was nearly 4.5, considerably larger than in most developed countries and in more than half the countries within Southeast Asia (United Nations Department of Economic and Social Affairs, 2019). Increasing access to SRH services is part of the United Nations Sustainable Development Goals set out in 2015 (United Nations Sustainable Development Goals, 2022), which seek to eliminate poverty, provide universal primary education, promote gender equality, and empower women. Men’s desire to maintain economic stability and provide for their family could act as a facilitator to influence contraception use, promote gender equality through joint FP decisions, and address the knowledge gap about how FP influences economics, all of which are critical to FP project implementation.
SRH/FP Knowledge and Partner Communication
We identified that knowledge deficits on such issues as proper use and side effects of contraceptives were a significant barrier to SRH/FP engagement in the Philippines, yet men generally maintained the locus of control in FP decision making. Studies did note that interventions facilitated by interpersonal factors such as social networks and peer mentorships improved men’s SRH/FP knowledge and engagement (Kadomoto et al., 2011; Lee, 1999; Morisky et al., 2005). Research in the Democratic Republic of Congo (DRC) identified that (a) social norms influenced young adults’ intention to use modern contraception, and (b) creating social influence strategies to change social norms could build a more supportive social environment for modern contraceptive methods (Costenbader et al., 2019). Although it is well documented that the FP knowledge deficit is inversely related to modern contraceptive use in the Philippines and other settings (Keesara et al., 2018; Sileo et al., 2015), more research is needed to provide clear evidence regarding social influences on men’s contraceptive use and engagement in SRH/FP with their partners.
Studies have sought to improve knowledge and power dynamics through interventions that center on partner communication as a facilitator of men’s engagement in SRH/FP (Lucea et al., 2013; Lundgren et al., 2012; Mason & Smith, 2000). Although prior initiatives for women’s health in the Philippines have tried to counter the imbalance created by men’s dominance by focusing initiatives solely on women, advocates claim that there are negative consequences to developing “women-focused” and “women-only” interventions within SRH/FP programs. For example, primarily focusing on women could alienate men from sharing responsibility for limiting family size, parenting, and housework while maintaining, as the economic provider for the family, authoritative influence over their partner’s SRH/FP decision making (Medina, 2001; Sternberg & Hubley, 2004).
Other countries have sought to involve both partners in SRH/FP through communication-centered interventions in which the quality and frequency of spousal/partner communication are essential factors contributing to increased men’s involvement in FP (Hartmann et al., 2012). One successful initiative used FP-focused SMS messaging between nurses and men to reduce SRH/FP misconceptions and stimulate communication within couples, which resulted in improved contraceptive access and partner communication (Harrington et al., 2019). Successes with innovative methods, such as SMS information sharing, demonstrate that novel approaches can harness existing facilitators to combat knowledge and relational barriers to men’s involvement in SRH/FP. More research is needed to address knowledge gaps, cultural norms, and gender power dynamics challenging informed FP decision making that benefits both men and women in the Philippines.
Limitations
One significant limitation to this systematic review is that themes were siloed into distinct categories informed by the Ecological Model for Health Promotion in an effort to understand complex influences on men’s involvement in SRH/FP health care and decision making. These themes are inherently intersectional and cross multiple levels and related themes, which could affect interpretation and integration of themes on male involvement in SRH/FP. There was a lack of relevant literature investigating the impact of SRH/FP policy, which creates potential gaps in findings related to policy-level factors. The authors acknowledge that this review is limited to cisgendered relationships and does not explore factors specific to the lesbian, gay, bisexual, and transgender community and SRH/FP decision making in the Philippines.
Conclusion
Researchers and policy makers have emphasized the global need to include men in SRH/FP programming, yet many developing countries, including the Philippines, face numerous barriers that impact men’s involvement. Although interventions and studies have identified an association between men’s involvement and contraceptive use in some settings (Hartmann et al., 2012; Shattuck et al., 2011), only a few published interventions have incorporated men. Men have expressed a strong desire to be included in FP programs, but significant barriers have been identified at all levels of the ecosystem that prevent men from participating fully in SRH/FP services and decision making in the Philippines. This review highlights many important barriers as well as existing contextual facilitators which can inform efforts by program developers and researchers to initiative meaningfully improvements in SRH/FP outcomes for men and women in the Philippines.
Footnotes
Appendix A
Appendix B
Author Contributions
A.L. participated in the first literature search, data extraction, and writing of the manuscript. M.A.R. participated in the updated literature search, as well as writing and editing of all sections for the final manuscript. C.B. and E.F. participated in the protocol development, data extraction, and editing of manuscript. A.W. completed the literature search and drafting of the methods section of the manuscript. E.L.S. participated in the protocol development, data extraction, drafting and the editing of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported through the RTI International University Scholars Program (PI: Stevenson).
