Differences in counseling men and women: family planning in Kenya

Patient Education and Counseling 39 (2000) 37–47 www.elsevier.com / locate / pateducou

Differences in counseling men and women: family planning in Kenya a, a b a Young Mi Kim *, Adrienne Kols , Peter Mwarogo , David Awasum a

Johns Hopkins University Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD 21202 -4024, USA b Family Health International, Africa Regional Office, Nairobi, Kenya Received 5 January 1999; received in revised form 20 July 1999; accepted 3 September 1999

Abstract A comparison of family planning sessions with male and female clients in Kenya found distinct gender differences. Most men came for information, while women wanted to adopt, continue, or change contraceptive methods. Consultations with men and couples were more than twice as long as consultations with women. Men communicated actively (for example, by volunteering extra information, asking questions, and expressing worries) during 66% of their turns to speak, compared with 27% for women. Providers offered men more detailed information than women, asked them fewer questions, issued fewer instructions, and responded more supportively. These communication patterns may be seen as a reflection of Kenyan gender roles and men’s and women’s different reasons for seeking family planning services. Kenyan providers need to improve the quality of their interactions with women. They also need to anticipate men’s outspokenness and understand the male agenda if they are to counsel men effectively.  2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Family planning; Communication; Physician–patient relations; Gender

1. Introduction In recent years, the Family Planning Association of Kenya (FPAK) has begun to encourage male participation in family planning and other reproductive health services. This is a dramatic change, since family planning information and services in Kenya, as in most countries, have long been packaged and *Corresponding author. Tel.: 1 410-659-6300; fax: 1 410-6596266. E-mail address: [email protected] (Y.M. Kim)

0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00089-0

delivered mainly to women. Most family planning services in Kenya are offered in health facilities seldom used by men, and 99% of modern contraceptive users are women [1]. Yet FPAK has come to appreciate that culture and tradition give men an important role in making fertility and family size decisions in Kenya; that women are more likely to adopt and continue using a contraceptive method when their partners support their decision; and that only a male method, the condom, can prevent HIV/ AIDS and other STDs [2–4]. FPAK’s male involvement initiative comes as

 2000 Elsevier Science Ireland Ltd. All rights reserved.

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Y.M. Kim et al. / Patient Education and Counseling 39 (2000) 37 – 47

rising levels of education among women, decreases in desired family size, and growing use of modern contraception have combined to reduce fertility. In 1984, the average Kenyan woman had close to eight children. By 1993, this number had dropped to 5.4 children, and men and women agreed that fewer than four children was ideal. Over the same time period, contraceptive use has become commonplace. In 1993, almost all married women of reproductive age knew of a modern contraceptive method, as well as a source for that method; 55% had at some time used a family planning method; and 27% were currently using a modern method [1]. In this context, reaching out to men may prompt couples who want to space or limit their childbearing to take action and adopt a family planning method. Yet in Kenya, as in reproductive health programs around the world, providers are ill prepared to counsel men and couples on family planning [5]. Existing training curricula for providers focus on women’s methods and women’s concerns, and most providers have little experience with male clients [6]. However, marked disparities in gender roles in Kenya [7–9] may lead men to communicate differently with providers than do women [10,11]. A prior study found that female family planning clients in Kenya spoke little and participated minimally in counseling sessions [12]. Kenyan men are expected to behave more assertively. Gender-based differences in contraceptive methods, patterns of sexual behavior, and family planning knowledge also may lead men and women to have distinct counseling needs [6]. For example, it is socially accepted, even expected, that Kenyan men will have multiple sexual partners, both in and outside of marriage, while women typically remain faithful to a single partner. This might make condoms an appropriate contraceptive option for men, even as women avoid the method because it is popularly associated with female promiscuity. While these arguments suggest that clients’ gender should affect both the style and content of family planning consultations, there has been no research in developing countries to explore the impact of gender on counseling. To explore possible differences in counseling women and men, this study analyzes transcripts of family planning consultations conducted by a variety of service providers in Kenya. The results not only

shed light on the special counseling needs of men, but also they question assumptions about the nature of the interaction between providers and female clients. Thus, these findings can help providers better meet the needs of female as well as male clients.

2. Methods

2.1. Data collection This report analyzes and compares transcripts collected during two different FPAK projects. The women’s transcripts were collected as part of the Provider and Client Information, Education, and Communication Project [13]. Research assistants observed 358 family planning counseling sessions at 25 service delivery sites in urban and rural areas throughout Kenya. The men’s and couples’ transcripts were collected two years later as part of the Male Involvement Project [6]. Research assistants observed 78 family planning sessions with male clients and couples at 19 study sites located in three project districts. After asking for the client’s and provider’s permission, the research assistants recorded each session on audiotape, completed an observation guide during the session, and interviewed the client afterwards. This report analyzes the taped sessions and uses only background sociodemographic data from the observation and interview instruments. The research assistants transcribed the audiotapes, translating the conversation from various local languages into English as they did so. Since they were present at the original sessions and later listened to the tapes, they also could comment on providers’ and clients’ body language and tone of voice. Problems in taping the consultations (faulty tape recorders, poor sound quality, incomplete recordings, and lack of permission to record) limit the number of usable women’s transcripts to 176, and of men’s and couples’ transcripts to 65.

2.2. Analyzing the transcripts After reviewing the women’s transcripts, the research team developed structured code guides to classify everything said during the consultation.

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While basing the code guides on the Roter Interaction Analysis System [14], the team intentionally modified the coding system to focus on client participation issues that emerged during an initial qualitative analysis of the transcripts. When the code guides developed for the women’s transcripts later were applied to the men’s and couples’ sessions, it was discovered that male clients had a greater repertoire of active communication behaviors than women and that providers also displayed some different behaviors when dealing with men and couples. To allow comparisons of the two data sets, these additional behaviors were incorporated into the original coding system. Since a consultation is in essence an exchange between two parties, the investigators decided to focus on the alternating turns of client and provider rather than the individual sentences or words uttered, although most prior studies have coded phrases or sentences. Thus codes were assigned to a client’s or provider’s entire turn, from the moment she or he began to talk until the other party entered the conversation. Three code guides were used: one for client communication, a second for provider communication, and a third to indicate how providers responded to active client communication. Table 1 lists the codes used in each of the three guides. Coding by turn expedites the coding process, highlights the alternating quality of the conversation, and allows the sequential analysis of client–provider remarks. However, this kind of coding does not

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measure the length of each turn, which ranged from a single word to several paragraphs, so the number of utterances (a phrase or sentence that expresses a complete thought) also was counted. Some turns include more than one utterance and call for more than one code, as when a provider first describes a method and then ends her turn with a question. In this situation, the entire turn still receives only one code—for the communication behavior deemed most likely to prompt client participation according to a hierarchy of codes. This example is coded as ‘‘asking a question’’ rather than ‘‘providing technical information’’. Sessions with couples (which comprised 24 of the 65 transcripts in the second data set) posed a challenge to a gender-based analysis, since each involved both a male and female client. It was found, however, that the male partner was more vocal in most couples’ sessions: male partners accounted for 77% of all client turns and an even greater percentage of all client utterances. When the couples’ and men’s transcripts are combined, about 90 percent of all client turns are made by a male client. As a result, including communication with female partners during couples’ sessions does not significantly affect the analysis. Because women’s speeches help establish the rhythm of alternating turns during couples’ sessions, the investigators retained them in the analysis. Thus, while the findings reported here usually combine data from couples’ and men’s sessions to illustrate male behavior patterns, the

Table 1 List of codes Client communication

Provider communication

Provider responses to active client speeches

Passive: Social conversation Brief response

Social conversation Gives technical information Counseling

Ignores and changes topic Ignores and continues on same topic

Active: Elaborate response Asks question Expresses concern Interrupts, changes topic Disagrees with provider Chooses method Seeks provider’s opinion

Instructs client what to do Open-ended question Closed-ended question Praise, positive emotions Criticism, negative emotions Invites client to speak

Disagrees Dismisses or scolds Supportive response Gives technical information

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couples’ transcripts do include a small amount of female talk. Couples’ sessions were not analyzed separately because of their small number, although some qualitative observations are reported. To check for inter-coder reliability, pairs of research assistants recoded 20 randomly selected women’s transcripts, and the kappa statistic was calculated [15]. There was substantial consistency in coding passive and active client communication (k 5 0.76, 91% agreement), types of active client communication (k 5 0.78, 85% agreement), and providers’ responses to active client communication (k 5 0.71, 82% agreement). There was only moderate consistency in coding types of providers’ speeches (k 5 0.56, 74% agreement).

2.3. Characteristics of providers and clients The two data sets were collected at different times and locations, but each included all six organizations offering family planning services in Kenya. Most of the providers in both data sets were women—74% in sessions with male and couple clients and 95% in sessions with female clients (Table 2). Compared to

men and couples, women clients were nearly twice as likely to consult clinic-based, health care professionals (for the most part, nurses) and less often saw workplace motivators or community-based providers. Both workplace motivators and community-based providers receive some training in family planning so that they can offer convenient services, on the job or at home, to co-workers and fellow community members. Workplace motivators are male, while clinic- and community-based family planning providers in Kenya are largely female. That men were frequently reached at work reflects the realities of Kenyan life, as does the men’s somewhat higher educational level compared with the women. However, these men cannot be considered representative of the general population. It is highly unusual for men to seek family planning services in Kenya. Their very presence at a consultation suggests that they are unusually open-minded, progressive, and / or concerned about their partners’ welfare. Also, the educational level of the men in this sample is higher than that of the population at large: 62% had at least some secondary education, compared with just 38% of a nationwide household sample of men aged 20–55 [1].

Table 2 Comparability of data sets a Issue

Sessions with male clients b

Sessions with female clients

Aged 20–29 Had secondary education or higher Not currently using family planning

49.9 62.3 82.1

60.0 45.7 44.4

Providers: Percent who were women Mean age Mean years of experience

74.1 36 years 6 years

95.1 38 years 7 years

Percent of sessions conducted by: Clinic-based provider Community-based provider Workplace motivator

34.6 41.0 24.4

63.4 36.6 0.0

Percent of clients who were:

a n 5 65 male clients (seen alone or as part of a couple); n 5 176 female clients seen alone; n 5 54 providers attending male / couple clients; n 5 61 providers attending female clients. b This data covers male clients seen alone and men who came together with their female partners.

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3. Results

3.1. Purpose and outcome of sessions Men and women had different reasons for talking with a family planning provider. The majority (82%) of the men, whether they came alone or with their partners, were not currently using family planning. (For men, family planning ‘‘use’’ is defined as either the man or his partner using a contraceptive method.) In contrast, only 44% of the women were not currently using family planning. Thus most women, but few men, had prior experience with contraception itself and talking with family planning providers. Non-users also had different agendas, depending on their gender. Men generally wanted information rather than contraceptive services and had not yet decided whether to adopt any method. In contrast, virtually all of the women already recognized the value of family planning and wanted to leave the session with a contraceptive method. This may be due, in part, to male / female differences in where the consultation takes place. Visits to clinics are always initiated by the client, who may be seeking the full range of contraceptive services offered there. In contrast, visits with community-based providers and workplace motivators often are initiated by the provider, who serves more as a source of information and referrals than actual methods. Men who come alone for counseling also are limited in their contraceptive options: without their partners present, they cannot adopt a method designed for use by women. As a result, providers serving male clients frequently engaged in advocacy, explaining the benefits of spacing children and smaller family size both for the individual and the nation. In contrast, providers serving female clients focused on the decision-making process and on instructing clients how to use their chosen method. Couple sessions were mixed in character. They included a substantial element of advocacy and information-giving even though most couples were prepared to adopt or continue using a method. Women typically came to the counseling session prepared to make a decision and left with a contraceptive method, a plan to return for a method at a

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later date, or a referral for other services. This also was true for more than half the couples. In contrast, most men (and many couples) sought and left purely with information or, sometimes, a supply of condoms. Rarely did men receive a referral or schedule another visit. Instead, providers simply invited them to return if they wished to talk further.

3.2. Length of sessions Men’s and couples’ sessions were considerably longer than women’s sessions as measured by the number of utterances spoken; an utterance is a phrase or sentence that expresses a complete thought. Men’s sessions included an average of 198 utterances, compared with 155 for couples’ sessions and 62 for women’s sessions. Sessions with new female clients (79 utterances) were longer than sessions with continuing female clients (48 utterances). Providers largely determined the length of the sessions by varying the amount of information they offered and the number of topics they addressed. Clients had far less impact on the session’s length, although they could extend a session by asking questions and raising concerns.

3.3. Client participation Approximately two-thirds of the men — whether seen alone or as part of a couple — played an active role in the counseling sessions; they asked questions, raised concerns, and replied at length to providers’ questions so that the lead moved back and forth between client and provider. These sessions were a true dialogue, in which clients were as important as providers in determining the content and direction of the discussion. Few sessions with women followed this pattern. Most female clients spoke little and rarely initiated a topic of conversation. Providers remained in tight control and dominated the conversation. Because men’s and couples’ sessions were longer than women’s sessions, they had nearly twice as many opportunities as women to speak: an average of 33 turns per session compared with 18 turns. However, both men and women spoke much more briefly than providers during their turns to talk.

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Because providers’ turns were consistently longer than clients’ turns, providers accounted for about two-thirds of all utterances spoken and clients, onethird. This two-to-one ratio holds true no matter what the sex of the client and no matter how long the session lasted. It is not how much they speak that differentiates male and female clients, but what they say. The majority (73%) of women’s turns were categorized as ‘‘passive’’, compared with 34% of men’s and couples’ turns. Passive turns include social conversation (such as ‘‘hello’’ or ‘‘I’m fine’’) and brief responses to provider questions that convey minimal information (such as ‘‘yes’’ or ‘‘two children’’). They have minimal impact on the direction of a session. In contrast, 66% of all men’s and couples’ turns and 27% of all women’s turns were considered ‘‘active’’ because they somehow interjected the client into the dialogue. Fig. 1 breaks down this active communication into five categories. For both men and women, the most common type of active communication was elaborating their responses to providers’ questions, using the opportunity to reveal additional information about themselves, their family planning needs, or their concerns. Male and couple clients elaborated their answers to about eight questions per session (41% of total active communication), compared with less than three questions for women (54% of total active

communication). Although providers asked men and women roughly the same number of questions (an average of 12 per session for men and couples compared with 11 for women), men more often volunteered extra information. Men also asked questions more often than women. About one-third of men’s and couples’ active turns included a question, compared with 19% of women’s active turns. Because men’s and couples’ sessions lasted longer and included more active communication than women’s sessions, this translates into a dramatic difference in the number of questions asked: men and couples posed more than seven questions per session, on average, compared with just one for women. Men’s questions tended to be more difficult than women’s: they sought more detailed information, inquired about broader economic, political, and social issues, and raised sensitive sexual issues. In addition, men frequently asked for clarification when they did not understand or were not convinced by what the provider said. Women’s questions tended to be less complex, to focus on the side effects and use of specific methods, and to relate to the client’s unique situation. These differences are due, in part, to women’s focus on getting a method rather than information. However, they also reflect the fact that men are simply interested in different issues than women and are less willing to accept providers’

Fig. 1. Percent distribution of client active communication.

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reassurances. At times, men directed the flow of the discussion with their questions, in sharp contrast to the women who almost exclusively followed the provider’s lead. Men expressed worries about family planning more often than women; worries made up 12% of men’s and couples’ active communication (an average of 2.6 turns per session), compared with 5% (or 0.3 turns per session) for women. Both men and women were concerned about the possible health impacts of contraceptives and about rumors. Men also worried about contraceptives’ impact on sexual satisfaction, while women worried about possible infertility after long-term use of a method. Requesting a method accounted for much of women’s active communication (18%) but little for men and couples (4%), who often sought information only. Men engaged in three behaviors that were not noted among women. First, they regularly volunteered opinions, related experiences, or announced that they would advocate family planning among their friends—without prompting from the provider. Second, men occasionally used metaphors to better express their questions and concerns, for example, comparing a vasectomy to an initiation ceremony or human reproduction to the growing of crops. Third, men typically murmured ‘‘yes’’, ‘‘okay’’, or ‘‘mmm’’ or repeated a few of the provider’s words to acknowledge the provider’s remarks. According to

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the research assistants who were present at the sessions, women leaned more heavily on nonverbal behavior to indicate that they were paying attention or even to reply to questions—nodding their heads or shrugging their shoulders, for example.

3.4. Provider communication Providers communicated differently with men and couples than with women, as is shown in Fig. 2. The greatest disparity was in the amount of information presented: 32% of all provider turns in sessions with men or couples were purely informational compared with just 6% for women. These figures are not an exact measure of the amount of information presented, however, because the codes do not reflect the length of each turn. Also, the hierarchical coding scheme gives low priority to presenting information. Despite these limitations, the large difference in the proportion of provider turns devoted to information does reflect several realities. First, sessions with men and couples often were devoted to giving general information on the benefits of family planning and the full range of methods available, while sessions with women focused on adopting or resupplying a specific method. Second, continuing clients — who were mostly women — received less information than new clients. Third, providers tended to give men and couples more detailed information

Fig. 2. Percent distribution of provider communication.

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and a richer description of the matter under discussion than women, using examples and metaphors to illustrate key points. Providers giving incomplete, untrue, confusing, or irrelevant information was an issue in all sessions. However, it posed more of a problem in sessions with men, who frequently asked difficult questions that strained the limits of providers’ knowledge. When providers were unsure of the answer to a question, they tended to stammer, raise their voices, get angry, or become harsh with clients. Their emotional response and tone of voice are clearly recorded in the audiotapes, although they could not be coded in the transcripts. Providers more often asked questions of women (in 58% of their turns) than men and couples (37%), perhaps because female clients needed more prompting to express themselves. The ratio of closed- to open-ended questions was similar, however, regardless of gender. Providers were more likely to use other kinds of prompts, such as repeating the client’s words or murmuring agreement, with men and couples than with women (6% versus 2%). Presumably because women were more likely to be using or adopting a method than men, providers issued instructions twice as often to them (8% versus 4%, data not shown). A separate coding guide was used to analyze providers’ responses to clients’ efforts to play an active role in the counseling session. When male clients communicated actively, providers almost always responded positively, by offering technical information, praise, or reassurance or by probing further into issues raised by the client. Only on rare occasions did providers ignore, disagree with, scold, or dismiss a male client who communicated actively. In contrast, providers ignored 22% of women’s active speeches and disagreed with 6% of them.

4. Discussion

4.1. Gender differences in client behavior When two people, such as a provider and client, share a task, sociological theories suggest that their relative power depends on two factors: differences in their expertise and the disparity in their social

standing [10,11]. The first depends on the nature of the task: the amount of relevant knowledge and skills possessed by each person dictates their informational influence. The second depends on personal characteristics: gender, age, ethnicity, income, education, and a host of other factors combine to determine each person’s normative influence. Thus, when a client and provider meet, each forms unspoken — and largely unconscious — assumptions about their relative influence in the consultation, assumptions that shape their behavior. Providers’ superior knowledge and skills in the field of family planning gives them informational power over the interaction. In developing countries like Kenya, providers’ monopoly on information goes unquestioned, although growing access to health information in industrialized countries may be leading consumers there to challenge health care providers. Research shows that technical expertise creates a sharply asymmetrical relationship between health professionals and patients in most settings [16]. Yet normative sources of influence may narrow — or exacerbate — the gap between client and provider. In Kenya, as elsewhere, gender shapes an individual’s social standing. Culture, customary law, social practices, and religious beliefs all place women in a subordinate status, a status that has persisted in the face of dramatic socioeconomic changes and constitutional guarantees of women’s equal rights [7,9,17]. Kenya may be seen as a true patriarchal society. Education, occupation, control over economic resources, and access to political power also contribute to social standing, and in Kenya all of these factors operate in favor of men. The disparity between men and women is manifested in behavioral norms which discourage women from showing initiative by asking questions or expressing ideas, particularly in the presence of their husbands. This ideal of the passive woman contrasts with male stereotypes of a dynamic and forceful family head who can influence the community and world around him [7,8]. When a male client is paired with a female provider, as is most often the case, the two sources of power — normative and informational — work in opposite directions. In this situation, research on gender and power suggests that a female provider’s technical superiority will outweigh a male client’s

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social superiority [10,11]. In Kenya, family planning clients do indeed respect providers because of their professional status, regardless of their own or the providers’ sex. In contrast, when a female provider counsels a female client, normative and informational influence flow in the same direction. In Kenya, not only do family planning providers know more about technical matters than their female clients, they also tend to be better educated, more highly respected, and of higher social status. As a result, the social gap between a female client and female provider is wide. Theoretically, this pattern also would apply to male providers serving male clients, but there were too few of these sessions to analyze separately. The findings of this study fit this paradigm. Male clients participate far more actively in counseling sessions than do female clients and have greater influence over the session’s content, direction, and length. While providers remain in charge no matter what the gender of the client, sessions are more balanced when the client is male. Of course, other factors may also be at work, most notably the differences in men’s and women’s motivation for attending the session and their exposure to the media. Men may play a more active role than women because they are seeking information rather than a method and because they want to clarify what they have read in magazines and newspapers. While men’s emphasis on information probably contributes to gender differences in communication patterns, it does not fully explain those differences. A qualitative analysis of the 24 couples’ sessions, most of which focused on adopting or changing methods, found that men tended to ask more questions than their female partners, raise difficult issues such as sex drive, and challenge what providers said even when a method, rather than information, was their goal. The small size of the study sample precluded a quantitative analysis of male clients by reason for coming to a clinic. Interestingly, medical research in developed countries has found a dissimilar pattern, in which, if any gender differences are noted, female patients participate more than male patients in health care consultations attended largely by male physicians [16,18– 20]. Gender disparities in education, occupation, and other indicators of social status are far smaller in

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these countries than in Kenya, so that men’s and women’s normative influence are more in balance. In addition, Western behavioral norms consider the ‘‘sick’’ role more appropriate for women than men and expect women to disclose personal problems while men suffer in silence. Women in these societies also may be more knowledgeable than men about health matters [21]. In the context of a medical consultation, these factors would heighten the influence of female patients more than their male counterparts.

4.2. Providers’ treatment of men and women Overall, providers spent more time with men than women, offered men more detailed information, and responded more supportively when men participated. There are many possible reasons. First, the social position of male clients tends to equalize their relationship with female providers, as discussed above. This may be especially true of the better educated men who consult family planning providers. Second, traditional gender roles may lead providers to treat men with greater respect than women, while gender-based behavioral norms encourage men to make greater demands on providers. Third, the subject matter of family planning consultations may put female providers at a disadvantage. Cultural inhibitions on discussing sexual matters with the opposite sex may make female providers feel uncomfortable with male clients despite their training. Fourth, providers may view male clients as ‘‘special’’ and give them extra attention because relatively small numbers of men seek family planning services in Kenya [22].

4.3. Improving family planning counseling The most important implications of this study concern how well Kenyan providers counsel the women who form the majority of their clientele. The findings reveal that many providers are shortchanging women, offering them less time and attention than their male counterparts. Training is needed to ensure that providers offer women the same detailed information that they give men, encourage women to participate more, and help women communicate their needs and concerns. Providers also should be taught

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to encourage female partners to participate equally in couples’ sessions, for example, by directing an equal amount of the conversation to the woman, by prompting the woman to speak more often, and by including the woman in responses to questions from men. As for male clients, formative research for the FPAK Male Involvement Project found that family planning providers in Kenya overwhelmingly favored greater male participation in family planning but felt that they lacked the skills and experience to serve male clients adequately [6,22]. Their concern was echoed at a 1997 male involvement workshop held in Kenya. Participants from more than a dozen countries agreed that effective counselors for men have special qualities, notably a knowledge of male roles and concerns and the ability to talk openly about sexuality [5]. This study confirms that Kenyan providers who counsel men must anticipate the more challenging content and outspoken style of male communication as well as men’s motives for seeking services. Thus, reaching out to men may demand additional training for providers and special informational materials [5,23]. Such training was recommended in the mid-term evaluation of FPAK’s male involvement project [24]. The results of this study — in which most clients, regardless of gender, saw female providers — also shed light on an important practical issue: how well can female providers serve male clients? Some family planning managers have assumed that men feel more comfortable talking about reproductive health with other men [3]. This does not seem to be the case in Kenya, where men routinely see female nurses for medical problems. Male clients spoke willingly about reproductive health issues with female providers in these sessions and, when interviewed, said they did not believe that the health provider’s gender was an issue [22]. The findings raise serious questions, with no easy answers, about the value of counseling couples rather than individuals. Some family planning professionals have assumed that it is beneficial for male partners to accompany women to counseling sessions because it encourages couple communication and male support for the woman’s family planning decision [3]. Yet the present study shows that the presence of a husband or male partner frequently reduces already

low levels of female participation to a bare minimum. If women are to feel free to voice their own needs and concerns (especially about sensitive issues such as domestic abuse or when they disagree with their partners), it may be better for them to come alone, at least for their first visit [5]. Yet a woman may benefit from the presence of a male partner, even if it silences her, because he may raise issues that she would be reluctant to bring up herself and may elicit more information from the provider. Further research is needed on the benefits and disadvantages of couple counseling.

Acknowledgements This study was made possible by financial support from USAID under Cooperative Agreement DPE3052-A-00-0014-00 and IPPF / Vision 2000. The data was collected by the Family Planning Association of Kenya as part of the Kenya Client-Provider IEC Project and Male Involvement Project. We thank Milka Juma, Isabel Chege, Margaret Thuo, Stephen Mucheke, Dan Odallo, and Shanyisa Khasiani for helping collect the data; Katherine Holmsen and ´ for coding the transcripts; and Gary Bruce Moren Lewis, Phyllis Tilson Piotrow and Ward Rinehart for reviewing this paper.

References [1] National Council for Population and Development, Central Bureau of Statistics, and Macro International. Kenya Demographic and Health Survey 1993. Calverton (MD): Macro International, 1994. [2] Fayorsey C. Family planning in Africa: the relevance of gender issues. In: Regional Institute for Population Studies, (Ed.). Developments in family planning policies and programmes in Africa. Legon, Ghana: University of Ghana, 1989:194–229. [3] Green CP, Cohen SI, Belhadj-El Ghouayel H. Male involvement in reproductive health, including family planning and sexual health. UNFPA Tech Rep 28. New York: United Nations Population Fund, 1995. [4] Hawkins K. Male participation in family planning: a review of programme approaches in the Africa region. London: International Planned Parenthood Federation, 1992. [5] Wegner MN, Landry E, Wilkinson D, Tzanis J. Men as partners in reproductive health: from issues to action. Int Fam Plann Perspect 1998;24:38–42.

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