What contextual factors and mechanisms facilitate male involvement in women's sexual and reproductive health in Sub-Saharan Africa? A rapid realist review protocol [version 1; peer review: 2 approved with reservations]

Background:  Sexual and reproductive health (SRH) outcomes of women within low resource contexts continue to be of concern to policymakers. Notably, sub-Saharan Africa (SSA) continues to lag behind other regions of the world in improving SRH outcomes for women in the region. A key suggested strategy is male involvement through interventions that respect, promote and facilitate women in taking care of themselves and their new-borns. However, factors such as social-cultural barriers may preclude men's involvement in these programmes. There is a need for a context-specific understanding of gender dynamics and interaction and the mechanisms that enhance or impede men's involvement. Methods: We will employ a rapid realist review (RRR) methodology to examine what mechanisms and contextual factors are essential to facilitate the involvement of men in women's SRH programmes in SSA. In keeping with the realist literature we will follow six steps, which will include: (1) developing a theory, (2) developing a search strategy, (3) selecting and appraising documents, (4) extracting data, (5) analysing data and synthesising the evidence, and (6) presenting and disseminating a revised theory. We will also engage with key stakeholders who will provide local contextual insights and with experts in the subject area. The review findings will be shared with relevant stakeholders using a variety of avenues including through publications, at conferences and on social media platforms. Discussion: This review will identify the mechanisms and contextual factors that facilitate or hinder men's involvement in women's SRH programmes in SSA. The rationale for adopting an RRR approach is to help gather the information within a relatively short period to ensure Open Peer Review


Introduction
Sexual and reproductive health (SRH) outcomes of women within low resource contexts continue to be a subject of concern 1 . Although there has been a notable improvement in key health outcomes globally over the past two decades, sub-Saharan Africa (SSA) continues to lag behind other regions 2 . For example, the region accounts for 66% of global maternal mortality 2,3 . This has been attributed majorly to socio-economic and health system factors such as poverty, low literacy levels and limited health, human and physical infrastructure 4 . Male involvement in women's SRH has been recommended as a critical strategy for the improvement of health outcomes for this cohort. It is relevant to realising the global sustainable development goals 3 and 5 3,5 . Male involvement in women's SRH is a broad term whose scope includes not only men's physical presence during women's reproductive care but also socio-economic and emotional support for women's health decision making 6,7 . This is based on the premise that, in most societies, men act as gatekeepers and primary decision-makers regarding resource utilisation and access to critical services, including reproductive health 5 . Their decisions at all levels of society, both communal and at the basic family unit, can either impede or facilitate access to essential health services. This impacts on the health of women and girls.
Evidence suggests that despite challenges, male involvement in women's health, particularly in low and middle-income countries, is yielding positive outcomes. For example, some programmes have reported increased adherence to ante-natal care attendance, birth readiness and delivery at a health facility where a male partner was involved 8,9 while other programmes have shown an increase in the number of couples availing for HIV testing and those taking antiretroviral prophylaxis 10 . However, challenges to male involvement have also been noted; despite their gatekeeping and decision-making roles, men have not been traditionally involved in women's health 10 . Social-cultural barriers, such as societal constructions of masculinity, appear to prevent men from active involvement 11 . Women and girls' sexual and reproductive health is mainly perceived as "female business", with men taking on the role of the provider of funds [11][12][13][14] .
Furthermore, the accompaniment of women by their partners to health facilities is perceived as a form of emasculation, through crossing rigid lines of gender roles and norms, set by a highly patriarchal society 11 . Other barriers to male partner involvement include economic barriers related to missed work opportunities due to accompaniment to health facilities as well as additional costs such as transport, more especially for men in the low-income bracket 11,13 . The perceived negative attitudes of staff at health facilities and in other cases, a lack of privacy at facilities, may preclude men's involvement [11][12][13] . Limited knowledge among men on the importance of engaging in women's health as well as lack of interest in women's health are other notable barriers 15 . Due to the vital role that men play in society within the SSA context, it is essential to further investigate critical drivers for facilitating their participation in women's SRH.
The need to facilitate men's involvement in women's SRH in SSA is well articulated in the literature. It includes several systematic reviews 8,9,16 that synthesis and assess available evidence to enhance and promote evidence-informed policymaking 17 . However, systematic reviews fail to demonstrate how programmes work in diverse settings and within different populations 18 , information that would be critical for informing policy decisions.
In this paper, we provide a protocol for a rapid realist review (RRR) that examines what contextual factors and mechanisms are essential in facilitating men to get involved in women's SRH in SSA. The RRR methodology, developed by Saul and colleagues 19 , is based on the realist philosophy whose premise is to ascertain how programmes or interventions operate, or why they fall short, in particular environments and conditions 20 . Accordingly, because observations on their own cannot explain causal linkages between variables, it becomes necessary to demonstrate why relationships occur and to show what it is that leads to specific outcomes 21 . The outcome of an intervention, therefore, depends on particular decisions taken (or not) in regards to intervention and how actors' reason about opportunities or resources availed by the intervention 22 .
In realist reviews (RR), the Context + (plus) Mechanism = Outcome (CMO) links form the fundamental principles 23 . Context denotes the history, culture, norms, beliefs, social networks as well as pre-existing structural organisations of the communities in which the interventions are conducted 24,25 . Mechanisms refer to the 'triggers' that lead participants to get involved or not in interventions and relates to their responses to the various intervention strategies and resources 25 . Outcomes are the intended or unintended results based on the interplay between mechanisms and context 22 . In RRRs, the emphasis tends to be on the links between the interventions and outcomes, and RRRs use programme theories to help explain how and why particular interventions produce specific outcomes within specific populations 19 .
The main review objective is to examine what contextual factors and mechanisms play a role in facilitating men to get involved in women's SRH programmes in SSA.

Specific objectives include:
1. To understand the different forms and types of male involvement in women's SRH 2. To identify contextual conditions and mechanisms that facilitate or impede men's involvement and develop an explanatory programme theory 3. To produce guidelines for consideration in the development of interventions to promote male involvement in women's SRH

Methods
For the proposed study, we adopt the RRR methodology as it is best suited in contexts where evidence is limited and allows for the synthesis of knowledge in a considerably shorter time, compared to a traditional RR, making it possible to respond to time-sensitive policy decisions 19 .
A critical strength of RRRs lies in the engagement of local reference groups and experts panels in the review process 19 . Local reference groups contribute local contextual knowledge and include those individuals who are the target of the review findings, for example, policymakers, local community groups, the private sector, or charitable organisations. As this review will inform the development of strategies to tackle the practice of female genital mutilation/cutting (FGM/C), the local reference groups will consist primarily of individuals from nongovernmental organisations (NGOs) with this remit. Potential local reference groups will include representatives from these organisations; the Ministry of Health, Kenya; anti-FGM/C organisations, including Men-End FGM network, AkiDwA (Akina Dada wa Africa), an organisation that seeks to enhance justice and equality for women in Ireland; and CARA projects, an Irish NGO working in Kenya with a focus on child protection. The local reference group will share their knowledge and experience and help identify reports that can be included in the review and ultimately ensure that results have relevance for the local context 19 . In preparation for this review, the first author, PM, has met with potential individuals and groups who will be part of the local reference panel.
Expert panels include individuals knowledgeable in the content area. They are usually tasked with ensuring that the scope of the review remains focused and the process of searching for relevant literature is streamlined. In addition, they participate in the synthesis of findings while ensuring appropriate interpretation of the results 19 . For the proposed review, the expert panel will consist of seven members with experience in women's health, methodologies that promote public involvement, nursing, public health, medical anthropology, psychology and health systems. We will employ a snowballing process to establish a panel of experts with experience in the field under study. In contrast, the local reference panel membership will be agreed by the expert panel 26 . The time commitment required by the expert and reference groups will be kept to a minimum and highlighted in the invitation.

Search strategy
In keeping with the realist literature, we will follow six steps in conducting the review (Pawson et al. 20 and Wong et al. 27 ). This will entail: (1) developing a theory, (2) developing a search strategy, (3) selecting and appraising documents, (4) extracting data, (5) analysing data and synthesising the evidence, and (6) presenting and disseminating a revised theory.
Before the review commences, the expert panel will hold their first meeting to agree and clearly define the scope of the RRR, decide on terms to be included when searching the literature, and on the databases to be searched. The primary researcher (PM) will carry out an initial search of the literature to develop familiarity with the various male involvement strategies relevant to women's SRH in SSA. To search for relevant literature, the 'intervention', 'population' and 'context' will be included. The interventions to be studied include SRH programmes or initiatives, for example, family planning, ante-natal care and post-natal care programmes, and programmes for couples' counselling. The population of interest will be men (husbands, partners, spouses) involved in these interventions or programmes. The review will include studies located in SSA and conducted in any type of setting, including community, household, hospital or other health care facility settings. No restrictions will apply to research articles' study designs or to the year they were published. However, studies not addressing male involvement in women's SRH, not conducted in SSA and those in languages other than English will be excluded. We will also exclude commentaries, letters to editors and opinion pieces.
PM and ADB will undertake a search of the literature in consultation with a University faculty librarian. Databases are likely to include Web of Science, Pubmed, EMBASE, MEDLINE, and PsycInfo, based on other reviews 28 conducted in the SSA context. We anticipate that the literature for this topic will be diverse and hence we will use extensive searching of grey sources, such as OpenGrey, Google Scholar and DODRIA -Africa's data directory -for relevant documents. Documents and articles, as identified by the local reference and expert panel members, will supplement the initial search. We will also search websites, such as those of the United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Health Organization (WHO). The search will be iterative and refocused as the review evolves. PM and ADB will screen titles and abstracts for relevant literature.

Data extraction
Data extracted will include information that helps identify contextual conditions and mechanisms that would facilitate male involvement in women's SRH programmes. Such data would consist of i) the form and types of these programmes (family planning, ante-natal, post-natal), ii) pre-involvement activities such as communication campaigns (through media, mobile phones) sporting activities, the formation of men's clubs, men's health clinics, workshops, seminars, iii) settings where programmes are introduced, and the iv) outcomes associated with these programs (for example increased ante-natal care attendance; reduced mortality and morbidity (mother and baby); decreased/increased intimate partner violence).
Two reviewers (CK and EK) will independently extract the data through a selection of text excerpts 20 . We will use a modified version of the template for Intervention Description and Replication (TIDieR) to extract data 29 . In the case of disagreements between the reviewers, consensus or engagement of a third reviewer will follow. The search for evidence and data extraction is expected to take between 12-14 weeks. The team will hold weekly data sessions to assess the review process. Extracted data will be reviewed for completeness by TK and EM.
Synthesising the evidence The experts, as mentioned earlier, and reference panels will scrutinise initial review findings, synthesis, examine and discuss the identified CMOs based on their experiences. Data will be synthesised to generate a 'programme theory' that aligns with the focus and scope of the review 22 and the 'programme theory' will be refined through group and individual discussions 30 . This RRR will adhere to the realist publication standards guidelines, some recent RRRs will also inform Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) 27 and the methodology.
During the initial planning stages of this protocol, an advisory group made up of anti-FGM/C experts working at the grassroots level in Kenya was set up. The group will have a representative at the local reference panel, and their input is expected to enhance the quality of the review process and the refining of the 'programme theory'. Importantly, the advisory team will play a critical role in supporting the dissemination of the review findings to policymakers and other knowledge users 31 .

Dissemination
The results that will emerge from the RRR will potentially be useful to policymakers and other key stakeholders, including NGOs and groups working to involve men in women's SRH programmes in SSA. The findings will also be presented to key policymakers, and relevant stakeholders and the aforementioned advisory group will be instrumental in enabling this process. We will also draft publications that will be submitted to high-impact, peer-reviewed journals, and the findings will be presented at academic conferences. We envision to present the results at the Africa Health Agenda International Conference. Also, an infographic will be developed based on the review findings and disseminated via social media platforms, for example, twitter, using various hashtags.

Study status
Formation of the expert panel is complete. The searching of the literature has not commenced.

Discussion
The planned RRR will synthesise and generate evidence on the contextual factors and mechanisms that enhance or hinder male involvement in women's SRH programmes. The findings will potentially have relevance to programmes that involve men, either as partners or spouses, or even key decision-makers. The RRR will provide knowledge synthesis within a short period, and to ensure that the evidence generated is relevant and suitable for the knowledge users, local reference panels and expert panels will guide the RRR. Involving these groups in the process not only facilitates the efficiency of identifying essential materials to include in the review, but has the potential to produce sufficiently robust findings which can inform current practice 19 . We expect the review will have a political impact, influencing the development of national policy frameworks on male involvement in countries of SSA where such frameworks are lacking. The programme theories emerging from this work also have the potential to be adapted to the other contexts, for example, Ireland and the UK where there is a growing population from SSA.

Data availability
No data is associated with this article.