摘要：Objectives. We examined the effect of a peer-delivered educational intervention, the Malawi Male Motivator intervention, on couples’ contraceptive uptake. We based the intervention design on the information–motivation–behavioral skills (IMB) model. Methods. In 2008 we recruited 400 men from Malawi's Mangochi province who reported not using any method of contraception. We randomized them into an intervention arm and a control arm, and administered surveys on contraceptive use at baseline and after the intervention. We also conducted in-depth interviews with a subset of intervention participants. Results. After the intervention, contraceptive use increased significantly within both arms ( P < .01), and this increase was significantly greater in the intervention arm than it was in the control arm ( P < .01). Quantitative and qualitative data indicated that increased ease and frequency of communication within couples were the only significant predictors of uptake ( P < .01). Conclusions. Our findings indicate that men facilitated contraceptive use for their partners. Although the IMB model does not fully explain our findings, our results show that the intervention's content and its training in communication skills are essential mechanisms for successfully enabling men to help couples use a contraceptive. During the 1980s many health promoters implemented sexual and reproductive health programs designed to empower women and protect them from the impact of men's behavior. 1 The 1994 International Conference on Population and Development in Cairo, Egypt, reemphasized that family-planning interventions should engage men and acknowledge their role in reproductive health services as a means to improve the reproductive health of women and men. 2 Since this conference, many organizations have begun advocating for male involvement in reproductive health services, and researchers have identified a link between male involvement and increases in contraceptive use. 1 , 3 , 4 Men in the developing world (and particularly in sub-Saharan Africa) are often the primary decision-makers about family size and use of family planning. 5 – 7 A considerable discordance between spouses on questions of family planning and desired family size has also been identified; in some developing countries, levels of communication on these topics are low. 3 Interspousal communication is related to contraceptive decision-making and positively affects contraceptive uptake and continued use, 3 whereas failure to communicate reproductive intentions limits couples’ effective and sustained contraceptive use. 6 , 7 Interventions targeting men have taken traditional public health forms: communication skills counseling, 8 promotion through local leaders and extension workers, 9 , 10 and mass-media campaigns. 11 , 12 In Ethiopia, involving men in family-planning discussions was found to increase uptake of modern contraceptives, 13 and in Bangladesh, counseling husbands about contraceptives was found to lower spouses’ discontinuation rates for long-acting methods (e.g., Norplant). 14 After examining couples’ decision-making processes in Malawi, Mbweza et al. suggested that couples follow 4 steps: (1) initiate communication, (2) explore options, (3) find solution(s), and (4) make final decisions. 15 Although these steps are useful, they are hard to follow unless both partners come to the discussion with a clear understanding of the benefits and challenges of each method and the communication skills to talk openly. Couple discordance about fertility intention and contraceptive use can pose a major barrier to consistent contraceptive use that is difficult to measure. 16 , 17 Male involvement in family planning matters. The challenge of increasing men's involvement in family planning is to identify the messaging that will most effectively encourage their involvement. Peer networks and mass media have been identified as the primary sources of family-planning information for men. 18 , 19 Evidence has shown that programs targeting men should develop messages focused on the economic and health benefits of limiting births. The inclusion of financial benefits was found to be more convincing for men than were maternal–child health considerations alone, 20 but this is not to suggest that men do not care about the welfare of their families. Research has found that men approve of using family planning, are concerned about the welfare of their families, 21 , 22 and will positively participate in family-planning discussions when provided the opportunity. 13 Despite the examples cited above, there are few examples of rigorously evaluated male-targeted family-planning interventions in the current literature, and even fewer that are based on theoretical models. 1 , 23 – 26 In Malawi, as in the rest of sub-Saharan Africa, there is a substantial need to improve family-planning uptake. The country has a high fertility rate: the average number of children borne by a woman during her reproductive years (aged 15–49 years) is 6.34. Despite modern contraceptive use tripling since 1992, the prevalence rate for contraceptive use is currently only 26%. 2 Young people in Malawi are particularly in need of family-planning information, as illustrated by high rates of early marriage and pregnancy and low rates of modern contraceptive use. One third of all women aged 15 to 19 years have been pregnant, and only 7.6% are currently using a modern contraceptive method. 2 Among married women aged 15 to 19 years, 26.1% have an unmet need for family planning, and despite the fact that the health care decisions of nearly three fourths of married women are made by their husbands, more than one third have never spoken to their husbands about family planning. 2 We evaluated the Malawi Male Motivator intervention, a theory-based intervention designed by Save the Children to increase use of family planning among young Malawian couples. Building upon research showing that men tend to get reproductive health information from peers, the intervention relied on a male outreach worker, referred to as a male motivator, to target husbands. Save the Children had previously implemented several projects to increase family-planning knowledge and contraceptive use among youth in Malawi. Project staffers often found that they were unable to reach young married women. As a result, the Malawi Male Motivators intervention was developed to reach the husbands of these women, who were often excluded from other intervention efforts. The structure of the intervention was based on the information–motivation–behavioral skills (IMB) model, 27 an empirically validated model of health behavior. 28 , 29 The IMB model has been applied to a range of sexual and reproductive health issues, including HIV prevention, condom use, and adolescent contraceptive use. 28 – 30 The Malawi Male Motivator project represents the first application of this model specifically for the promotion of male involvement in contraceptive use.
