Systematic review of reviews on interventions to engage men and boys as clients, partners and agents of change for improved sexual and reproductive health and rights

Abstract

Objectives Evidence regarding interventions to engage men and boys to improve sexual and reproductive health and rights (SRHR) has grown rapidly across subtopics such as HIV, family planning and gender-based violence (GBV). We conducted a review of the effectiveness of interventions to engage men and boys across SRHR domains, lessons learnt about successful programming, and about harms/unintended consequences, in low- and middle-income countries (LMIC).

Design Systematic review of reviews following Cochrane guidelines.

Data sources PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane were searched (18 October–9 November 2022; 9 September 2024).

Eligibility criteria Eligible reviews were published since 2015, covered WHO-defined SRHR domain(s) and focused mostly on LMIC.

Data extraction and synthesis Data extraction by multiple reviewers focused on intervention effectiveness, implementation best practices, unintended consequences, and quality/risk of bias.

Results Thirty-five systematic reviews were included, comprising ~960 primary studies. Reviews focused on HIV prevention/care, reproductive health, maternal and newborn health, and GBV. Reviews consistently concluded that men were successfully engaged, yielding benefits to both women and men’s SRHR outcomes; no adverse intervention impacts on prevalence of SRHR outcomes were reported. We summarised the interventions most consistently found to be effective across reviews, in a programmer-friendly visual mapped onto a framework of men as clients, partners and agents of change. Person-centred, gender-transformative, multilevel approaches were most effective. Remaining evidence gaps include engaging men as contraceptive users, sexually transmitted infections other than HIV, preventing unsafe abortion and SGBV as experienced by men and boys.

Conclusions There is substantial evidence supporting a range of successful interventions to engage men and boys to improve SRHR, with markedly similar principles and approaches emerging across SRHR domains. It is time to scale up and integrate these strategies, monitoring for any potential harms and tailoring as needed to socio-cultural contexts and for specific vulnerable subpopulations.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

• This systematic review of 35 reviews brings together the evidence regarding interventions to engage men and boys to improve sexual and reproductive health and rights (SRHR) in low and middle-income countries.

• The authors map out which male engagement interventions and implementation strategies have consistently been shown to be effective across SRHR domains.

• The methodology used was robust and included a comprehensive search strategy organised based on an established framework for male engagement, as well as data screening, extraction and synthesis by multiple experienced reviewers.

• This systematic review of reviews was necessarily reliant on the objectives and scope of the included reviews.

• The search was limited to reviews available in English in the peer-reviewed literature, which may have resulted in exclusion of certain otherwise relevant reviews.

Introduction

Building on discussions that started at the global population and development meetings in Cairo (1994) and Beijing (1995), there is now widespread recognition that men and boys’ engagement in sexual and reproductive health and rights (SRHR) is crucial for achieving equitable outcomes for all. This includes outcomes for men and boys themselves, who also face SRHR-related health concerns, such as high HIV-related morbidity and mortality and sexual violence.1–5 It also includes outcomes for their female partners, especially adolescent girls and young women who are often additionally vulnerable due to inequitable gendered relationship power dynamics, as well as outcomes for their children. Engaging men and boys, also referred to as ‘male engagement’ and sometimes ‘male involvement’, entails the active participation, involvement and inclusion of men and boys in a wide range of SRHR practices, programmes and policies, such as accompanying female partners to antenatal visits, using pre-exposure prophylaxis (PrEP) to prevent HIV acquisition for themselves and their partners, and engaging in critical reflection and advocacy around gender-based violence (GBV). Effectively engaging men and boys in SRHR seeks to break down barriers that may limit their involvement and facilitates their roles as supportive partners, advocates, and allies in promoting SRHR of all individuals.

Sexual and reproductive health can be defined as ‘…a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity… All individuals have a right to make decisions governing their bodies and to access services that support that right. Achievement of sexual and reproductive health relies on the realisation of sexual and reproductive rights’.6 The importance of engaging men and boys has been increasingly embraced within multiple domains under the SRHR umbrella, for instance, related to HIV prevention, contraception/family planning, maternal and newborn health, and preventing GBV. In parallel, the evidence base for effective interventions to engage men and boys in these areas has greatly expanded. A 2010 review of 58 evaluation studies addressing male engagement in a range of SRHR issues reported promising results but found that interventions tended to be short and few programmes went beyond the pilot stage.7 Since then, dozens of systematic reviews on male engagement to improve SRHR have been published. Still, the literature, including systematic reviews, remains largely siloed within SRHR domains, obscuring potentially informative commonalities. There also remains substantial uncertainty regarding which male engagement intervention strategies are effective as well as best practices for implementing these strategies—particularly among institutions charged with promoting SRHR in a given country—and an overarching framework for these strategies is needed. Questions also persist about potential unintended consequences on women’s autonomy and SRHR.

We conducted a systematic review of reviews to elucidate lessons learnt about effectiveness of different types of programming to engage men and boys (ages 10 years or older), in different geographic regions, and by SRHR domains/outcomes, while also assessing any reports of harms or unintended consequences. Systematic reviews of reviews aim to summarise evidence across multiple systematic reviews, as opposed to summarising evidence across multiple individual primary studies/papers.8 We did not include reviews focused on sexual and/or gender minority men’s engagement in SRHR, since there is another sizeable literature on this topic, and the types of programming, and effectiveness, may differ for these populations. This research was part of a project focused on translating HIV prevention evidence into action in sub-Saharan Africa (currently called insight2implementation), which is part of the South-to-South HIV Prevention Learning Network (SSLN). SSLN stakeholders from multiple countries in Eastern and Southern Africa identified a need for evidence synthesis on strategies to engage men and boys as a priority. To organise our review, we applied an existing framework on male engagement that delineates programming for: (1) men and boys as clients, to meet their own healthcare and prevention needs; (2) men as partners, to engage them as equitable and supportive intimate partners; and (3) men as agents of change, to create enabling environments that promote gender equity and health.9

Methods

For our review, we followed the Cochrane guidelines for how to conduct overviews (ie, systematic reviews of reviews).8 Ethical approval was not required for this review as it did not entail research on human subjects as patients or informants. The review of reviews is registered with Research Registry (unique identification number (UIN): reviewregistry1884).

Results

Figure 1 shows a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram. In total (across the first and second searches), 903 reviews were imported for screening, of which 149 duplicates were removed. Of the remaining 754 review titles and abstracts screened, 661 did not meet inclusion criteria. Of the 93 full-text reviews screened, 53 were excluded. Five reviews initially included in the set of final reviews, were subsequently rated as having low quality during the quality assessment (met five or fewer of the 11 criteria) and hence were dropped from the final analysis. A list of reviews excluded at or after the full-text review stage, and main reason for exclusion, is included in online supplemental table 1. This yielded a final total of 35 systematic reviews.

Discussion

In this systematic review of reviews, we sought to bring together the evidence around interventions to engage men and boys to improve SRHR in low- and middle-income countries. Across 35 systematic reviews of ~960 primary studies, reviews consistently concluded that men are willing to engage as clients, as partners and as agents of change and that male engagement was measurably beneficial to both women and men’s SRHR outcomes. Effective intervention strategies were identified for each of the SRHR topic areas that reviews focused on, including HIV testing, VMMC, HIV risk reduction, family planning, PMTCT, maternal and newborn health, reproductive health and GBV. To engage men and boys as clients, effective strategies focus on providing convenient and private services/product options, such as community-based HIV services, and increasing awareness and demand,64 as well as reaching/expanding access to men as family planning users. To engage men as partners, effective strategies concentrate on offering couples counselling by specially trained staff using evidence-based counselling techniques, ensuring men know precisely how they need to be involved and avoiding only trying to reach men secondhand such as via their partners. To engage men as agents of change, gender transformative programming at the group and community levels has consistently proven effective—with multiple programmes now evaluated across contexts and with specific best practices identified for implementation—especially when complemented with community mobilisation to shift gender norms. These interventions can be further tailored to new social-cultural contexts via community-partnered formative assessments to maximise acceptability, resonance, impact, and sustainability and minimise any potential unintended harms.

None of the 35 included reviews found any primary study showing adverse impacts of an intervention on prevalence of women’s SRHR outcomes, such as increasing GBV perpetration or victimisation, or impeding women’s access to SRHR services. Most, although not all, reviews appeared to have assessed adverse effects reported in primary studies, although this was rarely a primary objective. Nonetheless, reviews consistently emphasised the importance of careful intervention design in partnership with communities, and monitoring of any harms, especially in the case of vulnerable subpopulations.

Nearly all reviews found that multicomponent and multilevel interventions were most effective. Examples include complementing individual-level education and service delivery with promoting society-wide awareness of HIV prevention products/diagnostics or family planning products or complementing couples counselling with making health facilities more welcoming towards men and changing the normative environment to foster men’s support of their partners’ SRHR. Moreover, there is a clear need for structural change, most critically a shift in the gender norms and systems that sustain gender inequality and violence.65 These conclusions align with findings from another systematic review of reviews which sought to gauge the proportion of SRHR programmes for men and boys that met the definition of gender transformative and found that only a small proportion (<10%) did so.12

There was also notable consistency in specific successful approaches found across reviews. One such approach was changing gender attitudes and norms. Currently, this is seen mainly in GBV prevention programmes (and sometimes HIV programmes)—other SRHR domains would benefit from this approach such as male infertility or sexually transmitted infections beyond HIV. A second approach was building couple communication and conflict resolution skills as a key facilitator of a range of men’s and couples’ SRHR outcomes. A third was promoting men’s detailed knowledge of products/services. There is notably low population-level awareness of certain products/services, like vasectomy and HIV self-testing, as well as specific ways men should support women’s SRHR. It is the responsibility of public health systems, not men themselves, to raise this awareness and promote informed decision-making.

The quality of the included reviews was quite high, per the AMSTAR 2 tool criteria. Review findings varied regarding quality/risk of bias for the primary studies they included. For the most part, reviews under men as clients were high quality, those under men as partners were quite low quality (particularly for reviews related to PMTCT and maternal and newborn health), and under men as agents of change were variable quality (with reviews appearing to differ in the standards applied). A critical quandary for the field is how best to evaluate, what standard of evidence should be required, for complex, multicomponent, multi-level interventions that are often implemented in complex environments.

There was a heavy geographic focus on Africa, and specifically Eastern and Southern Africa (sometimes by design, sometimes because primary studies had only/mainly been focused in that region). This makes our findings most representative of, and generalisable to, that region. This is especially true for reviews under the men as clients and men as partners categories—while reviews under men as agents of change tended to focus much more broadly across geographic regions. There is a need for geographical expansion of the evidence base for some of this work beyond Eastern and Southern Africa, while the evidence for men as agents of change is relatively global at this point.

There were also several gaps regarding the seven SHRH domains and types of interventions. Very few reviews covered the WHO SRHR domains of preventing unsafe abortions or SRHR in disease outbreaks. A limited number of reviews focused on men as contraceptive users (vs only as partners),30 31 42 with each concluding that there is a need for expanded research on this topic, particularly as new male contraceptive methods become available. Only two reviews40 42 directly addressed the critical HIV prevention option of PrEP—with men as PrEP users or partners of users. No reviews focused explicitly on sexually transmitted infections besides HIV. In addition, no reviews were available that focused on sexual and gender-based violence as experienced by men and boys—which evidence has shown is quite common and associated with various negative health outcomes for them and their partners.4 5 With regard to types of interventions, virtually no approaches to engaging men included social media (noting the review related to mHealth primary focused on SMS text/voice messages)—which may be an important future focus since many reviews highlighted a need to promote broad societal awareness of SRHR services/products as well as shift social norms. Almost no reviews included interventions delivered at workplaces (and the two that did focused on HIV service delivery only).

As suspected when taking on this review, there was substantial siloing by SRHR domain/topic of evidence reviewed. Over half (54%) of reviews covered only one domain, and most others covered two domains. Moreover, most reviewers (though not all) reflected on and compared their findings only with other systematic reviews in their own domain or even their own particular area such as couples HIV testing or PMTCT. Our review of reviews clarified and confirmed that there are markedly similar findings across SRHR topic areas reaffirming men’s willingness to engage, and their desire for information as well as few concerns about potential harms for women.

It is important to consider our findings in light of several potential limitations. Findings from a systematic review of reviews are necessarily reflective of the set of systematic reviews available for inclusion. For instance, there was a heavy focus on HIV services in our review, given so many included reviews focused on this topic. The magnitude and breadth of included reviews help assuage this concern. In addition, conducting a review of reviews, rather than of primary papers, may have led to the exclusion of relevant primary papers. Cochrane guidelines advise against adding primary papers to the set of included systematic reviews in most cases.8 Limiting eligibility to reviews published in English could also have excluded reviews focusing more on certain regions (eg, West Africa; Latin America). Additionally, we did not include certain topics that from our perspective fell outside the scope of this review: men as caregivers (no explicit SRHR outcomes); couples/men’s infertility issues (available reviews were largely biomedical in nature); and child marriage (a separate and large body of research in itself). Finally, we did not search the ‘grey literature’ which may have resulted in missing certain reviews, although systematic reviews are typically published in peer-reviewed literature.

Conclusion

We believe that given the substantial evidence supporting a range of successful interventions to engage men and boys to improve SRHR, the time has come to widely scale up these interventions. A combination of multiple strategies at different levels, integration across SRHR areas and with programming that also includes women and children and fundamentally transforms gender relations and systems,12 65 will be critical for achieving the adequate scale and sustainability required for public heath impact on SRHR outcomes. It is clear the field is still evolving and further research is warranted, including on effectiveness in certain geographic areas, optimal implementation models, new products/technologies, appropriate sociocultural contextualisation and continued monitoring for any harms. Yet, we now know enough to move ahead with scaled up programming—the need for improving SRHR among men, women, families and communities is too great to wait.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Ethics statements

Acknowledgments

We would like to sincerely thank the country champions and other stakeholders in the Sycona/insight2implementation (i2i) initiative and South-to-South HIV Prevention Learning Network (SSLN) for their request for synthesis of evidence about how to engage men and boys in HIV prevention and SRHR—which was the impetus for this review—as well as their reflections and feedback regarding emerging findings. In addition, we want to acknowledge and express our gratitude to Mary Chu for her online database literature search support, Grace Maguro for her support with initial data extraction and Micah Fineberg for graphic design of the conceptual model.