Sex Education, 2018

VOL. 18, NO. 2, 206–218

https://doi.org/10.1080/14681811.2017.1417831

MenCare+ in South Africa: findings from a gender

transformative young men’s group education on sexual and
reproductive health and rights
Harald Keddea  , Kerryn Rehseb  , Giovanni Nobrec  and Wessel van den Bergc 
a
Rutgers, Utrecht, The Netherlands; bMosaic, Cape Town, South Africa; cSonke Gender Justice, Cape Town,
South Africa

ABSTRACT ARTICLE HISTORY

This paper details findings from an evaluation of a gender- Received 19 July 2017
transformative sexual and reproductive health and rights group Accepted 11 December 2017
education programme facilitated with young men aged 15–24 years
KEYWORDS
in South Africa. A total of 475 young men participated in the Sexuality education; sexual
group education programme. A self-administered pre- and post- health; young men; gender
questionnaire survey was conducted with a sample of the participants, attitudes; South Africa
and focus group discussions were facilitated. A total of 265 young men
completed both the pre and post-questionnaires. Findings from the
surveys as well as the focus group discussions showed positive changes
in gender equitable attitudes, contraception and condom use. Results
indicate that the young men who participated in the group education
learned to identify harmful gender norms and actively questioned
these constructs both within their personal lives and in the broader
community. The intervention enabled some participants to envision
alternative versions of masculinity and femininity, thus enabling them
to adopt a new way of being, with transformed attitudes concerning
household and gender roles.

Introduction
South Africa has a robust legislative and policy environment that seeks to protect and
empower women and girls. Despite domestic and internationally aligned policies, govern-
ment-led programmes and active civil society organisations, patriarchal social norms and
discriminatory practices persist. One such set of practices sees men as the head of the house-
hold, the material providers, the ‘protectors’ of the family and household decision-makers.
In contrast, a women’s role is often related to care, for the children, for the family, but with
little, if any, decision-making power (Silberschmidt 2011). Labour migration practices, orig-
inating during the apartheid era and continuing today, see many men forced to be physically
absent in their homes and separated from their partners and/or children. Labour migration
can be considered a contributing factor to the current view of gender roles, in that a man’s

CONTACT  Harald Kedde  h.kedde@rutgers.nl

© 2017 Informa UK Limited, trading as Taylor & Francis Group
 SEX EDUCATION   207

worth is synonymous with his ability to provide financially, while a woman’s worth is inex-
tricably linked to the provision of care (Mkhize 2006).
Research suggests that dominant ideologies teach children from a young age that women
and girls should assume caring roles such as raising children and performing household
tasks, while men’s identity should be defined by their individuality, their ability to take risks,
and their ability to earn an income and provide for the family (Rolleri 2014). These ideologies
have led to women more often experiencing the negative impact of prevailing gender norms
(Gupta, Ogden, and Warner 2011). This can be seen in the persistent harmful social norms
in South Africa; social norms that contribute to the sustained high prevalence of gen-
der-based violence, particular against women and girls and sexual minorities. In addition to
gender-based violence, discriminatory practices, social norms and persistent stereotypes
negatively impact on health access for women and health seeking behaviour for men.
(Jewkes, Flood, and Lang 2015; Peacock and Barker 2014).
Research with men and boys worldwide has shown how inequitable gender norms
increase the use of sexual and physical violence, as well as sexual risk behaviour, and nega-
tively influence men’s role in parenting and caregiving (van de Berg et al. 2013; Levtov et al.
2015; Pulerwitz et al. 2006). Therefore, full equality for women cannot be achieved without
more equal and respectful relationships and fair participation in caregiving by men.
Harmful gender norms also affect men’s sexual and reproductive health. For example,
when men equate their masculinity with sexual dominance over women, or with risk taking,
they are more at risk of contracting a sexually transmitted infection (STI) and to having
negative attitudes towards condom use (Peacock et al. 2009). Men’s own sexual and repro-
ductive health also suffers in terms of access to services: firstly, on the demand side, where
the harmful norms mentioned above increase risky sexual behaviour and discourage men
from monitoring their health or accessing health services; and secondly, on the supply side
where health worker attitudes and sexual and reproductive health services are often not
gender sensitive in how they cater particularly to men (Shand et al. 2014).
South African government policies and programmes acknowledge and refer to the impor-
tance of engaging men and boys as clients and partners in sexual and reproductive health
and gender-based violence programming. In practice, however, across East and Southern
Africa, gender-based violence, sexual and reproductive health, and maternal and child health
programmes and services continue to be focused on women and children. One study in
Uganda for example found that a lack of privacy and confidentiality and matching low levels
of male involvement in sexual and reproductive health to impact on the uptake of services
by women and girls (Kipp et al. 2007; Stern et al. 2015). In other words, men are at risk of
adverse sexual and reproductive health, and this increases the health risks that women and
girls face.
There is growing evidence that efforts to increase the uptake of sexual and reproductive
health and rights and reduce gender-based violence can be more effective when boys and
men are engaged well-designed, short-term, interventions using a gender transformative
approach (Barker, Ricardo, and Nascimento 2007; Dworkin, Fleming, and Colvin 2015).

MenCare+
In this paper we present findings from the evaluation of a gender transformative group
intervention for young people on sexual and reproductive health and rights in South Africa
208   H. KEDDE ET AL.

carried out as part of the MenCare+ programme (http://men-care.org/what-we-do/program-

ming/mencareplus/). MenCare+ is an innovative, large-scale four-country initiative imple-
mented in Brazil, Indonesia, Rwanda and South Africa. The initiative comprised a series of
interventions over a three-year period from January 2013 to December 2015. It aimed to
transform prevailing notions of masculinity that have a negative impact on people’s sexual
and reproductive health and rights and family well-being. It was anticipated that the pro-
gramme would lead to:

• improved equitable involvement of men in domestic work and childcare;

• improved sexual and reproductive health and rights and relational well-being of women
and men;
• a decrease in gender-based violence; and
• an increase in the use of contraceptive and health-seeking behaviour of men.

MenCare+ was designed as a comprehensive programme, with a set of complementary

and integrated interventions, which were expected to have a greater impact when combined
than implementation of only one or two components. The programme was designed in line
with the socio-ecological model, with interventions being implemented at multiple levels:
individual, relationship, community and societal (CDC 2015). Interventions at the individual
and group level included group education on sexual and reproductive health and rights and
equality for young men and women, and on maternal, new born and child health and car-
egiving for fathers and mothers. These groups were accompanied by community-level cam-
paigns to change social and gender norms. At the societal level, partner organisations worked
with health services to improve the quality and accessibility of sexual and reproductive
health services, including training of health sector staff to promote adolescent and father-
friendly services, and by providing individual and group counselling for men who use vio-
lence. Partner organisations also advocated with key policy- and decision-makers to create
an enabling environment for sexual and reproductive health and rights, violence prevention
and men’s involvement in maternal, newborn and child health.

Study objective and research questions

This paper’s objective was to evaluate one aspect of the MenCare+ programme, namely
young men’s gender transformative group education on sexual and reproductive health and
rights in Cape Town, South Africa. The main hypothesis was that a change in gender equitable
attitudes among young men aged 15–24 years would affect their sexual risk behaviour,
attitudes towards contraception and health-seeking behaviour. More specifically, we aim to
provide insight into the following areas:

(1) to what extent did this intervention change the gender equitable attitudes of
participants,
(2) to what extent did the intervention change participants’ attitudes towards and the
use of contraceptives, and
(3) how did the intervention influence participants’ lives; in particular, how did partic-
ipants benefit from the intervention?
 SEX EDUCATION   209

Gender-transformative approaches to change

Gender-transformative approaches seek to reshape gender relations so as to be more gender
equitable, largely through interventions aiming to counter the impact of harmful gender
and sexual norms, for both women and men (Barker, Ricardo, and Nascimento 2007; Dworkin,
Fleming, and Colvin 2015; Pulerwitz et al. 2006; Rolleri 2014). Gender-transformative
approaches challenge internalised belief systems, closely held gender identities, entrenched
institutionalised structures and gender roles. The change observed through the implemen-
tation of a gender-transformative approach is often emergent rather than linear; it is multi-
dimensional and sensitive to diverse actors’ experiences of change (Kantor and Apgar 2013).
Changes in gender relations and/or challenging gender roles are often defined in ways
that men may view as threatening to their traditional roles as income earners and heads of
households (Barker 2000). With the engagement of men and boys in gender transformative
interventions, the role that men play in sexual and reproductive health and rights can be
more fully acknowledged as they are provided with the opportunity to examine, unpack
and question harmful gender norms (Rolleri 2014). A gender-transformative approach tries
to change gender roles so as to establish more respectful and egalitarian relationships (Gupta
2000). It encourages men to become the agents of positive change by acting from a more
critical understanding of gender roles and understanding how these norms can negatively
affect their lives and those of their partners and families. Engaging men and boys in gender
transformative work needs to stretch beyond addressing individual gender inequities to
actively challenging the prevailing inequity in society and institutions such as government
or service providers (Barker 2000). It is important to acknowledge that a gender transform-
ative process is an interactive, long-term process that allows for the learning of new behav-
iours through practised and repeated action (Courtenay 2000).

Young people’s gender transformative group education on sexual and reproductive

health and rights
The MenCare+ intervention encompassed a gender transformative approach to sexual and
reproductive health and rights, gender equality and caregiving. As one part of the
MenCare+ South Africa project, local organisations facilitated group education sessions with
young men on sexual and reproductive health and rights and gender equality, using an
adaptation of the Program H manual first developed by Promundo-Brazil (Promundo 2002).
Program H is an initiative developed in Latin America to promote more gender-equitable
attitudes among young men. It works in group educational settings and at the community
level to change community norms about what it means to be a man. Program H is named
after homens and hombres, the words for men in Portuguese and Spanish. The programme
tries first and foremost to tap into the ‘alternative’ voices that exist in low-income commu-
nities, that is, the voices of young and adult men who have been questioning traditional
views of what it means to be a man (Barker et al. 2006).
MenCare+ South Africa undertook a participatory process to adjust the content to the
South African context to ensure relevance and applicability to the target group. The adap-
tation process followed three steps: the first consisted of an initial implementation of the
standard Program H manual, followed by a reflective focus group with participants and
facilitators about the relevance of the sessions. The second step was an adaptation workshop
210   H. KEDDE ET AL.

Table 1. Thematic session overview of the young people’s group education on sexual and reproductive
health and rights.
Session 1 Getting to know each other
Session 2 The sexual and reproductive body
Session 3 The erotic body, male sexuality and pleasure
Session 4 Gender roles and sexual orientation
Session 5 Let’s talk about contraception and pregnancy
Session 6 Respecting yourself and others
Session 7 Gender, HIV and Aids
Session 8 Sexual violence, physical violence and respect
Session 9 Alcohol abuse: risks, violence, HIV and Aids

with facilitators, participants and curriculum experts in which sessions were reviewed one
by one, and adjustments were made or new sessions added. The last step was a test of this
adapted version with a group of participants to include final adjustments.
The final contextualised group education comprised nine structured sessions that
included content on gender, relationships, sexuality, contraceptive use, caregiving, sexual
and domestic violence and sexual and reproductive health and rights. The two-hour
sessions were mostly conducted in school classrooms or community halls with 15–20
young men who participated in all nine sessions. A thematic overview of the sessions is
given in Table 1.

Methodology
Quantitative data
A self-administered questionnaire was completed by the participants before and after the
group education (pre-post test design). Quantitative data were collected by the implement-
ing partner organisations – Sonke Gender Justice and MOSAIC Training, Service and Healing
Centre for Women – throughout the three-year implementation period (2013–2015). Data
were then analysed by independent external evaluators. The questionnaire included ques-
tions about participants’ demographic characteristics: gender, age, relationship status, living
status, and level of education, followed by four sections on (1) attitudes towards gender
equality; (2) attitudes towards contraceptives; (3) sexual behaviour, condom use and shared
decision-making; (4) health seeking behaviours with regard to sexual and reproductive
health-related issues, and being comfortable talking to a health care professional. The time-
frame for health seeking was set at three months, which was approximately the duration of
a single intervention.

Sample
During the implementation period, a total of 621 young men participated in the group
education. For this study, a convenience sample was selected: a total of 265 men filled in
both the pre- and post-test questionnaire, and only these participants were included in the
quantitative analysis.
 SEX EDUCATION   211

Measures and statistics

Gender equality was measured using thirteen items selected from the Gender Equitable
Men (GEM) Scale developed by Pulerwitz and Barker (2008). The full GEM scale is a twen-
ty-four item tool that measures gender norms related to sexual and reproductive health,
sexual relations, violence, domestic work and homophobia. We decided to work with thirteen
items from this scale, selected through a careful matching with the thematic content of the
programme. Scoring consisted of 1 (Agree), 2 (Partially agree), and 3 (Not agree) to each of
the thirteen questions, resulting in a maximum summed score of 39, which would reflect
the highest level of gender equal attitude.
Attitudes towards contraceptives were measured using six items of the Contraceptive
Attitude Scale developed by Black and Pollack (2011). Some items were revised to fit the
target group. Examples of questions include: ‘Condoms ruin the sex act’, and ‘Couples should
talk about contraception before having sex’. Scoring consisted of 1 (Agree), 2 (Undecided),
and 3 (Disagree) on each of the six questions, resulting in a maximum summed score of 18,
which would reflect the highest level of positive attitude towards contraceptives.
Condom use was measured using one self-constructed question, ‘Did you use a condom
last time you had sex?’, answered by indicating 1 (Yes) or 2 (No).
Shared decision-making on condom use was measured with one question, ‘Who made
the decision to use a condom?’ Scoring consisted of 1 (Me), 2 (My partner), and 3 (Both).
Paired sample T-tests were used to determine whether there was a significant difference
between pre- and post-test scores. Significance testing was conducted using an alpha level
of .05. Fisher Exact Test was used to compare percentages, before and after having received
the intervention. Data were analysed using SPSS 21.0 software.

Qualitative data
Qualitative data were collected by means of four Focus Group Discussions (FGDs) with 33
young men. Convenience sampling was again used, and informed consent was provided by
all respondents. The FGDs lasted 1–1.5 h in length, and were conducted by independent
external evaluators, using a semi-structured FGD guide, focusing specifically on the added
value of the intervention, perceived changes that participants had experienced in their lives,
and their way of thinking after participation in the group education sessions. The FGD guide
was developed in close collaboration with programme implementation staff, and was trans-
lated into English, Afrikaans and Xhosa. The language use in the FGD was determined by
the main language spoken by the young men involved. All the FGDs were facilitated by male
evaluators and were audio-recorded and were transcribed verbatim. The external evaluators
also made field notes, which they used in combination with the transcripts to conduct a
qualitative analysis of findings. Ethical approval for this evaluation was obtained from the
Foundation for Professional Development’s Research Ethics Committee, which is registered
with the National Research Ethics Council of South Africa.
212   H. KEDDE ET AL.

Results
Gender equitable attitudes
Gender equitable attitudes improved significantly for participants in the group education.
The mean scores of participants who filled in all 13 items of the questionnaire on the GEM
scale increased significantly from 27.1 to 31.5 out of a maximum score of 39 (N = 200;
p < .001). To increase the sample size, an additional paired sample T-test was conducted for
all participants who filled in at least two thirds of the items, which in this case applied to
those who responded to at least 9 of the 13 questions. In this enlarged sample, the mean
scores on the GEM scale increased significantly from 27.9 to 28.2 (N = 262; p < .01). Further
more, it was found that all 13 items tested separately were significantly different with p levels
varying from p = .000 to p = .020, see Table 2.
At item level, the largest positive changes were found in responses to the following three
items: (1) ‘Changing diapers, giving the kids a bath, and feeding the kids are the mother’s
responsibility’ (+29.3% disagreeing with the statement; p < .001); (2) A woman’s most impor-
tant role is to take care of her home and cook for her family (+28.3%; p < .001); (3) A man
should have the final word about decisions in his home (+28.3%; p < .001). Two items were
significant at the p < .05 level: ‘I would never have a gay friend’ (n = 254; p < .05), and ‘It is

Table 2. Statistical differences in gender equitable attitudes of male participants before and after sexual
and reproductive health and rights group education.
% % Is the change statistically
% agree % agree disagree disagree significant? (paired sample
Questions pre-test post-test pre-test post-test T-test; 95% confidence)
A woman’s most important role is to N = 262 Yes p = .000
take care of her home and cook for 6.1% 34.4%
her family
Women who carry condoms on them N = 260 Yes p = .000
are ‘easy’ 40.4% 61.2%
Changing diapers, giving the kids a N = 257 Yes p = .000
bath, and feeding the kids are the 26.8% 55.3%
mother’s responsibility
In my opinion, a woman can suggest N = 258 Yes p = .004
using condoms like a man can* 66.3% 78.3%
It is a woman’s responsibility to avoid N = 256 Yes p = .000
getting pregnant 32.0% 57.4%
A man should have the final word N = 258 Yes p = .000
about decisions in his home 26.0% 54.3%
A woman should tolerate violence in N = 254 Yes p = .000
order to keep her family together 47.6% 64.2%
A man and a woman should decide N = 259 Yes p = .000
together what type of contracep- 65.3% 80.7%
tive to use*
It is okay for a man to hit his wife if N = 257 Yes p = .001
she won’t have sex with him 77.4% 87.5%
I would never have a gay friend N = 254 Yes p = .020
37.0% 46.1%
*If a guy gets a woman pregnant, the N = 256 Yes p = .000
child is the responsibility of both 68.8% 82.0%
It is important that a father is present N = 256 Yes p = .015
in the lives of his children, even if 78.1% 85.2%
he is no longer with the mother*
Real men only have sex with women N = 261 Yes p = .000
21.8% 37.9%
*
Percentage that agreed with the statement is presented.
 SEX EDUCATION   213

important that a father is present in the lives of his children, even if he is no longer with the
mother’ (n = 261; p < .05), indicating that the positive shifts in attitudes towards these matters
were relatively smaller than those found in the other items.

Attitudes towards contraceptives

Young men’s attitudes towards contraceptive use changed significantly upon completion
of the group education (T0 = 13.8; T1 = 15.1; N = 201; p = .000). At item level, the young men
displayed a more positive attitude towards contraceptives on four of the six items (see Table
3). However, the items ‘Condoms are an effective method of preventing the spread of HIV
and sexually transmitted diseases’ and ‘Condoms are not reliable in preventing pregnancy’
were found to remain the same post-group education (see Table 3).

Condom use and decision-making

To calculate the difference in the young men’s condom use before and after the group edu-
cation, only those respondents who indicated being sexually active at the time of data
collection were included. Condom use of the young men after the group education increased
with 10.9% points from 57.1 to 68.0% (Fisher’s Exact Test; N = 201; p = .000).
Table 4 presents the results detailing whether the use of a condom was a shared decision
or not. Respondents who were not sexually active at the time of data collection, or those
who did not use a condom the last time they had sex, were excluded from the analysis of
decision-making for condom use. The majority of young men indicated that the decision to
use a condom was made together with their partner; the percentage of young men who
made this decision with their partner increased by 11.7 percentage points from 54.3 to 66
percent after the group education.

Table 3.  Differences in attitudes towards contraceptives of participants before and after group
education.
% Is the change statisti-
% agree % agree disagree % disagree cally significant? (95%
Questions pre-test post-test pre-test post-test confidence)
Men who use contraceptives seem N = 234 Yes p = .000
weaker than men who do not 42.7% 63.7%
Couples should talk about N = 241 Yes p = .019
contraception before having sex*
77.2% 85.1%
Two people having sex should use N = 237 Yes p = .000
some form of contraceptives if
they aren’t ready for a child* 72.6% 88.2%

Condoms are an effective method N = 244 No p = .994

of preventing the spread of HIV
and sexually transmitted 67.2% 73.4%
diseases*
Condoms are not reliable in N = 244 No p = .320
preventing pregnancy
29.5% 34.8%
Condoms ruin the sex act N = 243 Yes p = .000
34.6% 58.8%
*
The direction of these items is different and responses had to be recoded in order to calculate the mean score.
214   H. KEDDE ET AL.

Table 4. Shared decision-making on condom use in relation to actual condom use at last sex.
Who made the decision to use a condom?
Me My partner Both Total
32.6% (n = 60) 13.0% (n = 24) 54.3% (n = 100) 100% (n = 184)
30.4% (n = 59) 3.6% (n = 7) 66.0% (n = 128) 100.0% (n = 194)

Use of health care services

The use of health care services by young men with regard to sexual and reproductive health
issues remained approximately the same before and after the group education. One third
of the young men (32.9%) had contacted a health care professional in the last three months
at a clinic or hospital, which is 2.4% more than had done so before attending the sessions.
The percentage of young men who felt comfortable asking health care professionals for
information about sexuality related issues increased from 68.2 to 77.5% after attending the
group education.

Qualitative findings – ‘What does it mean to become a man?’

Data from the focus group discussions supports the quantitative results. After attending
group education, young men expressed the view that to be a young man was to be respon-
sible, supportive to your partner and community, and a role model to other young men in
their community. Participants mentioned that in contrast to this, in their communities pop-
ular ideas of what it means to be a young man were to smoke, to drink, to be a gangster and
to have many girlfriends.
Yes, being umajita [cool guy], a gangster and having many girlfriends … things like that …
that’s a man.
… as young men we drink and get drunk, once we are drunk some of us win girlfriends and
have unprotected sex with them …
Some of the young men reported that the programme taught them that hitting and abusing
their girlfriends was wrong.
Yes a lot has changed, for me I grew up knowing from the way my father used to do things, that
a woman do not have a right to say anything, I knew that the only way to resolve any issues with
a woman is to hit her …… But now through the sessions, I know that it is important to listen to
your girlfriend’s facts instead of shutting her up. Most of the time I’ve realised that she has an
important point which I was not going to hear if I shut her up.
Most boys don’t know how to resolve issues because the girls shout at them, the only thing
that most boys knows is to hit them in order to shut them up. So this program has taught them
that such thing is wrong. Now if my girlfriend shouts at me, I rather walk away than to hit her, I
then come back when we are both calm to discuss the issues that caused problems but if she’s
still upset I leave her until she’s calm.
There were also reports of improved communication about contraceptive use between part-
ners as well as increased acceptance of gay men.
The programme has changed me, now I am able to communicate with my girlfriend about
contraceptives, I even accompany her to the clinic.
We have learnt to respect and accept guys who have relationship with guys …… I used to ignore
them and we used to call them names …… now I respect their choices.
 SEX EDUCATION   215

Further, focus group discussion participants indicated that after participating in the pro-
gramme they took the responsibility to ensure that they have protected sex, carry condoms
with them to ensure they are available, and that they use a condom each time they have
sex. Participants also discussed what the programme has taught them about sexually trans-
mitted diseases and their symptoms.
… sometimes my girlfriend do not like an injection because she says it will make her fat … in
that case I have to use condom because it’s both our duty to use contraceptives not only hers
…. I always think that it will not be fair to make her pregnant at a young age because we both
need to finish school …. so I always make sure that we are having protected sex.
The programme has taught me the risks and dangers of unprotected sex, there was an example
that was made during one of the session on contraceptives where we were told not to trust
condoms brought by other people (partner) because it’s impossible to see if the other person
has put the needle through the sealed condom; as a result, since that time I always carry my
own condoms.
Significant barriers to men accessing sexual and reproductive health services were found
during the qualitative analysis. One of the main barriers was the fact that sexual and repro-
ductive health clinics were perceived to be a woman’s domain. Additionally, health care
workers tended to express negative attitudes towards their clients. Men recommended that
clinics needed to be more ‘friendly’ towards men, both in terms of the infrastructure and
décor and in terms of the health care workers’ attitudes towards men.

Discussion
In this study, participant’s gender equitable attitudes increased significantly post-interven-
tion. The use of health care services by young men with regard to sexual and reproductive
health issues however did not increase after the group education. However, more men did
report feeling comfortable asking a health care professional for information about sexuality
related issues.
Several factors may underlie the discrepancy between respondents’ improved attitudes
and the lack of increase in service-use. In some ways this discrepancy is surprising since
MenCare+ was implemented using a socio-ecological model which combined community
level health promotion, the education of health service providers and group education.
Perhaps the timeframe of nine weeks (one session per week) of the MenCare+ programme
was too short to trigger an increase in the use of sexual and reproductive health services. It
is also possible that some respondents lived far from likely suitable service providers. It is
also worth noting that community level health service provider education was not completed
across all of the intervention sites, and that this may have affected patterns of use.
This study found a statistically significant and positive shift in participant’s attitudes
towards contraception, as well as a substantial increase in joint-decision-making with respect
to condom use. The number of men who indicated using a condom last time they had sex
increased by 11% points. The use of condoms as well as the commitment to use condoms
when engaging in sex is supported by the qualitative data. The relationship between high
levels of gender equitable attitudes and positive attitude towards contraception and shared
decision-making is consistent with the findings of a study by Pulerwitz and Barker (2008)
where a subset of young men aged 15–24 years were found to be more likely to think more
216   H. KEDDE ET AL.

positively about contraception as well as show increased engagement with their partner
about contraception use.
Foss et al. (2008) found that the decision to use condoms is influenced by the type of
partnership and the perceived risk. Individuals with perceived risk (Green and Murphy 2014)
or high susceptibility (Carpenter 2010) are more likely to seek help from a health service
provider. If such perceptions are coupled with strong cues to action and a high level of
self-efficacy, the individual is more likely to embark on changing his behaviour. Findings
from this study suggest that young men’s group education on sexual and reproductive health
and rights provided participants with the triggers necessary for change, whilst fostering a
sense of self-efficacy. These results confirm the hypothesis that an increase in gender equi-
table attitudes will likely improve the likelihood of success of sexual and reproductive health
and rights education and the uptake of contraceptives.

Study limitations
This study has several limitations, such as the lack of long term follow up, the absence of a
control group, and the inability to generalise findings to other settings. Also, the study took
place within a context in which the main aim of resource allocation was not to provide data
for the study but to effect social change. This may have improved the real-world applicability
of findings but limited the scope for evaluation opportunities such as follow up data collec-
tion or pre-intervention FGDs.
In addition, the sample was a convenience sample not representative of all young men
in Cape Town. Low literacy levels among some participants may also have created difficulties
since in some groups participants asked for help. This was mitigated by data-collectors going
through the questionnaires question by question with the group and explaining where
necessary.

Conclusion
Despite these limitations, study results support the conclusion that gender transformative
group education can contribute to young men having more gender equitable attitudes and
the improved uptake of contraceptives. Young men in this study learned to identify harmful
gender norms and left the intervention actively questioning these both within their personal
lives and the broader community.
Study findings lead us to make three recommendations for future implementation. The
first of these emerges from the discrepancy between young men’s positive attitudes towards
accessing sexual and reproductive health services and their actual uptake of the services.
The socio-ecological nature of the MenCare+ model is one of its strengths and this discrep-
ancy emphasises the need to combine group education with the effective community pro-
motion of health services and education of health workers. The second recommendation is
that health departments develop ways to ensure facilities are more gender sensitive and
responsive, for example by displaying promotional materials that depict men who are access-
ing services, or by matching service provision with the working hours of men in a particular
community. The third recommendation is that future group education interventions about
sexual and reproductive health be developed to be explicitly gender transformative, with
 SEX EDUCATION   217

the ability to improve gender equitable attitudes among participants, since this holds the
potential to strengthen young people’s sexual and reproductive health.
Evidence in support of gender transformative interventions is growing, and along with
other encouraging reports of effective change strategies, this study contributes towards
making it more feasible for health departments and other stakeholders to improve health
and gender equality, and to bring such evidence based strategies to scale.

Acknowledgements
This study would not have been possible without the young men who participated in this study. Their
openness and willingness to participate provided us with valuable insight to aid in the planning of
future interventions that seek to strengthen sexual and reproductive health education and access to
services and work in pursuit of gender equality.

Funding
MenCare+ was funded by the Ministry of Foreign Affairs (Ministerie van Buitenlandse Zaken) of the
Netherlands [grant number 24935].

ORCID
Harald Kedde   http://orcid.org/0000-0003-1175-7298
Kerryn Rehse   http://orcid.org/0000-0002-4737-3918
Giovanni Nobre   http://orcid.org/0000-0003-4302-2245
Wessel van den Berg   http://orcid.org/0000-0003-0030-5886

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