Abstract
While family planning (FP) programs have the capacity to empower women, support gender equality, and reduce poverty, male involvement is an influential factor for the uptake of FP that has been lacking. In the past decade, there have been more progressive FP policies and growing attention on male involvement in FP in the Philippines, providing an opportunity to develop evidence-based interventions to better integrate men into FP services by approaching care delivery from a family-focused perspective. This paper sought to understand the current role of men in FP services and explore how to strengthen facilitators and overcome barriers to optimize men’s involvement in FP in the Philippines. Using the Ecological Model for Health Promotion, this qualitative study used convenience sampling to collect data through in-depth interviews and focus group discussions at all levels of the ecosystem. All data were collected in the Albay area, with the exception of some policy data collected in Manila. Qualitative analysis was guided by content analysis. The final sample included 66 participants across the ecosystem. Two primary themes emerged: (1) Resources and health care systems structure impact on male involvement in FP and (2) Education and training that support male involvement in FP. The findings of our qualitative study suggest that while men in the Philippines and their ecosystems support men’s FP involvement, the inconsistent health care systems and protocols are not yet reaching men with information and education they need to help them make informed FP decisions with their female partners.
Keywords
Introduction
While family planning (FP) programs have the capacity to empower women, support gender equality, and reduce poverty, male involvement is an influential factor for the uptake of FP that has been lacking. Over the past 30 years, international support for the involvement of men in FP has been increasing, beginning with the 1994 Cairo and 1995 Beijing International Conference on Population and Development (ICPD), which made recommendations to improve men and women’s reproductive health through men’s involvement (Ketting, 1996; World Health Organization, 1995). In 2012, the London Family Planning Summit expanded on these recommendations and developed initiatives through their FP2020 goals to improve FP programs and male involvement in low- and medium-income countries (United Nations Population Fund, 2017). Many countries pledged to incorporate increasing male engagement in FP into their FP2020 goals, including the Philippines.
As a result of the Philippines committing to the FP2020 goal of pursuing human rights–based FP, the government increased funding and policy support to decrease unmet FP needs (FP2030, 2023). This commitment led to several policies, including the Responsible Parenthood and Reproductive Health Act of 2012 (2012), which recognized reproductive health as a human right and guaranteed the promotion of gender equity and equality. The Philippines passed Republic Act 11223 shortly thereafter in 2018, which committed to provide universal health care and access to affordable FP (Universal Health Care Act, 2018). By 2017, the current use of any contraceptive method was at 51.1%, and 28.3% had never used a modern FP (Nagai et al., 2019). While FP has seen improvement during increased government policy and funding for FP access, population uptake and use is still low.
In many countries throughout the world, gender dynamics and men’s disapproval of FP have a significant negative impact on the levels of contraceptive use, even when resources are available and accessible (Chandra-Mouli et al., 2014; Withers et al., 2015). A review of the literature on men’s involvement in FP in The Philippines suggests that women’s partners, most often men, play a crucial role in reproductive decision-making and greatly impact the uptake of FP services (Lantiere et al., 2022). Other literature has reported low involvement of men in FP services can be attributable to lack of information and inaccessibility to services (Kassa et al., 2014), and men’s deterrence from FP has been connected to their decreased perception of risk, misunderstanding, or misinformation about FP methods and services, and a lack of time or interest (Lucea et al., 2013). However, there are also factors that encourage men’s participation in FP, including couple’s joint decision-making, social and financial resources, and couples’ desire to control family size (Lucea et al., 2013; Lundgren et al., 2012).
Although there has been increasing recognition that men want to be involved in FP services and attitudes toward FP are shifting (Bag et al., 2022; Bietsch, 2015; Kaida et al., 2005), few FP programs have successfully integrated men (Geltore & Lakew, 2022; Lundgren et al., 2012). Current programming in the Philippines is guided by frameworks for male engagement that address gender norms and involvement of men, offering evidence-based interventions that can be implemented to enhance men’s involvement in FP (United States Agency for International Development [USAID], 2018). This framework includes engaging men as FP users, engaging men as supportive partners, and engaging men as agents of change—acknowledging that men can themselves use FP, support their own families to use contraception, and be advocates for FP in the public sphere.
In the past decade, there have been more progressive FP policies and growing attention on male involvement in FP in the Philippines. This has provided an opportunity to develop evidence-based interventions to better integrate men into FP services by approaching care delivery from a family-focused perspective. In addition, researchers utilized in-depth interview (IDI) and focus group discussion (FGD) findings to understand the current role of men in FP services and explore how to strengthen facilitators and overcome barriers to optimize men’s involvement in FP in the Philippines. Findings from this study can inform approaches to improve current standards of men’s involvement in FP in the Philippines and inform strategies for FP service delivery.
We used the Ecological Model for Health Promotion (Figure 1) as the guiding theoretical framework to understand men’s involvement in FP in the Philippines (McLeroy et al., 1988). This model is an adaptation of Bronfenbrenner’s ecological systems theory. In this model (1992), health behavior is seen as the outcome of five levels of the environment in which an individual lives and uses visual depictions of the interconnected relationship between individuals and groups, and their environments. A systems orientation approach sees that individuals influence and are influenced by other people, organizations in their community, available resources and institutions, and social norms and rules. Levels of the system include (1) individual factors: knowledge, attitudes, skills, and so on; (2) interpersonal: social network; (3) organizational: environmental, formal (and informal) rules and regulations for operation; (4) community: relationships among organizations, cultural values, norms; and (5) public policy: local, state, and national laws and policies (Sallis et al., 2008). Given the bidirectional and complex influence between intimate partners’ use of FP, this study collapsed Levels 1 and 2 (individual and interpersonal factors), noting that a study of this scope would not adequately elucidate the nuances between these two levels. The aim of this project was to understand the multidimensional influences (barriers and facilitators) of men’s involvement in FP services and decision-making in the Philippines, including men’s support for FP use for their partners and/or for themselves.
Ecological Model for Health Promotion
Method
Study Population/Location
Because of the high unmet needs for FP in certain regions of the Philippines, this qualitative study primarily focused on the Albay province, which has unmet contraceptive needs higher than national average (J.J. Dela Rosa, personal communication, January 15, 2020). All data were collected in the Albay area, with the exception of some policy data that was collected in the capital, Manila. Research Triangle International Institutional Review Board approval was received (00020435) and verbal consent was obtained and recorded on a dedicated form in a protected electronic file prior to data collection. Convenience sampling was used for all levels. We sampled for each level of the Ecological Model:
Interpersonal/Intrapersonal Level: Defined as partners of men during childbearing years, and men during their childbearing years. Participants from these levels were recruited via the Barangay Health Centers, Rural Health Units, City Health Offices in which data were collected for the Community level, using a convenience sampling approach. Barangay are small territories throughout the country and are the smallest unit of government in The Philippines; letters of invitation to participate in IDIs and FGDs were distributed by providers to women and men seeking FP care.
Community Level: Barangay and rural health unit health care providers (e.g., physicians, nurses, health educators, administration, support) and community leaders (e.g., mayors and governors, traditional religious leaders). Two barangay units were included for recruitment to represent the Albay province, one from the rural area and one from the urban area. All members of the health care team were invited to participate via letter of invitation. Community leaders were identified through current in-country contacts and invited to participate by letter of invitation.
Institutional Level: Defined as secondary and tertiary health care providers within the Albay province (e.g., physicians, nurses, health educators, administration, support); private/public academic settings (e.g., major training and teaching hospital in Albay which is involved in health worker education and training); department of health regional and provincial training units. All members of the health care team were invited to participate via letter of invitation and were identified through current in-country and professional contacts.
Public Policy Level: Participants included senior FP policy makers from the National, Provincial, and Municipality Department of Health, Family Health Office, and the Population Commission and national FP non-governmental organization (NGO) leaders. These individuals were invited via letter.
Data Collection
Interpersonal and intrapersonal levels: FGDs were conducted for both the Interpersonal and Intrapersonal levels of data. Trained research nurses conducted IDIs with participants from men and partners to understand their experiences and why they chose to use or support the use of FP. Interviews were conducted in a combination of Tagalog and Bicol which is the local dialect, and audio recorded using an encrypted recorder. The interviews focused on (1) potential benefits, (2) challenges, (3) risks, and (4) opportunities for increasing men’s involvement in FP clinical and education services in the Philippines. In addition, a group of men and women participated in FGDs, which comprised participants who completed IDIs. There was one male-only and one female-only FGD at each of the two barangays, thus four total focus groups. A semi-structured FGD guide was used to guide the FGD to understand the men’s opinions on FP, perspectives on benefits and harms, and perspectives on facilitators and barriers, guided by Krueger and Casey (2014), and the research nurses were provided comprehensive training in conducting FGDs prior to data collection. Each FGD lasted about 30 min, was conducted by a trained research nurse in Tagalog, and was audio recorded using an encrypted recorder.
Public policy, institutional and community levels: The principal investigator (PI) and a trained research nurse conducted in- person IDIs with participants from these levels using a standard question guide. All interviews and FGDs were conducted in English, and a combination of Tagalog and Bicol which is the local dialect, depending on the respondent, then audio recorded, and transcribed. The interviews focused on (1) potential benefits, (2) challenges, (3) risks, and (4) opportunities for increasing men’s involvement in FP clinical and education services in the Philippines.
Data Analysis
IDIs (all levels) and FGDs: Interview notes were reviewed based on broad themes of interest, namely: potential benefits of greater involvement of men in FP clinical and education services; challenges in engaging more with men; possible risks associated with greater men’s involvement in FP; and opportunities for involving men in FP. Interviews were coded manually by two authors, with any differences in coding resolved through discussion. Once consistency with coding was ensured, coding proceeded with the primary author coding all IDIs/FGDs, and 50% being coded by another author (A.L.). Qualitative analysis was guided by content analysis as described by Miles and Huberman (1994), resulting in themes and explanations about barriers and facilitators of men seeking care within FP settings.
Results
The final sample included 66 participants who completed either an IDI (n = 48) or one of four FGDs (each with 4–5 participants, total n = 16). All focus group participants represented the interpersonal/intrapersonal level, all lived within the barangay were interviewed, and were Filipino. We interviewed 11 individuals at the community level, 14 individuals at the institutional level, and five individuals at the public policy level (Table 1). Individuals were all at least 18 years of age and actively seeking FP.
Ecosystem and Key Informants
Note. BHW = Barangay Health Worker; DOH: Depatment of Health; IDI = in-depth interview; FGD = focus group discussion; FP = family planning; NGO = non-governmental organization.
Multi-level factors influencing male involvement in the delivery of and decision for FP services emerged from the individual interviews with key informants and FGDs with men and their female partners, including factors at the interpersonal, institutional, community, and public policy levels. Most reported barriers and facilitators to male involvement at each socio-ecological level emerged within two key themes: health care system structures and resources that impact male involvement in FP and education and training that impact male involvement in FP. Findings on barriers and facilitators are presented within these two major themes at each socio-ecological level. Given the significant focus on female FP methods, we highlight data pertaining to the male FP methods (condom, non-scalpel vasectomy [NSV]).
Resources and Health Care Systems Structure Impact on Male Involvement in Family Planning
Interviews and FGDs revealed that health care systems and available resources were important factors for male involvement at each socio-ecological level. Participants discussed public policy and institutional standards that shape health care systems and resources, as well as standards of care, provider training, and personal resource factors that affected male access to and involvement in FP. Below we discuss specific health care system and resource barriers and facilitators to male involvement that key informants and focus group participants reported at each socio-ecological level.
Key Findings
- Healthcare systems, policies, and protocols need standardized guidance that increases focus on male involvement in FP in the clinical setting.
- Individual resources and community resources are often insufficient to reach men with FP education and counseling in the clinic setting.
Health Care Systems and Resource Barriers
Key informants who worked at the policy (e.g., government officials, NGOs) and institutional levels in government or non-profit organizations reported that health systems policies for health systems and health systems protocols still do not focus enough on improving male involvement in FP. Policy-level informants noted that while national laws promote FP in the Philippines, the specific language surrounding male involvement and inclusion in FP is vague, leaving it up to local public officials to interpret and administer programming within their communities. Informants mentioned that since the health system is decentralized, local officials’ cultural/religious beliefs and local priorities have a large influence on health care initiatives, which often do not prioritize men in FP.
Informants described that institutional-level health care initiatives focus so heavily on creating female-centric health care structures that men are often overlooked in clinical protocols for FP education and records keeping. Informants pointed out that there is no policy or guideline at the institutional level for initiating FP conversations with men who visit clinics, which is left to provider discretion, “. . . like for regular consultations like blood pressure we will give them an idea on what family planning is all about” (Urban Midwife). Lack of structure can lead to confusing conversations for patients who might receive conflicting advice and misinformation. FP recording systems are female-centric, even with male contraceptive distribution. For example, condoms distributed during FP visits are systematically recorded as a female method, not a male method, which overlooks any recording of condom distribution to men.
Informants mentioned that lack of institutional protocols for male involvement in FP affect community-level and clinic-level standards of care. Community-level informants reported that clinics are encouraged to conduct FP education, counseling, and decision-making during the female clinic visit, during which men are often absent due to a variety of barriers. Therefore, women often make FP decisions independently in the clinic, leading to partner conflict and FP abandonment later on. One midwife shared the story in which she inserted contraceptive implants into three women in 1 day. They all returned the next day to remove it because their husbands did not approve. “Some women are very eager to have the method without the consent of their husbands . . . there are various incidents that some women are hiding that they are using a methods [i.e. implant]” (Regional NGO Officer). Informants discussed that FP offered depends on community-level resources. Only a few providers in limited locations offer NSV, which creates transportation, time, and cost barriers to NSV uptake.
Focus groups and key informants reported lack of individual resources and unsupportive health systems staff served as barriers to male involvement in FP planning. Focus group participants discussed that while male partners wanted to attend clinics with their partners, demanding work schedules and lack of financial resources to miss work prevented them from attending appointments or taking a more active role in contraception through NSV, which would require time off for the procedure and recovery. Many male participants said they did not feel welcomed by the health care staff when they attended the clinic or felt they needed to be invited to attend. As one focus group participant said, “I did not experience attending family planning visits yet. We were not invited to attend family planning” (Rural Male FG). Individual clinician’s religious beliefs may impact which FP services are offered in different health care systems, such as one interviewed midwife who did not offer intrauterine devices to patients, due to the belief they were an abortifacient, which went against her religious values.
Key Findings
- There are few facilitators to male involvement through current health care systems, but male and female partners saw modern FP as a means to increase their economic resources by controlling family size.
Health Care Systems and Resource Facilitators
Participants did not discuss any existing facilitators to male involvement through health care systems and clinical support at any socio-ecological level except at the individual level. At the individual level, men and women were attracted to modern FP to increase the family’s economic resources. Both men and women consistently described that having access to modern FP would allow them to have fewer babies, which translated to more disposable income and opportunities for their children. As one participant stated, It is not just having more children if there is no family planning, if we don’t have control in our family; it is important that we have control in our family so that we can provide our children with a good education. (Rural Male 2)
Education and Training That Supports Male Involvement in FP
The second primary theme that emerged from these FGDs and interviews was the critical role that education and training played at supporting male involvement in FP at every level of the socio-ecological model. Key informants and focus group participants discussed the influence that national education initiatives, standardized training protocols, and public education needs have on male involvement in FP. Below we discuss the education-specific barriers and facilitators that participants felt played a role impacting male involvement in FP.
Key Findings
- Standardized health care provider training that focuses on male education and involvement in FP is lacking.
- Misinformation and lack of education among men is a significant barrier to FP use, since men are primary decision-makers both at home and in the community.
Education Barriers to Male Involvement in FP
Key informants did not identify any educational barriers to male involvement in FP at the policy level; however, they did discuss a need for education and training at an institutional level. Informants reported that while health care providers receive regular continuing education related to FP, these education and training modules still focus primarily on FP with women. Informants said lack of training that is specifically focused on male involvement in FP could hinder changes in health care provider approaches in the clinical setting, especially among community health workers, who would have the greatest access to men in the community setting.
Key informants and focus group participants discussed how misinformation and lack of FP education addressing FP misconceptions in the community hindered male involvement at both the community and interpersonal levels. Informants pointed out that there is a strong belief at the community level that men and their wives resist NSV because of the association with infidelity; if a man gets a NSV, he has less to worry about there being an unintended pregnancy with the woman he is engaging in sex with outside his marriage. Focus groups and informants said that most men have limited understanding of or misinformation about modern contraceptive methods and their side effects, especially in rural areas. As one participant noted, “In my observation, especially in the uplands, in general, they do not have enough knowledge and sometimes lack knowledge about family planning” (Rural Male FG). Informants pointed out that misinformation among male partners is perpetuated by their absence at clinic visits where FP education generally occurs, and it is put on female partners to pass on that knowledge.
Informants asserted that focusing on male education is important due to societal norms that position them as major decision-makers at both the community and interpersonal levels. In Filipino culture, male partners still act as primary decision makers on FP use; therefore male-focused education on FP and modern contraception is needed to affect modern FP use. Informants pointed out that the majority of existing decision-makers at the community level are men, including barangay leaders and the mayors within barangays and municipalities. Therefore, their education and knowledge about FP and modern contraception influence priority setting for local community initiatives, many of which do not focus on the involvement of men in FP.
Key Findings
- National initiatives and updated health care training that focus on male involvement are structurally in place to increase knowledge about FP us among men.
- Community members, health care providers, and many male partners in Filipino communities are motivated to increase male education about FP use in their areas.
Education Facilitators to Male Involvement in FP
Key informants reported that both policy-level and institutional-level education efforts, such as national initiatives and training models, have facilitated male involvement in FP. For example, two national initiatives (USAPAN and KATROPA) that are designed to address what Filipino men know about FP and other related topics, such as gender equity, have been implemented. These programs are funded on a national level and implemented at the community level, which informants said should address educational barriers and misinformation preventing male involvement in FP. Informants reported that institutional-level training models for health care providers had been updated to include men in FP education, which improved FP education delivery to men in local communities. For example, one School of Nursing informant said, “The new approach this time is that we are not only concentrating [on] the mother and the child. It is now, all across. It now includes men” (FP Academic Training). The regional and provincial department of health updated guidance to encourage providers to use a life stage approach initiative focused on male FP education. For example, a couple is required to take educational training about FP before they can marry, and poverty prevention programs now have a section that includes FP that would be given to men.
Focus group participants and informants said that communities and individuals were willing and motivated to give and receive education on FP and help improve male involvement. Health care provider informants generally voiced support male involvement in FP and reported that their health centers encouraged men’s attendance at FP visits. One midwife stated, “we call for an assembly where men are included in the invitation to attend and sometimes during the farmer’s meeting” (Rural Midwife). Informants pursued non-conventional methods to educate their male patients about FP and connect them to FP services. For example, one midwife reported that she uses every well-child/immunization visit to discuss current and future FP, because they are more likely to see men at these visits due to national campaigns that encourage more men to attend pediatric visits. Male focus group participants and interviewees expressed desire and motivation to learn about FP, but they admitted that most of their education available to them came directly from their female partners.
Discussion
We designed this study to explore the barriers and facilitators associated with men’s involvement in FP in the Philippines. The findings of our qualitative study suggest that while men in the Philippines and their ecosystems support men’s FP involvement, the inconsistent health care systems and protocols are not yet reaching men with information and education they need to help them make informed FP decisions with their female partners. Health care system gaps and provider training gaps at community, institutional, and public policy levels limit their reach to men, and misinformation among male-decision makers needs correction. However, advances in policy and institutional training are shifting focus to close these gaps in male education and involvement in FP at interpersonal, community, institutional, and public policy levels, and there appears to be individual- and community-level motivation to gain knowledge about modern FP.
Overall, participants expressed an appreciation for the economic benefits provided by FP and verbalized interest in learning more about FP and attending FP classes and health visits. Their support of men’s FP involvement was enabled by an ecosystem where wives/partners, service providers, various institutions, and policy initiatives encouraged men’s involvement in FP. While this ecosystem facilitates FP support among Filipino men, traditional gender roles and mindsets hinder men’s FP involvement.
Gender norms and patriarchal privilege influence men’s FP involvement and the use of men’s FP methods. Similar to our findings, previous studies conducted in the Philippines identified that men’s FP involvement is often limited by their belief that their role as the patriarch is solely to provide for their families and that FP is the women’s responsibility (Cuaton, 2019; Lee, 1999). For example, male participants expressed a desire to approve their partners FP use, while rejecting the idea of using other FP methods such as NSV. While NSV is more efficacious and has a quicker recovery time than female sterilization methods, our findings suggest that NSV uptake is low due to stigma and misperceptions such as diminished masculinity, impotence, and a reduction in penis size (Shih et al., 2011). Continued work at various levels of the ecosystem that seek to challenge these beliefs is needed. For example, KATROPA (“Troop Mate”) sessions are offered through the Commission on Population (Popcom) centrally located in Manila, Philippines. Planned as a series of 2-hr sessions, or whole day, 6 modules on various topics including FP are delivered at regular sessions via regional offices across the country. Studies conducted in other low- and middle-income countries also reported that NSV reluctance was closely associated with a sense of lost “masculinity” (Kabagenyi et al., 2014), as well as fear of public knowledge (Scott et al., 2011). Such misperceptions are reinforced in the clinical setting as NSV is not routinely offered, and factual information is not consistently provided. To increase NSV uptake, access to information related to NSV needs be offered in clinical and community settings to dismantle existing stigma and misperceptions associated with NSV.
At the macro-level, inconsistent, sporadic, and fragmented ecosystem support for men’s involvement in FP emanates from institutionalized gender biases and patriarchal norms. Reproductive health services were observed to be primarily female-focused and health care providers felt ill-equipped to educate men in FP. For example, a Filipino FP program implemented by the Department of Social Welfare and Development encourages, but does not require, men to join program meetings for families to receive program assistance and primarily discusses only female FP methods. The lack of male inclusion in FP clinics was reinforced by inconvenient clinic hours and a sense of unwelcomeness in the clinical setting. Another structural issue was the lack of clear protocols at a clinic level to support male engagement in FP education when they did visit. The fragmented ecosystem support stems from policies which lack a systematic, sustained effort to reach men and engage them equitably.
The facilitators and barriers of men’s involvement in FP are driven by a net effect that influences FP uptake, adherence, and discontinuation. The unmet need for FP remains high and is indicative of the stronger influence of barriers over facilitators. As long as the messaging of men’s FP involvement is not supported throughout the ecosystem, the status quo will prevail. The patriarchal narrative must be continuously challenged to shift to a stance of unconditional support where men respect their wife/partner’s decision to use FP or take full responsibility for contraception by engaging in FP methods, such as NSV.
Determining strategies for involving men in FP in the Philippines is not new. In a 2005 study examining male engagement in FP commissioned by the Philippines, researchers identified similar barriers and recommended similar approaches to increase this involvement including better monitoring and social acceptance (Clark et al., 2008). However, over a dozen years later, there have not been meaningful changes.
Limitations
While this study did collect data at all levels of the ecosystem, some voices may not have been included. At the individual level, we did not ask participants if they had a history of using FP. In future work, ascertaining this information would allow the ability to note any difference in views between users and non-users, and sharpen our understanding of involvement if those who say they support FP are actually using FP. The small sample size associated with qualitative and ecological studies limits the ability to generalize findings.
Conclusion
This study identified that while men in the Philippines are generally supportive of the use of FP within their own relationships, they are heavily influenced by existing traditional masculinities, and any changes to the current status threatens to disrupt the patriarchal privilege. This privilege exists at all levels of the ecosystem, and the facilitators and barriers this team identified were unstable opposites, making it challenging to promote forward change. Comprehensive and multilevel approaches are needed to increase meaningful acceptance and actualization of the involvement of men into FP decisions.
Footnotes
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 work was supported through the RTI University Scholars Program for Academic Researchers (Stevenson).
