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Received: 30 November 2022
DOI: 10.1002/cl2.1296
SYSTEMATIC REVIEWS
Involving men and boys in family planning: A systematic
review of the effective components and characteristics of
complex interventions in low‐and middle‐income countries
Áine Aventin
1
|Martin Robinson
1
|Jennifer Hanratty
1
|Ciara Keenan
1
|
Jayne Hamilton
1
|Eimear Ruane McAteer
2
|Mark Tomlinson
1,3
|Mike Clarke
1
|
Friday Okonofua
4
|Chris Bonell
5
|Maria Lohan
1
1
Queen's University Belfast, Belfast, Northern
Ireland
2
University College Cork, Cork, Ireland
3
Stellenbosch University, Stellenbosch,
South Africa
4
WHARC, Benin City, Nigeria
5
London School of Hygiene and Tropical
Medicine, London, UK
Correspondence
Áine Aventin, School of Nursing and
Midwifery, Queen's University Belfast,
Belfast, Northern Ireland.
Email: a.aventin@qub.ac.uk
Abstract
Background: Involving men and boys as both users and supporters of Family Planning
(FP) is now considered essential for optimising maternal and child health outcomes.
Evidence on how to engage men and boys to meet FP needs is therefore important.
Objectives: The main objective of this review was to assess the strength of evidence
in the area and uncover the effective components and critical process‐and system‐
level characteristics of successful interventions.
Search Methods: We searched nine electronic databases, seven grey literature
databases, organisational websites, and the reference lists of systematic reviews relating
to FP. To identify process evaluations and qualitative papers associated with the included
experimental studies, we used Connected Papers and hand searches of reference lists.
Selection Criteria: Experimental and quasi‐experimental studies of behavioural and
service‐level interventions involving males aged 10 years or over in low‐and middle‐
income countries to increase uptake of FP methods were included in this review.
Data Collection and Analysis: Methodology was a causal chain analysis involving the
development and testing of a logic model of intervention components based on
stakeholder consultation and prior research. Qualitative and quantitative data
relating to the evaluation studies and interventions were extracted based on the
principles of ‘effectiveness‐plus’reviews. Quantitative analysis was undertaken
using r with robust variance estimation (RVE), meta‐analysis and meta‐regression.
Qualitative analysis involved ‘best fit’framework synthesis.
Results: We identified 8885 potentially relevant records and included 127 in the
review. Fifty‐nine (46%) of these were randomised trials, the remainder were quasi‐
experimental studies with a comparison group. Fifty‐four percent of the included
studies were assessed as having a high risk of bias. A meta‐analysis of 72 studies
(k= 265) showed that the included group of interventions had statistically
significantly higher odds of improving contraceptive use when compared to
Campbell Systematic Reviews. 2023;19:e1296. wileyonlinelibrary.com/journal/cl2
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https://doi.org/10.1002/cl2.1296
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© 2023 The Authors. Campbell Systematic Reviews published by John Wiley & Sons Ltd on behalf of The Campbell Collaboration.
comparison groups (odds ratio = 1.38, confidence interval = 1.21 to 1.57, prediction
interval = 0.36 to 5.31, p< 0.0001), but there were substantial variations in the effect
sizes of the studies (Q= 40,647, df = 264, p< 0.0001; I
2
= 98%) and 73% was within
cluster/study. Multi‐variate meta‐regression revealed several significant interven-
tion delivery characteristics that moderate contraceptive use. These included
community‐based educational FP interventions, interventions delivered to women
as well as men and interventions delivered by trained facilitators, professionals, or
peers in community, home and community, or school settings. None of the eight
identified intervention components or 33 combinations of components were
significant moderators of effects on contraceptive use. Qualitative analysis
highlighted some of the barriers and facilitators of effective models of FP that
should be considered in future practice and research.
Authors' Conclusions: FP interventions that involve men and boys alongside women
and girls are effective in improving uptake and use of contraceptives. The evidence
suggests that policy should continue to promote the involvement of men and boys in
FP in ways that also promote gender equality. Recommendations for research
include the need for evaluations during conflict and disease outbreaks, and
evaluation of gender transformative interventions which engage men and boys as
contraceptive users and supporters in helping to achieve desired family size, fertility
promotion, safe conception, as well as promoting equitable family planning decision‐
making for women and girls.
1|PLAIN LANGUAGE SUMMARY
1.1 |Involving men and boys in family planning is
effective in increasing contraceptive use
Most family planning interventions involving men and/or boys are
effective at increasing contraceptive use. Effective types of interven-
tions include community‐based educational programmes targeting
males as well as females of all ages, and programmes delivered by
professionals, trained facilitators or peers.
Engaging men and boys in enhancing gender equality for women
and girls as part of family planning programming was highlighted as a
key strategy, but this remains under‐used.
1.2 |What is the review about?
This systematic review of intervention evaluation studies is about
how to enhance future programming with men and boys to meet
needs for family planning for women and men in low‐and middle‐
income countries (LMICs).
Addressing unmet needs for family planning is a major challenge
in LMICs. Addressing male involvement in family planning is also a
challenge, as it is in these countries where men's control over family
planning decision‐making for women and girls is known to be
greatest. It is important to involve men and boys in ways that support
women's and girls' choices, as well as men's own family planning
needs.
We used a novel method called causal chain analysis to focus on
the content of interventions that may work better than others. This
involved developing a picture of important programming components
with stakeholders and testing how these components affect the
impact of different interventions on family planning outcomes.
What is the aim of this systematic review?
This review assesses the strength of evidence of involving
men and boys as users and supporters of family planning.
The review also aims to uncover the effective components
and critical process‐and system‐level characteristics of
successful interventions.
1.3 |What studies are included?
We included 127 papers which examined the effectiveness of
interventions that included men and/or boys in LMICs as programme
participants using experimental or quasi‐experimental methods.
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We also included 23 qualitative studies and process evaluations
which reported why and how some programmes might have been
effective.
The studies were conducted worldwide in LMICs, over half in
Africa. A third of the studies were conducted on programmes that
made a special effort to engage males. Less than a quarter of the
studies addressed gender inequality as part of the programme.
1.4 |What are the main findings of this review?
When considered together, the interventions included in this review
were effective in increasing contraceptive use. The most effective
interventions are community‐based educational programmes offered in
schools, communities and homes or community facilities, and interven-
tions involving multiple components, delivered by professionals, trained
facilitators or peers to both males and females for over seven months.
Brief programmes of less than three months are also effective.
Added to this, related implementation studies identified the
importance of promoting gender‐equitable attitudes and social norms
for women and girls among men and women at the individual, wider
family, community, health service and societal level as part of family
planning programming.
Some studies also emphasised structural factors such as the
importance of widening women's access to education and labour
markets.
1.5 |What do these findings mean?
A wide range of family planning interventions which involve men and
boys in LMICs have shown efficacy in increasing contraceptive use.
The success of family planning programmes that involve men and
boys is most often measured by contraceptive use to the relative neglect
of other outcomes, such as met need for family planning, equitable family
planning decision‐making,orgenderequality.Ouranalysisindicates
some promising intervention characteristics, which are more effective in
promoting contraceptive use than other characteristics.
Our qualitative analysis also highlights the under‐used strategy
of addressing gender equality attitudes and norms, from the
individual to the structural level.
The findings of this review will be of interest to programme
designers wanting to increase male engagement in family planning in
gender‐equitable ways. The review can also help in measuring
programme efficacy beyond contraceptive use, to also include gender
equality and met family planning needs.
1.6 |How up to date is this review?
The review authors searched for experimental evaluations in August
2020 and ‘connected’process evaluations and qualitative studies in
June 2021.
2|BACKGROUND
2.1 |The problem
The World Health Organisation estimates that there are approximately
300,000 deaths per year, or 800 every day, among women and girls
during childbirth or arising from pregnancy‐related complications,
including unsafe abortion. Almost all (94%) of these preventable
female deaths occur in low‐and middle‐income countries (LMICs)
(World Health Organisation & Press, 2019). The problem is especially
acute among adolescent girls. Complications during pregnancy and
childbirth are the leading cause of death for 15–19‐year‐old girls
globally, with the vast majority of these occurring in LMICs (World
Health Organization, 2020). Unintended and mistimed pregnancies
also contribute to the burden of high infant morbidity and mortality
(Kozuki et al., 2013; Say et al., 2014;A.Singhetal.,2013). Around
2.7 million new‐borns die every year in LMICs and many more suffer
from diseases relating to preterm birth, being small for gestational age
or malnutrition (Guttmacher, 2017).
The importance of sexual and reproductive health and rights
(SRHR) as the bedrock to maternal and child health, economic growth,
and the wellbeing of humanity was recognised 25 years ago in the
international agreement of the International Conference on Population
and Development (Starrs et al., 2018). As part of the contemporary
global agenda to attain the sustainable development goals (SDGs),
SRHR constitutes two targets (3.7 and 5.6), interlinking the SDGs of
health and gender equality (United Nations & UN General Assembly,
2015). Family planning (FP) is a central tenet of SRHR enabling people
to avoid unintended pregnancy, attain their desired number of
children, and/or determine the spacing of pregnancies. Effective FP
is achieved through the use of contraceptive methods, provision of
safe abortion, and prevention and treatment of infertility. Worldwide,
however, more than 200 million have an unmet need for family
planning –wanting to avoid pregnancy but not using modern
contraception and each year 25 million unsafe abortions take place
(Starrs et al., 2018).
Involving men and boys in FP is increasingly recognised as
essential to addressing unmet FP needs and in turn transforming
maternal and child health outcomes (Croce‐Galis et al., 2014; Hardee
et al., 2017; Lohan et al., 2022; Phiri et al., 2015a; Sahay et al., 2021),
with programmes that adopt a focus on transforming gender
inequalities for women and girls showing particular promise (Barker
et al., 2007; Phiri et al., 2015b; Ruane‐McAteer et al., 2020).
The underpinning rationale for involving men in FP recognises that, in
many countries, men are the primary decision‐makers on family size
and may control or inhibit women's use of FP as well as
acknowledging that men themselves may have unmet needs in
relation to FP (Nzioka & Press, 2002). In practice, ‘involving’men and
boys in FP can range from encouraging men to be supporters of
autonomous FP decision‐making among women and girls, to more
inclusive conceptualisations of men and boys as both supporters and
users of contraceptive methods, leading change in relation to
addressing unmet FP needs in their families and communities as
AVENTIN ET AL.
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well as meeting their own reproductive health needs (Hardee
et al., 2017; Lohan, 2015; Sahay et al., 2021).
International policy debates on SRHR, and FP specifically, have
therefore moved beyond the polemic of whether to involve men and
boys towards the important question of how to involve men and boys
(Ruane‐McAteer et al., 2020). The how question relates to how to involve
men and boys in LMICs in ways that challenge patriarchal control over
women and girls' use of FP and how to involve men as users and co‐users
of FP. The question is further to address what characteristics or
components of FP interventions allow men to engage with FP alongside
women in ways which enhance health and gender equality for all.
2.2 |The intervention
The review reported here included behavioural and service‐level
interventions aiming to improve the uptake of FP and involve men or
boys in LMICs as intervention recipients. Eligible interventions included
thosethataimedtoincreasetheuptakeofFP(maleand/orfemale
contraception; safe abortion and safe post‐abortion care) in order to
ensure decreased unmet need for FP; avoidance of unintended or
unwanted pregnancies; birth spacing (i.e., choice in relation to time period
between pregnancies); and/or birth limiting (i.e., choice in relation to
limiting family size). The review focuses on ‘complex’interventions. While
we recognise that some interventions, such as those with only one
component, may be considered ‘simple’, following UK Medical Research
Council guidelines (Craig et al., 2008) we recognise that even interven-
tions with one component may be considered complex when they target
a number of different behaviours, a variety of outcomes, or may effect
behaviours via a number of different pathways.
While FP methods also include medical, surgical, and behavioural
(lifestyle) interventions for addressing infertility,wedidnot
examine these in the current review. The majority of fertility‐focused
interventions are medical or surgical in nature (Ruane‐McAteer
et al., 2019), and those that target behavioural determinants
are generally focused on lifestyle changes such as reducing
smoking and obesity and increasing exercise (Lan et al., 2017). In
consultation with our study's international expert advisory group,we
agreed that because the theoretical basis, components, and character-
istics of such interventions differ greatly from those aiming to prevent
unintended pregnancy, they were outside the scope of the current
study. While we agreed that should an included study address infertility
alongside any of the other FP outcomes it would be eligible for
inclusion, no such studies were identified.
Eligible interventions include those delivered in education, health
or community settings aiming to increase capability (knowledge,
skills), opportunity (access, social support) and motivation (attitudes,
norms) to use FP methods via mass, small or social media information,
face‐to‐face communication; health service enhancements; monetary
and other incentives; and access to FP methods. The intervention
approaches were grouped under the following categories:
•Theoretical approach (e.g., behaviour change theory; gender theory);
•Approach to intervention design (e.g., co‐design or co‐production);
•Materials & procedures (including approach to engaging men and
type of contraceptive method);
•Who provides (e.g., health or education professionals, peers,
trained facilitators);
•Who receives (e.g., adolescents/youth/adults; males only; males
and females);
•Modes of delivery (e.g., face‐to‐face, online; individuals/couples/
community);
•Delivery setting (e.g., home, community, educational);
•Dose and intensity (how much, how often, how long);and
•Tailoring, modifications, adherence or fidelity.
Interventions that vary on whether and how they address
unequal gender norms in FP were also included. The modification of
gender norms can be categorised on a continuum from ‘gender‐
unequal/neutral’approaches which reinforce or ignore unequal
norms, roles and relations, thereby perpetuating gender‐based
discrimination; to ‘gender‐sensitive/specific’approaches, which do
consider gender norms, roles and relations and/or men and
women's specific needs or roles but do not seek to change gender
inequalities; to ‘gender transformative’approaches which are
inclusive of gender‐sensitive and gender‐specific strategies, but
also challenge gender inequalities by transforming harmful gender
norms, roles and relations through programmatic strategies that
foster progressive changes in power relationships between women
and men (Interagency Gender Working Group, 2017; World Health
Organisation, 2011).
2.3 |How the interventions might work
This review draws upon a Causal Chain Analysis (CCA) (Kneale
et al., 2015,2018), the first step of which is to use a logic model to
encapsulate how an intervention might work. The logic model is used
to frame data extraction and subsequent analysis of intervention
characteristics and outcomes presented (see Section 5.3). This
approach addresses a common criticism of systematic reviews and
meta‐analyses on the need to go beyond effectiveness analyses
towards a more nuanced identification of the active ingredients of
effective interventions (Pawson et al., 2005), testing of causal
pathways, and identification of system‐and process‐level barriers
and facilitators to effective intervention.
The initial review logic model (Supporting Information: Appendix 1.0)
was built based on: (a) a consultation with our expert advisory group; (b) a
rapid review of programme theories used in FP interventions involving
menandboys(Robinsonetal.,2021) and (c) the research team members'
ownexpertiseofinterventiondesignandevaluationinSRHRand
involvement in prior systematic reviews conducted for the WHO on male
engagement interventions in SRHR (Ruane‐McAteer et al., 2019,2020). It
provides a visual representation of how, and under what circumstances,
FP interventions might work to increase uptake of FP, help people attain
their desired family size and ultimately result in improvements in SRHR,
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maternal and child health, gender equality, quality of life and livelihoods
for all.
Informed by realist interpretations of causality (Pawson
et al., 2005), the logic model sets out the multiple possible pathways
through which each intervention component, or combination of
components, would bring about positive outcomes and change. In
essence, we hypothesise that in order to positively impact maternal
and child mortality and morbidity indicators, FP interventions involving
men and boys first need to effect change in one or more outcomes at
proximal (individual), intermediate (interpersonal, community, organi-
sational/service) and distal (structural) levels. As illustrated in the
model, changes in these outcomes follows from exposure to an
intervention, although different combinations of intervention char-
acteristics are possible and may have differential impact and may also
be influenced by the characteristics of the participants and the context
in which the intervention takes place. Each FP intervention will include
core components as well as a set of resources and theory underlying
its implementation. Further, the logic model recognises that interven-
tions can fail to produce change because of issues relating to design or
implementation processes (e.g., the intervention may not be well
implemented, implementation may not trigger mechanisms or mecha-
nisms may not generate outcomes) and, therefore, incorporates ways
of understanding the success of the implementation. It also recognises
that potential negative outcomes are possible for every intervention
and incorporates potential indicators of these.
2.4 |Why is it important to do this review?
To the best of our knowledge, this is the first systematic review in the
field which focuses on understanding the effective characteristics and
components of interventions involving men and boys in FP using
causal chain analysis. Our review builds upon prior research in the field
of male engagement and SRHR, which includes two WHO evidence
and gap maps (EGM https://srhr.org/masculinities/rhoutcomes/ and
https://srhr.org/masculinities/wbincome/)(srhr.org) and a systematic
review of reviews of male engagement interventions across all SRHR
outcomes (Ruane‐McAteer et al., 2019). There are also two previous
systematic reviews of male engagement in relation to gender‐
transformative SRHR interventions (Barker et al., 2007;Ruane‐
McAteer et al., 2020) focusing on intervention evaluation as well as
the characteristics of effective interventions.
Specifically in the field of FP, three previous reviews focus on an
analysis of the characteristics and components of FP interventions,
including an analysis of male involvement (Lopez et al., 2009;
Mwaikambo et al., 2013; Phiri et al., 2015a). A further relevant review
specifically on male engagement in FP and examining programme
components was published while we were conducting the current
systematic review (Sahay et al., 2021).
While our review analysis is based upon quantitative experimental
evaluations of interventions, the review also includes an analysis of the
available qualitative process evaluations of the interventions under
study. The qualitative analysis helped to inform hypotheses of effective
characteristics and components as well as our interpretation of review
findings. Our review also benefits, as noted above, from consultations
held with a multi‐disciplinary international advisory group based and/or
working in LMICs in relation to SRHR. The findings of this review will be
of benefit to programme planners and policy makers in family planning
because of the wide policy interest in male engagement and the specific
focus of effective programming components of interventions involving
men and boys in FP. The review will also help to inform the WHO's
Research Priority Setting Exercise on Masculinities and SRHR https://
masculinities.srhr.org/.
3|OBJECTIVES
The primary aim of this review was to uncover the effective
components and characteristics of complex FP interventions involv-
ing men and boys in LMICs. In addressing this, we examined the
following questions:
(1) What is the nature and extent of experimental evidence on
engaging men and boys in FP and what gaps in research
knowledge exist?
(2) What are the impacts of FP interventions involving men and boys
on FP‐related outcomes?
(3) What are the effective components of interventions that achieve
positive change in intended FP outcomes?
(4) What characteristics and combinations of characteristics are
associated with positive FP‐related outcomes?
(5) Do outcomes vary by context and participant characteristics?
(6) Are there any unintended or adverse outcomes?
(7) What are the system‐and process‐level barriers to and
facilitators of effective models of FP involving men and boys?
4|METHODS
4.1 |Criteria for considering studies for this review
4.1.1 |Types of study designs
As per our protocol (Aventin et al., 2021), included studies were
randomised trials (individual or cluster) and quasi‐experimental studies,
including quasi‐randomised trials (groups allocated using non‐random
methods) and pre‐and post‐test studies with a comparison group and,
where available, their associated qualitative/mixed methods studies
(e.g., formative qualitative research, process evaluations, and qualitative
research exploring accounts of how the interventions work). Non‐
experimental pre‐and post‐test studies (i.e., those without a comparison
group) were excluded. Mixed methods evaluations were included when
the quantitative design satisfied the criteria mentioned above.
Included studies must have reported interventions or programmes
implemented in countries categorised as Low Income, Lower‐Middle
Income, or Upper‐MiddleIncomebytheWorldBank(WorldBank,2019)
AVENTIN ET AL.
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at the time the search was conducted. Studies that reported on multi‐
country interventions were eligible if they met the criteria as occurring
in at least one LMIC.
4.1.2 |Types of participants
The review focuses on FP interventions delivered in LMICs, which
involved men or boys as recipients. Included studies must therefore have
involved males of any age, of any sexual orientation and gender identity.
Whileweconsideredoutcomesforbothwomenandmen,studieswere
only included if boys or men received the intervention. Studies or
interventions that including girls or women only were excluded.
4.1.3 |Types of interventions
Included interventions were FP‐focused behavioural and service‐
level interventions, directly targeting or involving men or boys in
LMICs. The interventions were delivered in health, education, and
community settings in LMICs. Comparators included alternative
interventions, usual standard care and no intervention.
4.1.4 |Types of outcome measures
The outcomes for this review were selected in a stakeholder‐
informed logic model development phase. We consulted with FP
experts to develop a review logic model (see Aventin et al., 2021)
which illustrated relevant proximal and distal outcomes relating to
maternal and child health and FP. While we anticipated that some
outcomes featured in the review logic model, such as community,
organisational and structural level outcomes and distal impacts, may
not have been measured in the included studies, we aimed to
examine any combination of outcomes provided.
Examples of eligible primary outcomes included: sexual and
reproductive health behaviours (e.g., male and female contraceptive
uptake and sustained use, reductions in unprotected sex, birth
spacing, birth limiting); gender equitable attitudes and behaviours (e.g.,
changed attitudes and norms, decreased male‐dominated FP
decision‐making); FP service use and engagement (e.g., knowledge
and use of FP services, use of safe abortion; support for partner
engagement an increased trust in FP services); Fertility (e.g.,
adolescent/early pregnancy and unintended pregnancy rates). Finally,
we included met need for FP as a key rights‐based primary outcome.
Examples of eligible secondary outcomes included: psychosocial
determinants of FP such as knowledge, attitudes and social norms;
factors relating to relationship quality and discordance such as couple
communication and intimate partner violence; attitudes towards FP
services including more positive attitudes towards help‐seeking in
relation to FP; and community, organisational and structural level
outcomes including gender equitable attitudes and support for FP in
wider social contexts.
4.2 |Search methods for identification of studies
As we sought to include both quantitative studies and qualitative
studies in the review, the search had two phases. The first phase was
a comprehensive search for randomised trials and quasi‐experimental
studies. The second phase was a search for qualitative studies limited
to the specific experimental evaluation studies identified in phase
one to be included in the causal‐chain analysis. We used EndNote x9
software to remove duplicates in the search. We used EPPI Reviewer
4 software for data management, screening, extraction, and appraisal
and further identification of duplicates with its more sensitive and
configurable duplicate identification tool.
4.2.1 |Search strategy
Evaluation studies
The Phase 1 search was conducted using searches of the databases,
grey literature sources and other approaches in August 2020
detailed below. The search included any available studies up until
the specified dates.
1. Searches of academic literature and databases (CINAHL <August 26,
2020>, Ovid MEDLINE
®
ALL <August 26, 2020>, Ovid APA PsycInfo
<August, Week 3 2020>, Social Science Citation Index–expanded
<August 26, 2020>, Cochrane Library (including CENTRAL) <August
26,2020>,OvidEmbase<August25,2020>,Scopus<August26,
2020>, WHO Global Health Library <August 26, 2020>).
2. Searches of grey literature sources were searched using a
selection of key terms on grey literature databases for any
materials available to August 20, 2020 (ETHoS, ClinicalTrials.gov
Register, ProQuest Dissertation & Thesis A&I, OpenGrey.eu,
ELDIS.org) and searching of reports shared by relevant organisa-
tion websites (DFID, FP2020, United Nations Library/UNFPA
<August 11, 2020>, IPPF <August 12, 2020>, 3ie <August 12,
2020>, USAID <August 12, 2020>, Promundo <August 11,
2020>, FHI360 <August 13, 2020>, Population Council <August
13, 2020>, Population Reference Bureau <August 20, 2020>,
Institute for Reproductive Health <August 20, 2020>, Marie
Stopes <August 20, 2020>). The results were hand searched for
potentially relevant articles for the current review. These searches
were supplemented with limited searches of the internet using
Google <August 10, 2020> and project keywords.
3. Other approaches to identify eligible studies involved eliciting
recommendations from disciplinary experts through the study's
International Expert Advisory Group, and checking reference lists of
relevant reviews identified during screening, a previous published
EvidenceandGapMap(EGM)(Ruane‐McAteer et al., 2019)anda
hand‐search of the Campbell Systematic Reviews journal.
Connected papers
The Phase 2 search was conducted using the Connected Papers
resource (Eitan et al., 2021) to identify relevant papers by searching
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prior and derivative work. This resource generates ‘citation maps’
from similar or related publications based on co‐citation and text
similarity assessed by machine learning across Scopus Databases.
A Connected Papers graph was generated for each of the included
studies in the review. The titles and abstracts of all linked results
provided by the mapping tool were hand searched for relevance.
4.2.2 |Search limits
Evaluation studies
The search was not limited by publication status, date, or language of
publication.
Connected papers
To keep the number of studies manageable, previous research by
study authors not directly related to the intervention of interest and
secondary analyses of data conducted outside the intervention study
were not eligible for inclusion.
4.2.3 |Search terms
Evaluation studies
In Supporting Information: Appendices 2.0, we include the search
strings used for our Phase 1 searches. Some of these strings were
adapted from Ruane‐McAteer et al. (2018) and combined using
Boolean Operator AND for terms relating to FP AND men/boys. We
combined these with sensitive search filters for study design, adapted
from the filter produced by Cochrane Effective Practice and
Organisation of Care (2017) sample search for quasi‐experimental
studies. We applied the LMIC filters developed by Cochrane EPOC
group (EPOC LMIC 2020, v.3). These filters are based on the World
Bank list of countries (2019, https://epoc.cochrane.org/lmic-filters).
Searches were tested and adjusted as necessary to account for the
unique indexing, field codes and truncation for each database.
Interventions
Given the very broad range of potential interventions we did not limit
our searches by intervention terms in the initial stages. However, we
subsequently developed this search string as follows:
(1) Search for the combination of the terms for population AND
family planning AND study design AND LMIC in two databases
(PsycInfo and Medline).
(2) Scan the first 200 records retrieved in each database to quickly
identify studies that appear to meet our eligibility criteria (400
records screened).
(3) We used this selection of studies to develop and test a
comprehensive list of intervention terms.
(4) We then screened a further selection of 200 records in each
database to identify a new set of potentially eligible studies. This
new set was then used to verify that the newly developed string
captured the second set of potentially eligible studies and did not
exclude any potentially relevant study.
(5) The first set of intervention terms failed to capture one
potentially relevant study identified in step 4. The intervention
term list was expanded to capture the relevant term (in this case
‘training’) and the process above was repeated once more. All
relevant records were identified in the next round. We were
therefore satisfied that adding intervention terms improved
search specificity without adversely affecting sensitivity.
We recognise that the strategy combines five search strings,
which can result in a less sensitive search. However, given the
breadth of the interventions of interest, this was necessary to
maximise the specificity of the search and reduce the number of
irrelevant records retrieved.
4.3 |Data collection and analysis
To ensure the most effective use of finite time and resources, subsets
of the data were used for different review questions (see Table 1).
While all 127 studies were included, a subset of studies reporting
contraceptive use outcomes (72 studies) was used in the meta‐
analysis, and a further subset of 33 studies which included
interventions with a male engagement component (see Table 1for
definition) and reported contraceptive use outcomes, were used to
examine impacts on intermediate outcomes. The decision to focus
the bulk of the quantitative analyses on studies that reported
contraceptive use outcomes was driven by, firstly, contraceptive use
being the most reported FP outcome and thus yielded the most data
for further analysis. Other outcomes (such as FP service use or birth
spacing) were less frequently reported limiting the potential for
adequately powered analysis. Secondly, resource limitations pre-
vented dual extraction of all outcome data for all 127 studies.
The decision to focus on the male engagement studies for elements
of the CCA was informed by discussions among the review team and
the International Advisory Group to focus attention on interventions
that involved active and intentional male engagement.
4.3.1 |Selection of studies
Evaluation studies
Records identified in the searches were entered into EndNote v9 and
duplicates removed. Two review authors independently screened
titles and abstracts to exclude studies that were obviously irrelevant.
To ensure quality control, Cohen's kappa was calculated between
three reviewers on the first 100 records, selected at random, and
discussed to resolve any disagreements of eligibility. This process was
repeated until Cohen's kappa reached 0.41 or above and we were
satisfied that the screeners were making consistent decisions.
We then retrieved studies considered potentially eligible in full
text. Dual independent screening of all full texts was undertaken by
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two review authors. The screening and quality control process outlined
above was repeated with a smaller sample of 10 full texts, employing
independent dual screening of records thereafter. Any disagreements
were discussed with a third review author until a consensus was
reached. Cohen's Kappa was once again calculated for this initial full
text screening, and for the completed full text screening process
ensuring adequate inter‐rater reliability (McHugh, 2012).
Connected papers
A citation map was generated for a sub‐set of included evaluation
studies (33 studies with a male engagement component) and the
connected publications were examined to identify eligible process
evaluations and qualitative studies (‘connected papers’). This included
investigations of the programme under evaluation conducted in
intervention piloting and refinement, simultaneously with delivery, or
following implementation assessing aspects of its design and delivery.
This led to the identification of 8 qualitative studies and 15 process
evaluations for analyses in this review. These studies related to 14 of
the 33 male engagement studies.
4.3.2 |Data extraction and management
Evaluation studies
A data extraction form (Supporting Information: Appendices 3.0) was
piloted on 11 studies. Following this, the only content change made
to the form was the addition of the Male Engagement code under the
Intervention Characteristic domain. This was added because it became
clear early in the review process that this was a substantive
differentiating factor in some intervention designs. No other content
changes were made to the data extraction form.
Data preparation was performed using Microsoft Excel.
Qualitative data extraction and synthesis was performed using
annotation function in EPPI Reviewer. Outcome and numeric data
were extracted in duplicate for all studies subject to causal chain
analysis. This included all outcome data relating to ‘contraceptive
use’for all 127 included studies where available, and all reported
FP outcome data (including contraceptive use and all other
reported data for intermediate outcomes) for the 33 male
engagement studies.
Due to resource constraints and the large number of eligible
studies, a deviation from protocol was implemented (see 4.4 below).
Dual extraction of Study Characteristics and Intervention Character-
istics was conducted for 28% [n= 36] of included studies only and
dual Risk of Bias Appraisal was conducted for 50% [n= 64] of
included studies only. We evaluated the reliability of this approach
and concluded that it was acceptable in accordance with accepted
standards (Landis & Koch, 1977;McHugh,2012), thus the
extraction of Study Characteristics,Intervention Characteristics,and
Risk of Bias Appraisal by one review author was implemented for the
remaining studies.
As the characteristics and components of interventions were a
central feature of this review, care was taken to extract and code
this data according to the a priori defined categories outlined in the
TABLE 1 Intervention component names, definitions, and examples
Component name Definition Examples
Gender Transformative Addressing gender inequalities and/or harmful/
restrictive gender norms.
Interventions which may be inclusive of gender sensitive, and
gender aware education, but also include discussion of
gendered norms, or gender power and challenging of
gender‐inequalities.
Information & Education Providing information and education about FP methods,
practices and outcomes.
Information provision in clinics; educational programme;
informational materials dissemination.
Problem‐Solving & Skills Activities used to increase FP related skills and
competencies; Identifying barriers and facilitators of
FP communication and access.
Demonstrations of correct contraceptive use; workshops and
roles plays about FP communication; behaviour modelling.
Social/Peer/Mentor
Support
Activities to foster social support in engaging in FP. Outreach by male motivators and mentors; peer support;
engaging religious leaders; community dialogue to
support FP.
Subsidisation &
Incentives
Subsidisation or free provision of FP and/or incentives
to reinforce use of FP.
Free or discounted contraceptives and materials; vouchers for
FP services; conditional cash transfers for use of FP.
Communication Communication‐based strategies for improving FP
outcomes.
Couples counselling; social marketing, mass media, mHealth,
hotlines.
Health Service
Enhancement
Programme activities intended to improve health service
provision related to FP.
Training for healthcare providers; integration of FP services
with other healthcare services.
Male Engagement Programmes with a substantive aim, identified in
objectives or procedures, to engage men and/or
boys to impact FP outcomes.
Tailored materials and procedures to engage men and boys;
purposive targeting of men and boys to effect FP
behaviour change.
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initial review logic model (Supporting Information: Appendix 1.0),
whilst also permitting the inclusion and/or refinement of compo-
nent names and definitions as coding proceeded. The final
component names and definitions used for coding and reporting
are included in Table 1.
All studies coded as containing a ‘male engagement’component
(see definition inTable 1) were assessed independently by two review
authors to verify the presence of this component. Disagreements
about the presence of this component in three studies were resolved
by discussion with a third review author.
Connected papers
Qualitative data extractions were done for the 23 connected papers
and, where reported, the subset of 33 male engagement evaluation
studies. Extraction was conducted by one review author in EPPI and
checked by a second author. Data constituted verbatim sections of
text describing:
(1) full or partial causal‐chain descriptions, whereby authors explain
or hypothesise what caused an outcome and under which
circumstances;
(2) reflections of the original authors on how specific elements of an
intervention worked/might have worked; and
(3) statements on how specific mediators, moderators, and system‐
and process‐level barriers and facilitators impacted/may have
impacted on outcomes.
4.3.3 |Assessment of risk of bias in included studies
Evaluation studies
Assessment of methodological quality and risk for bias in randomised
trials was conducted using the Cochrane Risk of Bias tool for
Randomised Controlled Trials (RoB 1) (Higgins et al., 2011). This is a
standard tool, which takes the forms of a series of questions about
the randomisation procedures and blinding. Non‐randomised studies
were coded using ROBINS‐I (Sterne et al., 2016). As noted above,
dual risk of bias appraisal was conducted for 50% [n= 64] of included
evaluation studies. We evaluated the reliability of this approach and
concluded that it was acceptable in accordance with accepted
standards (Landis & Koch, 1977; McHugh, 2012), and risk of bias
appraisal by one review author was implemented for the remaining
studies.
Connected papers
Qualitative studies were coded by one review author using the
Jimenez and colleagues (Jimenez et al., 2018) critical appraisal tool
and quantitative process evaluation studies using the EPPI‐Centre &
EPPI‐Centre Social Science Research Unit (2003). These codes were
checked by a second review author. We did not exclude any studies
from the review on the basis of quality, rather, we conducted a
sensitivity analysis exploring the impact of including low quality
studies on the overall findings.
4.3.4 |Criteria for determination of independent
findings
There were sufficient eligible studies reporting multiple and depen-
dent effect sizes (i.e., occurring in more than 20 eligible studies) so
robust variance estimation (RVE) was employed to account for
dependency in the data. This technique calculates the variance
between effect sizes to give a quantifiable standard error for the
variable of interest. It has been shown to calculate correct results
with a minimum of 20–30 individual studies (Hedges et al., 2010),
although it performs better with more studies.
4.3.5 |Measures of treatment effect
Outcomes were typically reported as dichotomous data so meta‐
analysis was conducted using odds ratio (OR), with a random effects
model. We focused our analysis on contraceptive use because this
was the most measured outcome across all studies.
4.3.6 |Unit of analysis issues
Multiple intervention groups
We used RVE to account for dependencies in the data and to allow us
to make use of multiple effect sizes reported in single studies.
Multiple interventions per individual
We coded each study according to intervention components. We
used meta‐regression to assess the effectiveness of individual and
combined intervention components.
4.3.7 |Dealing with missing data
Of the 127 included studies, 12 study reports did not contain
sufficient data to allow calculation of effect size estimates for the
primary outcome of our analyses, contraceptive use. When appropri-
ate, we contacted the original authors to request necessary summary
data, such as means and standard deviations or standard errors.
Where no information was provided, the study was not included in
the meta‐analysis and was included in the narrative synthesis only.
We were unable to retrieve information for 40 effect sizes across
12 included studies. These studies were included in the review but
excluded from the meta‐analysis.
4.3.8 |Assessment of heterogeneity
Heterogeneity was assessed first through visual inspection of forest
plots and checking for overlap of confidence intervals and second
through the Q,I
2
and Tau
2
statistics. Investigation of the source of
heterogeneity is addressed in data synthesis section.
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4.3.9 |Assessment of reporting biases
We assessed small study bias (such as publication bias) using a
regression test for funnel plot asymmetry (Egger et al., 1997). The
model used was a weighted regression with multiplicative dispersion
using sampling variance as predictor.
To ensure robustness of the review and to account
for individual studies that appear to exert an undue influence
on findings, process sensitivity analysis was carried out on
domains relating to the quality of the included studies
(Cooper, 2016).
4.3.10 |Data synthesis
We adopted a Causal Chain Analysis (CCA) (Ivers et al., 2014; Kneale
et al., 2018; Tanner‐Smith & Grant, 2018) approach to data synthesis.
The logic model was tested using appropriate meta‐analytic
techniques combined with findings from narrative synthesis of
evaluation study findings and qualitative analysis of connected
papers. The process involved the following:
(1) Multivariate pairwise meta‐analysis to assess the overall
effectiveness of the interventions on reported FP outcomes;
(2) Meta‐regression to assess the impact of multiple intervention
components and characteristics on FP outcomes; and
(3) Narrative synthesis involving the identification of characteristics
and components of included interventions and ‘best‐fit’frame-
work synthesis of connected qualitative studies and process
evaluations to identify barriers and facilitators to effective
models of FP.
As noted, different subsets of the data were used for the review
questions (see Table 2). All 127 studies were included in the narrative
synthesis relating to review questions 1 and 6. The subset of 72
studies are those that report contraceptive use outcome data and
had outliers removed and this subset was used for questions 2–5. A
further subset was created of male engagement studies. This subset
of 33 studies are those that report contraceptive use outcome data,
had outliers removed, and included a ‘male engagement’component
(i.e., explicitly stated an intention or practice of engaging men/boys
either through their objectives or tailoring their practice for males in
order to impact FP outcomes). These studies were used in the
TABLE 2 Summary of analysis procedures used for each review question
Review question Analysis approach
1. What is the nature and extent of experimental evidence on
engaging men and boys in FP and what gaps in research
knowledge exist?
Summary statistics and narrative synthesis for 127 studies.
2. What are the impacts of FP interventions involving men and boys
on FP‐related outcomes?
Multivariate pairwise meta‐analysis of the effect of interventions on
‘contraceptive use’compared to comparisons for 72 studies (see
Supporting Information: Appendices 7.1).
Multivariate pairwise meta‐analysis of the effect of interventions on
intermediate FP outcomes
a
compared to comparisons for 33
b
male
engagement studies (see Supporting Information: Appendices 7.2).
3. What are the effective components of interventions that achieve
positive change in intended FP outcomes?
Meta‐regression to estimate variance accounted for by the identified
intervention components and combinations of components for 72
studies.
4. What characteristics and combinations of characteristics are
associated with positive FP‐related outcomes?
Meta‐regression on extrinsic (year of publication); methodological (study
design); and substantive (intervention design, dosage, intervention
setting; intervention theory of change; who delivers) variables for 72
studies.
5. Do outcomes vary by context and participant characteristics? Multivariate meta‐analysis of dependent effect sizes with robust variance
estimation on characteristics of context (region) and participants (age
and sex) for 72 studies.
6. What adverse effects were reported? Narrative synthesis of any reported adverse effects in 127 studies and
qualitative synthesis of 23 connected papers (See Supporting
Information: Appendices 7.3).
7. What are the system‐and process‐level barriers to and enablers of
effective models of FP involving men and boys?
Qualitative synthesis using a ‘best‐fit’framework synthesis approach for 23
connected papers (11 connected qualitative studies and 12 connected
process evaluations).
a
Intermediate FP outcomes: attitudes to FP services; contraceptive attitudes; contraceptive knowledge; FP communication; gender equitable behaviours
and beliefs; joint FP decision‐making; and FP service use.
b
Thirty‐four male engagement studies less removal of one study with outliers.
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analysis in questions 2. The analytic approach for each of our
objectives is summarised in Table 2.
4.3.11 |Approach to meta‐analysis
Given the diverse range of interventions included in this review,
random effects models, using RVE, were used as the basis for meta‐
analysis. The analyses were conducted using rand the range of
commands externally developed to conduct meta‐analysis with r
including metafor and clubSandwich (Megha Joshi, 2022; Michael
Kossmeier, 2020; Pustejovsky & Tipton, 2018; Viechtbauer, 2010).
4.3.12 |Main effects
The main effects analysis, synthesising the evidence on the effects of
the interventions was undertaken using multivariate pair‐wise meta‐
analysis outlined above for each outcome in turn.
4.3.13 |Sensitivity analysis
For each outcome, the following sensitivity analyses was undertaken
to assess whether there were potential influences relating to studies
that appear to exert an undue influence on findings. We used meta‐
regression to assess the impact of:
•Year study was conducted
•Study design (cluster‐RCT, RCT, Quasi‐experimental)
We did not conduct sensitivity analysis on study risk of bias due
to the mixture of RCTs and non‐RCTs.
4.3.14 |Subgroup analysis and investigation
of heterogeneity
The complexity of the logic model means that there were many possible
subgroup analyses and meta‐regressions to assess the differential
effects in relation to the components of interventions, characteristics of
the intervention delivery, population of interest and context. Using
robust variance estimates, we conducted analysis for the following:
•Geographical region
•Who delivered the intervention (peers, professionals, trained
facilitators, etc.)
•Intervention dosage
•Intervention design
•Population included (males only or males and females)
•Intervention setting
•Age of participants (adolescents, adults, both)
•Presence or absence of a theory of behaviour change
This exploratory analysis used single‐variable, no intercept model
and we did meta regression using residual maximum likelihood
(REML). The meta‐regression model was a no‐intercept effect size
model with dummy codes for each included variable.
4.3.15 |Treatment of qualitative data
Qualitative data extracted from the 23 connected papers (15 process
evaluations and 8 qualitative studies) were analysed using a ‘best‐fit’
framework synthesis approach (Booth & Carroll, 2015; Carroll
et al., 2013). Where possible, qualitative data was also extracted from
the subset of 33 male engagement studies. The a priori framework used
to code the data constituted categories from the review logic model
(Supporting Information: Appendix 1.0). One author coded the data
deductively using the a priori framework and subsequently conducted
thematic analysis. Inductive, thematic analysis techniques were used for
data that could not be coded under existing categories. Codes and
resulting categories were checked by a second author and any
differences in opinion were resolved through discussion. The synthesis
findings were used to inform decision‐making in relation to the
quantitative synthesis and to help explain and provide additional
evidence for the outcome patterns reported in the quantitative
synthesis. Information from the critical appraisal tools was not used
to exclude studies but a sensitivity analysis was conducted by excluding
low‐quality studies and to test the impact of these exclusions on the
overall synthesis of findings. Conclusions were integrated at the end of
the review process in the conclusion and discussion section and used to
inform a revised version of the review logic model.
4.4 |Deviations from protocol
4.4.1 |Data extraction
The published review protocol (Aventin et al., 2021)specifiedthat
data extraction and risk of bias appraisal would be carried out in full
by two reviewers independently. Due to the large number of
included studies (127) and resource constraints, this was not
possible. We have upheld standards in line with the methodological
guidance specified by the Campbell MECCIER guidelines (Methods
Group of the Campbell Collaboration, 2019)inlightofthese
constraints. One review author completed data extraction and risk
of bias appraisals for all 127 included studies. In total, 36 (28.1%)
included studies were subject to dual data extraction of intervention
characteristics, and 64 (50%) risk of bias appraisals were done by
another member of the review team independently. To ensure
accurate extraction of numerical data, contraceptive use outcome
and numeric data were extracted in duplicate for all 72 studies
subject to quantitative analysis and checked by an experienced
methodologist who conducted the analyses. Intermediate outcome
and numerical data (extracted only for the 33 male engagement
studies) was extracted by an experienced research assistant and
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checked by one review author and an experienced methodologist
who conducted the analysis.
Duplicate extraction and appraisal were subject to evaluation by the
review team to ensure consistent decision‐making by a single reviewer.
To assess inter‐rater agreement and provide a measure of internal
validity, we present the kappa statistic, κ. Generally, Cohen's kappa is
used most often as it determines agreement between reviewer A and
reviewer B (Landis & Koch, 1977) but the Fleiss kappa statistic may be
used where there are multiple reviewers extracting the same data
(Fleiss, 1971). The kappa statistic is preferable to reporting percent
agreement, as the possibility of agreement occurring by chance is
included in the equation. We used this to establish internal consistency
across the team. This measure was checked using the irr package in R.
Calculation of Fleiss' kappa was determined to be favourable for data
extraction (Percent Agreement = 94.6, κ= 0.70) and risk of bias tools
(Percent Agreement = 87.4, κ= 0.56).
Reliability of data extraction was deemed acceptable in accord-
ance with accepted standards (Landis & Koch, 1977;McHugh,2012),
thus the extraction of Study Characteristics, Intervention Character-
istics, and Risk of Bias Appraisal (see Supporting Information:
Appendices 3.0, Data Extraction Form) by one reviewer was accepted.
4.4.2 |Analysis
Although it had been our intention to conduct the full causal chain
analysis on all included studies, our inclusion criteria led to the
inclusion of a large number of studies (127). Time constraints led us
to focus our resources of dual extraction and data analysis of
intermediate outcome data for a subset of 44 male engagement
studies only, 33 of which were included in the meta‐analysis as these
included a contraceptive use outcome. These studies were used to
answer review Q2 regarding the effectiveness of interventions on
intermediate FP outcomes and they were also used as the basis for
selecting the 23 connected papers (i.e., the connected papers relate
to the 33 male engagement evaluations studies).
Finally, in a deviation from our per‐protocol analysis we did not
conduct analysis separately for different follow‐up times as planned.
Instead, we used RVE to allow us to combine multiple effect sizes on
the same outcome from each study while accounting for dependency in
the data. We did not conduct separateanalysiswherethesameoutcome
construct was measured but across multiple time domains, such as
through the collection of both post‐test and further follow‐up data.
5|RESULTS
5.1 |Description of studies
5.1.1 |Results of the search
Figure 1shows the results of the search process. A total of 8885
potentially relevant records were identified from our academic and
grey literature searches, after excluding 8318 duplicates. The 8885
articles included 168 records that were identified from hand searches
of the reference lists of 89 review articles. All 8885 records were
screened for relevancy based on their title and abstract and, of these,
5044 were excluded because they were obviously irrelevant to this
review (e.g., records related to animal studies, studies of infant
mortality, health interventions explicitly not related to FP behaviours
such as child nutrition and smoking cessation, reporting of national
demographic and health surveys). The titles and abstracts of the
remaining 3841 records were screened according to the following
criteria:
1. Related to a psycho‐social or behavioural FP intervention
2. Related to a Randomised Controlled Trial or Quasi‐Experimental
Design
3. Involved males in intervention delivery
4. Conducted in a Low‐or Middle‐Income Country(ies)
These criteria were applied in sequential order for the purposes
of exclusion and inclusion of records in title and abstract screening
and led to the following exclusions:
•not related to a psycho‐social or behavioural FP intervention
(n= 2864, 80.5%) (e.g., surveys of family planning attitudes or
practices, commentary on family planning, an intervention
unrelated to family planning behaviours),
•ineligible study design (n= 633, 17.8%) (e.g., pre‐post‐intervention
designs, lack of a comparison group, intervention protocol or
development paper, review of interventions),
•did not involve men or boys in intervention delivery (n= 55, 1.6%),
•not conducted in a LMIC (n= 5, 0.01%),
•unavailable publication abstract or full text, thus awaiting
classification (n= 5, 0.01%).
Following title and abstract screening of identified studies, 280
records were subject to full‐text screening. In assessing studies for
eligibility at this stage, the same four criteria were applied to the
records marked for inclusion at the title and abstract screening stage.
This led to the exclusion of a further 147 records for the following
reasons:
•Did not evaluate an intervention (n= 40, 27.2%)
•Did not evaluate a relevant intervention (n= 32, 21.8%)
•Ineligible study design, i.e., no comparison group (n= 48, 32.7%)
•Did not deliver intervention to men or boys (n= 21, 14.3%)
•Was not conducted in a LMIC (n= 6, 0.4%)
Five records were removed following closer examination during
data extraction for the following reasons, which are in line with the
eligibility criteria for this review: lacking a comparison group exposed
to a different or no intervention (Baochang et al., 1998; Nabaggala
et al., 2019); intervention content related to HIV prevention
exclusively (Harvey et al., 2000; Vernon et al., 1990); intervention
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delivered to females only despite appearing to encourage male
involvement (Jahanfar et al., 2005). The review team was unable to
acquire abstract or full‐text resources for a total of 19 records,
meaning these were labelled as ‘Awaiting Classification’and did not
advance to eligibility assessment or inclusion.
5.1.2 |Included studies
A total of 127 evaluation studies were included in the review. Of
these, 106 were identified from database and grey literature
searches, 18 from review forward searching, and 3 from searches
of the EGM (Ruane‐McAteer et al., 2019) (see Section 4.2.1).
As noted, a total of 23 ‘connected’process evaluations and
qualitative papers relating to 14 of the included experimental
evaluation studies were also included.
Review question 1: What is the nature and extent of experimental
evidence on engaging men and boys in FP?
This section reports findings relating to Review Question 1 on the
nature and extent of experimental evidence on engaging men and
boys in FP. An overview of the characteristics of all included studies
(n= 127) (see Table 3) is followed by a summary of characteristics of
the 44 studies that had a male engagement component (see Table 4).
Finally, the characteristics of the 23 connected papers are outlined.
Supporting Information: Appendices 4.0 provides detailed study
FIGURE 1 INVOLVE_FP review PRISMA flow diagram
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TABLE 3 Key summary statistics for all included studies (n= 127)
Characteristic N% Characteristic N%
Region Intervention design
Asia 37 29 Community Based Educational 101 80
Africa 67 53 Maternal & Child Health Programme 5 4
America 25 20 Contraceptive Counselling 21 16
Study design Components included
RCT 51 40 Information & Education 123 97
QE 68 54 Social/Peer Mentor Support 58 46
cRCT 8 6 Communication 51 40
Publication type Male engagement 44 35
Journal Article 103 81 Service Enhancement 41 32
Report 14 11 Problem Solving & Skills 35 28
Thesis 5 4 Subsidisation & Incentives 34 27
Presentation Abstract 1 1 Gender Transformative 29 23
Year of publication Number of components
1965–1985 8 6 1 10 8
1986–2011 74 58 2 to 4 90 71
2012–2019 45 35 5 to 7 27 21
Intervention recipients Dosage
Men and Women 118 93 <3 months 42 33
Men only 9 7 3–6 months 20 16
Adolescents only 39 31 7–12 months 24 19
Adults only 31 24 >12 months 38 30
Adolescents and adults 57 45 Intervention setting
Mode of delivery Community only 36 28
Individuals only 18 14 Home only 6 5
Couples only 3 2 Healthcare only 25 20
Groups only 45 35 Schools/Universities only 37 29
Media only 3 2 Mixed settings 21 17
Mixed modes 54 43 Not specified 2 1
Not specified 4 3
Intervention provider Outcomes reported
Professionals only 38 30 Contraceptive use 72 57
Peers only 12 10 Pregnancy, pregnancy timing and desired family size 36 28
Trained Facilitators only 31 24 Contraceptive attitudes 49 39
Mhealth only 8 6 Contraceptive knowledge 52 41
Media only 2 1 Communication about FP 29 23
Mixed providers 25 20 Service use 31 24
Not specified 11 9 Equitable decision‐making about FP 12 9
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TABLE 4 Key summary statistics for male engagement studies (n= 44)
Characteristic N% Characteristic N%
Region Intervention design
Asia 16 36 Community Based Educational 26 59
Africa 24 55 Maternal & Child Health Programme 3 7
America 4 9 Contraceptive Counselling 15 34
Study design Components included
RCT 19 52 Information & Education 42 95
QE 21 48 Social/Peer Mentor Support 19 43
cRCT 4 Communication 20 45
Publication Type Male Engagement 44 100
Journal Article 33 75 Health Service Enhancement 17 39
Report 6 14 Problem Solving & Skills 8 18
Thesis 2 5 Subsidisation & Incentives 9 20
Presentation Abstract 3 7 Gender Transformative 15 34
Year of publication Number of components
1965–1985 3 7 2 6 14
1986–2011 20 45 3 to 4 21 48
2012–2019 21 48 5 to 6 17 39
Intervention recipients Dosage
Men and Women 37 84 <3 months 10 23
Men only 7 16 3–6 months 10 23
Adolescents only 2 5 7–12 months 8 18
Adults only 19 43 >12 months 11 25
Adolescents and adults 23 52 Mixed dosage 4 9
Mode of delivery Not specified 1 2
Individuals only 9 20 Intervention setting
Couples only 1 2 Community only 14 32
Groups only 11 25 Home only 4 9
Mixed modes 22 50 Healthcare only 14 32
Not specified 1 2 Schools/Universities only 3 7
Mixed settings 9 20
Intervention provider Outcomes reported
Professionals only 17 39 Contraceptive use 34 77
Peers only 4 9 Pregnancy, pregnancy timing & desired family size 21 48
Trained Facilitators only 12 27 Contraceptive attitudes 19 43
Mhealth only 3 7 Contraceptive knowledge 16 36
Mixed providers 7 16 Communication about FP 11 25
Not specified 1 2 FP Service use 11 25
Joint FP decision‐making 8 18
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information for the 127 studies included in the review. Tables 3and 4
provide summary statistics for all included studies and male
engagement studies, respectively.
Study characteristics all evaluation studies (n = 127).
Year of publication, participants and study design. The review includes
studies published between 1965 and 2019 (Figure 2), with a third
of these (n= 43) published since 2012. The studies included a total
of 491,365 participants. Fifty‐one (40.2%) of the included studies
were randomised trials (RCTs), eight (3.1%) were cluster rando-
mised trials (cRCTs) and 68 (53.5%) were quasi‐experimental
studies (Figure 3).
Study location. The included studies provide a global scope of
reported experimental evaluations of FP programming with men
and boys in LMICs. Figure 4illustrates the geographic dispersion of
study locations. Over half of studies (n= 67) took place in Africa.
Among the most common study sites were Kenya (n= 10), South
Africa (n= 7), Nigeria (n= 6). This was followed by Asia (n= 37), with
China (n= 12), India (n= 7), Bangladesh (n= 6), and Vietnam (n= 4) the
most frequently reported study locations. Around 20% (n= 25) of
studies took place in the Americas. Most common study sites were
Mexico (n= 7), Brazil (n= 3), Guatemala (n= 3), and Colombia (n= 3).
Intervention design & components. The studies involved three broad
categories in relation to the central design of the intervention—
community based educational interventions (n= 101), contraceptive
counselling (n= 21), and maternal and child health programmes (n=5)
(Figure 5). Interventions were delivered across a variety of settings
including schools and universities (n= 37), the community (n= 36),
FIGURE 2 Study design (all included studies)
FIGURE 3 Study design (all included studies) FIGURE 5 Intervention design (all included studies)
FIGURE 4 Study locations
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healthcare settings (n= 25), homes (n= 6), and some combination of
these (n= 21).
Figure 6shows that intervention recipients were most often both
men and women (n= 118), but some were delivered to men only
(n= 9). The interventions were delivered to adolescents (age 10–19)
(n= 39), adults (n= 31) or both (n= 57). Participants received the
intervention as individuals (n= 18), couples only (n= 3), groups
(n= 45), or via a combination of different modes of delivery (n= 54).
Several different intervention providers were noted (Figure 7),
and these included: professionals such as teachers and nurses
(n= 38), trained facilitators (n= 31), trained peers (n= 12), mHealth
(n= 8), or a combination of these (n= 25). Some mHealth (n= 8) and
digital/mass media (n= 2) interventions were delivered remotely with
no human contact involved.
As illustrated in Figure 8, the most common intervention
component or strategy was the Provision of Information or Education
about FP and contraception, with 123 (97%) of studies incorporating
this. Other commonly included components were social/peer mentor
support (n= 58, 46%) and Communication (n= 51, 40%). Less common
were Problem‐Solving and Skills building (n= 35, 28%), subsidisation and
incentives (n= 34, 27%), and gender transformative components
(n= 29, 23%). While all interventions in the included studies involved
men or boys in their delivery, only 35% (n= 44) of included studies
substantively incorporated intervention components designed to
engage males with through their objectives or tailored delivery for this
group.
Those interventions categorised with the Male Engagement
component (N= 44) were those that included substantive engage-
ment of men and boys evidenced either through their objectives or
tailoring their practice for males purposefully. Examples of this
include:
•Explicit targeting of husbands for counselling to increase accep-
tance of female family planning methods (Amatya et al., 1994;
Fisek & Sumbuloglu, 1978; Ha et al., 2005a).
•Male promoters used to disseminate information to males and
increase acceptability of male family planning methods and
participation (Bertrand et al., 1982; Shattuck et al., 2011).
FIGURE 6 Intervention recipients (all
included studies)
FIGURE 7 Intervention providers (all included
studies)
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•Tailored messaging and communication for the purpose of
involving men and boys (El‐Khoury et al., 2016; Fleming
et al., 2018; Mantell et al., 2017; Sebastian et al., 2010).
•Intervention objectives specifically and exclusively targeting men
(Exner et al., 2009; Sahip & Turan, 2007; Shattuck et al., 2011).
The number of components (Figure 9)judgedpresentineach
intervention, based on the descriptions provided by study authors,
ranged from 1 to 6 (Mean = 3.8). Most studies (n= 116, 91%) described
an intervention comprised of multiple different component types, with
51.9% of described interventions comprising two or three different
component types. Noted within evaluations of these complex interven-
tions was the difficulty in parsing the effects of different components
and strategies (see Firestone et al., 2016).
Reported outcomes (Figure 10). Few studies distinguished whether
effects were related to the study's primary or secondary outcomes.
Outcomes were judged to be measured at various levels: individual
(e.g., relating to individual FP attitudes and behaviour beliefs),
interpersonal (e.g., relating to relationship and FP behaviours
between individuals), organisational (e.g., organisational policy and
practice changes that increase involvement of men in FP), and
structural (e.g., public policy and support for male involvement in FP).
Most outcomes assessed by the included studies were Individual
Level Outcomes (n= 127) (see review logic model Supporting
Information: Appendix 1.0 for examples), with some studies address-
ing Interpersonal Outcomes (n= 38), and few evaluating Organisational
(n=8) or Structural Outcomes/Impacts (n= 1). A minority of studies
examined outcomes at multiple levels, with the most common
involving a combination of individual and interpersonal level
outcomes. Studies which examined outcomes at higher levels did
so simultaneously with the preceding levels of outcomes. All studies
that assessed Interpersonal outcomes also assessed Individual level
outcomes (n= 38), five studies that assessed Organisation outcomes
also assessed Interpersonal outcomes, and the one example assessing
structural outcomes assessed outcomes at all preceding levels.
Most commonly studies targeted and assessed outcomes at the
individual level (n= 127). By far the most common individual‐level
outcomes targeted and measured were changes in contraceptive use
(n= 72), contraceptive knowledge (n= 52), and changes in attitudes
about FP/contraceptives (n= 49). Birth spacing and delay (e.g.,
delayed first pregnancy, intentions to limit family size, total fertility
rate) was assessed chiefly in interventions delivered to adults or
groups inclusive of all individuals of reproductive age (n= 36).
Interpersonal level outcomes were assessed in n=38 studies. Of
these, the most common were Communication (n=29)and Joint decision‐
making around FP (n= 12). Perhaps unsurprisingly, interventions attempt-
ing to address these were those involving males and females in delivery
(n= 10 out of 12). The remaining two studies/interventions were
delivered to males exclusively, however, these emphasised building
communication skills and the promotion of joint FP decision‐making.
Organisation‐level outcomes were assessed in n= 8 studies and
chiefly addressed increasing service engagement and accessibility for
all, not necessarily specifically for males. A small number of studies,
FIGURE 8 Percentage of intervention
components (all included studies)
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AVENTIN ET AL.
however, did consider enhancing gender equitable beliefs among
service providers (n= 3) (Khatun et al., 2011; Timol et al., 2016;
Vernon & Dura, 2004).
One study (Singh et al., 2016) that included FP as part of
community health intervention delivery assessed structural level
outcomes, but only assessed service use indicators and did not assess
any individual level FP outcomes.
Study characteristics male engagement studies (n = 44). As noted, 44 of
the included studies included a male engagement component
designed to actively engage men and boys in FP. The characteristics
of these studies are outlined in Table 4and Figures 11–14.
Most of these 44 studies were conducted in Africa (55%),
followed by Asia (36%) and America (9%), with just under half (48%)
published since 2012. Approximately half (52%) of the studies were
FIGURE 9 Number of different components
(all included studies)
FIGURE 10 Outcomes reported (all included
studies)
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RCTs and the other 48% were quasi experimental studies. Seventy‐
seven percent of the 44 studies (n= 34) reported contraceptive use
outcomes, with 48% (n= 21) reporting a heterogeneous mix of
outcomes relating to pregnancy, pregnancy timing and desired family
size. Forty‐three percent (n= 19) reported attitudes about contra-
ceptives, 36% (n= 16) knowledge about contraceptives, 25% (n= 11)
communication about FP, 25% (n= 11) service use and 18% (n=8)
joint FP decision‐making.
Most of the interventions in the included studies had a
community‐based educational (59%, n= 26) or contraceptive coun-
selling (34%, n= 15) focus with a small number (7%, n= 3) focussed
on maternal and child health. Eighty‐seven percent (n= 38) of the
studies included interventions that contained between 3 and 6
components, with all but two (95%) including an information and
education element. Forty‐five percent (n= 20) included a communi-
cation component, 43% (n= 19) a social/peer mentor component,
39% (n= 17) a health service enhancement component and 34%
(n= 15) a gender transformative component.
The majority of interventions (84%, n= 37) were delivered to
men and women. This subset was slightly different than all included
studies in that it included fewer interventions that targeted
adolescents only (only 5% (n= 2) of male engagement studies
targeted adolescents only compared with 31% (n= 39) of all
FIGURE 11 Region (male engagement studies)
FIGURE 12 Year of publication (male
engagement studies)
FIGURE 13 Intervention recipients (male
engagement studies)
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included studies). Of male engagement studies more targeted adult
populations (43% (n=19)comparedwith24%(n= 31) of all included
studies. The studies showed an almost even range of dosage
timeframes (ranging from 18% (n=8)for7to12monthsto15%
(n= 11) for >12 months). Half of the interventions were delivered
using mixed delivery modes (50%, n= 22) with the remainder
delivered to groups only (25%, n= 11) or individuals only (20%,
n= 9), couples only (2%, n= 1) or not specified (2%, n=1).Inrelation
to intervention providers, professionals were the most common
(39%, n= 17), followed by trained facilitators (27%, n= 12) and
mixed providers (16%, n= 7). Four studies (9%) used peers only, and
3 (7%) used MHealth only.
Study characteristics connected papers (n = 23). An overview of the
characteristics of these 23 included studies can be found in
Supporting Information: Appendix 4.2. Almost three‐quarters of the
studies (N= 17, 74%) were published since 2012, with 11 (48%)
published between 2015 and 2019. Two studies (Ross et al., 2007;
Bertrand et al., 1982) reported findings that were more than 40 years
old. Fifteen of the studies were process evaluations and eight were
qualitative studies, all directly connected to the evaluations outlined
above.
Four of the papers (Harrington et al., 2016; Harrington
2017a,2017b; Harrington et al., 2019) related to the same MHealth
intervention (MobileWatchXY) and three others (McCarthy
et al., 2018a,2018b,2019) to TFPA's ‘Healthy Lifestyles’app. Nine
of the study samples were pregnant or postpartum women and their
partners and six included adolescents. Most of the process evalua-
tions aimed to explore the feasibility of ongoing or future experi-
mental work and reported development and acceptability of planned
interventions. Qualitative studies explored perceptions of FP, couple
communication about FP, gendered power dynamics and women's
negotiation of FP, and barriers and facilitators of FP uptake or to
including men and boys in FP.
5.2 |Risk of bias in included studies
A full breakdown of risk of bias judgements for all studies may be
found in Supporting Information: Appendix 5.0.
5.2.1 |Evaluation studies
The risk of bias across included studies is summarised in
Figure 15. Overall, only one study was judged to have a Low
risk of bias. Most were found to have a Moderate to High risk of
bias with five determined to have an irreconcilable or ‘Critical’risk
FIGURE 14 Intervention recipients (male
engagement studies)
FIGURE 15 Overall risk of bias for evaluation
studies
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of bias. A full breakdown of risk of bias judgements for all
evaluation studies can be found in Supporting Information:
Appendices 5.1.and5.2.
Those quasi‐experimental records identified to have a critical
risk of bias (n= 5) predominately received this classification due
to under‐reporting of study design and methodology. The
majority of quasi‐experimental studies were judged to have a
Serious risk of bias (70.6%). Most records were judged to have a
Serious risk of bias in multiple domains, however most common
Serious judgements related to the treatment of missing data
(ROBINS‐I: Domain 5) and potential bias due to confounding
(ROBINS‐I: Domain 1).
In total n= 21 RCT studies were judged to have a High risk of
bias, with records showing a high risk of bias across multiple domains.
However, the most common judgements were for deviations from
intended intervention (RoB2.0: Domain 2b) and risk of bias arising
from randomisation process (RoB2.0: Domain 1).
5.2.2 |Connected papers
We appraised qualitative studies using Jimenez et al. (2018)critical
appraisal tool and quantitative process evaluation studies using the
EPPI Centre Tool (EPPI‐Centre & EPPI‐Centre Social Science
Research Unit, 2003)(seeTable5). A full breakdown of risk of
bias judgements for all domains of each tool is included in
Supporting Information: Appendix 5.0. Three process evaluations
(Daniele, 2017; Mantell et al., 2006)werejudgedtohavelowrisk
of bias, while the remainder were judged to have moderate risk of
bias. One qualitative study (McCarthy, 2019)wasjudgedtohavea
high risk of bias, because of lack of full reporting on several of the
domains.
5.3 |Synthesis of results—Causal chain analysis
5.3.1 |Review question 2: What are the impacts of
FP interventions involving men and boys on FP
outcomes?
The effects of FP interventions on ‘contraceptive use’outcomes
The meta‐analysis of 72 studies (k= 265) revealed that the FP
interventions had statistically significantly higher odds of improving
contraceptive use when compared to comparison groups (OR = 1.38,
CI = 1.21 to 1.57, PI = 0.36 to 5.31, p< 0.0001). The groups who
received the FP interventions were one and a third times more likely
to experience improved contraceptive use.
As there were substantial variations between the studies in terms
of their effect sizes (heterogeneity Q= 40,647, df = 264, p< 0.0001;
I
2
= 98%), we investigated I
2
further and found that 25% of
heterogeneity was between cluster/study and 73% was within
cluster/study. We know that the multilevel model contains two
variance components (sigma^2_1 and sigma^2_2), for the between‐
cluster heterogeneity and the within‐cluster heterogeneity. There-
fore, about 25% of the total variance is estimated to be due to
between‐cluster heterogeneity, 70% due to within‐cluster heteroge-
neity, and the remaining 5% are sampling variance. This is an
investigation of the total remaining variance after outliers were
removed following the process outlined by (Viechtbauer, 2010).
To test for publication bias, a weighted regression with
multiplicative dispersion using sampling variance as a predictor was
utilised. This test found no evidence of publication bias (p= 0.48) (see
Figure 16), indicating that there was an accurate representation of
the literature of interest.
The effects of male engagement interventions on contraceptive use
and intermediate FP outcomes
When we separated the male engagement studies that reported
contraceptive use from the larger dataset, we examined the impact
of these interventions (male engagement interventions with a
contraceptive use outcome (n=33 k= 226) on intermediate out-
comes measured by the included studies. Identified intermediate
TABLE 5 Risk of bias in connected papers
First author and year Study design
Overall risk of
bias judgement
Ahmed et al. (2015) Process Evaluation Moderate
Akhter et al. (1993) Process Evaluation Moderate
Baqui et al. (2018) Process Evaluation Low
Bertrand et al. (1982) Process Evaluation Moderate
Daniele (2017) Process Evaluation Low
Doyle et al. (2011) Process Evaluation Moderate
Harrington (2017a) Process Evaluation Moderate
Harrington (2017b) Process Evaluation Moderate
Khan et al. (2008) Process Evaluation Moderate
Mantell et al. (2006) Process Evaluation Low
McCarthy et al. (2018) Process Evaluation Moderate
McCarthy et al. (2018) Process Evaluation Moderate
Ngure et al. (2012) Process Evaluation Moderate
Ross et al. (2007) Process Evaluation Moderate
Turan (1997) Process Evaluation Moderate
Cooper et al. (2014) Qualitative Study Moderate
Ghule et al. (2015) Qualitative Study Moderate
Harrington et al. (2016) Qualitative Study Low
Harrington et al. (2019) Qualitative Study Moderate
Hartmann et al. (2012) Qualitative Study Moderate
Jewkes et al. (2008) Qualitative Study Moderate
McCarthy (2019) Qualitative Study High
Nair et al. (2019) Qualitative Study Moderate
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outcomes included: attitudes about FP services; attitudes about
contraception; knowledge about contraception; FP communication;
gender equitable beliefs; joint FP decision‐making; and FP service
use. We conducted multivariate pairwise meta‐analysis across 33
studies (k= 226) but urge caution in interpretation as Tipton
demonstrates that the Satterthwaite approximation is valid so long
as the df is >4 and this is only the case for contraceptive attitudes
and contraceptive knowledge in these exploratory analyses,
indicating that the analysis is underpowered for outcomes. To
allow for estimation of the variance components the Satterthwaite
approximation was used to account for two different sample
variances where only estimates of the variance are known.
The analysis is useful to calculate an approximation to the effective
degrees of freedom (Keenan et al., 2021).
While the male engagement interventions appear to be improv-
ing the outcomes measured (the ORs were >1 for all outcomes apart
from equitable FP decision‐making (OR = 0.95)), the results were
statistically significant only for contraceptive attitudes (OR = 1.26,
CI 0.97–1.64, p= .02). Table 6presents individual findings for each of
the outcomes.
5.3.2 |Review question 3: What are the effective
components of interventions that achieve positive
change in contraceptive use outcomes?
Table 7summarises results from the meta‐regressions across
72 studies (k= 265) with all 8 identified intervention components
added in the model. The test of moderators provides an
omnibus test of all components (QM(df = 8) = 27.5844, p= 0.0006)
and this indicates that the explained variance across this data is
significantly greater than the unexplained variance, overall.
As highlighted in Table 7, none of the components were
individually more effective than the others in improving contraceptive
use. ‘Information and Education’(OR =1.30, 95% CI 0.76–2.23,
p=0.34), ‘subsidised or incentivised contraception’(OR = 1.24, 95%
CI 0.93–1.65, p=0.15), ‘health service enhancement’(OR = 1.16, 95%
CI 0.87–1.54, p=0.31), problem‐solving and skills (OR = 1.1, 95% CI
0.68–1.78, p=0.71) and ‘gender transformative’(OR = 1.04, 95% CI
0.73–1.5, p= 0.82) components had non‐significant positive effects.
The remaining three components, ‘communication’,‘social/peer sup-
port’,and‘male engagement’had non‐significant negative effects.
FIGURE 16 Funnel plot examining
publication bias
TABLE 6 Impact of male engagement FP interventions on intermediate outcomes
Outcome N(k)ORCI PI pValue
Attitudes FP Services 3 (9) 1.16 0.75–1.77 0.34–3.94 0.18
Contraceptive Attitudes 8 (25) 1.26 0.97–1.64 0.39–4.10 0.02
Contraceptive Knowledge 10 (33) 1.19 0.93–1.52 0.37–3.86 0.40
FP Communication 5 (9) 1.20 0.78–1.84 0.35–4.09 0.28
Gender Equitable Behaviours & Beliefs 3 (7) 2.55 1.56–4.17 0.73–8.90 0.20
Equitable FP Decision‐making 3 (8) 0.95 0.60–1.52 0.28–3.30 0.89
FP Service Use 5 (25) 1.36 0.94–1.96 0.41–4.54 0.14
Note: Bold text indicates adequately powered analysis, the other variables had too few studies reporting the outcome of interest to be adequately
powered.
Abbreviations: CI, confidence interval; k, number of effect size estimates; N, number of studies; OR, odds ratio; PI, prediction interval.
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We undertook further analysis to assess the combination of
components. However, given that there were 33 identified
combinations of components in the included studies this
exploratory analysis should be interpreted with caution. As
illustrated in Table 8, the only combination of components
adequately powered to detect moderating effects were interven-
tions that included ‘information & education’and ‘problem
solving & skills’components. Interventions that used this
combination of components did not show statistically significant
effects (OR =1.08, 95% CI 0.74–1.57, p= 0.71).
5.3.3 |Review questions 4 and 5: What
characteristics and combinations of characteristics are
associated with positive FP‐related outcomes? Do
outcomes vary by context and participant
characteristics?
All included studies (n= 127)
In Table 9, we present ten potential moderators of contraceptive
use using robust variance estimates. This exploratory analysis
used a single‐variable, no‐intercept model. Estimates presented
are ORs.
Significant differences in effects were associated with year of
publication (F
6,259
= 36.17, p< 0.0001), study design (F
3,262
= 25.42,
p< 0.0001), whether or not there was a behaviour change theory
present (F
2,263
= 24.86, p< 0.0001), who the intervention provider
was (F
10,255
=47.78, p< 0.001), dosage (F
6,259
=26.15, p= 0.0002),
sex of intervention recipients (F
2,263
= 24.31, p< 0.0002), age of
intervention recipients (F
3,262
= 24.36, p< 0.001), the setting in
which the intervention was delivered (F
9,256
= 29.44, p< 0.0005),
the region in which the intervention was implemented
(F
16,249
= 45.32, p= 0.0001), and the intervention design
(F
3,106
=31.24,p≤0.0001).
These results suggest that several intervention characteristics
predicted contraceptive use. Firstly, intervention design appeared to
act as a moderator of effect, with community based educational
interventions showing statistically significant effects (estimate = 0.35,
p= 0.001). Interventions with designs primarily focused on contra-
ceptive counselling (estimate = 0.07, p= 0.65) did not show signifi-
cant differences in effect and maternal and child health programmes
were not powered to detect trustworthy differences (n= 4, df = 2.4,
p= 0.019). Dosage was also a significant moderator of effect with
intervention durations of <3 months (estimate = 0.38, p= 0.02); 7–12
months (estimate = 0.48, p= 0.0001); >12 months (estimate = 0.30,
p= 0.028) showing statistically significant effects. Interventions with
a mid‐range duration of 3–6months did not show significant effects
(p= 0.17). Both interventions based on a theory of change (estimate =
0.39; p= 0.011) and those not based on a theory of change
(estimate = 0.30; p< 0.001) were significant moderators of effects
on contraceptive use. In relation to the setting in which the
intervention was delivered, those delivered in community only
(estimate = 0.32, p= 0.013), home and community (estimate = 0.39,
p= 0.013), and schools only (estimate = 0.37, p= 0.015) showed
statistically significant moderating effects. The intervention provider
or who delivers the intervention was also examined and revealed that
interventions delivered by trained facilitators only (estimate = 0.63,
p= 0.008), professionals only (estimate = 0.28, p= 0.011), and peers
only (estimate = 0.22, p= 0.030) were significant.
The meta‐regression also highlighted that participant characteristics
predicted contraceptive use. Across 72 studies (k= 265), all age categories
of intervention recipients were statistically significant moderators:
adolescents only (estimate = 0.39, p= 0.012); adults only (estimate = 0.35
m, p= 0.017); both age groups (estimate = 0.287, 0.004). Further, the sex
of intervention recipients was a significant moderator of effects with
interventionsdeliveredtomalesandfemales(estimate=0.32,p< 0.001)
showing statistically significant effects. Intervention delivered to males
only did not show significant effects (p=0.20).
TABLE 7 Summary of correlated effects meta‐regression results linking intervention components to contraceptive use
n(k)ORt(df) pValue 95% CI 95% PI
Component 72 (265)
Gender Transformative 1.04 0.293 (22.29) 0.772 0.73–1.50 0.25–4.34
Information & Education 1.30 0.836 (8.09) 0.427 0.76–2.23 0.30–5.71
Male Engagement 0.95 −0.412 (41.99) 0.682 0.71–1.26 0.23–3.87
Problem Solving and Skills 1.10 0.348 (5.94) 0.740 0.68–1.78 0.25–4.73
Social/Peer Support 0.86 −1.105 (41.81) 0.275 0.64–1.16 0.21–3.52
Subsidised/Incentivised Contraception 1.24 1.329 (36.55) 0.192 0.93–1.65 0.30–5.05
Communication 0.82 −1.524 (39.14) 0.136 0.61–1.10 0.20–3.35
Health Service Enhancement 1.16 1.032 (40.04) 0.308 0.87–1.54 0.28–4.74
Abbreviations: 95% CI, 95% confidence intervals for the meta‐regression coefficients; k, effect estimates; n, number of studies; OR, odds ratio; PI, 95%
prediction intervals for the meta‐regression coefficients.
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5.3.4 |Review question 6: What adverse impacts
were reported?
None of the evaluation studies reported adverse outcomes, although
one study (Harrington Elizabeth et al., 2019) did report potential
negative consequences. Namely, some women were concerned male
partners may suspect them of engaging in covert contraceptive use, and
that factual information about potential bleeding and other side effects
as a result of a LARC method may discourage male acceptance of these.
Four connected papers mentioned adverse consequences relat-
ing to involving men and boys in FP. Only two studies directly
indicated evidence relating to a lack of adverse effects on family life
and FP decision‐making (Daniele, 2017; Turan et al., 2001). While not
directly implicated as an adverse outcome, one study (Harrington
et al., 2016) discussed the possible negative implications (including
the possibility of confrontation and violence) of covert contraceptive
use among women. A further study (Harrington et al., 2019) also
notes the potential negative consequences of male resistance to
TABLE 8 Summary of correlated effects meta‐regression results linking combinations of intervention components to contraceptive use
Combination n(k)OR t(df) pValue CI PI
G + I + PSS 1 (2) 1.78 13.2 (1) 0.05 0.50–6.32 0.27–11.91
G + I + PSS + C 3 (8) 1.42 1.08 (1.98) 0.40 0.69–2.93 0.29–6.96
G + I + PSS + C + H 2 (3) 1.52 9.22 (1) 0.07 0.59–3.89 0.28–8.32
G + I + PSS + IN 1 (2) 0.67 −9110 (1) 0.00 0.20–2.28 0.10–4.36
G + I + PSS + SO 4 (8) 1.41 4.25 (2.87) 0.03 0.75–2.66 0.30–6.66
G + I + PSS + SO + C 2 (6) 1.00 0.262 (1) 0.84 0.44–2.28 0.19–5.16
G + I + PSS + SO + C + H 1 (2) 1.79 6940 (1) 0.00 0.43–7.37 0.24–13.26
G + I + PSS + SO + IN + C + H 2 (8) 1.10 0.716 (1) 0.60 0.48–2.55 0.21–5.73
I + PSS 10 (49) 1.08 0.383 (8.06) 0.71 0.74–1.57 0.25–4.67
I + PSS + C 3 (16) 1.14 0.457 (1.71) 0.70 0.57–2.29 0.24–5.53
I + PSS + C + H 1 (1) 3.66 NA NA 0.87–15.42 0.49–27.57
I + PSS + H 4 (13) 1.30 1.65 (2.79) 0.20 0.72–2.33 0.28–6.01
I + PSS + IN 5 (24) 2.90 2.55 (3.74) 0.07 1.72–4.88 0.64–13.11
I + PSS + IN + C 1 (4) 2.23 322 (1) 0.00 0.76–6.58 0.37–13.27
I + PSS + IN + C + H 2 (6) 1.28 4.32 (1) 0.14 0.55–2.97 0.25–6.64
I + PSS + IN + H 2 (12) 2.35 0.745 (1) 0.59 1.08–5.12 0.47–11.83
I + PSS + SO 2 (4) 1.04 0.118 (1) 0.93 0.43–2.53 0.20–5.55
I + PSS + SO + C 3 (3) 0.97 −0.127 (1.97) 0.91 0.41–2.31 0.18–5.11
I + PSS + SO + C + H 4 (23) 1.19 0.936 (2.84) 0.42 0.68–2.09 0.26–5.48
I + PSS + SO + H 1 (8) 1.10 4.81 (1) 0.13 0.39–3.05 0.19–6.29
I + PSS + SO + IN 2 (8) 1.51 1.6 (1) 0.36 0.69–3.33 0.30–7.66
I + PSS + SO + IN + C 4 (13) 1.03 0.111 (2.68) 0.92 0.56–1.88 0.22–4.80
I + PSS + SO + IN + C + H 2 (10) 0.98 −0.0466 (1) 0.97 0.46–2.11 0.20–4.92
I + PSS + SO + IN + H 4 (10) 2.19 2.39 (2.63) 0.11 1.16–4.16 0.46–10.38
I + SO + C 1 (6) 1.46 9.52 (1) 0.07 0.52–4.12 0.25–8.45
I + SO + H 1 (5) 2.20 133 (1) 0.00 0.76–6.35 0.38–12.92
I + SO + IN + C + H 1 (4) 0.88 −1180 (1) 0.00 0.30–2.58 0.15–5.20
PSS + H 1 (1) 3.07 NA NA 0.64–14.80 0.37–25.5
PSS + IN 1 (5) 1.16 8.85 (1) 0.07 0.41–3.31 0.2–6.77
Note: Bold text indicates adequately powered analysis, the other variables had too few studies reporting the outcome of interest to be adequately
powered.
Abbreviations: C, Communication; G, Gender Transformative; H, Health Service Enhancement; I, Information & Education; IN, subsidised or incentivised
contraception; ME, Male Engagement; PSS, Problem Solving & Skills; SO, Social/Peer/Mentor Support.
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TABLE 9 Summary of correlated effects meta‐regression results on contraceptive use and extrinsic, methodological, and substantive variables
Variables Categories n(k) estimate (SE) t(df Satt) CI
pValue
(Satt) Test of moderators
Extrinsic variable
Year 1960–1969 1 (1) 0.73 (0.693) NA −0.628–2.089 NA F(df1 = 6, df2 = 259) =
36.17, p≤0.0001
1970–1979 2 (13) 0.34 (0.327) 1.166 (1) −0.301–0.98 0.451
1980–1987 1 (1) 2.157 (0.805) NA 0.58–3.735 NA
1980–1989 3 (17) 0.128 (0.262) 0.282 (1.99) −0.387–0.642 0.804
1990–1999 7 (20) 0.58 (0.204) 1.925 (5.49) 0.179–0.98 0.107
2000–2009 27 (100) 0.403 (0.102) 4.002 (23.57) 0.203–0.603 <0.001
2010–2019 31 (113) 0.17 (0.1) 2.24 (25.27) −0.025–0.365 0.034
Methodological variables
Study design c‐RCT 4 (15) 0.114 (0.267) 0.362 (2.8) −0.409–0.638 0.743 F(df1 = 3, df2 = 262) =
25.42, p< 0.0001
RCT 27 (109) 0.383 (0.088) 3.905 (35.8) 0.211–0.555 <0.001
QE 41 (141) 0.266 (0.107) 3.306 (22.7) 0.055–0.476 0.003
Substantive variables
Behaviour change
theory
TOC present 20 (67) 0.388 (0.128) 2.86 (16.9) 0.137–0.639 0.011 F(df1 = 2, df2 = 263) =
24.86, p< 0.001
TOC not present 52 (198) 0.299 (0.075) 4.05 (45.2) 0.151–0.447 <0.001
Intervention Provider Media 2 (7) 0.184 (0.347) 0.328 (1) −0.496–0.864 0.798 F(df1 = 10, df2 = 255) =
47.78, p≤0.001
Mhealth 4 (17) 0.341 (0.271) 0.836 (2.24) −0.189–0.871 0.483
Peers 9 (22) 0.219 (0.177) 2.72 (6.89) −0.128–0.566 0.030
Peer & Media 1 (6) 0.001 (0.407) 4.25E + 15 (1) −0.796–0.798 <0.001
Professionals 21 (102) 0.284 (0.103) 2.82 (17.53) 0.082–0.485 0.011
Professionals &
Media
2 (8) −0.208 (0.333) −1.19 (1) −0.861–0.445 0.444
Professionals &
Peers
13 (42) 0.2 (0.144) 1.79 (10.08) −0.082–0.482 0.103
Trained Facilitator 12 (32) 0.632 (0.155) 3.35 (9.76) 0.328–0.935 0.008
Trained Facilitator &
Peers
4 (23) 0.128 (0.231) 0.582 (2.57) −0.325–0.581 0.608
Not specified 4 (6) 1.379 (0.329) 2.68 (2.63) 0.734–2.025 0.086
Dosage Less than 3 months 16 (61) 0.378 (0.143) 2.648 (13.52) 0.098–0.657 0.02 F(df1 = 6, df2 = 259) =
26.15 p= .0002
3–6 months 13 (39) 0.217 (0.174) 1.475 (10.37) −0.124–0.557 0.17
7–12 months 13 (50) 0.48 (0.159) 4.382 (10.65) 0.169–0.792 0.001
12+ months 24 (104) 0.3 (0.109) 2.358 (21.68) 0.086–0.513 0.028
Mixed 5 (10) 0.175 (0.286) 0.747 (3.81) −0.386–0.736 0.498
Not specified 1 (1) −0.582 (0.816) NA −2.182–1.017 NA
Sex Male only 8 (17) 0.336 (0.232) 1.46 (5.77) −0.119–0.79 0.196 F(df1 = 2, df2 = 263) =
24.31, p< 0.0002
Male and Female 64 (248) 0.321 (0.068) 4.72 (56.78) 0.188–0.454 <0.001
Age Adolescents only 14 (51) 0.392 (0.153) 2.97 (11.5) 0.093–0.691 0.012 F(df1 = 3, df2 = 262) =
24.36, p< 0.0001
Adults only 20 (89) 0.346 (0.125) 2.67 (16.5) 0.101–0.591 0.017
Both age groups 38 (125) 0.287 (0.09) 3.13 (33.3) 0.11–0.463 0.004
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TABLE 9 (Continued)
Variables Categories n(k) estimate (SE) t(df Satt) CI
pValue
(Satt) Test of moderators
Setting Community 25 (82) 0.322 (0.113) 2.724 (21.41) 0.101–0.544 0.013 F(df1 = 9, df2 = 256) =
29.4395, p= 0.0005
Healthcare 17 (72) 0.283 (0.131) 1.876 (14.18) 0.025–0.54 0.081
Home only 3 (6) 0.33 (0.373) 0.9 (1.93) −0.401–1.06 0.466
Home & Community 8 (36) 0.388 (0.193) 3.46 (6.01) 0.01–0.765 0.013
Home & Healthcare 1 (4) 0.802 (0.493) 463.944 (1) −0.164–1.768 0.001
Schools 11 (42) 0.372 (0.167) 3 (9.1) 0.045–0.7 0.015
Schools & Healthcare 4 (14) 0.484 (0.275) 1.955 (2.59) −0.055–1.023 0.160
Community & Schools 1 (1) −0.582 (0.81) NA −2.17–1.005 NA
Not specified 2 (8) −0.292 (0.387) −0.456 (1) −1.05–0.466 0.727
Region Asia 2 (5) 1.226 (0.426) 5.565 (1) 0.392–2.06 0.112 F(df1 = 16, df2 = 249) =
45.3192, p= 0.0001
Caribbean (Americas) 1 (2) 0.407 (0.572) 53.259 (1) −0.714–1.528 0.012
Central Africa 1 (4) 0.197 (0.476) 1024.592 (1) −0.735–1.129 <0.001
Central America 2 (8) 0.304 (0.35) 3.188 (1) −0.382–0.989 0.194
Central Asia 1 (2) −0.767 (0.713) −57.865 (1) −2.164–0.629 0.011
East Africa 19 (79) 0.226 (0.118) 3.163 (16.23) −0.006–0.457 0.006
East Africa, Southern
Africa
1 (4) −0.021 (0.468) −99.528 (1) −0.939–0.897 0.006
East Asia 6 (17) 0.488 (0.222) 1.178 (4.35) 0.053–0.922 0.299
Middle East (Africa) 3 (21) 0.137 (0.27) 1.604 (1.81) −0.392–0.666 0.263
North America 4 (21) 0.568 (0.27) 2.071 (2.27) 0.039–1.096 0.159
South America 3 (11) 0.43 (0.289) 0.929 (1.75) −0.137–0.997 0.463
South America,
Central America
2 (3) −0.08 (0.517) −0.183 (1) −1.093–0.935 0.885
South America,
South Asia
1 (7) −0.704 (0.439) −7.177 (1) −1.563–0.156 0.088
South Asia 9 (31) 0.558 (0.182) 2.154 (6.94) 0.201–0.915 0.069
Southern Africa 6 (21) 0.112 (0.216) 1.065 (4.49) −0.311–0.535 0.341
West Africa 11 (29) 0.458 (0.176) 3.844 (8.69) 0.114–0.801 0.004
Intervention design Community Based
Educational
56 (193) 0.349 (0.072) 4.692 (48.27) 0.208–0.491 <0.001 F(df1 = 3, df2 = 106) =
31.2429, p< 0.0001
Contraceptive
Counselling
12 (50) 0.066 (0.148) 0.467 (9.6) −0.223–0.356 0.651
Maternal & Child
Health Programme
4 (22) 0.705 (0.254) 5.708 (2.42) 0.207–1.202 0.019
Note: Effect sizes in bold are statistically significantly different from zero at alpha level α= 0.05 with df > 4. The results also indicated that some
variables relating to study context and design characteristics were predictors of contraceptive use. First, studies that took place in the regions of
West Africa (estimate = 0.46, p= 0.004) and East Africa (estimate = 0.23, p= 0.006), showed a statistically significant mod erating effect. Further, year
of publication emerged as important, with more recent studies published between 2000 and 2009 (estimate =0.40, p< 0.001) and 2010–2019
(estimate = 0.17, p= 0.04) showing statistically significant effects. Finally, study design was highlighted as a moderator, with RCTs (estimate = 0.38,
p< 0.001) and quasi‐experiments (estimate = 0.27, p= 0.003) showing statistically significant moderating effects. Cluster RCTs did not show
statistically significant effects (p=0.74).
Abbreviations: CI, 95% confidence interval; k, number of effect estimates; n, number of studies.
AVENTIN ET AL.
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female empowerment and female contraceptive use in the context of
unequal relationship power dynamics.
5.3.5 |Review question 7: What are the system‐
and process‐level barriers and facilitators of FP
involving men and boys? A qualitative analysis
The aim of the analysis was to synthesise patterns or themes across
included studies that related to author‐reported barriers and
facilitators of impact. The aim was to use this data to help explain
the outcome patterns identified in the quantitative analysis.
Findings of the qualitative analysis are presented below under the
overarching categories of ‘system‐level’and ‘process‐level’barriers and
facilitators of effective models of family planning involving men and
boys. ‘System‐level’refers to the characteristics of social systems in the
broadest sense. These include environmental factors impacting upon
where and how interventions are offered, such as economic and legal
climate, as well as predominant values, norms, roles, and beliefs of
individuals, families, communities, organisations, countries, and regions.
‘Process‐level’refers to the operational aspects of research and
intervention implementation processes.
System‐and process‐level categories were presented separately
in the original review logic model (Supporting Information:
Appendix 1.0)as‘individual’,‘external’, and ‘process’factors, each
with a number of sub‐categories, and are therefore also categorised
as such below. Several new sub‐categories (themes) presented during
the analysis process. These are highlighted below. Supporting
Information: Appendix 6.0 provides examples of data relating to
each of the themes.
System‐level barriers and facilitators
Findings relating to 14 individual‐level a priori categories (see
below) emerged as author‐reported barriers and facilitators of
effectiveness and impact in the connected papers. There was no
information identified for five of the a priori categories (religion/
religiosity, gender identity, sexual orientation, disability, or ethni-
city). In relation to external‐level barriers and facilitators, findings
related to three of the a priori categories were included in the
connected papers (gender, cultural and religious norms; health
systems and services; and FP supply chain). No information was
retrieved relating to political and economic climate; legal and
historical context; health policies and strategies; conflict; disaster;
disease; or climate‐stress.
Three additional categories emerged from the thematic analysis
that related to individual, interpersonal‐and community‐level
systems: (1) Knowledge about FP among individuals, couples, the
wider family, and community; (2) FP communication and decision‐
making norms and preferences, which emerged as a sub‐theme of the
a priori ‘perceived gender and cultural norms’category; and (3) Social
network influences on decision‐making about family planning, which
was closely linked with different modes of FP knowledge. Themes
and sub‐themes are highlighted in bold below.
Barriers and facilitators affecting individuals. Analysis of the included
connected papers revealed several system‐related barriers and facilita-
tors at the individual level. Three studies mentioned socioeconomic
factors, including educational attainment and women's employment
outside the home (Bertrand et al., 1982; Mantell et al., 2014;Turan
et al., 2001) as potential facilitators of FP use. Adding information on
the importance of age and life stage, Turan et al. (2001) also reported
that men who were older and more educated were more likely to
engage with their FP intervention. Two studies mentioned the
importance of migrant status, relating the negative impact of men
working away from the household for periods of time as a barrier to FP
uptake (Cooper et al., 2014;Daniele,2017). One study (Bertrand
et al., 1982) reported the advantage of urban versus rural residence
when considering FP intervention implementation.
Individual attitudes, values and beliefs about FP, including
attitudes about FP services, were indicated as important in eight
studies (Cooper et al., 2014; Daniele, 2017; Doyle et al., 2014;
Hartmann et al., 2012; Khan et al., 2008; Nair et al., 2019). Some
reported that increased perceptions of risk caused by delayed
initiation of contraception (Cooper et al., 2014) or beliefs that FP
use would have economic advantages (Hartmann et al., 2012) were
associated with positive impacts while misconceptions that contra-
ception causes infertility (Khan et al., 2008) and negative attitudes
about condom‐use within marriage had opposite effects (Ghule
et al., 2015) Two studies noted that attitudes about reduced sexual
pleasure acted as a barrier to condom use (Ghule et al., 2015; Khan
et al., 2008). One study noted the facilitating effects of positive past
FP behaviours and experiences indicating that a history of safe
sexual practice was predictive of continued FP use (Daniele, 2017).
An additional category, relating to knowledge about FP was
presented as relevant in seven studies (Cooper et al., 2014;M.
Daniele, 2017;Harrington,2017a; Harrington et al., 2019;
Hartmann et al., 2012;Khanetal.,2008; McCarthy et al., 2018)
Authors reported the beneficial impacts of increased knowledge
(Cooper et al., 2014;Daniele,2017;Harrington,2017a; Hartmann
et al., 2012) and some highlighted the damaging impacts of lack of
knowledge or inaccurate knowledge on FP use (Ghule et al., 2015;
Harrington, 2017a;Khanetal.,2008;O.L.McCarthyetal.,2018b).
Two studies reported that knowledge played an important inter-
mediary role in contributing to increased couple communication
(Daniele, 2017; Hartmann et al., 2012).
Eight studies discussed the influence of perceived gender and
cultural norms on acceptance and use of FP (M. Daniele, 2017; Ghule
et al., 2015; Harrington et al., 2016; Jewkes et al., 2010;O.L.
McCarthy et al., 2018b,2019). These studies noted the inequalities
that favoured men as household decision‐makers and stigmatised sex
outside of marriage. Male consent or ‘permission’for women's use of
FP emerged as a sub‐theme of perceived gender and cultural norms
(Daniele, 2017; Harrington, 2017a; Harrington et al., 2016,2017).
Some studies noted that women's acceptance of gender norms
relating to FP were common (Daniele, 2017; Doyle et al., 2014;
Jewkes et al., 2010) while one study highlighted women's responses
to inequalities. These included ‘sweet talk’with sexual partners or
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concealed use of contraception when they were experiencing a lack
of congruence with cultural expectations on childbearing or thought
joint‐decision‐making about FP unattainable (Harrington et al., 2016)
One study reported an adverse impact of men ‘dominating
conversations’in couple counselling sessions (Daniele, 2017). A
central barrier to couple communication about FP or promoting joint
or female‐led decision‐making was perceived gender and cultural
norms that saw women as responsible for family planning and cultural
norms that stigmatised men's move away from dominance as the
head of the household decision‐making (Doyle et al., 2014; Ghule
et al., 2015; Harrington et al., 2016).
The importance of communication about FP and decision‐
making norms and preferences emerged as an important theme that
was not highlighted in the a priori framework. Ten studies
(Daniele, 2017; K. Doyle et al., 2014; Ghule et al., 2015;
Harrington, 2017a; Harrington et al., 2016; Hartmann et al., 2012;
Jewkes et al., 2010; McCarthy et al., 2018b; Nair et al., 2019; Turan
et al., 2001) referred to this. While some studies reported that male
decision‐making about FP remained an accepted norm and prefer-
ence for both women and men (Daniele, 2017; Ghule et al., 2015;
Harrington et al., 2016,2019), there were also reports of the positive
influence of improved spousal communication and joint decision‐
making about FP [(Daniele, 2017; Doyle et al., 2014; Harrington
et al., 2017; Hartmann et al., 2012; Nair et al., 2019; Turan
et al., 2001) or female led decision‐making on the contraceptive
method used (Daniele, 2017). One study (Jewkes et al., 2010)
reported positive impacts on cultural norms relating to inter-
generational communication about sex. Another study reported
barriers to FP relating to a lack of confidence due to prohibitive
norms relating to communicating about sex with partners, parents,
and FP service providers (O. L. McCarthy et al., 2018b).
Relatedly, three studies (M. Daniele, 2017; Harrington et al., 2019;
Hartmann et al., 2012) highlighted the importance of relationship
status/quality as a key determinant of FP use. While some noted
positive impacts (Daniele, 2017), others noted the damaging impacts
of unequal power dynamics in relationships (Harrington et al., 2019).
Relatedly, three studies mentioned the influence of marital status/
type on FP use (Daniele, 2017; Khan et al., 2008; McCarthy
et al., 2018b). As noted, newly married couples were often subject
to social expectations for early pregnancy (Khan et al., 2008;O.L.
McCarthy et al., 2018b). One study (Daniele, 2017) alluded to the
potential differences in men's willingness to engage with FP when
they were in a monogamous versus polygamous marriage, with the
latter proposed as leading to less investment in the healthcare of
each wife. HIV status was mentioned as a key factor in two studies,
with both noting that HIV positive status was associated with
increased contraceptive use (Mantell et al., 2014; Ngure et al., 2012).
Reproductive history and intentions for future childbearing
and the sex of existing children emerged as key influences on FP
use(Ghuleetal.,2015; Harrington et al., 2016;Nairetal.,2019;
Ross & Bang, 1966). Two studies noted preferences for sons
(Ghule et al., 2015; Nair et al., 2019)andthree(Ghuleetal.,2015;
Harrington et al., 2016;Ross&Bang,1966)reportedthecultural
significance of childbirth early in marriage. All noted that the
absence of either would result in limited use of FP. Further, birth
spacing norms were highlighted as important in one study (Khan
et al., 2008).
While co‐residence with extended family (an a priori category)
was not mentioned directly in any studies, mentioned in six studies
was the strong influence of perceptions of wider family expectations
on FP decision‐making (Cooper et al., 2014; M. Daniele, 2017; Ghule
et al., 2015; Khan et al., 2008; McCarthy et al., 2018b;
McCarthy, 2019). ‘Mothers of husbands’were noted as particularly
influential (Khan et al., 2008; O. L. McCarthy et al., 2018b). This
theme appeared to be linked to the broader concept of community
knowledge about FP.
Barriers and facilitators at the external system level. Four key themes
relating to external systems emerged from the connected papers.
Three of these were a priori categories (gender, cultural and religious
norms; health systems and services; FP supply chain] and one
additional category emerged from the thematic analysis (social
network influences).
The positive influence of social networks beyond the family on
FP uptake and use emerged as important across seven of the
connected papers (Cooper et al., 2014; Daniele, 2017; Doyle
et al., 2014; Ghule et al., 2015; Harrington et al., 2016; Hartmann
et al., 2012; Jewkes et al., 2010). Male peers and ‘male motivators’
were seen as particularly influential facilitators.
Nine studies highlighted the broad influence of gender, cultural
and religious norms on FP decisions (Daniele, 2017; Doyle
et al., 2014;Ghuleetal.,2015; Harrington et al., 2016;Jewkes
et al., 2010;Khanetal.,2008; McCarthy et al., 2018b; Nair
et al., 2019) Perceptions of these are noted under individual‐level
factors above. Key highlighted norms included early childbearing for
newly married couples (Ghule et al., 2015;Khanetal.,2008);
religious beliefs norms condoning sex outside of marriage
(McCarthy et al., 2018b) preferences for sons to act as heirs and
provide for elderly relatives (Ghule et al., 2015; Nair et al., 2019)
and males as dominant household decision‐makers (Harrington
et al., 2016; Jewkes et al., 2010; Nair et al., 2019). As noted, there
were suggestions that shifts in these norms resulted from engage-
ment with the FP interventions.
Health systems and services was noted as an important factor
by four studies (Baqui et al., 2018;Daniele,2017;Doyle
et al., 2014). Four studies discussed the impacts of incorporating
FP services within existing maternal and child health (MCH)
services (Baqui et al., 2018;Daniele,2017; Doyle et al., 2014).
One of these (Baqui et al., 2018) reported that the addition of FP
services that engaged men and boys did not have adverse effects
on existing services, while the others noted that men were
concerned that they would not be welcome to attend MCH
settings (Daniele, 2017) or did in fact experience barriers including
overcrowded delivery rooms, as well as biased, undermining and
negative attitudes from healthcare workers (Doyle et al., 2014;
Nair et al., 2019).
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Two studies indicated the importance of FP supply chain, the
availability of contraceptives and services, in encouraging FP uptake
and use (Ahmed et al., 2013; Ross & Bang, 1966).
Barriers and facilitators at the process level. Six a priori categories
(intervention acceptability; intervention costs, sustainability, and
replicability; quality of delivery; provider‐preparedness; participant
recruitment, retention, and representativeness; and study design and
characteristics) emerged as potentially important influencing factors.
Two additional categories (reach and favourability of contraceptive
method) also emerged as relevant.
Four studies (Akhter et al., 1993; Ghule et al., 2015;
Harrington, 2017a; Harrington et al., 2019) noted the importance of
intervention acceptability. Two studies noted the facilitating effects of
culturally acceptable interventions (Harrington, 2017a;Harrington
et al., 2019). Satisfaction with contraceptive methods was noted by
two studies (Akhter et al., 1993; Ghule et al., 2015), with physical side‐
effects presented as key barriers to female use of FP. Another (O. L.
McCarthy et al., 2018b) noted the negative impact of intervention
costs. Two studies (Ahmed et al., 2013; Nair et al., 2019) indicated the
importance of quality of delivery on intervention outcomes. Five
studies commented on provider‐preparedness to deliver FP (including
provider characteristics), with the trustworthiness, knowledge, and
flexibility of providers highlighted as key (Daniele, 2017;Khan
et al., 2008; McCarthy et al., 2018b). One study noted challenges in
engaging men when healthcare providers were female (Daniele, 2017).
Four studies mentioned participant recruitment and retention as
potential influences on programme effectiveness, issues around
engaging men in couple‐focused sessions or with MCH service
settings highlighted as particularly challenging (Daniele, 2017;
Harrington, 2017a; Nair et al., 2019; Turan et al., 2001) Further,
five studies (Bertrand et al., 1982; Daniele, 2017; Harrington
et al., 2019; Jewkes et al., 2010; McCarthy et al., 2018b) highlighted
the importance of the specific characteristics of the study design as
important. One study (Harrington, 2017a) noted contamination
across intervention and control communities as a barrier to impact,
while the others implicated particular aspects of their programme
design (e.g., communications, assertiveness skills session, instant
messages) as key. Relatedly, two studies (Bertrand et al., 1982; Ghule
et al., 2015), discussed the importance of reach. These related to how
study processes might ensure that they are able to reach those in the
most rural or hard‐to‐reach areas. Finally, two studies (Akhter
et al., 1993; Ghule et al., 2015) noted the importance of the
favourable attitudes towards or satisfaction with the contraceptive
method being used.
Sensitivity analysis
Only one of the connected papers was deemed to have a high risk of
bias (McCarthy, 2019). This study contributed data to two of the
themes (co‐residence with extended family and gender norms). When
we removed it from the analysis the impact was considered
negligible. This was because both themes were supported by
evidence from several other studies.
6|DISCUSSION
6.1 |Summary of main results
Our meta‐analysis of 72 studies and 265 measures of effects of
interventions involving men and boys in FP found that, when
compared with comparison groups, these interventions exert a
moderate, yet statistically significant, positive impact on contracep-
tive use. The reader should note that this analysis does not compare
interventions that involve men and boys with those that do not.
Studies included in this review demonstrate effectiveness in
increasing contraceptive use when they are compared to comparison
groups, which received a range of interventions including no
intervention (care as usual) and alternative interventions, which
may also have included men and boys.
While the impact of these interventions on contraceptive use
was clear, the causal chain was not. We found that across the range
of proximal and distal outcome measures (including contraceptive
use, desired family size, pregnancy, pregnancy timing, gender
equitable attitudes, communication about FP, equitable decision‐
making about FP, attitudes about FP, knowledge about contra-
ceptives, and FP service use) there were few clear or consistent
findings. Individual studies produced a mix of results, using highly
heterogeneous interventions, composed of several components, and
implemented in a variety of contexts, among diverse populations.
Our analysis revealed that the high heterogeneity of effects
among included studies was mostly due to within study variability.
We therefore sought to uncover the effective characteristics and
combinations of characteristics of included interventions. However,
such was the variability in relation to outcome measures used, that
our analysis of 33 interventions including a male engagement
component and contraceptive use outcome was only powered to
detect the moderating potential of two intermediate outcome
measures (contraceptive attitudes and contraceptive knowledge) and
it emerged that only attitudes about contraception had a significant
moderating impact on contraceptive use outcomes.
The next step in our analysis involved examining the effective
components of included studies. Multi‐variate meta‐regression of 72
included studies that reported contraceptive use outcomes indicated
that none of the eight intervention components identified were
statistically significantly more effective than the others in improving
contraceptive use. This is perhaps not surprising given that all
interventions included multiple components. We found 33 different
combinations of components in use across the 72 studies reporting
contraceptive use outcomes and none of the combinations emerged as
statistically significantly more effective than the others. When we
examined a subset of 33 of the included studies, those involving active
engagement of men and boys in FP and the outcome of contraceptive
use, we found that the impact of these studies on contraceptive use
was not statistically significantly better than those that merely
involved men as programme recipients. While at first glance these
findings may appear frustratingly inconclusive, and perhaps of little
value to programme planners, the findings indicate that a number of
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different components and combinations of components are possible
and effective. This review presents the first collated categorisation of
existing interventions involving men and boys in family planning and
their components. Given the variety of contexts in which such
interventions are implemented, and the recognition that one size does
not fit all, this range of possibilities is welcome.
The moderator analysis was able to disentangle some of the
complexity relating to the characteristics of included interventions,
with clear indications emerging regarding promising methods of
engaging programme participants and approaches to implementing
interventions that involve men and boys. Meta‐regression across 72
studies highlighted the positive impact of community‐based educa-
tional FP interventions, delivered to women as well as men, by
trained facilitators, professionals, or peers in community, home and
community, or school settings. Programmes that primarily involved
contraceptive counselling did not statistically significantly moderate
effects on contraceptive use and the analysis was not powered to
detect the impact of maternal and child health focused programmes.
The evidence also supported approaches targeting adolescents or
adults alone, as well as those that targeted both age groups. In
contrast to the findings of previous research (Lopez et al., 2009) our
analysis found that both interventions based on an explicitly named
theory of change and those not reported to be based on a theory of
change were effective in positively impacting contraceptive use.
In relation to dosage, the analysis suggests that both short
interventions of less than 3 months and those of 7 months or longer
are effective moderators of positive impacts on contraceptive use,
however, interventions of intermediate timeframes of between 3 and
6 months did not show statistically significant effects. While this
finding may appear peculiar, and is difficult to explain definitively, it is
possible that content‐and behaviour‐related issues are at play. For
example, shorter interventions generally target simpler behaviours,
while longer interventions tend to target more complex behaviours
over a longer period. One possible explanation for this finding is that
some mid‐length interventions may attempt to address complex
behaviours in too short a timeframe.
The analysis suggested that the field of involving men and boys
has improved in relation to its capacity to show impact in the last
twenty years, with studies published from 2000 onwards emerging as
positive moderators of impact. The results also suggest that there
may be lessons to learn from programmes implemented in Western
and Eastern Africa where positive effects were statistically signifi-
cantly more pronounced. The reader should note, however, that
given the diversity of studies included and the lack of studies in some
regions, the analysis was not powered to detect the impact of studies
conducted in some regions including South and Central America,
Central Asia, and Central Africa. Further, this analysis does not
compare interventions that involve men and boys with those that do
not. Studies included in this review demonstrate effectiveness in
increasing contraceptive use when they are compared to comparison
groups, which received a range of interventions including no
intervention (care as usual) and alternative interventions, which
may also have included men and boys.
Our qualitative syntheses of findings from 23 connected
qualitative and process evaluation papers related to 34 male
engagement studies with a contraceptive use outcome revealed
several potential barriers and facilitators of effective models of FP
involving men and boys. Central here were system‐and process‐
level barriers and facilitators that echoed findings reported in the
quantitative synthesis including the importance of promoting
positive attitudes about contraceptives, involving trained peers as
programme facilitators, and the value of community‐based educa-
tional programmes.
Reflecting the finding relating to the importance of attitudes
about contraceptives as a moderator of contraceptive use, the
connected papers reported the facilitative effect of changing
attitudes of not only individual men and women, but also those of
the wider social network, including family members and peers.
Repeatedly, social norms and expectations that encouraged early
childbearing, preferences for sons, encouragement of male domi-
nance in decision‐making and stigmatisation of their engagement in
FP, were highlighted as barriers. Conversely, and reflective perhaps
of the positive effects of peer facilitated and community‐based
interventions, the positive attitudes of the wider family, peers and
community relating to FP were reported as key facilitators.
Though knowledge was not a significant outcome in the
quantitative analysis, the crucial importance of accurate knowledge
about FP as a facilitator was highlighted in the connected papers,
with some studies noting the mediating effect of knowledge of
communication about FP. Further, the inclusion of an ‘information
and education’component in almost all included interventions and
the moderating effect of interventions focused on a community‐
based educational model was reflective of this. In addition, the
positive impacts of using trained facilitators or peers and profes-
sionals to deliver interventions may reflect the key goal of
interventions to impart accurate knowledge about FP.
Communication between couples, joint FP decision‐making, and
perceptions of gender and cultural norms emerged as important
facilitators in the connected papers, although components specifi-
cally targeting these outcomes and reports of their measurement
appeared much less frequently than attitudinal and behaviour level
contraceptive use or pregnancy‐related outcomes. Equally, the focus
on pregnancy related outcomes and female contraceptive use
suggests that many of the included FP interventions see men as
facilitators of women's contraceptive use rather than FP users
themselves.
Key facilitators of FP use were socioeconomic factors including
older life stage, women's employment outside the home, and men's
education level.
6.1.1 |Revised logic model
Based on the available evidence and the input collected during our
stakeholder meeting, we revised the initial review logic model in the
following ways (see Figure 17):
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•All information that was not evidenced (i.e., not significant or not
included) in the included evaluation studies and connected papers
was changed from black to grey font to highlight areas for future
research to consider.
•Intervention component headings were changed to reflect more
appropriately terms used in the literature. In particular, ‘gender
dialogue’was changed to ‘gender transformative’; information was
changed to ‘information and education’,‘skills‐building and
problem‐solving’were combined, ‘social support’was changed to
‘social/peer mentor support’,‘incentivisation’was changed to
‘subsidisation’and incentivisation’,‘Communication’was changed
to ‘Communication about FP’and ‘male involvement’was changed
to ‘male engagement’. Additionally, ‘free contraceptives’was
added to ‘subsidisation' and incentivisation’and ‘subsidised or
free FP methods’removed from ‘health service enhancement’.
•Under intervention characteristics only evidence‐based character-
istics after the sub‐headings were left in place. The ‘why’and
‘tailoring & modifications’headings were removed. The remaining
elements that were not reported or evidenced were changed to
grey coloured font.
•Under potential negative outcomes ‘male resistance to FP leading
to covert use and unmet need’was added and the remaining items
which were not reported were changed to grey font.
•Under process metrics, reach and favourability of contraceptives
were added.
•For the remaining sections, all information not reported was
greyed out and information reported left in place.
6.2 |Overall completeness and applicability of
evidence
We followed a pre‐registered peer‐reviewed protocol that was
developed in consultation with expert stakeholders and methods
experts. A comprehensive search was conducted to identify relevant
studies and two reviewers worked independently to select studies
using the predetermined eligibility criteria and extract outcome data
using a standardised data extraction form. To the best of our
knowledge, the evidence presented in this review represents the
totality of experimental and quasi‐experimental research from LMICs
on the impacts of FP interventions involving men and boys on FP
outcomes. We include the broadest range of information available on
the nature, extent, and characteristics of experimental evidence in this
field from 127 experimental and quasi‐experimental evaluation studies
and 23 connected process evaluations and qualitative studies relating
to a subset of 33 of the evaluation studies. The large number of studies
included in this review meant that data extraction and analysis were
more time consuming than expected (searches were conducted in
August 2020). However, given the slow‐moving nature of publication
in this field, the review is timely and, therefore, applicable to those
involved in the current development and implementation of FP
interventions involving men and boys in FP in LMICs.
Some possible limitations on the applicability of the findings
should be noted. First, as noted above this analysis does not compare
interventions that involve men and boys with those that do not.We
also noted that most of the included studies targeted older
FIGURE 17 Revised review logic model
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adolescents and men, so these findings cannot be reliably applied to
younger adolescents or children. Country range in the included
evaluation studies was narrow within regions with fewer studies from
the Americas and Asia than from Africa. Further, as we did not
conduct analyses regarding urban and rural settings for intervention
delivery, it was not possible to conclude whether findings from rural
areas are applicable to urban areas and vice‐versa. Given potential
differences in these settings and the implications for intervention
implementation, for example, some interventions may require the
availability of facilities only present in urban areas or community
networks only evident in rural areas, this is an important
consideration.
We also found that there was an absence of comparable
measures for some outcomes that may be of particular interest to
some practitioners. For example, some studies used bespoke
measures of gender equitable behaviours and beliefs and joint‐
decision‐making about FP, making it difficult to explore these
important outcomes in‐depth. This is particularly relevant when we
consider the potential for FP interventions that involve men and boys
to negatively impact the already skewed existing power dynamics.
Understanding, for example, what ‘gender‐equitable decision‐making’
involves and ensuring consistent measurement across studies would
allow us to scrutinise and work to eliminate any possible adverse
effects. There was also a lack of data on more distal outcomes such
as pregnancy, birth spacing, fertility rates, and met need for FP and
related outcomes such as intimate partner violence. This may equally
be considered a limitation of the current review, and of the extant
evidence in the area.
Finally, as noted, the included studies were highly heteroge-
neous in nature, combining a range of components and character-
istics. Although we endeavoured to disentangle these, we ultimately
found too many different combinations of characteristics and
components to clearly determine the causal chain. We have,
however, made progress in this regard and we anticipate that the
detailed results and revised review logic model may provide much
needed clarity in relation to promising practices for engaging men
and boys in FP in ways that promote health and wellbeing for both
women and men.
6.3 |Quality of the evidence
Risk of Bias analyses indicated that 69 of the 127 studies (54%) had a
high risk of bias with serious concerns, while 5 studies (4%) had
a critical risk of bias. Fifty‐two studies (41%) were accessed as having
a moderate risk of bias with some concerns, and only one study was
determined to have a low risk of bias. The majority of the 15 process
evaluations and 8 qualitative studies were judged to have moderate
risk of bias (78%) while only one study was judged to have a high risk
of bias and four studies (17%) to have a low risk of bias.
The risk of bias findings should not necessarily be considered
indicative of poor study design quality, rather that the majority were
conducted in challenging contexts, which affected the proper
implementation of the study. The LMIC settings in which these
studies were conducted might in part contribute to the need to take
pragmatic steps to improve implementation and evaluation. This
finding is reminiscent of a previous review of male engagement and
sexual and reproductive health and rights interventions published by
some of the study authors (Ruane‐McAteer et al., 2020). Forty
percent of the studies included in this review were RCTs, with the
remaining using quasi‐experimental designs. While some might argue
that quasi‐experimental studies are potentially lower in quality than
the ‘gold‐standard’RCT, it should also be noted that quasi‐
experimental studies are often a valid alternative in contexts in
which ethical or resource constraints prevent the use of RCTs
(Thomas, 2016).
6.4 |Limitations and potential biases in the review
process
Our inclusion criteria led to a larger than expected number of
included studies. Our decision, due to resource restraints, to focus
some of the analysis on a subset of studies (namely first those that
included a contraceptive use outcome (72 studies) and second those
that had an active male engagement component and contraceptive
use outcomes (33 studies)) reduced the number of studies and
associated effect sizes that could be examined as part of the meta‐
analysis, limiting our ability to examine some elements of the causal
chain in more depth. Further, the use of a sample of associated
connected process evaluations and qualitative studies instead of a full
search for all relevant papers in the field may have biased our
findings.
We included all contraception use in the contraceptive use
outcome. This included the very small number of studies that
included withdrawal as a method of contraception. We used
systematic review process methods to minimise bias during the
review process. As noted, a deviation from protocol was implemen-
ted in relation to dual extraction of data relating to study
characteristics, intervention characteristics, and risk of bias assess-
ments. Although this process introduces the possibility of bias, we are
confident that the reliability of this approach is in line with accepted
standards (Landis & Koch, 1977; McHugh, 2012).
As noted, the analysis does not compare interventions that
involve men and boys with those that do not. There was large
heterogeneity in the comparison groups of the studies. Also, as
noted only studies that included a comparison group were included
in this systematic review. This has the potential to exclude
important evaluations conducted by practitioners (e.g., before‐
after evaluations), which are often done without comparison
groups. Given the expense involved in conducting controlled
experiments, and the fact that this study focused on low resource
settings, this could be considered a limitation. However, from the
perspective of methodological rigour, RCTs and quasi‐
experimental studies with a comparison group ensure assessment
of the effectiveness of interventions.
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While information was available in most studies to calculate
effect sizes, this was not always the case. The study team contacted
authors to request additional data to facilitate this, however, no
authors responded with the required information. It is possible that
this resulted in biased findings. Also, we did not extract data on the
urban/rural breakdown, a limitation of our review, considering that
there was some evidence that this distinction is important.
Moderator analyses are exploratory in nature and should always
be interpreted with caution (Borenstein et al., 2009). Additionally,
these types of analyses generally have low statistical power owing to
missing data in the primary research due to the incomplete reporting
of many of the variables of interest. Analyses are restricted
considerably due to this issue and robust conclusions from these
analyses are constrained.
6.5 |Agreements and disagreements with other
studies or reviews
Overall, the findings of this review reinforce and expand the findings
from prior research in this field. Our finding relating the effectiveness
of FP interventions involving men and boys confirm and expand on
those of a review by Phiri and colleagues (2015a), which involved a
narrative synthesis of findings from ten randomised controlled trials.
Building on findings of prior reviews conducted by members of the
current review team (Robinson et al., 2021;Ruane‐McAteer
et al., 2019,2020) and others (Sahay et al., 2021), our review uncovers
the complexity of characteristics and components of a subset of
interventions that involve male engagement in SRHR, adding multi-
variate statistical analyses to help uncover effective characteristics.
Our findings of the significant positive effect of the following
intervention characteristics, namely, multi‐component community
based educational interventions; interventions targeted to both males
and females; and interventions of longer duration (at least seven
months) delivered by professionals and or trained facilitators or peers
are consistent with those identified in a review of engaging men and
boys in gender‐transformative SRHR interventions (Ruane‐McAteer
et al., 2020). In addition, however our review has identified that brief
interventions of less than three months in the field of family planning
also demonstrate effectiveness. In support of findings of a recent
review from Sahay and colleagues (2021) and an analysis of the
FP2020 commitments made by several LMICs in relation to involving
males in FP programmes (Hook et al., 2021), this review confirms the
importance of improving knowledge and attitudes related to contra-
ception as a means of increasing its uptake and use. Further, in
common with the evidence and gap map of engaging men and boys
relating to all SRHR outcomes (Ruane‐McAteer et al., 2019), we found
that addressing gender inequitable norms was not ubiquitous among
these programmes. While in their map, they estimated that only 8% of
evaluated male engagement interventions across all SRHR outcomes
included a gender‐transformative approach, we estimated that 23% of
the evaluated interventions in this review of FP interventions adopted
gender‐transformative components. Likewise, both reviews identified
that few interventions that have been evaluated using experimental
methods include broader structural components.
Our finding that both interventions with and without a clearly
specified theory of change are effective moderators is different to
a previous review by Lopez et al. (2009)whichfoundtheory‐based
interventions to be more effective. It is important to note,
however, that although some of our included studies did not
clearly indicate that the intervention was based on a theory of
change, it is possible that the theory was not reported or
recognised. Indeed, the use of behaviour change theory in FP
programmes is argued to be under reported and under detailed
(Robinson et al., 2021). While the incorporation of explicit
theoretical grounding may serve to advance the field, this may
notbesufficientinisolation, with calls for evidence‐led pro-
gramme development also (Raj et al., 2016). These results indicate
successful programme development and implementation may
thereforebetheory‐or data‐driven, and prompt recommendation
that both approaches be incorporated.
7|AUTHORS CONCLUSIONS
Family planning interventions that involve men and boys alongside
women and girls are effective in improving uptake and use of
contraceptives. Programmers across the world have developed and
evaluated a wide range of interventions, as rich and varied as the
contexts in which they are delivered. This variability, while necessary
to some degree, also has implications for evidence synthesis.
Heterogeneity of components, characteristics and outcomes meant
that some meta‐analyses were not possible with the current data set.
This review did, however, unravel some parts of the causal chain,
highlighting effective characteristics of existing interventions, and
determining that there was no significant difference in the size of
effect of eight different components or combinations of components
on contraceptive use. The implications of this for practice and
research are outlined below.
7.1 |Implications for practice and policy
Stakeholder involvement was central in this project, with an
international advisory group of more than 30 expert members from
9 different countries around the world participating in planning the
review, developing the initial and revised versions of the review logic
model, interpreting the implications for findings, and disseminating
evidence.
The evidence suggests that existing effective interventions
should be adapted and implemented across LMICs where there is
unmet need for family planning. While approaches to involving
men and boys in family planning are complex, the research
indicates that practitioners should utilise multi‐component inter-
ventions and can choose from a variety of different components
depending on the population and setting in which it will be
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delivered. The mixed methods evidence examined in this review
suggests that programme planners should consider the following
points when seeking out, adapting, evaluating, and implementing
interventions:
1. Promote gender equity in FP and reduce the negative impact of
harmful masculinities by involving women as well as men in
programmes and implementing interventions that use gender
transformative elements. Programmes can do this by facilitating
communication about FP and joint FP decision‐making among
couples, promoting female empowerment to decide on FP method
use, and encouraging men as supporters of FP, but also users of
FP in their own right. There is also a role for practitioners in
reducing stigma around the involvement of men in FP and
providing FP services that welcome men as well as women.
2. Harness the power of positive role models by empowering
trained peer mentors and trained facilitators and professionals to
implement culturally adapted interventions. Use community‐
based educational approaches that improve accurate knowledge
and positively change attitudes and FP among the wider social
network in order to positively impact restrictive social and cultural
norms.
3. Consider the use of multi‐component, multi‐level interventions
adapted and matched to meet local needs and addressing
relevant system‐and process‐level barriers to effective FP
intervention. This review identified the use of eight different
components and 33 different combinations of these that were
effective moderators of impact on contraceptive use. While all of
the different combinations of components were effective in
moderating contraceptive use, none of the different combina-
tions stood out as more effective than the others. This list should
not be considered exhaustive and creative ways of developing
and implementing new components and combinations of
components are encouraged. While the evidence presented
here suggests that interventions based on a clearly identified
behaviour‐change theory have no more impact on contraceptive
use outcomes then those that do not, we recommend that
practitioners consider theories of change as a fundamental
aspect of programme planning.
4. Addressing socioeconomic inequalities. Policy that aims to
improve women's education and opportunities for employment
outside the home as well as the provision of free or subsidised
FP services and contraception would go some way towards
encouraging uptake of FP and addressing unmet need in LMICs.
5. Carefully consider proximal and distal outcomes. The evidence
presented in this review revealed a gap in interventions that move
beyond the interpersonal level to impact community, organisa-
tion/service, and structural level outcomes. There is also a need to
consider and measure the longer terms impacts of FP interven-
tions and more uniform methods of outcome measurement. This
will facilitate drawing conclusions on the effectiveness of FP
approaches in future.
7.2 |Implications for research
The analysis identified some gaps in evidence in relation to our
review questions that have implications for future research.
First, in relation to the populations under study, few studies were
available from South and Central America, the Middle East, and
Northern Africa. Within regions, research tended to be focused on
particular countries, with only 17 LMICs represented in the review.
Given the importance of local cultural norms as barriers or facilitators
of uptake of FP, much more evaluation research is needed
internationally, with research funds targeted at countries in which
unmet need for FP and robust evidence is lacking. It would also be
valuable for future reviews to collate data on whether studies are
conducted in urban or rural settings. Data collection for this study
occurred during the COVID‐19 pandemic so we examined the data
for studies that took place during disease outbreaks. We found none.
Equally, we found no studies that took place in conflict, disaster, or
climate stressed contexts. Given the continued impact of these
factors across the world and their potential implications for
increasing unmet need for FP, further research in these settings is
urgently needed.
In relation to intervention and study characteristics, we found
that reporting within studies was variable, with many studies not
following recommended reporting guidelines. We extracted PROG-
RESS Plus criteria (O'Neill et al., 2014) when it was available but these
details were too sporadically reported to include in the analysis.
Similarly, some studies provided insufficient or unclear information
on intervention characteristics, with a variety of terms used for the
same components. This made it very difficult to code and categorise
data. Future intervention evaluation studies should use recognised
behaviour change terminology such as that proposed by Michie et al.
(2011) and also ensure to use appropriate intervention reporting
guidelines such as TiDiER.
On an outcome level there were few studies that examined
interventions delivered beyond the individual or interpersonal levels.
There is much room for programme planners and evaluators to
intervene as these levels as recommended elsewhere (Ruane‐
McAteer et al., 2020). Further, none of the included studies reported
the use of participatory designs, an approach that is recommended
for future work to ensure the relevance of intervention and study
designs for particular contexts. More research is also needed on
intervention designs based on incorporating male involvement in FP
with maternal and child health programmes. Some studies included
reported promising results, but the studies were too few to conduct
meaningful analysis.
A related recommendation for researchers relates to how
outcomes are measured across included studies. We established
high heterogeneity in relation to how outcomes were measured
across different studies, using different assessment methods,
outcome measures, timings and methods of reporting. Very few
studies distinguished between primary and secondary outcomes. This
makes synthesis and meta‐analysis of results challenging. Research
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using standardised measures is highly recommended and reporting of
experimental studies should follow the CONSORT checklists.
A further recommendation relates to the absence of economic
evaluations of these interventions. Only three of the included studies
(Bertrand et al., 1982; Diop et al., 2004; Townsend et al., 1987)
examined cost‐effectiveness, so research exploring this important
factor is urgently needed.
A final methodologically focused recommendation relates to the
development and adaptation of interventions and conduct of experi-
mental research in this field. As noted, we faced significant challenges
in our attempts to unpack the causal chain, in part because of the
complex nature of the included interventions. This has implications for
future development and evaluations in this field. While FP interven-
tions that involve men and boys include an ‘intervention package’that
consists of multiple components and that may independently contrib-
ute (either positively or negatively) to overall effects, it is extremely
difficult to understand the individual and combined impact of different
components using classical experimental methods. Further research
should therefore consider alternative methods that are capable of
uncovering the individual and combined effects of intervention
components. One such approach is the Multiphase Optimisation
Strategy (MOST) (Collins, 2018), which involves a three‐phase process
to prepare, optimise (using factorial experimental designs) and evaluate
complex behavioural interventions. None of the studies included in this
review included this approach.
The legacy of a focus on population control and global
patriarchal norms has undeniably influenced the state of current
FP interventions, which centre around birth limiting and birth
spacing and women's central role as contraceptive users. While we
intended to study unmet FP need, we found that the most common
included outcome across all studies was contraceptive use and
unmet family planning need was rarely studied. Areas and topics of
interest for future FP interventions should include engaging men
as contraceptive users, supporters, and agents in helping to
achieve desired family size but also in fertility promotion
interventions, safe conception interventions (i.e., HIV positive
conception), and family planning decision making in non‐
heterosexual relationships.
Similarly, all interventions included in this review adhered to
binary and cis‐normative concepts of gender identity and sexuality.
Family planning remains a pertinent issue for those identifying as
LGBTQI+, with authors noting that even those who have transitioned
socially or hormonally are in need of support to ensure they can
achieve their desired family size (Francis et al., 2018). The
experiences of transgender individuals remain critically under‐
investigated in relation to family planning, hence given the novel
and unmet need for this group further research is called for into the
need to involving transgender men in family planning.
Finally, notably absent from the interventions included in this
review were behavioural interventions that support those who do not
ever wish to become parents. Given the reported pressures placed on
young couples to engage in childbearing noted in this review and
increasing trends of individuals deciding to delay or avoid parenthood
(Mauceri & Valentini, 2010; Nomaguchi & Milkie, 2020; Umberson
et al., 2010), it is likely that this subgroup of people represent a
significant yet neglected population that deserve the attention of
future research.
CONTRIBUTIONS OF AUTHORS
Principal Investigators: ÁA, ML
Expert advice and guidance: MC, MT, FO, CB
Searches and Screening: MR, JeH, JaH, ÁA, ML
Data Extraction: MR, JaH, ER, ÁA,
Content: ÁA, ML, MR, ER, CB
Analysis: MR, CK, JeH, ÁA, ML, ER
Synthesis: ÀA, MR, JeH, ML
Dissemination: FO, MT, ÁA, ML
DECLARATION OF INTEREST
This project was funded by the Centre of Excellence for Develop-
ment Impact and Learning (CEDIL) with support from UK Aid from
the UK government. The funding body had no role in the study
design, or decision to publish findings. The authors have no conflicts
of interest to declare.
PRELIMINARY TIMEFRAME
The preliminary timeframe for submission of the completed review
was one year following protocol publication. This was delayed by two
months (the protocol was published in January 2021 and the
completed review submitted in March 2022).
PLANS TO UPDATE THIS SYSTEMATIC REVIEW
The authors seek support to update the results of this review in line
with emerging evidence in the field. We anticipate that the need for
the next update will be considered in 5 years.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
Deviations from the review protocol are presented in Section 4.2.1.
PUBLISHED NOTES
None.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the contributions of the
project's international expert advisory groups who took time to provide
feedback and input into the review priorities throughout its conduct.
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How to cite this article: Aventin, Á., Robinson, M., Hanratty, J.,
Keenan, C., Hamilton, J., McAteer, E. R., Tomlinson, M., Clarke, M.,
Okonofua, F., Bonell, C., & Lohan, M. (2023). Involving men and
boys in family planning: A systematic review of the effective
components and characteristics of complex interventions in
low‐and middle‐income countries. Campbell Systematic Reviews,
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