i ENSIGN COLLEGE OF PUBLIC HEALTH, KPONG EASTERN REGION, GHANA ASSESSING TAXI DRIVERS KNOWLEDGE AND ATTITUDE THAT INFLUENCE PARTNER USE OF MODERN FAMILY PLANNING METHODS IN WA MUNICIPALITY OF GHANA BY MARTIN KANGMENNAANG (157100058) A Thesis submitted to the Ensign College of Public Health in Partial fulfilment of the requirements for the degree MASTER OF PUBLIC HEALTH JUNE 2017 ii DECLARATION AND CERTIFICATION I, MARTIN KANGMENNAANG declare that this submission is my own work towards the MPH and that to the best of my knowledge, it contains no material previously published by another person nor material which has been accepted for the award of any other degree of the University, except where due acknowledgement has been made in the text. MARTIN KANGMENNAANG …………… ………… 157100058 Student’s Name Signature Date Student’s ID Certified by: …………………………………………. …………………… …………… Supervisor’s name Signature Date Certified by: ………………………………… …………………. …………….. Head of Department’s name Signature Date iii DEDICATION This work is dedicated to the Almighty God whose abundant grace, mercy and love have seen me through the period of this program. Secondly to my dear wife madam Fina Yirilabuo and lovely children Micaiah and Micah Kangmennaang. Thanks a million times for your love, encouragements and support. You are a wonderful wife, mother and friend. I love you with all my heart. God richly bless you. iv ACKNOWLEDGEMENT My thanks go first to the Almighty God for the strength, knowledge and understanding given to me in the pursuits of this research. Second, I wish to thank my dear wife Mrs. Fina Yirilabuo Kangmennaang for giving me the support I needed. My sincere thanks go to my brother Mr. Joseph Kangmennaang for his financial assistance during the course of this program. . I extend my gratitude to Dr. Frank Baiden my able supervisor for his supervision, encouragement, good critiques and immense support during the period of data collection and useful pieces of information which led to the completion of the research. I wish to state that I am personally accountable for any shortcoming of this study. I wish to also acknowledge the financial assistance I received from Ensign College of Public Health, may the good lord bless you abundantly. v ABSTRACT Background: The uptake of modern family planning (FP) methods remains a major challenge in sub-Saharan Africa. Current use of modern contraceptive methods in Ghana stand as 22%. This is in spite of considerable public education and investment in the provision of services. The Upper Wes Region of Ghana has some of the worst indicators of FP uptake in the country. It has been postulated that this may be due to the highly patriarchal social system. An improved understanding of male attitude towards family planning in the Region will help in the design of interventions targeted at improving male acceptability and overall increased FP uptake. Methods: This is a cross-sectional study that employed a questionnaire administered to taxi drivers (an entirely male-dominated vocation) in four communities in Wa, the regional capital. The questionnaire enquired into socio-demographic background, knowledge of family planning methods and attitudes towards their use. Questionnaires were administered by trained fieldworkers at various taxi stations in the communities. Descriptive analysis compared findings in the present survey with the findings in a similar study in Wa in 2013 that used the same instrument and interviewed 250 respondents. Bivariate and multivariate analysis explored the association between the socio-demographic background of respondents, attitudes towards FP and respondents’ willingness of to pay for FP services. Results: Four hundred and ten male taxi drivers were interviewed. The median age was 34 (interquartile range 28-42) years. Only 12.1% of respondents had been schooling beyond high school. The majority (59.7%) were Muslims and of the Waali and Dagarti tribes (91.5%). About 62.1% of respondents approved of FP use (82.4% in the 2013 survey). More than half (61.2%) of respondents indicated a willingness to pay the cost of FP services to their partners. The independent predictors of this willingness were: Approval of FP (Odds Ratio OR= 6.77 95% Confidence vi Interval-CI 3.73-12.28), past experience with couple counseling (OR= 4.20, 95% CI 1.35 - 13.09), believing that wife access to family planning will make her unfaithful (OR= 0.27, 95% CI 0.13 – 0.57), being Waali/Dagarti (OR= 0.81, 95% CI 0.02 – 0.32) and having more than one wife (OR= 0.18, 95% CI 0.06 – 0.51). Conclusion: There has been reduction the number of men indicating FP approval since 2013. Male attitudes towards FP are rooted within levels of FP education, ethnicity and fear of spousal infidelity. A multidimensional approach is needed to overcome male apprehensions towards spousal adoption of FP in this community. vii LIST OF ABBREVIATIONS AIDS-----------------Acquired Immune-Deficiency Syndrome ANC-------------Antenatal Clinics CHPS CMP-------------Community Health Based Planning and Services Compound. CHRAJ------------------Commission on Human Right and Administration Justice CI----------------------Confidence Interval. DHS---------------------Demographic Health Survey FM--------------------------Frequency Modulation FP----------------------Family Planning GDHS---------------------Ghana Demographic Health Survey GPRTU----------------------Ghana Private Road Transport Union HIV-------------------Human Immune Virus HOSP-----------------------Hospital HW-------------------------Health Worker ICPD--------------------International Conference on Population and Development IPPF---------------------International Planned Parenthood Federation IUD-------------------Intrauterine Device MBCP--------------------Male Birth- Control Pill MCH-------------------Maternal and Child Health MDG-----------------Millennium Development Goals OR--------------------Odds Ratio SHEP----------------------School Health Program SSA-------------------Sub- Sahara Africa STI---------------------------Sexually Transmitted Infections TV--------------------------Television UWR-----------------------Upper West Region WHO-----------------World Health Organization viii TABLE OF CONTENT ENSIGN COLLEGE OF PUBLIC HEALTH, KPONG EASTERN REGION, GHANA .............. i DECLARATION AND CERTIFICATION ................................................................................ ii DEDICATION ........................................................................................................................... iii ACKNOWLEDGEMENT ......................................................................................................... iv ABSTRACT .................................................................................................................................... v LIST OF ABBREVIATIONS ................................................................................................... vii TABLE OF CONTENT ........................................................................................................... viii LIST OF TABLES .................................................................................................................... xii LIST OF FIGURES ..................................................................................................................... xiii LIST OF APPENDIXES .......................................................................................................... xiv CHAPTER ONE ............................................................................................................................. 1 1.0 INTRODUCTION ................................................................................................................. 1 1.1 Background of the Study ....................................................................................................... 1 CHAPTER TWO ............................................................................................................................ 5 2.0 LITERATURE REVIEW ...................................................................................................... 5 2.1 Availability and accessibility of family planning service to males. ...................................... 7 2.2 Utilization of family planning service by males ................................................................... 8 2.3 Knowledge and perception of males about family planning ................................................. 9 2.4 Religious and cultural influence on modern family planning services ................................. 9 2.5 Roman Catholicism ............................................................................................................. 10 2.7 Protestantism ....................................................................................................................... 11 2.8 Islam .................................................................................................................................... 11 2.8 Islamic beliefs about family planning ................................................................................. 12 ix 2.9 Covert family planning ........................................................................................................ 13 Problem Statement ................................................................................................................... 13 Research Questions .................................................................................................................. 15 OBJECTIVES .......................................................................................................................... 15 CHAPTER THREE ...................................................................................................................... 17 3.0 METHODOLOGY .............................................................................................................. 17 3.1 Study Site ............................................................................................................................ 17 Map of Wa municipality ........................................................................................................... 18 3.2 Physical features,Geology and Soil Characteristics of Wa municipality ............................ 18 3.3 Vegetation ........................................................................................................................... 19 3.4 Climate ................................................................................................................................ 19 3.5 Study Design ....................................................................................................................... 20 3.6 Study Population ................................................................................................................. 20 3.7 Inclusion Criteria ................................................................................................................. 20 3.8 Sample Size Calculation ...................................................................................................... 20 3.9 Sampling Method ................................................................................................................ 21 3.10 Data Collection Method .................................................................................................... 21 3.11 Data Management and Analysis ........................................................................................ 22 3.12 Pre-Test ............................................................................................................................. 22 3.13 Challenges of the Study ..................................................................................................... 22 3.14 Ethical Consideration ........................................................................................................ 23 3.15 Expected outcome of the Study ......................................................................................... 23 3.16 Dissemination of Findings ................................................................................................ 24 CHARPTER FOUR ...................................................................................................................... 25 4 RESULTS............................................................................................................................... 25 x Background Characteristics ....................................................................................................... 25 4.1: Demographic Characteristics ............................................................................................. 25 4.2 Marital Status ...................................................................................................................... 26 4.3: Religious beliefs of respondent .......................................................................................... 27 4.4 Number of children of respondents ..................................................................................... 27 4.5 Number of wife/ wives of respondent ................................................................................. 28 4.6 Attitude of men towards modern contraceptive use ............................................................ 29 4.7 Knowledge and use of various contraceptives methods ...................................................... 30 4.8 Use of modern family planning contraceptives ................................................................... 31 4.9 Male attitude towards partner use of modern family planning ........................................... 32 4.10: Male and partners currently using FP .............................................................................. 32 4.11 Reasons for the choice of modern family planning by respondents in Wa municipality .. 33 ................................................................................................................................................... 33 4.12 Modern family planning service delivery points in Wa municipality ............................... 36 4.13 Male attitude towards partner use of modern family planning in Wa municipality ......... 37 4.14. Couples attending family planning counselling sessions together ................................... 38 4.15: Respondents accompanying partners to antenatal clinic in Wa municipality .................. 39 4.16: Respondent’s willingness to pay for the cost of family planning services provided to their partners. ..................................................................................................................................... 40 4.17: How worried will respondent be if you found out that your partner was using family planning method without your knowledge? .............................................................................. 41 4.18: Testing for association between background characteristics and some selected variables ................................................................................................................................................... 42 4.22: Demographic characteristics and willingness to pay for FP as a proxy indicator of male attitude ....................................................................................................................................... 45 xi 4.23 Attitude towards modern family planning and the willingness to pay for modern family planning services ....................................................................................................................... 47 4.24.1: Comparison of 2017 and 2013 attendance of FP counseling and usage of FP methods by respondents ................................................................................................................................ 48 4.24.2: Comparison of Approval and Promotion of FP in 2017 and 2013 ............................... 49 CHAPTER FIVE .......................................................................................................................... 50 DISCUSSION .......................................................................................................................... 50 5.0 Introduction ............................................................................................................................. 50 5.1 Background Characteristics ................................................................................................. 50 5.2 Knowledge and attitude of men towards modern contraceptives use ................................. 51 5.2.1 Knowledge and Perception ............................................................................................... 51 5.2.2 Counseling of men in family planning ............................................................................. 51 5.2.3: Respondents who were using FP at the time of the interview ........................................ 52 5.2.4 Information on modern family planning in Wa municipality .......................................... 52 5.2.5 Men involved in antenatal services (ANC) and FP discussion ........................................ 52 5.2.6 Male attitude towards partner use of family planning ...................................................... 54 CHAPTER SIX ............................................................................................................................. 55 6 CONCLUSION AND RECOMMENDATIONS ................................................................... 55 6.2 RECOMMENDATIONS .................................................................................................... 55 7.0 REFERENCES ....................................................................................................................... 57 8.0 APPENDIXES ........................................................................................................................ 62 xii LIST OF TABLES Table 3.8.1: Sample Size Calculation……………………………………………………………20 Table 4.4: Number of children of respondents ............................................................................ 27 Table 4.5: Number of wives of respondents ................................................................................ 28 Table 4.6.1: Men knowledge about the promotion of modern family planning. ........................ 29 Table 4.6.2: Approval of the use of modern contraceptive to stop unwanted pregnancy ........... 29 Table 4.7: Knowledge of family planning contraceptives........................................................... 30 Table 4.8 :Use of family planning contraceptives ....................................................................... 31 Table 4.18: Testing for association between number of children and approval of family planning ..................................................................................................................................................... 42 Table 4.19: Testing for association between current usage of family planning and where respondents get the services from. .............................................................................................. 43 Table 4.20: Testing for association between approval of usage of family planning and the last time respondents discussed family planning with partners. ........................................................ 44 Table 4.21: Testing for association between respondent’s current usage of family planning method and the spouse needs to use family planning methods/devices. ..................................... 45 Table 4.22: Demographic characteristics and willingness to pay for FP as a proxy indicator of male attitude .............................................................................................................................. 45 Table 4.23; Willingness to pay for FP as a proxy indicator of male attitude. ............................. 47 xiii LIST OF FIGURES Figure 4.2: Marital status of respondents .................................................................................... 26 Figure 4.3 Respondents Religion ................................................................................................ 27 Figure 4.11.1: First reason for the choice of modern family planning method by respondents. . 33 Figure 4.11.2: Second reason for the choice of modern family planning methods by respondents. ..................................................................................................................................................... 34 Figure 4.11: Third reason for the choice of modern family planning method by respondents ... 35 Figure 4.12: Where respondents and partner mostly get the family planning contraceptives service from. ............................................................................................................................................ 36 Figure 4.13.: Couples Discussion of Modern Family Planning Methods at Home. .................... 37 Figure 4.14: Have respondents and partners ever attended family planning counselling sessions together. ....................................................................................................................................... 38 Figure 4.15: respondents ever accompanied his partner to the antenatal clinic in the past one year ..................................................................................................................................................... 39 Figure 4.16: Respondents willingness to pay for the cost of family planning for their partners. 40 Figure 4.17: whether respondents will worried if partners used family planning without their knowledge. .................................................................................................................................. 41 Figure 4.24.1 : Compares attendance of FP counseling and use of FP methods in 2013 and 2017. ..................................................................................................................................................... 48 Figure 4.24.2: Comparing Approval of FP and Promotion of FP in 2017 against 2013 ............. 49 xiv LIST OF APPENDIXES 8.1 Questionnaire on male knowledge and attitude that influence partner use of modern family planning services. ...................................................................................................................... 62 8.2 Letter of introduction to the station master wa central. ....................................................... 62 8.3 Letter of introduction to the station master kpaguri lorry station. ...................................... 62 8.4 Letter of introduction to the station master kambali lorry station. ...................................... 70 8.5 Letter of introduction to the station master bamahu lorry station. ...................................... 71 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Background of the Study Family planning is a method used to control or space childbirth either naturally or artificially. It allows couples to attain their desired number of children and determine the spacing of pregnancies (WHO, 2015). Family planning and its interventions are among the most cost-effective health interventions especially considering their close link with maternal and infant health and survival. An important intervention towards achieving this target is the promotion of modern family planning (FP) among women in sub-Saharan Africa (SSA). Uptake of modern FP methods remains low in SSA and this is associated with a high incidence of unwanted pregnancies, unsafe abortions, unplanned deliveries and maternal mortalities. One of the significant limitations of the policy has been the non-involvement of males in family planning either as users or supporters of their partners in the use of family planning methods. Almost all, if not all family planning methods or program were women-oriented with very few aimed at involving men both as users and supporters .The reasons for placing greater emphasis on women instead of men were that since women bear the risks and burden of pregnancy and childbearing, they should have the greatest stake and interest in protecting their own reproductive health (Olawepo and Okedare, 2006). It was against this background that most of the modern family planning methods developed since 1960, such as the Pill, Intra-Uterine Device (IUD), Injectable, Diaphragm/Foam/Jelly and Norplant were focused on women. The only methods for men are limited to Condoms and Vasectomy (Population Reports, 1998). It is also important to 2 state that the clinic-based service delivery designed for family planning has made it difficult to include men. Services have often been offered in maternal and child health (MCH) clinics (Olawepo, 2003). It is based on this that many men see these clinics and their staff as serving only women and children and thus not male-friendly and convenient. In view of this men feel uncomfortable seeking services in that setting. The active involvement of men will undoubtedly increase their commitment and joint responsibility in all areas of sexual and reproductive health. The ignorance of males (husbands and partners of female clients) of family planning was a large constraint on the success of family planning efforts when women were the only targets. Male involvement in family planning (FP) means more than increasing the number of men using condoms and having vasectomies; male involvement also includes the number of men who encourage and support their partner and their peers to use FP and who influence the policy environment to be more conducive to developing male-related programs. In this context “male involvement” should be understood in a much broader sense than male contraception, and should refer to all organizational activities aimed at men as a discrete group which have the objective of increasing the acceptability and prevalence of family-planning practice of’ either sex (Becker and Costenbender, 2001). Involving men and obtaining their support and commitment to family planning is of crucial importance in the Africa region, given their elevated position in the African society (Ann Biddlecon and Bolaji.Fapohunda .,1998). Most decisions that affect family life are made by men. Most decisions that affect political life are made by men. Men hold positions of leadership and influence from the family unit right through the national level (IPPF, 1984) The involvement of men in family planning would therefore not only ease the responsibility borne by women in terms 3 of decision-making for family-planning matters, hut would also accelerate the understanding and practice of family planning in general. Historically, the predominant methods of preventing births in most parts of the world were methods used by or requiring the cooperation of men. The oldest of these, coitus interrupts or withdrawal, was known to at least three ancient religious traditions (Cummings and Bremner, 1994) and historical demography reveals that it was the principal method responsible for the demographic transition in Europe in the last century (Wrigley, 1969). It is still used by estimated 35 million couples worldwide, and is the method most widely used in Turkey, a country with substantial access to modem methods. Nearly as many couples are thought to rely on periodic abstinence or the rhythm method (Herndon, 1992). Globally, there are over one hundred and twenty million (120 million) couples who do not use contraceptives despite the fact that they want to space child bearing, and an additional three hundred million (300 million) are dissatisfied with most of the family planning methods available. Assessment of available research found that there is still a lack of representative data on male, especially, related to knowledge and attitude towards family planning, as well as data on service for males. Besides, there is no strategic presentation for males and family planning, In the Ghanaian society, men are considered not only as leaders and family heads but decision makers in all aspects of life including contraceptive use. Thus, it is the man who decides the family size. He also decides whether the search for the male or female child should continue or not. It is the man who decides on his own wishes whether there should be intimacy between the couple and it is the responsibility of the woman to satisfy the sexual desire of her man at all costs and times without getting pregnant. It is against this background that all efforts are made to actively involve 4 men in family planning issues since the success of any family planning program depends to a greater extent on the involvement of both the wife and husband. Regrettably, this does not seem to be the situation in the Wa District where most men believe ignorantly that the practice of family planning should be the sole responsibility of the woman and not the man and hence their minimal or non-involvement in family planning practice. 5 CHAPTER TWO 2.0 LITERATURE REVIEW The use of any method of FP (Family Planning) by women is often influenced by their husbands. Men have rarely been involved in either receiving or providing information on sexuality, reproductive health, or birth spacing. They have also been ignored or excluded in one way or the other from participating in many FP programs as FP is viewed as a woman’s affair. Traditionally, men are the heads of households and decision makers in all issues in their respective households. Men decide on FP and the number of children as well as how to use what is produced by the family. Also, findings have shown that since men were the decision makers, they were expected to initiate discussions on FP and the number of the children the couple want to have. Men were perceived as the sole providers for their family needs. Women were not considered decision makers, but implementers of what had been decided by men, without questioning men’s decisions. The high level of awareness about contraception but very low level of use has been established in studies in Nigeria According to a survey conducted in the United States, it was realized that on average, males comprise only 6% of all family planning clinic clientele, who really use the service (Burt, Aron & Schack, 1994). At the US-Federally subsidized clinics, males made up only 2% of the total client population, meaning few men patronize the family planning service. Evidence suggests husband’s/partner’s support for family planning influences a woman’s modern contraceptive use. (Mubita-Ngoma & Kadantu, 2010; Stephenson & Tsui, 2002; Williamson, Parkes, Wight, Petticrew, & Hart, 2009) 6 Since the 1994 International Conference on Population and Development (ICPD), interest in men’s involvement in reproductive health has increased. Evidence indicates that male involvement can lead to contraceptive uptake through the pathway of increased spousal communication. However, FP programs have traditionally focused on women as the primary beneficiaries and men have been considered as the silent partners of the services Consequently, in recent years the importance of including men in reproductive health matters has received increasing recognition. A key recommendation of both the 1994 international Conference on Population and Development and the 1995 fourth World conference on women was that programs encouraged husbands and wives to share in the responsibilities pertaining to fertility and reproductive health. A first step towards increasing men’s participation in the reproductive health is to understand their knowledge, attitude and practices regarding a range of issues. Until recently, data about men’s family planning, knowledge, attitude and practices were scarce. Most large-scale family planning surveys-the knowledge, attitudes and practices and the world fertility surveys, the contraceptive prevalence surveys and the first round of the Demographic and Health survey (DHS), included only women and focused on determinants of their contraceptive use (Drennan, 1998) The lack of attention to men in surveys probably reflected their limit options for participating in contraceptive use (Ringheim, 1993). A woman can, of course control her fertility without her husband’s cooperation, yet when men and women are aware of and responsive to each other’s health needs, they are more likely to obtain necessary services. Moreover, strengthening communication between partners about reproductive health promotion can lead to better health for the entire family (Drennan, 1998) 7 2.1 Availability and accessibility of family planning service to males. Despite the fact that men play an important role in reproductive health, studies have shown that there are certain hindrances to male utilization of family planning service. Range of family planning methods available to men is limited, and this as a result inhibits men’s capacity to participate in fertility regulation. (Green, et., al.,1995). The inadequacy of male method of contraceptives has caused considerable media attention surrounding a recent breakthrough, in the development of a male birth-control pill (MBCP). The fact of the issue is that, production of a new male method of contraceptive is still about 5-10 years away with some technical hurdles to overcome ( Duorsky, 2008). Men would use a hormonal male contraceptive, delivered by injection and/or implant; this would be less intrusive method, likely that men will show more interest in using family planning (Heinemann et. al., 2005). Other studies have revealed that there are a lot of choices to make on family planning methods for male, including the traditional methods, but because of certain beliefs coupled with inadequate knowledge of certain methods of contraception some men are against their use with reasons best known to them (Nzoka, 2000). Here, the reality is that family planning services available for men are few and, besides, the facilities providing family planning services are also not enough, even the few available are not male user-friendly. According to a survey on approved contraceptive use, men’s lack of access to the family planning service is a barrier to its use. Therefore, men cannot share their responsibility on reproductive health, including family planning if they cannot access the service. Most family planning clinics, according to a study mainly cater for women, so men are not comfortable visiting these clinics (Population Report, 1994). This contradicts the findings of a study done in Danfa, Ghana that showed that men can easily access family planning service (IPPF, 1984). The study shows that 8 men even prefer buying the condoms from existing mobile outreach clinics than buying it from drug stores. Similarly, a case study conducted in Khaochakan district in Thailand showed that majority of males knew where the family planning service was available, some know about health centers, others, hospitals whiles some primary health care units and drug stores. The real situation on the ground is that although men are aware of family planning service, access and utilization is low and poor. According to a Bangladesh Health and Demographic survey which aimed at identifying the factors that influence male involvement and access in family planning, male participation is strongly influenced by demographic, socio-economic, cultural and psychological, communication and service factors (World Population Policies, 2003). 2.2 Utilization of family planning service by males According to a survey conducted in the United States, it was found that on average; male comprise only 6% of all family planning clinic clientele (Burt, Aron and Schack, 1994). This compared to a research carried out in Danfa in Ghana, males prefer visiting mobile clinics for obtaining condoms rather than buying it in a store (IPPF, 1984). This indicates that males patronized the service brought to them at their door step rather than going to the health centers. Another survey revealed that even though there has been some success in trying to increase male utilization of family planning service, the reality remains that most males do not utilize the service and it is evident that while some positive strides have been taken, some negative influence act to inhibit male utilization of family planning service (Sonenstein and Pleck, 1995). GDHS (2014) results of a survey showed that married men and sexually active men who reported having ever used one or more male methods of contraception, which are male sterilization, male condom, periodic abstinence and withdrawal, the most popular male method, the condom has been used by few males, both married 9 and unmarried males. While male sterilization is practically non- existent in Ghana. What is known in literature is that most male methods are used by few males. Of the other two traditional methods, according to studies periodic abstinence is reported as used more than withdrawal by both married and unmarried men (GDHS, 2014). A study was conducted in northern Nigeria on the linkages between socio-economic characteristics, attitudes and familial contraceptive use. The result disclosed that there is high knowledge of contraceptive but low rate of its utilization. Community and culture affect a person’s attitude towards family planning, desired sex of children, preferences about family size, family pressure to have children and whether FP accords with customs and religious beliefs (Dixon- Meuller, 1999). According to a study conducted on knowledge of and attitudes about family planning and its use by a convenience sample of men in Ghana. It indicated that increase in knowledge has significant effect on the respondents. The study again identified socio-cultural misconceptions resulting from lack of knowledge and education as the main deterrents for the use of different family planning methods including vasectomy (Rhoda Adwoba Akafuah and Marie-Antoinette Sossou 2008). 2.3 Knowledge and perception of males about family planning In Ghana, knowledge of contraception is higher among males than females, however, usage is low (GDHS, 2014). Contraception in general is perceived to be a woman’s business and women who use contraceptives are stigmatized and accused of promiscuity by society 2.4 Religious and cultural influence on modern family planning services Considering religious affiliations, Catholics and Muslims have been regarded as Pronatalists in their ideology on contraception; they observe population increase as positive and objective 10 artificial fertility control mechanisms. However, as mentioned by (Palamuleni, 2014), the strength of one’s religiosity or degree of one’s adherence to the norms of a given religion may exert an influence on one’s mode of life including reproductive behaviors; knowledge of family planning services is an essential pre-condition for practicing contraceptives. Studies have documented that some of the obstacles faced by individuals or couples who want to delay or avoid a birth include lack of knowledge about methods and how to use or where to obtain family planning services (Robey et. al., 1996). 2.5 Roman Catholicism Within Catholicism, the primary purpose of marriage and sexual intercourse is procreation (Schenker, 2000). Every act of intercourse must remain open to conception. Contraception destroys any potential to produce new life and violates the principal purpose of marriage (Schenker and Rabenwu, 1993). This contraception ban is against unnatural means of contraception, which include chemical and barrier methods (Schenker and Rabenwu, 1993). Abstinence and the rhythm method are the only officially approved methods of birth spacing (Schenker and Rabenwu, 1993). These forms of family planning may be used for medical, economic, and social indications (Schenker, 2000) Contraceptive intent and results when these methods are used are no longer considered sinful (Gudorf, 2003) All other forms of birth control are forbidden. (Schenker and Rabenwu, 1993). In Catholicism, new life is treated as a person from the moment of conception (LoPresti, 2005) All forms of abortion and emergency contraception are prohibited (LoPresti, 2005) except for measures normally taken to save a mother that result in the death of the fetus (Gudorf, 2003) 11 2.7 Protestantism Literal interpretation of the Bible has resulted in disapproval of contraception among conservative Protestants, such as Evangelical and Fundamentalist Protestants; the use of contraception would violate God’s command to “be fruitful and multiply.”(LoPresti, 2005). Protestants believe that marriages should be procreative; there are no prohibitions against using contraception within a marriage that already has children (LoPresti, 2005). Reproductive health decisions, such as the final size of the family, the appropriate conditions for contraception and the choice of contraception, are left to the discretion of the couple (LaHaye and LaHaye, 1998) Virtually all liberal Christian communities accept the use of contraception within marriage for the purpose of exercising responsible parenthood, enhancing marital love, and protecting women’s health (LoPresti, 2005) Health care providers should begin contraception discussions with Protestant patients by determining which Protestantism denomination the couple are affiliated with and whether they adhere to conservative beliefs about contraception. Protestantism considers abortion a sin; however, the permissibility of abortion and emergency contraception varies between denominations. Conservative Protestantism has condemned all abortion (LoPresti, 2005). The majority of mainstream conservative Protestant denominations permit terminations when the mother’s life is threatened (LoPresti, 2005). In situations of unwanted pregnancies, the decision is left to the woman. Liberal Protestants favor a woman making her own decision to actualize her moral agency (LoPresti, 2005). 2.8 Islam Central to the beliefs of Islam is that Allah—God—is the creator of the universe and humankind (Rashidi and Rajaran, .2001), (Hasna, 2003) Islam is a comprehensive system used to regulate 12 spiritual and political aspects of individual and communal life (Rashidi and Rajaran, 2001) By studying various religious sources, Islamic jurists classify human actions as obligatory, recommended, permitted, disapproved but not forbidden, or forbidden (Hasna, 2003). Distinct schools of Islamic jurisprudence have developed over time (Omran, 1992). These schools represent different traditions of interpretation and are not considered distinct denominations (Omran, 1992). 2.8.1 Islamic beliefs about family planning The majority of Islamic jurists indicate that family planning is not forbidden (Omran,. 1992). Muslim opinion regarding the further classification of contraception ranges from permissible to disapproved (Omran, 1992). Some fundamentalist Muslims insist that any form of contraception violates God’s intentions (Poston, 2005). Historically, coitus interruptus has been permitted in the Quran (Poston, 2005). When contraception justification is provided, such as health, social, or economic indications, coitus interruptus becomes recommended (Omran, 1992). Through analogous reasoning, authorities permit modern methods of contraception as lawful, given that they are temporary, safe, and legal (Scenker and Rabenwu, 1993). Any device that does not induce abortion (Poston, 2005) and is reversible may be used (Omran, 1992). Irreversible sterilization methods are not permitted (Hasna, 2003). Contraception may be used only within marriage (Pennachio, 2005). Justifiable reasons for contraceptive usage include health risks, economics, preservation of the woman’s appearance, and improving the quality of offspring (Maquire, 2001). Health risks need not be life- threatening (Omran, 1992). Continuous hormonal contraception, as it is reversible, is permissible as a form of contraception; however, it may not be acceptable to some women who value regular monthly menstruation. In contraception discussions with Muslims, health care providers should 13 first determine whether the couple holds conservative beliefs about contraception and whether they consider contraception to be permissible and encouraged or permissible yet disapproved. The Islamic concept of Hejab—modesty—may affect gynecological care (Pennachio, 2005). Some societies interpret this concept as meaning health care practitioners of the same gender are required to carry out all medical examinations (Dhami and Sheikh, 2000). Such religious restrictions among traditional Muslims may prevent women having intimate examinations when a health care provider of the same sex is not readily available (Rashidi and Rajaran, 2001), thereby influencing medical care and contraceptive decision-making. 2.9 Covert family planning The common definition of “covert use” is contraceptive use without the knowledge of the spouse. A study in Navrongo, Ghana (a rural setting), provided a unique opportunity to compare family planning service records on contraceptive use with survey interview data from the same women and their spouses (survey interviews were conducted by interviewers who were not aware of the contraceptive status of the respondent). Among 57 percent of the couples in which the wife was a known contraceptive user, the wife reported in the survey interview that she was using contraceptives and her husband reported that she was not (Phillips et al., 1997). A study in Uganda found that over 15 percent of women who were using contraceptives said that they were doing so without their partners’ knowledge (Blanc et al, 1996) Problem Statement Family planning and its interventions are among the most cost-effective health interventions especially considering their close link with maternal and infant health and survival. 14 An important intervention towards achieving this target is the promotion of modern family planning (FP) among women in sub-Saharan Africa (SSA). Uptake of modern FP methods remains low in SSA and this is associated with a high incidence of unwanted pregnancies, unsafe abortions, unplanned deliveries and maternal mortalities. Men’s participation is crucial to the success of family planning programs and women’s empowerment and associated with better outcomes in reproductive health such as contraceptive acceptance, continuation and safer sexual behaviors. Cultural or religious oppositions and gender-based barriers are some of the reasons for low utilization of family planning. Limited knowledge, choice, access to methods and attitudes of men towards family planning, perceived fear of side-effects and poor quality of available services are barriers to male acceptance of modern family planning services in SSA. Consequently, in recent years the importance of including men in reproductive health matters has received increasing recognition. A key recommendation of both the 1994 international Conference on Population and Development and the 1995 fourth World conference on women was that programs encouraged husbands and wives to share in the responsibilities pertaining to fertility and reproductive health, however, in most communities in Ghana such as Wa municipality still records low levels of male involvement in modern family planning usage. Hence, this study seeks to assess male knowledge and attitude that influence partner use of modern family planning services in the Wa Municipality of Ghana. 15 Research Questions 1. What are some of the factors that prevent males from assessing or practicing modern family planning services? 2. What socio-cultural and religious barriers prevent males from practicing modern family planning? 3. Do men have adequate knowledge on the importance of modern family planning with regards to prevention of unwanted pregnancies, birth or child spacing and prevention of STIs? 4. What is the level of involvement of men in modern family planning procedures? OBJECTIVES General Objective • To describe male knowledge and attitude that influence partner use of modern family planning methods in Wa Municipality Specific Objectives • To assess the level of awareness of the various modern family planning methods in Wa Municipality. • To assess the level of use (including their spouses) of modern family planning methods in Wa Municipality. • To assess attitude towards covert modern family planning use in Wa Municipality • To assess attitudes favoring couple counselling at ANC (Postpartum clinics) 16 • To compare all the above with findings made in similar studies in 2013 with the same design and instrument. • To identify male willingness to pay for modern family method. 17 CHAPTER THREE 3.0 METHODOLOGY 3.1 Study Site The Wa Municipality shares administrative boundaries with Nadowli District to the north, Wa East District to the east and to the west and the south Wa- West District. It lies within latitudes 1º40’N to 2º45’N and longitudes 9º32’W to 10º20’W. Wa Municipality has its capital as Wa, which also serves as the Regional capital of Upper West Region. It has a land area of approximately 579.86 square kilometers, which is about 6.4% of the Region. The Assembly is empowered as the highest political and administrative body charged with the responsibility of facilitating the implementation of national policies. 18 Map of Wa municipality 3.2 Physical features, Geology and Soil characteristics of Wa Municipality Wa Municipality lays in the Savannah high plains, which generally, is gently undulating with an average height between 160 m and 300m above sea level. The two main drainage systems in the capital include; Sing-Bakpong and its tributaries to the south and Billi and its tributaries to the north (Wa Municipal, 2014). Underlying the Municipality are predominantly Pre-Cambrian, granite and metamorphic rocks. There are two main types of soil; the laterite and the savannah ochrosols. The laterite soil occurs abundantly all over the Municipality and is excavated for roads and housing construction. The savannah ochrosols on the other hand are shallow but support the growth of a variety of crops including millet, sorghum, soya beans, groundnuts, rice and yams. 19 3.3 Vegetation The vegetation is one of the guinea savannah grassland type, made up of short trees with little or no canopy and shrubs of varying heights and luxuriance, with grass ground cover in the wet season. Commonly occurring trees are shea, dawadawa, kapok and baobab. Cashew and mango are exotic species that grow well in the area. 3.4 Climate Wa Municipality has two marked seasons, namely, the wet and dry seasons. The South- Western Monsoon winds from the Atlantic Ocean bring rains between April and October, while the North Eastern Trade winds from the Sahara Desert bring the long dry season between November and March. The mean annual rainfall varies between 840mm and 1400mm. Most of the rainfall occurs between June and September and it is not unusual to have very high rainfall figures concentrated in a few rainy days. One feature of the rainfall pattern is that it tends to occur in heavy downpours thus, that encourages run-off rather than soil moisture retention. Erratic rainfall regime is clearly shown in the water balance, which is a reflection of the poor soil moisture condition in the area. It has been calculated that there are four humid months, in terms of soil moisture conditions and the period is only adequate for the cultivation of crops such as millet, guinea corn, yam, groundnuts and beans. The rainfall pattern is irregular and unreliable. Sometimes, it results as long period of no rain during the farming season which affects harvest. 20 3.5 Study Design The study design is a descriptive cross-sectional one. A quantitative method of data collection was used to achieve this purpose of describing male knowledge and attitude that influence partners use of modern family planning methods in Wa municipality. 3.6 Study Population The study population for this study was Male Taxi Drivers (Married) residing in Wa municipality. 3.7 Inclusion Criteria The study participants were: 1. Married Taxi Drivers who falls within the study age group (18-69 years) 2. Married Taxi Drivers within the age specified and stays in the community for at least one year. 3. Taxi Drivers with at least one child who falls within the age group. 3.8 Sample Size Calculation Computation of the sample size came out with 377 males by using family planning prevalence rate of 50% confidence interval of z=1.96, margin of error=5%. The Calculated sample size yielded 377 respondents (410 Adjusted). Four hundred and ten (410) subjects was used for the study. Table 3.8.1: Sample Size Calculation Margin of Error 5% Confident level 95% 21 Population size 10,000 Prevalence of family planning 50% Addition 9% Total Sample size 410 3.9 Sampling Method A purposive sampling method was used to select four commercial towns (Wa Central, Bamahu, Kambali and Kpaguri) in Wa municipality for the study. A purposive sampling method was again used to select 103 respondents (Taxi Drivers) in the Wa Central and Bamahu communities and 102 respondents from Kambali and Kpaguri respectively. In all, a total of four hundred and ten (410) males’ taxi drivers of ages between 18-69 years were selected and interviewed. Research assistants were stationed at these four commercial towns to seek the consent and administered the questionnaire to consented Taxi Drivers. 3.10 Data Collection Method The method of data collection employed was interview through administration of questionnaire to achieve this purpose. The questionnaire was both open-ended and closed ended and also exploratory in nature to help respondents easily share their views. The questionnaire was 22 administered in a confined place to ensure privacy. The questionnaire was also translated into the local language (Waali and Dagaari) for easy understanding of the respondents. Again as part of the preparation for data collection two days were set aside to train four (4) research assistants in data collection skills to help with the administration of the questionnaire. 3.11 Data Management and Analysis Data entry (double entry) and cleaning was done using Excel and statistical analyses done with STATA 14. Discussion on analysis was done on both specific and general objectives. Comparative descriptive analysis was performed with test of proportions used to compare the responses from different backgrounds. Univariate, bivariate and multivariate analyses were performed to access how male knowledge and attitude influence partner use of modern family planning methods in Wa municipality of Ghana. A test of association was considered significant with a p-value of < 0.05. 3.12 Pre-Test The questionnaire was pre-tested in Tamale municipal on 20 taxi drivers. The purpose of the pre- test was to remove ambiguities and unnecessary items in the questionnaire and also to incorporate omissions that might have been omitted from the questionnaire. Pre-testing also gives a fair idea of the responses to be obtained from the field. 3.13 Challenges of the Study 1. Low level of participation by male. ---Effort was made to assure participants that no identifier (s) such as names and pictures will not be included in the study. 2. Some respondents were not willing to give all the information required by the researchers because of the fear of being penalized. ---Efforts was made to reduce this problem by assuring them of their confidentiality of all information provided. 23 3. Low response from Catholic and Muslim respondents due to their religious doctrine – Participants were assured that information given out is purposely for the research and not for any other purpose. 3.14 Ethical Consideration Ethical approval was obtained from the Ethics Review Board of Ensign College of Public Health. Municipal approval was also obtained from the chairmen of Ghana Private Road Transport Union (GPRTU) of the various study areas within Wa Municipality and individual informed consent sought from each participant before the questionnaire was administered to them. The participants consent was sought to involve them in the study. Informed consent that is the permission to involve them in the study was also sought from all the respondents before interviewing them. The purpose and the objectives of the study, and any potential risk or benefits inherent in the study was explained to the respondents. The respondents were given opportunity to ask questions about the study at any stage, and to withdraw from the study at any time they feel insecure. Privacy and confidentiality was ensured by dealing with the respondents on individual basis. 3.15 Expected outcome of the Study The findings of this study would be useful for the following policy regulation and implementation: 1. Family planning education programs 2. Maternal and child health 3. Health promotion activities. 24 4. Health education in schools (SHEP) 3.16 Dissemination of Findings The findings of this study would be disseminated to stakeholders such as Ghana Health Service, Ghana Education Service and CHRAJ for implementation of Policies and health education in improving family planning services and to avert the low level of male involvement in modern family planning in Wa-UWR. Stakeholders: A stakeholders meeting shall be held in the Wa municipality to disseminate the findings of the study. A research brief shall also be prepared and shared with stakeholders at both regional and national levels. Local FM Radio: Air time shall also be secured over the local FM station (Radio Upper West and Radio Progress) to organize a program to discuss the findings of the study. The program shall allow for listener participation through phone-in, whatsapp and text message. 25 CHARPTER FOUR 4 RESULTS Background Characteristics A structured questionnaire was administered to 410 respondents. The mean age of the respondents was 34 + 10.6 years with a minimum of 20years and a maximum of 69yers with a standard deviation of 10.59. 4.1: Demographic Characteristics Table 4. 1: Demographic Characteristics of Respondents VARIABLES FREQUENCY (%) Age Groups 20-29 130 (31.7) 30-39 148 (36.1) 40-49 81 (19.7) 50-59 34(8.2) 60-69 17(4.1) Educational Level None 71 (17.3) Primary 73(17.8) Middle/JHS 136(33.2) SSS/SHS/Vocational 80 (19.5) Tertiary/Polytechnic 49(12) Others 1(0.24) Ethnicity Waali/Dagaati 375(91.5) Fanti 7 (1.7) Akan 1(0.24) Others 27(6.6) 26 4.2 Marital Status Figure 4.2: Marital status of respondents Source: Field Work 2017 With reference to Figure 4.2, shows that married couples formed the majority of the respondents, out of the 410 respondents 371 respondents were married giving a percentage of 90.49%, followed by engaged respondents of 17 with a percentage of 4.15%. This indicates that the respondents who were interviewed majority were married couples. 90.4% 4.1% 2.6%2.6% Marital status MARIED ENGAGED CO-HABITING DIVORCED/SEPARATED/ WIDOWED 27 4.3: Religious beliefs of respondent Figure 4.3 Respondents Religion With reference to Figure 4.3 shows the religious levels of the respondents, it was evident that Islam was the religion of the majority (58%) of the respondents followed by Christianity (40%). The least religion was Traditional religion representing 2% of the respondents. 4.4 Number of children of respondents Table 4.4 Number of children of respondents 40.2% 58% 1.71% Religion of respondents CHRISTIAN MUSLIM TRADITIONALIST Number of Children Frequency (%) 1 110 ( 26.8) 2 80 ( 19.5) 28 * : Respondents who are married but without children were not considered here Source: Fieldwork 2017 The number of children of respondents as tabulated on Table 4.4 shows that majority of the respondents have at least a child during the period of the interview only about 8% of the respondents at the time of interview were not having a child. 4.5 Number of wife/ wives of respondent Table 4.5 Number of wives of respondents Number of wives Frequency (%) 1 357 (87.07) 2 32 (7.80) 3 10 (2.44) * : Respondents who are either divorced/separated or widowed are not represented here Source: Fieldwork Feb, 2017 Table 4.5 shows the number of wife/wives of respondents, it was evident that respondents with one wife formed the majority of the people interviewed with a corresponding 3 65 ( 15.9) 4 44 ( 10.8) 5 29 (7.1) 6 21 ( 5.1) 7 14 ( 3.4) 8 6 ( 1.5) 9 2 ( 0.5) 10 4 ( 0.9) 11 1 (0.2) 12 1 (0.2) 29 percentage of 87%, followed by respondents with two wives with a percentage of 7.8%, however, 2.7% of the respondents were either divorced, separated or widowed. 4.6 Attitude of men towards modern contraceptive use Table 4.6.1: Men knowledge about the promotion of modern family planning. Promotion of FP Frequency (%) Good 284(69.27) Bad 79(19.27) Indifferent 47(11.46) Source: Fieldwork Feb, 2017 Table 4.6.1 shows men knowledge about the promotion of modern family planning in Wa-UWR. The table indicates that out of the 410 respondents, 284 representing 69% said that the modern family planning is good and has to be promoted while 79 respondents representing 19% indicated that the modern family planning contraceptive is not good and has to stop, meanwhile 47 respondents with a percentage of 11.5% were indifferent about the promotion of modern family planning in the municipality. Table 4.6.2: Approval of the use of modern contraceptive to stop unwanted pregnancy Approval of FP Frequency (%) Yes 267(65.12) No 98(23.90) Not Sure 45(10.98) 30 Source: Fieldwork Feb, 2017 With reference to Table 4.6.2, which shows the approval of the use of modern family planning to stop or prevent unwanted pregnancies. 267 respondents corresponding to a percentage of 65% agreed for the use of modern family planning to prevent unwanted pregnancy. 98 respondents representing 24% did not agree for the use of modern family planning to prevent unwanted pregnancy and about 11% were indifferent about the use of modern contraceptives to prevent unwanted pregnancies in Wa municipality. 4.7 Knowledge and use of various contraceptives methods Table 4.7: Knowledge of family planning contraceptives. DEVICE YES (%) Pills 289 (70.50) IUD 54 (13.17) Injectable 316 (77.10) Implant 214 (52.20) Male condom 375 (91.50) Female condom 281 (68.54) Diaphragm 42 (10.24) Foam/jelly 88 (21.50) Rhythm 297 (72.44) Emergency 123 (30.00) Source: Fieldwork Feb, 2017 Table 4.7, Depict male knowledge of modern family planning contraceptives in Wa municipality. The knowledge of modern family planning contraceptive methods/device was assessed on the respondents. Male condom recorded the highest number of 375 respondents representing 91.50%, followed by Injectable representing 77%, next on the list is Rhythm 31 (Calendar) method with a percentage of 72.44%. Pills recorded 289 respondents representing 70.50%, making it the fourth on the list and last but not the least is Diaphragm with a percentage of 10.24%. 4.8 Use of modern family planning contraceptives Table 4.8 Use of family planning contraceptives DEVICE YES (%) Pills 52(12.68) IUD 3(0.73) Injectable 59(14.39) Implant 14(3.41) Male condom 276(67.32) Female condom 0 Diaphragm 0 Foam/jelly 3(0.73) Emergency 0 Rhythm 196(47.8) Source: Fieldwork Feb, 2017 With reference to Table 4.8, which shows the use of modern family planning contraceptives by commercial drivers in Wa municipality. It again came to light that male condom recorded the highest (67.32%) usage with respect to the various modern contraceptives. This was followed by the Injectable method which also recorded 14.39% .Next on the list is Pills with corresponding percentage of 12.68%. With regards to female condom, Diaphragm and emergency contraceptives no respondent or partner use it in the past one year. 32 4.9 Male attitude towards partner use of modern family planning With respect to respondents receiving family planning counseling in the past one year, only 26% had received counseling and the majority 73% had not received any form of family planning counseling within a whole year. 4.10: Male and partners currently using FP With regards to male and partner currently using family planning services, the study revealed that majority(68%) of respondents and their partners were not using any method of family planning services in Wa municipality. 33 4.11 Reasons for the choice of modern family planning by respondents in Wa municipality Figure 4.11.1: First reason for the choice of modern family planning method by respondents. The above figure 4.11.1, depicts the first reason why respondents use family planning services in Wa municipality. It became obvious that the very first reason for family planning usage in Wa municipality was availability, next to it is reliability, cost and safety respectively. The last but not the least reason was health workers advice and friends opinion. 0 5 10 15 20 25 30 35 33 18 32 10.9 2.9 1.46 0.24 0.24 First reason for the choice of FP AVAILABILITY COST RELIABILITY SAFETY PRIVACY EFFECT ON SEXUAL PLEASURE HEALTH WORKER ADVICE FRIENDS OPINION 34 Figure 4.11.2: Second reason for the choice of modern family planning methods by respondents. Source: Fieldwork 2017 0 5 10 15 20 25 30 35 40 45 10.24 16.83 42.44 13.17 4.63 2.68 5.12 1.22 3.41 0.24 Second reason for the choice of FP COST RELIABILITY SAFETY PRIVACY EFFECT ON SEXUAL PLEASURE EASE OF USE HEALTH WORKER ADVICE FRIENDS OPINION MY PARTNER WILL DECIDE REVERSIBILITY 35 With reference to figure 4.11.2, it shows the second reasons for the choice of family planning services in Wa municipality, safety recorded the highest reason followed by reliability and privacy, then health workers’ advice respectively. Figure 4.11.3: Third reason for the choice of modern family planning method by respondents Source: Field Work 2017. The above figure 4.11.3, shows the third reasons for the choice of modern family planning services in Wa municipality, it was evident that reversibility recorded the highest third reason for the choice of family planning services in Wa municipality followed by safety, health worker’s advice, my partner will decide, privacy, effect on sexual pleasure and ease of use as the main reasons for the choice of modern family planning in Wa municipality. 18.3 16.8 16.3 12.7 11.7 10.5 14.2 0 2 4 6 8 10 12 14 16 18 20 Reversibility Safety Health Worker Advice My Partner will decide Privacy Effect on Sexual Pleasure Others Third reason for the choice of FP 36 4.12 Modern family planning service delivery points in Wa municipality Figure 4.12: Where respondents and partner mostly get the family planning contraceptives service from. Source: Fieldwork 2017. On modern family planning service delivery points, figure 4.12 , shows that most of the respondents had their family planning services provided for them in the hospital (42%) followed by pharmacy (28%) and then health facility (21%), 41.95 21.22 2.2 27.8 2.93 3.9 0 5 10 15 20 25 30 35 40 45 HOSPITAL HEALTH CENTER CHPS CPD PHARMACY HEALTH WORKER FRIEND OTHERS Where respondents mostly get family planning service from 37 4.13 Male attitude towards partner use of modern family planning in Wa municipality Figure 4.13.: Couples Discussion of Modern Family Planning Methods at Home. Source: Fieldwork 2017. It is evident from figure 4.13, shows that majority of the respondents (55%) never discussed modern family planning services at home with their spouses, about 19% discussed it less than one year ago and about 14% also discussed it between one and three years interval whilst about 10% could not remember the exact year they discussed family planning methods with their spouses, 18.78 13.9 2.6 10 54.63 0 10 20 30 40 50 60 LESS THAN 1YR AGO BETWEEN 1- 3YRS AGO MORE THAN 3YRS AGO CAN'T REMEMBER NEVER DISCUSSED BEFORE The last time respondent discussed family planning with his partner 38 4.14. Couples attending family planning counselling sessions together Figure 4.14: Have respondents and partners ever attended family planning counseling sessions together. Source: Field Work 2017. The above Figure 4.14, shows that only about 11% of the respondents ever attended family planning counselling sessions with their partners and the rest about 89% had never attended any family planning counselling sessions with their partners. 10.98 89.02 Respondents attendance of fp counselling sessions together YES NO 39 4.15: Respondents accompanying partners to antenatal clinic in Wa municipality Figure 4.15: respondents ever accompanied his partner to the antenatal clinic in the past one year Source: Field Work 2017. With reference to Figure 4.15, which depicts whether respondents ever accompanied partner to ANC in the past, it was evident that about 55% and 59% accompanied their partners to ANC services in 2017 and 2013 respectively, however, about 44% and 37% in 2017 and 2013 said no to accompanying their partners to ANC services and about 1% and 4% said that it was not applicable to accompany their partners to ANC. 54.88 43.9 1.22 Have respondent s ever accompanied partner to anc in the past one year YES NO NOT APPLICABLE 40 4.16: Respondent’s willingness to pay for the cost of family planning services provided to their partners. Figure 4.16: Respondents willingness to pay for the cost of family planning for their partners. Source: Field Work 2017. Figure 4.16, shows the percentages of respondents who were willing to pay for the cost of family services provided for their partners, majority (61%) were willing to pay for the cost of FP services provided for their partners while about 29% refused to pay for the cost of FP services provided. Meanwhile about 9% were indifferent about whether to pay or not. 61.2 29.5 9.3 0 10 20 30 40 50 60 70 Yes No Not Sure Willing to pay for the cost of FP provided for their partners 41 4.17: How worried will respondent be if you found out that your partner was using family planning method without your knowledge? Figure 4.17: whether respondents will worried if partners used family planning without their knowledge. Source: Field Work 2017 With reference to figure 4.17, majority (72%) of the respondents said they would be very worried if partners used family planning without their knowledge. With regards to those who said they would not be worried only about 7% said they will not be worried if their partners used family planning services without their knowledge. 71.95 3.41 8.29 6.59 9.76 0 10 20 30 40 50 60 70 80 VERY WORRIED SOMEWHAT WORRIED WORRIED NOT WORRIED MY WIFE WON'T DO THAT How worried will respondent be if partner used family planning without his knowledge 42 4.18: Testing for association between background characteristics and some selected variables Table 4.18.1: Testing for association between number of children and approval of family planning Number of Children Approval of family planning by respondents Yes (%) Not Sure (%) 1 74 ( 27.7) 13 (28.8) 2 52 ( 19.5) 3 (6.6) 3 53 ( 19.8) 2 (4.4) 4 32 (11.9) 1 (2.2) 5 17 ( 6.3) 5 ( 11) 6 9 ( 3.3) 10 (22.2) 7 6 ( 2.2) 4 ( 8.8) 8 1 ( 0.3) 3 (6.6) 9 0 ( 0.00) 2 ( 4.4) 10 2 ( 0.74) 1 (2.2) 11 0 0.00 1 (2.2) *: Pearson’s Chi Square test, P< 0.0001. Respondents without children were omitted. Source: Field Work 2017 43 Tables 4.18 above shows significant association between the number of children per respondents and the approval of the use of family planning to stop unwanted pregnancies(P<0.05). Respondents who approved the use of family planning to stop unwanted pregnancies had between 1 to 6 children while those who disapproved the use of family planning had fewer children. Table 4.19: Testing for association between current usage of family planning and where respondents get the services from. Current usage of FP Where respondents get FP services Hospital Health Centre CHPS Compound Pharmacy Health worker Other Yes 60 34.8% 21 24.1% 1 11.1% 48 42.1% 2 16.6% 0 0.00% No 112 65.1% 66 75.8% 8 88.8% 66 57.9% 10 83.3% 16 100% *: Pearson’s Chi Square test, P=0.002 Source: Field Work 2017 Table 4.19, was to found out whether there was any association between partner who were currently using family planning method and where partners or respondents get the service from. The result on table 4.19, shows a significant association (P<0.05) between partners who were currently using family planning and where the services were obtained from. 44 Table 4.20: Testing for association between approval of usage of family planning and the last time respondents discussed family planning with partners. APPROVAL OF FP THE LAST TIME RESPONDENTS DISCUSSED FP WITH PARTNERS AT HOME < 1yr 1-3yrs >3yrs Cannot remember Never discussed before Good 70 90.9% 46 80.70% 7 63.6% 31 75.6% 113 50.44% Bad 4 5.19% 8 14% 4 36.3% 8 19.5% 74 33% Indifferent 3 3.89% 3 5.2% 0 0.00% 2 4.87% 37 16.5% *: Pearson’s Chi Square test, P< 0.0001 Source: Field Work 2017 It was again prudent to test for the association between respondent’s approval of the use of family planning to stop unwanted pregnancies and the last time couples/partners discussed family planning at home. As evident from Table 20, it was found out that there is a significant (P<0.05) association between respondent’s approval of the use of FP to stop unwanted pregnancies and the last time partners discussed FP at home. 45 Table 4.21: Testing for association between respondent’s current usage of family planning method and the spouse needs to use family planning methods/devices. Current usage of FP by respondent or partner Partner or spousal need to use FP Yes (%) No (%) Yes 105 (60.6) 27 (11.39) No 68 (39.4) 210 (88.61) *: Pearson’s Chi Square test, P< 0.0001 Source: Field Work 2017 4.22: Demographic characteristics and willingness to pay for FP as a proxy indicator of male attitude Table 4.22: Demographic characteristics and willingness to pay for FP as a proxy indicator of male attitude Variables Categories Willingness to pay Bivariate analysis Multivariat e analysis Yes OR(95 % CI) P- VAL UE OR(95% CI) P-VALUE Age Above 34yrs 110(56.1% ) 0.66(0. 44- 0.99) 0.04 0.64(0.3 5-1.14) 0.94 34yrs and below 141(65.9% ) Highest educational level Tertiary/Polytechnic 41(82%) 5.25(2. 08- 13.2) <0.01 1.86)0.6 5-5.60) 0.23 SSS/SHS/Vocational 46(57.5%) 1.56(0. 81- 2.98) 0.18 0.67(0.2 9-1.58) 0.45 Middle/JHS 87(64%) 2.04(1. 13- 3.70) 0.02 1.31(0.6 1-2.82) 0.47 Primary 44(60.3%) 1.74(0. 89- 3.41) 0.10 0.91(0.3 8-2.16) 0.88 None 33(46.5%) 1.00 46 Ethnicity Waali/Dagaari 220(58.7% ) 0.18(0. 06- 0.54) <0.01 0.83(0.0 2-0.33) <0.01 Others 31(88.6%) 1 Religion Muslim 138(56.3% ) 0.59(0. 39- 0.90) <0.01 1.31(0.7 4-2.35 0.34 Christian 113(68.5% ) 1.00 Number of children >4 33(42.3% 0.38(0. 23- 0.64) <0.01 1.00(0.4 4-2.30) 0.63 < OR = 4 218(34.3% ) Age of last child >3YRS 61(50%) 0.52(0. 33- 0.80) <0.01 1.47(0.5 7-3.82) 0.43 < OR = 3YRS 190(66%) *: OR=Odds Ratio, CI= confident Interval at 95%, < = Less than, P value= Probability value Source: Field Work 2017 From the above Table 4.22, it shows demographic characteristics. The Table indicate that male who belongs to the Waali/Daagari ethnic group were 0.83 times less likely to pay for the services of modern family planning (OR O.83 (0.02-0.33 CI, PV<0.01) 47 4.23 Attitude towards modern family planning and the willingness to pay for modern family planning services Table 4.23; Willingness to pay for FP as a proxy indicator of male attitude. Variables Categories Willingness to pay Bivariate analysis Multivariate analysis Yes OR(95% CI) P- VALUE OR(95% CI) P-VALUE Approve use of FP methods Yes 208(77.9%) 8.20(4.87- 13.80) <0.01 6.77(3.73- 12.28) <0.01 No 43(30.1%) Attended FP counselling together Yes 40(88.9%) 5.84(2.21- 15.5) <0.01 4.20(1.35- 13.09) 0.013 No 211(57.8%) Worried about FP making wife unfaithful Yes 166(55.3%) 0.23(0.12- 0.44) <0.01 0.27(0.13- 0.57) <0.01 No 70(84.3%) Consider divorce wife over covert use of FP Yes 26(48.7%) 0.53(0.32- 0.89) <0.01 0.66(0.32- 1.33) 0.25 No 215(64%) Number of wives >1 11(26.2%) 0.18(0.09- 0.39) <0.01 0.18(0.06- 0.51) <0.01 <1 235(65.8%) *:OR= Odds Ratio, CI= Confident Interval, <= Less than, >= Greater than, P value= Probability Value. Table 4.2 revealed that among the independent predictors of male attitude and willingness to pay for modern FP, the following predictors were statistically significant (Approval of the use of modern FP: OR 6.77, 3.73-12.28 CI, PV<0.01)(Attended FP counselling together, OR4.20, 1.35- 13.09CI, PV=0.013) (Worried about FP making wife unfaithful, OR 0.27, 0.13-0.57CI, PV<0.01) With regards to the number of wives, it was respondents who had more than one wife who were statistically significant with OR 0.18, 0.06-0.51CI and PV<0.01 48 4.24: Comparison of 2017 and 2013 attendance of FP counseling and usage of FP methods by respondents Figure 4.24.1 : Compares attendance of FP counseling and use of FP methods in 2013 and 2017. It was evident that in the year where more people attended FP counseling, more respondents used the FP services. This shows that FP counseling is a predictor of usage of FP contraceptives in the community. 51 26 0 10 20 30 40 50 60 Year 2013 Year 2017 Yes Attendance of FP counseling 69 32 0 10 20 30 40 50 60 70 80 Year 2013 Year 2017 Yes use of FP Methods 49 4.24.2: Comparison of Approval and Promotion of FP in 2017 and 2013 Figure 4.24.2: Comparing Approval of FP and Promotion of FP in 2017 against 2013 The comparison revealed that majority of respondents in 2013 approved the use of family planning to prevent unwanted pregnancies likewise its promotion as against a small proportion in 2017. This indicates that the promotion of FP education was high in 2013 than in 2017. 82.4 65.1 0 10 20 30 40 50 60 70 80 90 Year 2013 Year 2017 Yes Approval of FP 89.2 69.3 0 10 20 30 40 50 60 70 80 90 100 Year 2013 Year 2017 Yes Promotion of FP 50 CHAPTER FIVE DISCUSSION 5.0 Introduction In recent years, there has been a tremendous advancement in the development of safer and more efficient and effective contraceptives coupled with provision of available, accessible and affordable family planning services in every corner of the country. Globally in 2015, 57% of married or in-union women of reproductive age used a modern method of family planning constituting 90% of contraceptives users(Trend in contraceptive use worldwide 2015), yet large gaps remains in the proportion of total demand for family planning satisfied with modern methods in countries where overall contraceptive use is low. 5.1 Background Characteristics With regards to age group, the study found that males in the 30-39 age groups were in the majority (36%). Collectively majority (87.5%) of the respondents fell between the ages of 20-49yrs, and accidentally this age group forms the most sexually active age group in the population. The mean age of the respondents is 34yrs with a minimum of 20yrs and a maximum of 69yrs with a standard deviation of 10.59. With educational background, it was revealed that, those who had received some level of education are in the majority (82.6%) compared to those without any form of education. Moreover, the higher one moves along the educational ladder, the more knowledge about family planning the person has. However, it was found that education is not a predictor of the knowledge of modern family planning in Wa community. Concerning the ethnicity of the respondents, it was realized that 91.4% of the respondents were from the Waali/Dagaari ethnic group. 51 5.2 Knowledge and attitude of men towards modern contraceptives use 5.2.1 Knowledge and Perception It was found from the study that generally, across the age groups, more (54%) people have an idea about family planning than those who do not have any idea. The idea about family planning among men was to determine, how family planning is perceived among them. Apart from just having an idea, majority of the respondents seemed to have some level of knowledge about what family planning is. This confirmed a study done by GDHS, (2014) which disclosed that knowledge about family planning is high among males, and that, majority of men know at least one method of contraception. A similar study done in Nigeria also revealed that knowledge of family planning is high among male than females ( Alfred et, al., 2016). 5.2.2 Counseling of men in family planning The study showed that majority (73%) of men interviewed had never had a counselling before. This confirmed a study done in New York, on male involvement in reproductive health, which showed that, the range of family planning methods available, to men is sometimes limited and as a result, prevents men from fully participating in fertility regulation (Green et, al, 1995) Another study done in Tanzania on the impact of demand factors, quality of care and access to facility on contraceptive used found a positive relationship between quality which include counselling of family planning services and use of contraceptives (Arends-Kuenning and Kessy. 2007). 52 5.2.3: Respondents who were using FP at the time of the interview Concerning current use of family planning, it was revealed that only 32% of the respondents interviewed were using any family planning method. This study confirms the findings of GDHS (2014) that knowledge of family planning is high but low in usage. A similar studies done in Wa municipality on predictors of postpartum family planning uptake: understanding providers and potential family planning in the Wa municipality also found that only 46% were using FP (Tirah Haruna, 2012). In Nigeria a study on the role of men in family planning found out that only 32.3% of males were using any of the family planning methods ( Alfred et, al., 2016). 5.2.4 Information on modern family planning in Wa municipality With regard to where respondents get most information on modern family planning, it came to light that majority of the respondents get their information on family planning through the Radio (55.4%) and Health worker (20.5%), the rest were insignificant. This findings support a similar studies on attitude towards and use of knowledge about family planning among Ghanaian men, it revealed that the most source of family planning information were through the mass media (Radio and TV) (Ossou and Marie-Antioinette, 2008). 5.2.5 Men involved in antenatal services (ANC) and FP discussion The study determined to find out whether men were involved in antenatal and maternity service of their spouses. More than half of the respondents (55. %) had ever accompanied their spouses to ANC service. These findings were in contrast to the findings of a study on male partner 53 involvement in maternity care in Ablekuma South District (Doe and Roseline Dansowaa, 2013). They found out that 83% of males were involved in ANC However, the study affirms a similar work done in Russia on the presence of a companion during labour, which found that about 68% declined having their husbands present in ANC services ( Bakta and Lee. 2010). A similar study done in Uganda on male partner antenatal attendance and HIV testing in eastern Uganda shows that only 5% of men accompanied their spouses to ANC (Byamugisha et al, 2011). Concerning men who have ever discussed family planning with their spouses, the study shows that more than half of the respondent (54.63%) have never discussed family planning with their spouses. This findings confirms the work on discussion of family planning improve knowledge of partner’s attitude towards contraceptive, found out that couples do not discuss family planning issues in Sub-Sahara Africa (Derose et. al.,2014). With regards to the willingness to accompany partners to FP counselling sessions, it was revealed from the study that majority about (58%) expressed their willingness to accompany their partners to FP counselling sessions. These findings were in contrast to a study on male partner involvement in maternity care in Ablekuma South District, Ghana. They found out that majority (83%) of males were involved in ANC (Ossou and Roseline Dansowaa, 2013). These findings support a similar study done in UK on whose welfare in the labour room? He found out that men participations in maternal health was gradually increasing (Draper, 1997). 54 5.2.6 Male attitude towards partner use of family planning The study again sought to find out male attitude towards partner use of family planning in Wa municipality. The attitude of men were categorized into the following: the willingness to pay for the cost of FP service provided to their partners and covert use of FP by their spouses. Generally, the study revealed that male attitude is a major factor that affect modern family planning acceptance in Wa municipality. With regards to willingness to pay for FP services for spouse, the study revealed that 61% of the respondents were in the affirmative. Concerning covert use of family planning by partners, it was revealed that Out of the 410 respondents majority (72%) indicated that they would be very worried if their partners or spouses were involved in that. The findings in this study confirms a similar work in Uganda, they found out that disagreement between husbands and wives carries high social cost including violence, divorce or husbands bringing in another wife (Blanc, et, al., 1996). 55 CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusions This is one of the few studies that looked on male knowledge and attitudes that influence partner use of modern family planning in Wa municipality. Knowledge about family planning was high but utilization of the services was low. Male attitudes towards modern family planning in the study area were rooted in the levels of family planning education and fear of spousal infidelity. Men with higher level of education appears to have little interest in issues related to family planning. Educational level was significant predictor of knowledge about family planning. Males have high knowledge of family planning than their female counterparts. Majority of the respondents expressed worried over covert use of family planning by spouses. 6.2 RECOMMENDATIONS 1. A multidimensional approach is needed to overcome male apprehensions towards spousal adoption of FP in this community. 2. The Education and Promotion unit of Wa municipal Health Administration should collaborate with GPRTU to educate drivers on FP issues. 3. To improve maternal Health and reduce maternal mortality in Wa municipality, one of the key strategies the ministry of Health and Ghana Health Service can use, is the increased male involvement in maternity care. 56 4. Health facilities should restructure their maternal health clinics to make them more male friendly. The policy of not allowing male partners into the labour and FP service room must be reviewed. 5. 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