Men's perceptions of masculinities and sexual health risks in Igboland, Nigeria.
Subject: Masculinity (Physiological aspects)
Masculinity (Research)
Men (Physiological aspects)
Men (Sexual behavior)
Men (Research)
Authors: Odimegwu, Clifford
Okemgbo, Christian N.
Pub Date: 03/22/2008
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Men's Studies Press ISSN: 1532-6306
Issue: Date: Spring, 2008 Source Volume: 7 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Nigeria Geographic Code: 6NIGR Nigeria
Accession Number: 178535126
Full Text: After the 1994 International Conference on Population and Development, reproductive health programs responded to women's experiences of sexual and reproductive illness. However, there has been no commensurate systematic attempt to understand men's health issues. This study was designed to examine how men from a Nigerian ethnic group (i.e., the Igbo, formerly called the Ibo or Ebo) perceive masculinity and its impact on their sexual and other health needs. Qualitative data were generated and content analyses of the results were carried out. Participants indicated that there is a shift from traditional to non-traditional attitudes and practices among men in the area from which the sample was drawn. Factors responsible for this shift include education, religion, migration patterns, the influence of mass media and globalization. The men reported awareness of sexual and other health needs in the context of their experience of masculinity. Implications of findings for future research and advocacy are discussed.

Keywords: masculinity, health issues, Igbo, Nigeria

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A major turning point in the field of population studies occurred in 1994 when the International Conference on Population and Development (ICPD) asserted the need to involve men in health issues, especially those of reproductive health. Reproductive health programs that emerged from the Cairo and Beijing conferences emphasized women's reproductive health as a fundamental human right (Cliquet & Thienpont, 1995; Dudgeon, 2003). While reproductive health needs of men have been placed squarely on the research and policy agenda, there are still many unanswered questions about issues related to male sexual and reproductive health (Drennan, 1998, Mbizvo, 1996; Presser & Sen, 2000).

It is generally acknowledged that gender-based customs and ideas affect men's behavior, but there is a notable lack of research on men's understanding of gender issues and their impact on men's health in sub-Saharan African (AGI, 2002; Courtenay, 2000; Danforth & Green, 1997; Drennan, 1998; Hawkes, 1998; IPPF/RHO/AVSC, 1998; RHO, 1999; Sabo & Gordon, 1995).

Men's studies in Nigeria and elsewhere in Third World countries have shown that men need to participate in sexual and reproductive health programs (Ezeh, 1993; Feyisetan, Oyediran, & Ishola, 1998; SSRH, 1999; United Nations Population Fund/UNFPA, 2001). An over-emphasis on male involvement in women's reproductive health has led to an oversight of men's health needs. The ICPD Consensus has highlighted the need to involve men in achieving the objectives of that landmark conference (Davies, McCrae, Frank, Dochnahl, Pickering, & Harrison, 2000; Mundigo, 1998; Waldron, 1988). Existing studies in Nigeria looked at how to involve men in women's reproductive health issues such as obstetric care (Adewuyi, Odebiyi, Aina Bisi, Olatubara, Eniola, & Odimegwu, 2005; Adeyefa et al., 2004; Odimegwu et al., 2002), reproductive decision-making (Isiugo-Abanihe, 2003), and men's participation and responsibility in sexual and reproductive health (AGI, 2002; Mundigo, 1995; United Nations Population Fund/UNFPA, 1995). There have been studies of men's knowledge of and attitudes toward sexual and reproductive health needs of their partners (Bankole & Singh, 1998; Feyisetan, Oyediran, & Ishola 1998; Omideyi, Odimegwu, C., & Raimi, 1999). However, these studies fell short of investigating the issue of masculinity and its impact on men's health.

UNAIDS (2001) has highlighted critical masculine ideologies that affect men's sexual and reproductive health. Men's behavior is driven by traditional expectations about gender. For example, sexual initiation among men in most parts of the world is seen as a rite of passage to manhood (WHO, 2000). Men are under pressure to conform to often destructive ideas about what it is to be a man, ideas that emphasize sexual prowess, multiple sexual partnerships, and risk-taking. Obviously, these ideas place both sexes at greater risk of HIV and STIs. UNAIDS (2001) also noted that masculinity is related to hierarchy and power relations. At the same time, patriarchy is the dominant ideology in most African countries, including Nigeria. The Nigerian Population Policy of 1988 recognized the leadership and authority of men in making family decisions on issues of family size, subsistence, and social relations. The policy upheld patriarchy as being a guarantor of stability in the home (Dixon-Mueller & Germaine, 1996). This greater decision-making role of men has been acknowledged. For example, Karanja (1983) found that in most Nigerian households, husbands alone decided the most important issues affecting the family.

While feminist scholars have made advances in defining and obtaining public approval for women's sexual and reproductive health rights and needs, no such movement exists for men. Rather what results is a counter-reaction that sees men as the enemy rather than as partners. Although men have been included as research subjects, there are no studies to examine specifically men and the health risks associated with men's gender. Little is known about why men engage in less healthy lifestyles and adopt fewer health-promoting beliefs and behaviors. Even in studies that address health risks more common to men than women, the discussion of men's greater risks and the influence of men's gender is missing.

Mundigo (1998) pointed to the need to study the social norms and traditional customs that make it difficult for some men to become more directly involved in reproductive health matters or measures with their partners, arguing that discriminating against men in research will eventually have negative repercussions on women, too (Courtenay, 2000; Sabo & Gordon, 1995). Men must be understood and included in programs that strive for gender equality and equity.

This study was designed to examine men's perceptions of masculinity and its consequences for their sexual and other health needs. Rather than trying to understand what men believe and feel about their health problems, men have been studied from the perspective of what we could learn about them in order to convince them to participate in women's sexual and reproductive health programs that were already in place. Unless men's needs are identified, addressed and included in current reproductive health activities, however, it is unlikely that the well-being of women will be enhanced (Mundigo, 1998; RHO, 1999). To achieve the dual goal of gender equity and health among men and women, we must understand men's knowledge of the beliefs and practices that expose them to health dangers.

The overall purpose of this paper is to reveal the target group's knowledge of, attitudes toward and perceptions of masculinity and its impact on their sexual and other health needs.

The questions asked were: What are the traditional masculine ideologies of the area (Nigeria)? How are men's sexual and other health needs affected by their sense of masculinity? How can sexual and reproductive health programs better serve the needs of men?

Theoretical Framework

The study argues that boys learn to adopt masculine behavior that heightens their susceptibility to illness or accidental death. The social environment, including overall cultural and family values and peer relationships, teaches men and women to display distinct sex-typed behaviors and attitudes. Pleck (1981, 1995) posited that this influence is accomplished through the adoption of norms and stereotypes. Norms are prescriptions for how men and women should behave, while stereotypes are generalizations about what men and women are like and can do (Kimmel, 1996; Pleck et al., 1993; Mansfield, 2003).

Masculinity ideologies also play a part. These are ideas and concepts that individual men hold about what it means to be a man. The study of masculinity ideologies is concerned with the extent to which men endorse ideologies that emphasize self-reliance, competitiveness, emotional control, power over others, and aggression (Pleck et al). For example, a man might believe that men should keep their emotions under control, and that by extensions they should not be emotional when under stress. Endorsement of masculine ideologies might also involve a man's adherence to self-reliance in the face of hardship, a belief that competition in professional and social domains is crucial for success, a strong preference for resolving conflicts with aggression so as not to appear feminine, or a desire to demonstrate dominance and power over others in social interactions (Pleck, 1995). Subscription to traditional masculinity ideologies may influence men's health-seeking patterns. For example, men with traditional masculinity ideologies may deny or refuse to seek help for pain, illness, or emotional problems in an effort to avoid being perceived as vulnerable or weak (Kaufman, 1994; Mansfield). As a result, adherence to traditional masculinity ideologies is often hazardous to men's health (Mahalik et al., 2003).

Target Group and Methodology

The study was conducted in Imo State, in the southeastern part of Nigeria. All of the participants were Igbo, the third largest ethnic group in Nigeria and the principal ethnic group in the state. Two areas were selected from the state, one urban and one rural. The urban area was Owerri, the state capital, while the rural area was Orsu. Imo State was chosen for two reasons. First, it is the home of authentic Igbo culture and traditions and does not have a mixed culture, unlike other lgbo areas where people are drawn from different ethnic groups. Secondly, its proximity to the researchers made it the most accessible area to study.

Qualitative data techniques were used to collect information. This approach seemed most appropriate because the study concerned perceptions of a cultural phenomenon and this can best be captured using qualitative studies. Specifically, focus group discussions and in-depth interviews were used to identify gender-based cultural norms, beliefs, attitudes, and practices related to reproductive health and sexuality among the men studied.

Focus group discussion sessions were organized around four age groups: young males (15-24), young adults (25-39), adults (40-54), and older males (55+). These age groups often cut across important milestones in the lives of men in the population. One question we raised is whether masculinities vary by age groups. It was hypothesized that the age of participants would influence the perception and practice of their masculinity. Participants from each group were matched by age, education, and occupation in each research site. We believed that education and occupation are key socioeconomic characteristics that can affect perceptions of and attitudes toward masculinity.

A total of 20 group discussions were conducted, each including six to eight males who were purposively sampled. The men were randomly selected from selected households. During the discussions, we identified some interviewees who demonstrated good knowledge of the issues at stake. These people were then invited for an in-depth interview. Ten in-depth interviews were conducted with representatives of all age groups. One healthcare provider from each site was also interviewed.

The primary consideration in selecting an adolescent as a potential participant was that he must be sexually experienced. Ten community leaders (five rural, five urban) were also recruited as key informants. There were slight differences in the questions asked. While the group discussions dealt with broad issues of gender, socialization, masculinities, both the in-depth and key informant interviews focused on specific experiences of masculinity and cultural insights into this phenomenon.

Group discussions were conducted at places central to all the selected participants' homes. Such places include community halls, schools, and church hails. Selected participants were invited to come to a central location where the discussions were conducted. Facilitators were trained how to guide the flow of discussions so that all participants could contribute to the conversation. They were also taught how to handle participants who might try to dominate discussions.

Each of the interviews was guided by an interview protocol that focused on the objectives of the study. There were ten questionnaire items in the focus group discussion guide. The following questions were posed to the participants:

What does it mean to be a man the community? What are the qualities of a "real man" in Igboland? How do men prove their manhood in the community? What are the behaviors that expose men to health risks? and What are common sexual and other health needs boys and men have in the community?

These and other questions also guided the in-depth and key informant interviews. Group discussions and in-depth interviews centered on perceptions and beliefs about masculinity and awareness of how these affect sexual and reproductive health. In-depth interviews with key informants focused on the issues of community norms and the relationship of masculinity and men's health. The average duration of a focus group discussion was 90 minutes and the average time of an in-depth interview ranged between 90 and 120 minutes.

Group discussions with uneducated interviewees were conducted in the local language and led by research assistants who were trained in qualitative methodological techniques. All information was tape-recorded, transcribed, and translated by two of the research assistants. Each transcript was checked and double-checked by the second author, who was also the project manager. The transcribed focus group and in-depth data were analyzed for content in order to uncover themes and trends. We used a manual method to code the responses and categorize them according to themes of interest. The views highlighted in this analysis represent consensus views of the participants.

At the end of each question we made sure that the common opinion had been expressed and agreed upon by all the participants in the discussion. For each issue discussed, comments were compared on the basis of age, place of residence, and level of education. We focused on these variables since we hypothesized they were influencing the perceptions of and attitudes toward masculinity. We expected differential patterns of response between young and older men, educated and non-educated, working and non-working men, urban and rural respondents.

Knowledge and Perception of Traditional Masculinity

Generally and as expected, there was a predominance of traditional masculine beliefs and ideologies among the participants. All reported awareness of traditional roles and ideologies associated with masculinity in Igboland. There were no urban versus rural, educational, or age-related differences in the participants' perceptions.

In Igboland, a man is known by his ability to provide for his family, integrity, keeping secrets, bravery, nobility and ability to control his temper.

Equality between a husband and wife is not a traditional cultural norm among the Igbo. Analyses of the data clearly illustrated that the dominant position of the male continues to be upheld by many of those who participated in the group discussions.

These men showed that they are "real men" by accumulating many wives, exercising control over them, and making a contribution to the community. A male may be ridiculed in the community if he cannot control his immediate family. If a man's wife is unruly and is seen to dictate what happens in the family, he is not regarded as a "real man."

Participants (including in-depth interviewees and key informants) defined masculinity in terms of responsibility and desire for the opposite sex. To be a man is seen in terms of one's achievement. Broadly speaking, characteristics of manhood in the society include:

For adolescents, being a man implies that one has reached the age of taking responsibility for his decisions. Among the Igbo, the man is the primary decision-maker and able to fend for himself and his family. Igbo males are expected to be social achievers. A middle-aged man in one of the focus group discussions expressed these ideals as follows:

The responsibility of the man as protector, provider and main breadwinner was clearly expressed by one of the participants who explained that

As expressed by one participant and spontaneously agreed upon by others, an Igbo man is the bridge between his family and the external world as well as the link between the past and the future. He is the intermediary between his family and the group's ancestors.

Other characteristics of manhood were highlighted:

Focus group participants discussed the issue of becoming a man and the transition from childhood to manhood.

A young boy begins to understand that he is in the process of becoming a man when he observes biological or physiological changes in himself. One young adult linked changes in biological make-up with changes in societal perception:

The transition to manhood was also defined in terms of age.

An older man reaffirmed the notion of an Igbo man being a provider, breadwinner and problem-solver. He described a "real man" as one who is able to:

As the following comment indicates, manhood is seen as an achieved and ascribed status:

A young adult in an urban group discussion added that

The views expressed by these participants are in line with literary documentation of Igbo masculinity. In Chinua Achebe's classic novel (1958), Things Fall Apart, the ultimate show of masculinity by an Igbo male is said to be keeping women in line either through mental or physical abuse. In Igboland, to be a man is to be violent, strong, bold, fearless, competitive, and courageous. Showing any emotion is a sign of weakness or is considered to be a female trait. All that is good is considered masculine and all that is bad is thought of as feminine. This is shown in the use of both language and in work patterns (Mezu, 1999).

The agricultural system of the lgbo people supports sex-typed gender roles. The main crop is the yam and is synonymous with virility. Yams stand for manliness, and a male who can feed his family on yams from one harvest season to another is a "real man." The female crops of cocoyam and cassava are smaller and of less importance to the tribe. This reinforces the idea that to be manly is to be supreme and that women are much less valuable by comparison. Women are esteemed for their potential as mates and mothers (Achebe; Chun, 1990; Mezu).

Men are seen as the "head of the women," the king and defender of women from trouble. An Igbo man is not required to betray his emotions. A man or woman is described as the son, daughter, wife or daughter of a man. Most policy-makers are males, although there are an increasing number of females in policy-making institutions, which in most cases is a matter of tokenism, however, since women have no power to forward their views. The Nigerian constitution recognizes equality of sexes, yet male child preference is still common among the tribe (Odimegwu 1998, 1999).

Masculine ideologies are learned during the process of socialization. Two adult participants stressed the important role of the family:

The Igbo man is expected to participate in his community. Various institutions within his community play a vital role in teaching him to be a man. An adult pointed out that

The importance of biological changes leading to manhood was stressed by one man:

Older participants recounted how they were taught to be dominant over others, especially women, and not to cry over discomforts. They were taught to strive for success, to be powerful, fearless, bold, aggressive and competitive. Inability to demonstrate these qualities results in ridicule and shame. Male children are expected to learn from the older and noble men whose virtues and characters will make them become "real men":

Male children are taught how to be strong, tough, independent, firm and decisive. They are socialized to acquire masculine physical, leadership and sexual traits. A number of ways are designed for the young men to develop these traits. For instance, in order to develop physical traits,

To develop leadership traits, some positions are given to individuals to signify that they are "real men." It is believed that sexual promiscuity determines whether a male child is going to be fertile or not.

Perceptions of Sexual and Reproductive Health Risk

It is accepted that men in traditional societies with conservative cultural views are vulnerable to health risks (Mansfield, 2003). Some participants endorsed the idea that certain cultural practices place them at risk for adverse health outcomes. Adolescents as well as some older males agreed that engaging in risky behaviors such as smoking, alcohol consumption, drug misuse, and sexual promiscuity including non-condom use are risk factors for poor health status.

The men identified a number of health issues they have as a result of following traditional masculine practices. These include STIs (gonorrhea, syphilis, herpes, candidais, and HIV/AIDS), cancer, high blood pressure, heart failure, wet dreams, premature ejaculation, male infertility, and decreased libido.

Awareness of the adverse effects of certain cultural practices is leading to behavioral changes, including risk-reducing practices. For instance, some men now do not marry many wives to show that they are men, although some engage in multi-partnership. Participants described signs and symptoms of STIs such as milky discharge, swelling, and bloody urine as well as knowledge and awareness of HIV/AIDS. Healthcare providers who spoke of the increasing number of cases of STIs they treat on a daily basis confirmed the health concerns of the participants.

A concern with STIs has led some men to abstain from sexual intercourse or to use condoms when they do. Participants reported that men seek healthcare services in a number of ways. Some use traditional home remedies. Others go to religious services, or pharmacies and hospital clinics.

There are, however, obstacles to men obtaining health care including:

All the participants in the three interview series (focus group discussions, in-depth interviews, and key informants) observed that men are often neglected in healthcare policy-making and programming. They unanimously agreed that government and non-governmental organizations should be concerned about men's health needs. They argued that men are indispensable in any discussion in the community and therefore neglecting to address their needs is, as one man said,

They hold that until their problems are factored into current programs that primarily address the needs of women and children, the successes of improved women's health and the achievement of gender equality will remain a distant reality. The desire of the participants to be included in reproductive health education and services is evidenced by the following observations:

Many of the men singled out researchers, policy-makers and programmers in subSaharan Africa as being indifferent to their problems. Educated young adults in the urban centers questioned why international conferences have been held to address the problems of women, but none for men. They felt that adherence to masculine ideologies depends on individual convictions and objectives, and that demonstration of proof of manhood sometimes borders on pretension. Although barriers to health-seeking behavior were acknowledged, it was nonetheless emphasized that this is due not to the existence of masculine ideologies but to other factors because

Masculinities: Tradition and Change

Although the majority of the participants acknowledged their masculine ideologies and roles, they nevertheless reported changes in beliefs and practices. For instance, all the participants noted that the practice of confining women to roles in the home without allowing them to make other contributions to the family is changing since most men would marry educated wives and allow them to work and a make financial contribution to the family and community. They also noted that the notion that women's education ends in the kitchen has changed:

Another adult participant commented:

Participants in all the interviews described useful roles that educated and gainfully employed women now play in the family and community. They noted that women have been adequately mobilized to be involved in various community projects. Some of the participants who were not educated pointed out that if they were to marry again they would endeavor to make sure that their wives were educated so that they could contribute to family upkeep.

The practice of a sexual double standard for males and females is also changing. There was a consensus that being a man is not measured by accumulation of wives or by the number of sexual partners a man has. This used to be the pattern, but

The affirmation by some participants that traditional gender-role ideologies promote risk-taking behaviors and generally have negative effects on people's health is significant and came out strongly in all of the discussions. It is clear that men are beginning to be sensitive of the impact of traditional masculine ideologies and practices.

This view appeared in the other interviews and across all the categories of respondents.

The participants in all the interviews noted that traditional Igbo beliefs that tend to promote masculinity are undergoing change and no men currently hold these views strictly. They reported that, generally, men are accorded leadership authority in the home so that there can be peace and love. They asserted that men are expected to provide for the upkeep of the family and largely be responsible for most of the decisions made. However, they noted that this leadership position is not cast in stone to the extent that women may not be involved. Educated participants pointed out that they enjoyed joint decision-making with their spouses or partners.

Migration was singled out as a factor contributing to the shift from traditional to non-traditional views of masculinity through the diffusion of new ideas. Migrants who have moved from rural to urban areas are exposed to novel ideas, most of which are contrary to traditional ideas of masculinity. When they return home they often attempt to share these new ideas with others. The influences of the mass media cannot be ruled out either. Most religious groups are also encouraging their followers to be responsible in their lifestyles, and to abandon traditional beliefs and practices that do not promote healthy social and biological living. Thus education, religion, modernization, globalization, and the mass media are contributing to changes in masculine ideas and practices.

Conclusions

This study provides data about a range of conceptions of being a man among the Igbo living in southeast Nigeria. Although the participants commented on various aspects of traditional masculinity, they also pointed out that these beliefs and practices are no longer always serious issues and that society is changing as well as are attitudes toward traditional masculinity. Most important, men are now aware of sexual and reproductive health risks such as sexually transmitted infections, low sperm count, prostate cancer, impotency, and herpes. While they pointed out that some men seek out healthcare services when they are sick, they also noted that a number of factors affect men's ability to utilize healthcare services. These include age, type of illness, pride, a sense of inferiority, fear of stigmatization, and lack of information.

According to the participants, the deciding factor is the cost of treatment, which explains why when a person is sick, private treatment choice is not first explored. Other healthcare services are used instead including visiting herbalists and prayer houses, and abstaining from sex. That men utilize healthcare services is contrary to earlier findings (Courtenay; Eisler, 1995; Helgesson, 1994).

Most of the participants expressed a willingness to support and participate in reproductive health programs that are designed to address issues beneficial to them and their partners. They pointed out that there are a number of roles men can play in the preventing of the spread of HIV/AIDS and promoting the health and well-being of their partners. They emphasized the need to practice safer sex and promptly utilize healthcare services.

Igbo males are not averse to gender equality or equity programs. They suggested, however, that their needs should be factored into all programs. There is a definite need to promote programs to address such issues that are dear to men. These issues should cut across the various strata of society, since there is no clear-cut differential in knowledge of, attitudes toward and perceptions of masculinity and reproductive health in the various groups studied.

The implications of this study for further multidisciplinary and interdisciplinary research should be extended to incorporate men's sexual and reproductive health needs into existing reproductive health programs. This would be a step toward promoting more effective male involvement in these programs. Further investigations should be carried out regarding various social, psychological, and medical issues of concern to the population of men studied. Data collection instruments should be triangulated to produce even better research.

Rather than viewing men as an obstacle to women's reproductive health programs, it is necessary for researchers and programmers to focus on understanding and solving men's social and health problems. The new Nigeria Population Policy needs reviewing so that male health issues are given equal attention as those of women and children.

Although it is not possible to generalize from this study to the entire State of Imo or the entire Nigerian nation, the findings provide insights into conceptualizations of masculinity and how these affect health status and health-seeking behaviors among Igbo men in southeast Nigeria. The findings underscore the importance of research in providing program personnel and policy-makers with information about the health needs and concerns of men.

Finally, while men are expected to be responsible for their actions, as emphasized by some of the participants they must receive support and guidance from well-informed peers, support groups, and health-care providers. As an elderly key informant commented:

The study has some limitations. One is the manual approach to content analysis of the interviews. This could have led to some pertinent information being lost. A study of this nature with a huge data set could have been better analyzed with modern qualitative analysis software. This was not available at the time of the study. A second limitation is that the findings cannot be generalized to the entire population of Nigeria. To address this, we propose a nationwide survey that would focus only on men and be conducted with well-designed methodology and instruments. For now, the present study is the beginning of a detailed study of men and masculinity in Nigeria.

And lastly, we are pleased to report that the study is being replicated in Botswana in Southern Africa.

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CLIFFORD ODIMEGWU

University of the Witwatersrand, South Africa

CHRISTIAN N. OKEMGBO

Obafemi Awolowo University, South Africa

Clifford Odimegwu, Programme in Demography and Population Studies, University of the Witwatersrand, South Africa; Christian N. Okemgbo, Department of Demography and Social Statistics, Obafemi Awolowo University, South Africa.

Opportunities and Choices Reproductive Health Research Program, University of Southampton, Southampton, UK, graciously funded the first author when he was at the Harvard School of Public Health, Boston, MA. The authors are grateful to the management of the Takemi Program in International Health, Harvard School of Public Health, for logistical support in conducting the study and analyzing the data.

Correspondence concerning this article should be addressed to Clifford Odimegwu, Department of Demography and Population Studies Program, University of the Witwatersrand, South Africa. Electronic mail: Clifford.Odimegwu@wits.ac.za
A man in Igboland is known by ... his strength of character, not
   emotional or irrational or allows himself to be dominated by women.
   (Adult, age 55, rural, In-depth Interviewee or IDI).


Naturally it is the man because God has placed the man above the
   woman. But in some godly homes, women are often allowed to
   contribute to household decision-making, though most women would
   still allow their men to take the final decisions. (Young adult,
   urban, Focus Group Discussant or FGD)

   Men just as God created them are the head. There is always a head
   everywhere even in the office and it is the head that has the final
   say, even a man and wife are meant to agree but when they disagree
   it is what the man says that is binding because the woman is under
   him. The man when taking decision will make sure his decisions are
   for the good of the family. (Older adult, rural, FGD)


That one is not a man. Is he a man? When he does whatever his wife
   tells him to do? (Older adult male, IDI)


... being able to build a house, marry and maintain a wife,
   contribute to community development. (Older adult, age 67, rural,
   IDI)


I see myself as somebody with many responsibilities; somebody who
   excels in life, who should work hard to ensure that he, maintains
   that superiority as a man. Igbo culture attaches much importance to
   being a man. So I live up to that expectation and it gives me a
   very bold heart to achieve whatever I want to achieve. I must go
   to a great extent to achieve it. So I must do everything to defend
   that manhood.
   (Middle-age, urban, FGD)


You have to provide accommodation for your family, provide the
   needed protection to your family and food also, pay school fees for
   your children and siblings and meet up with other responsibilities.
   When you are doing these, people say that you are a man.
   (Middle-age rural, FGD)


When you call me a man, it talks about the issue of a burden
   bearer, a man who represents his father, a continuity of his
   family. When you call somebody a man, you are indirectly telling
   the person that he is standing in between the gap of your ancestors
   and people to come. (Older adult, rural, FGD)


A man is not to be timid, coward, talkative, and irrational. He
   should be strong, not emotional. (Middle-age, urban, FGD)


There are certain things you do and they will tell you that you are
   no longer a boy but a man; that you are supposed to act with your
   senses, reacts to things like a man. So that reminds you that you
   are now growing into that manhood. (Young adult, FGD)


Your biological make-up, your physique does tell you that you are a
   man: changes in your voice, hairs in your pubic areas, etc. You
   also think about societal perception. People will begin to treat
   you with respect; there will be a change in the type of
   responsibility that is given to you in your family, noble
   responsibilities. These will actually suggest to you that you are
   gradually becoming a man and no longer a boy. (Young adult, urban,
   FGD)


The person is of age not lower than 21 years; he has acquired
   knowledge of the circumstances around him and must be able to find
   solutions to certain problems coming from different directions to
   him. He must be able to understand issues as an adult. (Middle-age
   man, IDI)


... handle things himself, getting married and being able to take
   care of the lady, and her children. (Older man, 56, urban, IDI).


The way one knows a real man in Igbo land, the person ought to join
   his age grade meeting, do whatever the culture demands; some are
   initiated into manhood (iwa-akwa); some are made chiefs or other
   titles. So when a man is being honored with a chieftaincy title,
   gets married, is initiated into his age grade, then we know he is
   now a man and will be fully involved in community activities.
   (Older age, rural, FGD)


A man shows he is a man by taking part in community development
   programs. Men in the family bring up their children, take care of
   the surrounding. In the community, they make contributions to
   community development. (Young adult, urban, FGD)


The family is the socializing outreach for both the boys and me.
   The boy learns a lot from the family. Sexually he is always taught
   and warned how to take care of this or that. He learns masculine
   domestic responsibilities from the home. (Young adult, urban, FGD)

   In the society it involves the schools, church and other units. The
   principal teacher is nature because there are certain things you
   will see in your body to make you know you are a man. You will need
   not to be told. (Middle-age, rural, FGD, and middle-age, 45, rural,
   IDI)


... in the society, [socialization for manhood] involves the
   schools, churches and other units. (Middle-age, rural, IDI)


The principal teacher is nature because there are certain things
   you will see in your body to make you know you are a man. You need
   not to be told that you are of age. (Middle-age, rural, IDI)


Boys are meant to emulate the characters of noble men.... We all
   have to take examples from those who have lived before us, to see
   how much they have achieved their aims. They are expected to be
   well behaved and aim to be successful in life. (Young adult, rural,
   FGD)


... wrestling among boys is used to prove who is a man. Even the
   great hunters show their strength especially when they kill lion or
   have an incredible accomplishment which earn them the title "ogbu
   agu" [killer of lion], or when a man is able to fight for his
   village. (Older adult, rural, FGD)


Smoking can affect the lungs and causes cancer. Too much sex or
   masturbation affects one. These are the activities that endanger
   the health of adolescents. (Young adults, urban, FGD)

   Yes there is a connection between these. When a young man knows he
   is of age and he begins to drink and smoke, he will feel he is a
   big boy. When he does these, he will think that when he sees a lady
   and talk to her, she will take him as a big boy. Anybody who drinks
   and smokes too much will likely go out after some girls.
   (Adolescent, urban, FGD)

   Drinking and sexual promiscuity are common. Some men feel when they
   are drunk; they are high and have confidence. It is then you see
   them going after girls, messing around with them. They believe if
   you don't drink or smoke, you do not belong. Some men even go to
   the extent of betting on their abilities to drink so many bottles
   of beer. After drinking they will now want a lady who they will
   want to use. Some girls even like guys who drink and smoke.
   (Middle-age, rural, FGD)


... the need to be independent, fear of being perceived as
   vulnerable, ignorance, fatalism, cost, time and type of illness,
   and attitudes of health care providers" (Young adult, urban, IDI)


... indifference, carelessness, irresponsibility and dereliction of
   duty. (Middle-age, rural and urban men, IDI)


Though our culture encourages us to behave like men and we often
   tend to uphold masculine virtues, we should not be neglected in
   reproductive health care programme and delivery. (Adult, urban,
   FGD)

   It is not all men that stick to these masculine ideas. There are
   changes in beliefs and behavior by men because of the influence of
   education and religion, and mass media. (Young adult, rural, FGD)

   We are used to some of these cultural ideas and beliefs. It will
   take time for us to change what we have held for a long time. Daily
   we are learning new things, and also our children. We are now
   investing in the education of our daughters even our wives because
   we know the value of education. We are adjusting our lifestyles and
   beliefs, and hopefully we will get there but not to be as loose as
   the white men. But it is unfair to ignore us and our needs in
   various conferences and program. We need understanding and support
   not condemnation. (Middle-age, rural, FGD)

   Government is unfair to us. We pay taxes shoulder family and
   community responsibilities, yet we are often seen as the evil that
   needs to be tamed for women to enjoy health and equality. We will
   not support the idea of equality but mutual respect between men and
   women in relationships. (Older adult, urban, IDI)


no one wants to die in silence because of culture. (Young adult,
   urban, secondary and post-secondary education, FGD)


... we have realized that two good heads are better than one in
   family and community management. Women are encouraged now to go to
   school, work and make contribution to the society. (Middle-age,
   urban IDI)


In core traditional Igbo family nobody gave the women opportunity
   to contribute to a decision-making process. It is the man and the
   man alone. But there are changes due to education and migration
   Women can now contribute to family decisions, and in fact make
   significant contribution to the family. This is being realized by
   most men, and it is a good omen. (Middle-age, rural, IDI)


... men are realizing the dangers involved like the risk of
   contacting this dreaded disease (HIV) or having an illegitimate
   birth. We are also getting to know that it is not easy to cope
   economically with multiple wives and their children. (Older, rural,
   FGD)


In this era of HIV/AIDS, people have to be careful in the number of
   sexual partners they have. It is no longer a sign of manhood to
   have many girlfriends. You may contact disease and die thereby.
   There is a common knowledge that this practice of many girlfriends
   is not ideal. Although we are changing from that, yet, some young
   boys are still doing it. It is really not a cultural issue but an
   ego issue. Boys want to show off. (Middle-age, rural, FGD)


We men have been used to some of these issues; have been in
   positions of power and control. Hence we cherish our masculinity.
   Now you want us to relinquish our position. It is not easy, my son.
   It takes time but again, you must give us reasons why we should
   shift our traditional beliefs and practices as men. (Old age,
   rural, Key informant)


Table 1
Characteristics of Focus Group Participants, Southeast Nigeria

                             Number of
Participants                participants   Average age

Adolescents (15-24)
  Urban 1                        6             20.1
  Urban 2                        8             19.9
  Urban 3                        7             23.1
  Rural 1                        7             23.1
  Rural 2                        7             20.4
  Rural 3                        7             21.2

Young adults (25-39)
  Urban 1                        6             26.7
  Urban 2                        6             25.4
  Rural 1                        6             26.8
  Rural 2                        7             32.5
  Rural 3                        7             34.6

Middle-age adults (40-54)
  Urban 1                        7             45.3
  Urban 2                        7             45.6
  Rural 1                        8             45.7
  Rural 2                        8             46.8

Older adults (55+)
  Urban 1                        6             59.8
  Urban 2                        6             57.8
  Urban 3                        7             67.2
  Rural 1                        7             56.3
  Rural 2                        7             55.8
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