TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2)

Field Action Report/Saha Uygulama Raporu

Kor Hek. 2008; 7(2):97-106

Establishing Reproductive Health Education and Counseling in Military Services: The Turkish Model for Male Involvement [Askeri Birliklerde Üreme Sağlığı Eğitimi ve Danışmanlığı Sistemi Kurulması: Erkeğin Katılımının Sağlanması İçin Türk Modeli] SUMMARY Ministry of Health, Mother and Child Health and Family Planning General Directorate; Turkey Field Office of UNFPA, and Gulhane Military Medical Academy (GMMA) of Turkish Armed Forces have been conducting a program to increase male concern and participation in sexual and reproductive health in a positive and supporting way. Specialist physicians and nurses from military hospitals were trained by Ministry of Health as trainers (October 2002- September 2003) by one-week courses on interactive training skills. Primary physicians, nurses and medical petty officers were trained as field trainers and counselors (March 2003-April 2004). Training rooms with standardized training material were established in all of the military garrisons. Soldiers were given the one-day participatory course. Trained medical staff also provided individual counseling and services. All training rooms were coded and connected to Reproductive Health Network established within the Intranet of Army. Reproductive Health activities were included in the regular supervision scheme of the army. Since April 2004 740.000 soldiers were given the one-day course. A total of 4000 military medical staff was educated as Trainers. A total of 580 training rooms were established. Twenty of Military Hospitals became a center of reproductive health training and service delivery. Since large-scale intervention is necessary to reach male population, the army seems to be the best possible venue in Turkey. ÖZET Sağlık Bakanlığı, Ana Çocuk Sağlığı ve Aile Planlaması Genel Müdürlüğü, UNFPA Türkiye Bürosu ve TSK Gülhane Askeri Tıp Akademisi erkeklerin cinsel ve üreme sağlığına katılımını ve ilgilerini pozitif ve destekleyici yönde arttırmak için bir program yürütmektedirler. Sağlık Bakanlığı tarafından Askeri Hastanelerde çalışan uzman hekim ve hemşirelere eğitici olarak interaktif eğitim becerileri konusunda bir haftalık kurs verilmiştir (Ekim 2002-Eylül 2003). Pratsiyen hekimler, hemşireler ve sağlık astsubayları saha eğitimcileri ve danışmanlar olarak eğitim almışlardır (Mart 2003-Nisan 2004). Standart eğitim malzemeleri bulunan eğitim dershaneleri tüm askeri garnizonlarda tesis edilmiştir. Erlere bir günlük uygulamalı eğitim verilmektedir. Ayrıca eğitim almış sağlık personeli tarafından danışmanlık hizmeti verilmektedir. Tüm eğitim odaları kodlanmış ve Askeri Intranet içerisinde kurulan Üreme Sağlığı Ağına bağlantısı sağlanmıştır. Üreme Sağlığı faaliyetleri ordunun rutin denetleme listesine dahil edilmiştir. Nisan 2004 tarihinden buyana 740.000 askere bir günlük kurs verilmiştir. Toplam 4000 askeri sağlık personeli eğitimci olarak kurs görmüştür. Toplam 580 dershane kurulmuştur. Yirmi Askeri Hastane üreme sağlığı eğitim ve hizmet merkezi olarak yetkilendirilmiştir. Asker popülasyona ulaşmak için kapsamlı müdahaleler gerekli olduğundan, ordu Türkiye’deki en iyi ortam gibi görünmektedir.

Despite a growing awareness of the importance of involving males in reproductive health issues, information is lacking regarding the design and delivery of effective male-specific strategies. In this paper, we describe the evolution of a promising program in Turkey, Reproductive Health Program of Turkish Armed Forces, instituted through the collaborative efforts of the Mother and Child Health and Family Planning General Directorate of Ministry of Health, Turkey Field Office of UNFPA, and the Gulhane Military Medical Academy (GMMA). www.korhek.org

Anne Brigitte Albrectsen1, Sadettin Güngör2, Bilal Bakır3, Aygül Akyüz4, Ercan 3 4 Göçgeldi , Tülay Kaya , Mahir Güleç3, Metin Hasde3, Adviye 5 6 Temiztugay , Recai Pabuçcu , Gökhan Yıldırımkaya7. 1

Ministery of Foreign Affairs, 2 Denmark, Gulhane Military Medical Academy and School of Medicine Department of Obstetrics and Gynecology, 3 Department of Public Health, 4 5 School of Nursery, Ankara, Mother and Child Health and Family Planning General Directorate, 6 Ministry of Health, Ufuk University and School of Medicine Department of Obstetrics and Gynecology. 7 Ankara, UNFPA,Turkey Field Office, Turkey. Key words: Reproductive health, training, male, young, soldier. Anahtar kelimeler: Üreme sağlığı, eğitim, erkek, genç, asker. Sorumlu yazar/ Corresponding author: Bilal Bakır, GATA Halk Sağlığı AD. 06018 Etlik, Ankara, Türkiye. [email protected]

PROGRAM BACKGROUND Reproductive Health in Turkey Socio-economic and demographic indicators show Turkey, being a bridge between Asia and Europe, to be a developing country with a middle-income status. In 2005 it had an estimated human development index of 0.74 and a per capita income of $5000. The population in Turkey is over 70 million with life expectancy estimated at 69 years. It has a young population, with around 50% under the age of 20. 97

TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) The annual population growth rate was 14 per thousand by 1997; the crude birth rate is 23.4 per thousand, while the crude death rate is 6.7 in Turkey (1). Turkey followed a pronatalist policy prior to legalizing contraception and establishing a national family planning program in 1965, one of the oldest in the developing world. In 1983 trained nurses and midwives were authorized to insert intrauterine devices (IUDs) and Turkey became one of the first Muslim countries to legalize sterilization and abortion (2). In recent decades, important improvements have been achieved regarding reproductive health indicators in Turkey. The total fertility rate (TFR) declined from 5.1 children per woman of reproductive age in 1978 to 2.6 in 1998 (3). According to research carried out in 1997, at 8 of 615 hospitals in 53 provinces of Turkey, the maternal mortality rate was found to be 49.2 per 100,000 live births in Turkey (4). After the beginning of the present program, the findings of Turkish Demographic Health Survey 2003 (TDHS, 2003) were announced in 2004 and according to its results, total fertility rate decreased sharply to 2.2 which might be the replacement level for Turkey (5). On the other hand, shortfalls has still continued to exist, for example Adequate antenatal care (ANC) was lacking; in 1998, only 68% of pregnant women received ANC from trained health personnel and 73% of all births took place in a health facility (3,5). While 31.9% of pregnant women received no ANC from trained health personnel and 27% of all births occurred at home according to TDHS 1998, 18.9% of pregnant women received no ANC and 23% of all births occurred at home according to TDHS 2003. (6) Although, many successful interventions have been carried out to improve the reproductive health and status of women in Turkey, these efforts have been limited due to lack of male involvement. At present, counseling services in sexual and reproductive health are not sufficient to respond the needs of adolescents and youth in Turkey. Also, while many laws are supportive of gender equality, social life remains characterized by patriarchal ideology (2). The Role of Men in Reproductive Health Decision Making and Services for Men in Turkey The 1994 Cairo and 1995 Beijing Conferences highlighted the need to involve men in initiatives seeking to improve women’s health. (7,8). The involvement of men is sought not only because of the pivotal roles they play in women’s health, but also to 98

address men’s own health issues and in order to transform and expand masculine roles in ways that liberate men from oppressing and oppressive norms (9). Overall, however, it has been within the context of promoting women’s reproductive health and rights, equality and equity (10) and of empowering women that the concept is promoted. In Turkey, the husband is often the primary decision maker, and a wife's economic dependence on her husband gives him great influence in major household decisions (11). General knowledge and attitudes of men also influence women’s preference and options in decisions about family size and contraception, in part due to Turkey's spousal consent requirement for abortion and sterilization services and to the prevalence of traditional contraceptive methods (withdrawal and periodic abstinence) that require male cooperation (12). In family planning, men can support their wives’ use of family planning methods or they use condoms, refrain from having multiple sexual partners, or attend counseling sessions and seminars, or all of these. As husbands and fathers, men can be more aware of their partner’s and family’s needs and concerns, and better plan for their children’s future. As community leaders, men can influence public attitudes, and as government leaders, they can shape public policies (13). Despite their pronounced role in reproductive health decision-making, men are often not included in education, counseling, and services in Turkey. Excluding men from information, counseling, and services is to ignore the important role men's behavior and attitudes may play in couples' reproductive health choices (11).

PROGRAM DEVELOPMENT In Turkey every Turkish male citizen is obliged to do military service at the legal age of 20. Special groups like university graduates and binational Turkish citizens may be considered to be deferred until the end of the age of 38 for their military services. Some of the university graduates may perform their obligatory military service as military officers. So Turkish soldiers are mostly aged 20-22 and educated with High School level or less. Moreover, this large group includes those mostly come from rural areas. Another important characteristic of Turkish soldiers is being single. More than 90% of them begin their duties as single. Socially, the military service obligation is considered as a milestone for a regular Turkish male to get www.korhek.org

TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) married. Every year approximately 500.000 young men are recruited for their military service obligation and distributed to different military units located in different regions of Turkey. The duration of military obligation is 15 months. Previous Studies targeted Turkish Conscripts Tekbas attempted to start comprehensive initiative to educate Turkish soldiers and developed some IEC materials to be used in training Programs (14). One of these IEC materials was is a pocket book inspired from a very common tradition among Turkish soldiers. Bakir et al studied Soldiers’ knowledge levels on Family Planning and AIDS in two previous studies (15,16). While Acikel et al. (17) attempted to find out the knowledge level of soldiers on Sexually transmitted diseases, Kir et al (18) attempted to evaluate of HIV/AIDS knowledge level among soldiers in 2004. In another study It was tried to determine the prevalence of consanguineous marriages among Turkish soldiers (19). Some Turkish NGOs trained soldiers on Family planning issues with limited coverage of regional military units. One of these NGOs, Turkish Family Planning Foundation, created also some video films on FP targeted to Turkish Soldiers. In 2002 representatives of the partner institutions came together to discuss collaboration and a potential course of action to build a broad, sustainable program to increase young males concern and participation in sexual and reproductive health programs and services in a positive and supporting way for the benefit of women, men, and children and to promote gender equity in family and society. Constitution of Advisory Board and Project Implementation Team (PIT) In 2002, Commander of Health Command of Turkish Armed Forces; Ministry of Health, Mother and Child Health and Family Planning General Director, and Representative of Turkey Field Office of United Nations Population Fund constituted the Advisory Board for tailoring education and counseling programs to the effective military mechanisms. The Advisory board contributed in planning and monitoring of all activities of the Project with the opinions, recommendations, advices, and regulations. The Advisory Board also approved a Project Implementation Team (PIT). The PIT consisted of experts of partner institutions as follows: • Specialist physicians from Gulhane Military Medical Academy (GMMA), School of www.korhek.org

Medicine, Departments of Obstetrics & Gynecology, Public Health, Urology, Children’s Health & Diseases, and Family Planning • Specialist nurses from Gulhane Military Medical Academy, School of Nursing, Departments of Obstetrics & Gynecology and Public Health • Trainers of Ministry of Health (MOH) Mother and Child Health and Family Planning General Directorate • Technical Experts of Turkey Field Office of UNFPA (United Nations Population Fund) Project Implementation Team would be responsible mainly from the training program, training package, agenda, curriculum and evaluation of the project. Needs-Assessment This initial phase of the project focused on assessment of the conscripts with regard to their educational needs in the area of reproductive health (Figure 1). This assessment constituted the background for the formulation of an educational programme to meet those needs. The data for the assessment were collected by examining the curriculums of relevant schools and by conducting indepth interviews with administrators from each of the schools to identify what kind of education and training in these subjects they had received as opposed to what they needed. Through a descriptive, cross-sectional needs-assessment survey, in-dept interviews were conducted with a small sample of conscripts to explore their knowledge, perceptions, attitudes, and practices in various issues of reproductive health through which young males could be beneficially approached for health education. A synthesis of Bandura's social learning theory (20) and the theory of reasoned action to represents the theoretical framework for the program. A central tenet of social learning theory is that people learn as much by observing the experiences of others (i.e., through observational learning) as they do through direct experience, especially when they are observing a person they respect and perceive as being powerful or similar to themselves. According to the theory of reasoned action, behavioral intent and action are influenced by two important factors: one's attitude toward the positive and negative aspects of a particular behavior, and one's perceptions of social norms, or what important others think about engaging in the behavior. In designing the program, the Project

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TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) Implementation Team felt that field trainers who would help conscripts increase the knowledge about sexual and reproductive health issues, recognize the benefits of responsible behaviors and modify their behaviors in high-risk situations should be able to expose participants to positive role models. Project Implementation Team proposed the basic principles for the program. These principles were in accordance with the objectives of the Ministry of Health as well as UNFPA in Turkey and included: •

• •

•

•

•

•

Taking advantage of having a large number of qualified medical personnel within the health care system of army Starting and conducting the project concurrently in all garrisons of the Army as much as possible, Group education that use videos, role playing, and group discussion to challenge traditional perceptions and practices; Encouragement for men to practice independent thinking and reflection so that they can think critically about their own lifestyles; Giving information and opportunities for men to ask questions and get correct information about male and female reproductive health; Improving knowledge and attitudes regarding men's health issues, and strengthen intentions to engage in responsible reproductive health behavior; particularly for the risks of unprotected sexual intercourse, all phases of pregnancy and the birthing process, a more responsible model of parenthood, and violence against women. Increasing the awareness among young people as to access to appropriate and accurate information on SRH, to expand utilization of, and access to, primary and reproductive health care services.

Considering the hundred-thousands of turnover in conscript numbers annually, it was presumed that there must be thousands of trainers who would transfer the information and facilitate the learning activities. The Advisory Board reviewed the source of trainers and found out the newly graduated military medical doctors, military petty officers, and military nurses as the most easily adaptable population for the program. These groups had been provided with adequate information on subjects such as antenatal care, delivery, contraception and sexually transmitted infections, but they were not being trained to be 100

proficient in participatory teaching techniques and or counseling skills.

NeedsAssessment

Programme development

Educational Activities

Preparing IEC materails and establishing Training Rooms

Training of Academic Staff by Master Trainers of MoH

Training of concripts by Field Trainers and Consellors

Training of Field Trainers and Consellors by Master Trainers of MoH and Academic Staff

Monitoring and evaluation

Figure 1. Flow chart of intervention Activities

PROGRAM DELIVERY Preparation of IEC materials Because curriculum development and validation is a time-consuming and costly endeavor a technical subgroup assigned by the Project Implementation

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TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) the master trainers. The objectives of the reproductive health section of the programme were to provide: • basic information about the state of reproductive health in the world and in Turkey (demographic changes, population policies and regulation) • basic concepts about reproductive heath (ICPD Programme of Action, definitions and a comprehensive care approach) • the principles of fertility regulation and counselling (impact on maternal and child health, contraception, eligibility criteria and counselling) • the process leading to safe motherhood, safe reproductive health and healthy children (antenatal and delivery services, post-partum care, abortion and post-abortion care) • the importance of diagnosis and treatment of sexually transmitted infections and other genital tract infections (prevention, case management)

Team gathered and revised available training materials previously prepared by UNFPA and MOH. This team also prepared suitable models, guide books, pocket books, posters, audiovisual materials, and pre and post test questionnaires to be used throughout the trainings of Institutional Trainers, Field Trainers, and conscripts. Training of Institutional Trainers The next step in the project was to train the GMMA staff that would act as institutional trainers by improving their training skills and integrating their knowledge of reproductive health. The main criteria for the selection of institutional trainers were to be a specialist physicians or doctorate nurse with academic performance in the disciplines of public health, obstetrics and gynecology, urology, pediatrics, and family medicine. Master trainers, individuals who would be responsible for the training of the institutional trainers, consisted of 12 individuals who had previously trained and worked as trainers in national MoH projects on reproductive health. The institutional trainers would attend the training of field trainer’s courses. To this end, a fiveday training programme with three days allotted for training skills and with two days for acquisition of information on reproductive health was planned by

The objectives of the training skills section of the programme were formulated based on previous experience at the MoH courses. A summary of the programme content and duration of the course offered to the institutional trainers is given in Table 1.

Table 1. Programme content and duration of the reproductive health and training skills course sections for institutional trainers Training skills topics (total of 3 days)

Duration (min.)

Reproductive health topics (total of 2 days)

Duration (min.)

Introducing the programme and expectations

30

RH in Turkey and in the world

60

Adult learning and learning styles

60

Regulation of fertility

180

Positive training environment

60

Sexual health and Hygiene

120

Training techniques and facilitation skills

120

STDs and HIV/AIDS

120

Development of audio-visual training tools

60

Safe motherhood and responsible parenthood

120

Group dynamics

90

Communication - counseling

120

Demonstration coaching

90

Total duration

12 hours

Evaluation

60

Preparation for presentation

120

Participants' presentations

360

Evaluation of the course

30

Total duration

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18 hours

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TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) This programme also constituted the basis of the five-day courses offered to the field trainers in the next phase. Care was taken to have trainers who belonged to the different medical specialities as well. Totally 56 GMMA staff were trained by master trainers of MoH through three courses between October 2002 and February 2003. Considering the academic workload of these experienced trainers, a total of 179 specialist physicians and doctorate nurses were selected from the sixteen of the regional military hospitals to be trained as institutional trainers. Selection criteria were the same as the former selection except for academic performance. Institutional trainers of GMMA and master trainers of MoH merged together and trained those 179 personnel through ten courses conducted between June 2003 and September 2003. Thus, a total of 235 military medical staff was trained as institutional trainers. Training of Field Trainers 800 newly graduated and 2000 experienced primary physicians, nurses and medical petty officers were trained by 235 institutional Trainers and certificated as Reproductive Health Field Trainers and Counselors. The training of these field trainers was realized by conducting 168 courses, each lasting five days, between March 2003 and March 2004. Onehundred-and-four of 168 courses were held between October 2003 and December 2003 in sixteen different military hospitals. In 2005 and 2006 800 newly graduated personnel were trained in GMMA. Thus far, 3600 military medical personnel were certificated. The training content of the field trainers’ course was the same as the content of the institutional trainers (Table 1), and the training methods employed in all courses were completely based on participatory techniques such as small group discussions, roleplaying, case study, brainstorming and experiencebased learning. The number of institutional trainers conducting these courses was three institutional trainers per course. One master trainer of MoH or institutional trainer of GMMA was also present at each course to supply feedback to the institutional trainers and to act as a supervisor. Field trainers were expected to: • Create a positive learning environment • Listen • Be patient • Be participant-centered • Ask participants what they want to learn about 102

• • • • •

React positively to questions Be sensitive to non-verbal communication Use humour to ease embarrassment Be comfortable teaching the material Address different learning styles in their training activities of conscripts.

Establishment of Training Rooms for Conscripts A total of 580 training rooms were established in all of the military garrisons. Each training room was provided standard training material as follows: • Audiovisual materials and equipments per class: VCD player, CDs, Whiteboard/ flipchart, printer. • IEC materials per class: Registration notebook for the course, Posters, Basic essentials on SRH (book), FP guidelines (book), SRH Pocket book, • Demonstration kits per class: Models for female and male reproductive systems, contraceptives (Intrauterine devices, Oral contraceptive pills, Condoms), and penis models. • Televisions, computers, and video-projectors were not considered as essential in the training rooms. However, garrisons with capabilities were allowed free to support these materials. Training of Conscripts Following the achievement to the minimum required number of field trainers in all garrisons, the training of conscripts began in the spring of 2004 Ankara, and within a three-month period extended to the garrisons of the Army. The reproductive health and family planning curriculum of the conscripts comprised four modules: • Module 1: Anatomy of Reproductive system of males and females including sexual hygiene. • Module 2: Regulation of fertility including the reversible contraceptive methods (IUD, Oral contraceptives, Condoms) • Module 3: Sexually transmitted infections (STIs) and HIV/AIDS, particularly sign and symptoms and protection measures. • Module 4: Responsible parenthood including safe motherhood. Given the goals of the project, the PIT incorporated a module on gender equity and violence into the curriculum at the second year of the project. A guidebook designed for the use of field trainers outlined interactive and discussion-based strategies, such as role playing and games, designed to actively engage participants and to encourage them to share www.korhek.org

TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) their personal experiences. Activities are also designed to enhance problem solving and critical thinking skills, and to assist participants in applying the knowledge and skills they are learning to real life situations. All courses were conducted in a U-shaped sitting arrangement for a group of maximum 20 soldiers. Each conscript was given the opportunity for applying condoms on penis models. Prior to the onset of the course a pretest was given to each conscript to evaluate their level of information about related topics, and a post test was given at the end of the course to measure what has been accomplished. A RH pocket book including the summary of the information was given to the participants at the end of the one-day course. Videoclips specifically selected from the archives of MoH were shown conscripts in their spare times. Field trainers provided individual counseling and services in clinics in the field.

PROGRAM MONITORING Monitoring is being done by Coordination Counsel of Reproductive Health (CCRH) in the name of Turkish Health command with the support from 20 Collaborating Training Centers (CTCs) in various parts of the country initially. All the training activities are monitored regularly in military unit and a current status report is prepared. The Institute pursued its responsibilities of coordinating and monitoring the training activities with the help of sixteen Collaborating Training Centers (CTCs) in various parts of the country initially. Monitoring is done through: a. Network Monitoring with the help of Database: All 580 training rooms were connected to Reproductive Health Network established within the Intranet of Army. A number was assigned for each of the training room and a password and user name have been also given to the field trainer or the group of field trainers who serve at the same training room in order to access and input data into database using network of the Army. Transfer of basic demographic characteristics such as date of birth, city soldiers were born, city soldiers reside, educational status, marital status; results of pretest and post test scores and condom application status; newsgroup for the trainers for sharing experience; planning, programming, practicing and evaluating courses, and keeping the trainers and training materials up-to-date have been www.korhek.org

conducted by this online system. The first data was entered into database in April 2004. Thus far, data of approximately 500.000 conscripts have been transferred to the electronic database of the program. b. Field monitoring (quantitative as well as qualitative) included follow-up visits conducted by GMMA and MoH trainers. During the training of conscripts institutional trainers monitored, supported and evaluated field trainer’s performance and the training sessions. MoH trainers supported the Armed Forces in places where there were not enough military health personnel. Observations for ensuring quality of training made based on checklist prepared by CCRH. Reproductive Health activities were included in the regular supervision scheme of the army. The monitoring activities provided feed back for improvement. c. Review meetings: Meetings of Directors of CTC and CCRH members are conducted twice a year on army basis for reviewing the progress of RH Training activities in the army and sort out issues / problems regarding effective implementation of RCH Training. CCRH members Participation in weekly RCH review meeting conducted by MOHFW to give feed back and short out issues.

LESSONS LEARNED The Reproductive Health Program of the Turkish Armed Forces has completed its second year. Some important achievements have been established so far as declared at 9th ESC- Contraception Congress in İstanbul with several presentations (21-24). A paper on the first results of this program was also published in a 2007 number of Military Medicine (25). Approximately four thousand military medical staff gained experience in techniques of peer education, presentation, RH counseling, communication skills, and team-work that will also be valuable in every step of their personal career. When an idea, like male involvement in reproductive health, is perceived as “new”, community ownership is even more critical to the program success. The military personnel were sensitized to carry out information and sensitization activities on reproductive health. Army commanders, officers, and soldiers became much more aware of the various issues related to sexuality that need to be 103

TSK Koruyucu Hekimlik Bülteni, 2008: 7 (2) addressed, particularly sexual function and health, regulation of fertility and contraceptive methods, sexually transmitted diseases/HIV/AIDS, safe and responsible parenthood, gender equity, and sexual rights. Keeping in mind that the sustainability is very important when designing such programs, RH education was implemented into the curriculum of newly graduated doctors, nurses, medical petty officers, and residents of reproductive health specialties at GMMA. Twenty of all Military Hospitals also became a regional center of reproductive health training and service delivery. Thus, each year approximately 400 newly graduated military medical personnel will become field trainer. Since April 2004 training began in 580 training centers and approximately 740.000 soldiers were given the one-day course by the field trainers/counselors. Various studies have shown that educational exercises conducted using interactive teaching methods are more productive in bringing about changes in attitude and also in having a more lasting impact (26-28). Interactive teaching has been shown to be particularly effective in educational programmes in the area of reproductive health (29), and the participants in this project found it instructive and useful. Although a common assumption is that young men are not emotionally expressive, those attending the program actively participate and share their feelings and personal experiences during session activities. In fact, participants consistently report that they feel comfortable expressing themselves in the group setting. Klufio et al have stated that a time period of at least 8 to 10 years is needed for educational programmes to have a lasting impact on quality of health service provision and to reflect on health indicators (30). For this reason, evaluation of acquisition of knowledge is accepted as the first step in monitoring the efficacy of a new training programme. At the completion of the project it will be possible to make a more general evaluation, since the evaluation will also include the views of the recipients of reproductive health services. Some changes in health indicators may also become apparent at the end of 8–10 years and these may be used in the evaluation. Short-term positive feedbacks from trainers, military staff, and civilians suggest that the curriculum could engage young men 104

in positive activities regarding reproductive and sexual health issues. We are assured that it will not take a long time for initial examples of positive behaviors. Female perspectives on sexual health and related topics are important to young men. Although participants agree that it is easier to talk about some subjects in an all-male group, they have pointed out that a better understanding of the "female perspective" would strengthen their ability to communicate and engage in successful relationships with women. However, it is not possible to provide such an opportunity in our military services. The Project provided opportunities for members of institutional partners to discuss and exchange observations, and bring about transformation of their personal practices as well as new channels between the institutions for future collaborations. Although there are still many challenges ahead, the experiences of the partners of this project can be invaluable to other countries all around the world.

ACKNOWLEDMENTS We wish to express our thanks to all trainers and experts in this project. We are quiet sure that there were, are, and will be thousands of volunteers acting in this project. Each of them deserves much more than sincere thanks. We are also grateful to our conscripts for their enormous attention to this nationwide activity. This project has been supported by the UNFPA 3rd Country Programme for Turkey and conducted by the Turkish Armed Forces in cooperation with the Ministry of Health, Turkey. This paper was presented in part at the 9th Congress of the European Society of Contraception, Istanbul, Turkey, on May 4, 2006.

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