Afghanistan has undergone decades of war, displacement, famine, and oppression. As a result, the country's infrastructure has been shattered, professional capacity has been hugely depleted, and there is a significant shortage of medical facilities and health professionals. The health care crisis has particularly impacted Afghan women, who suffer the world's second highest maternal mortality and morbidity rates. One effective way to reduce maternal mortality is to provide quality family planning services to prevent unwanted pregnancies and to facilitate birth spacing. Yet most Afghan health providers, especially male providers, have never received basic training and education in family planning methods, sexually transmitted infections (STIs), and HIV/AIDS.

Besides the shortage of trained health providers, strict cultural restrictions hinder Afghan women's access to family planning services. Afghanistan is a highly patriarchal society where men make most of the decisions. Afghan women often lack the ability to make the most basic decisions, including those regarding their health and fertility. In many households men literally hold the key to the outside world, and women must ask permission from their husbands to leave the house or seek any type of medical services. In such a male-dominated society, men's comprehension and support of reproductive health and family planning methods are essential. Providing family planning education and services to Afghan men can be expected to increase their knowledge and support of contraception, which in turn would facilitate women's access to family planning services.

Responding to a clear unmet need for male involvement in family planning/reproductive health in Afghanistan, in 2007 Family Health Alliance (FHA) implemented the first male focused family planning/reproductive health training program for male doctors and nurses in Afghanistan.

To reduce maternal mortality and morbidity, increase access to family planning services by training male health providers as agents of change.

Program objectives are to promote male involvement in family planning; increase contraceptive knowledge (particularly condoms/vasectomy); improve detection/treatment of STIs; and expand STIs/HIV education for men. The programs employ an empowerment model of teaching which include role models, using Muslim health professionals, self-reliance, and teamwork strategies to address numerous challenges trainees face in a post-conflict environment.

The programs are implemented with the collaboration of Afghanistan's Ministry of Public Health and a number of local NGOs (non-government organizations).

The programs cover all family planning methods, with a focus on male-oriented methods such as condoms and vasectomy. The programs include strategies to promote self-reliance and cooperation, and encourage male health providers to become involved in increasing male participation in family planning in Afghanistan. The trainees receive training in detection, prevention and treatment of STIs prevalent in the male population, and are educated in HIV/AIDS and strategies that could help to prevent the spread of the virus. The programs also discuss how violence against women impinges on reproductive health. To foster critical thinking and to reiterate the importance of male involvement, at the completion of the programs the trainees are asked to illustrate the concept of male participation in Family Planning/Reproductive Health (see Photos/Multimedia).

FHA creates and produces all educational materials in the local language, Dari. Educational materials include manuals, handouts and posters on family planning methods and counseling, infection prevention and STIs/HIV/AIDS. Each trainee receives a set of educational materials to take back to their clinics in different provinces to use for education of the local population.

FHA's male health provider training program has found that education of Afghan male health providers in family planning/reproductive health leads to their active participation in counseling their male patients on family planning to address low contraceptive use and high maternal mortality. While originally considered controversial by some members of the Ministry of Public Health and local NGOs, the success of this program prompted policy changes at the Ministry of Public Health to expand reproductive health training programs to include training of male providers. The results of this program led to the expansion of male family planning programs in 2008.

One of the strengths of Family Health Alliance's (FHA) programs is its recognition of the challenges involved in providing training to post-conflict populations, such as health providers in Afghanistan. Populations exposed to great trauma and prolonged war often experience many negative emotions including feelings of exhaustion, low self-esteem, and depression leading to fatalistic views about the future. These emotions often result in the trainee's inability to recognize their own potential and their role as agents of change.

To increase knowledge and change behavior among such a population, it is important to utilize special teaching strategies to inspire, encourage, and enhance critical thinking and to assist in the learning process. FHA has designed and employs a unique empowerment model of teaching which includes role models, using Muslim health professionals, self-reliance, and teamwork strategies to address numerous challenges trainees face in a post-conflict environment. These strategies have resulted in a significant increase in knowledge and behavior change among its trainees.

The curriculum includes:

1. Empowerment strategies
2. Infection prevention techniques
3. Family planning counseling for male patients
4. Family planning/contraceptive methods (Injectables, oral pills, IUD's, tubal ligation, condoms, vasectomy)
5. STI's - detection, prevention, and treatment
6. HIV/AIDS - education and prevention
7. Violence against women and its relationship to health and progress

Each program is measured and evaluated in three different ways:

• Pretest/Posttest
• Evaluate trainees' knowledge
• Qualitative Questionnaire
• Accessing trainees' attitudes towards family planning, birth spacing, and male involvement
• Monitoring Data
• Behavior change -Trainees are monitored for 60 days after the completion of the program to access their participation and behavior change in addressing:
1. Birth Spacing
2. Male Involvement
3. HIV/AIDS
4. Condom use in HIV/AIDS prevention
5. Referring wife to the family planning clinic

In fall of 2008, Family Health Alliance (FHA) trained 59 male Afghan doctors and nurses from ten provinces, Badakhshan, Bamyan, Daikundi, Faryab, Kabul (Bagrami), Kapisa, Logar, Nangarhar (Soroobi), Panjshir, and Parwan, in four separate workshops.

In spring of 2008, Family Health Alliance (FHA) trained 42 male Afghan doctors and nurses from four provinces, Parwan, Panjshir, Kapisa and Kabul, in three separate workshops.

In summer of 2007, Family Health Alliance (FHA) trained 47 male Afghan doctors and nurses from three provinces, Parwan, Panjshir and Kapisa, in four separate workshops.

Evaluation and Outcome

Pre- and Post-Test

Evaluation of the three programs found a significant increase in trainee knowledge (mean pre- and post- scores 44% and 87% respectively).

Qualitative

Male doctors and nurses were asked to respond to questions regarding family planning and male involvement. Data across three questions asked indicates a strong desire among male providers to involve men in the process of family planning. Among the numerous responses we received, a few are included below:

1. How important is the participation of men in family planning?

"This is very important in Afghan society, because the ideas of men are more able to be accepted and unless men do not agree with their wives, their wives can not go with their ideas independently."

"Men should encourage their wives to have enough space 3 to 4 between their children. This will have good effects on the health of baby and mother. Parents also can take a better care of their children economically if there are just 3 to 5 children in their families. Smaller family is a better life.

"Afghanistan is a classic and traditional society and family planning is not successful unless men can take an active part in family planning. Men need to understand about family planning and children spacing, they need to be trained and understand how important this is. They need to agree with their wives on one way of preventing pregnancy."

2. What solutions can you suggest to increase men's participation in family planning in Afghanistan?

"I ask our government and health officials to conduct educational healthy courses and establish media centers to advocate for public awareness raising so that our people; especially men will know their responsibilities. They will also know what (family planning) method is more important to them and their family lives and they will use that method. Then, they will dedicate a healthy family to the society…"

"Since men are having more power in most aspects of live in most societies, the goal should be promoting and making gender equality and persuading men to be responsible for their sexual behaviors and other family and society duties."

"First of all, he should stop having unplanned child - if he wants a child, child spacing should be observed - child spacing needs to match with the age and life status of men - with enough advanced knowledge of consequences, he should decide how many children does he want- men need to be encouraged to respect the ideas and rights of their wives - they also need to know about the reproductive health rights of their wives and respect these rights…"

3. What initiatives you can take for better communication with your clients?

"We should be warm and friendly to clients, so they will talk to us about their problems. We need to be caring about clients, so they will trust us and eventually listen to our advices."

"We will use useful tools to help clients to listen to us so they will show their curiosity, like simple words and respecting their ideas. We can set up some kinds of men gathering from the people who come to pick up medicine couple of times a week, and give them a cup of tea while we are talking to them about health cares."

"Men of this county can be involved with a few ways; first, they need to be informed of benefits of family planning and why it is being halal and then, the importance of women's role should be discussed in the family and what will happen to a family without woman. Men also need to be motivated somehow and encouraged.

Monitoring
Monitoring data indicates that male health providers demonstrated a clear effort to apply knowledge and skills acquired.

Trainees were monitored for 60 days after completion of the program(s) to assess their participation/behavior change. Male doctors and nurses, trained in summer 2007, spring 2008, and fall 2008 programs, provided counseling to a total of 15,437 male patients in five subcategories: 92% of patients received counseling in birth spacing, 83% in male involvement, 85% in HIV/AIDS, 75% in condom as prevention, and 71% in referring wife to family planning clinic.