Men's Involvement in Antenatal Care Services (ANC) with a Case Study of Kibuli, Makindye Division, Kampala

MEN’S INVOLVEMENT IN ANTENATAL CARE SERVICES (ANC). A CASE STUDY

OF KIBULI, MAKINDYE DIVISION, KAMPALA DISTRICT.

NAMAKULA LILLIBET

(2010-BSCPH-FT-015)

A research report submitted to the Institute of Health Policy and Management (IHPM) in partial fulfillment of the requirements for the award of a Bachelors degree in Public Health

of International Health Science University (IHSU).

September, 2013.

DECLARATION

I, Namakula Lillibet, hereby declare that the contents of this research work are as a result of my findings and they have never been presented in any other University for an award.

Signed …………………………………… Date: ………………………………...

NAMAKULA LILLIBET

APPROVAL

This work has been approved under my supervision and submitted for examination by my approval.

Signed ………………………………………… Date: …………………

MRS. CHRISTINE GALUKANDE

DEDICATION

This work is dedicated to my parents Mr. and Mrs. Hodge Semakula, my family and friends for their undying love, care and support rendered to me throughout this course. May the almighty

God richly reward you.

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ACKNOWLEDGEMENT

I would like to express my sincere gratitude to the following for having made the completion of this work possible and successful.

I am grateful to God, above all, for having given me his grace to withstand all the challenges that this study presented, and for guiding me in every stage of this research.

This piece of work would not have been accomplished without the support of several people. It is impossible to mention all by name however my special thanks go to my parents Mr. and Mrs.

Hodge Semakula.

I sincerely thank my supervisors Mrs. Christine Galukande and Mr. Pardon Akugizibwe for their incessant nudging, words of wisdom and motivation. I am also grateful to other colleagues and lecturers that patiently guided me and encouraged me to work harder.

I am thankful to all my classmates and friends of the academic year 2010-2013 who were of great support throughout my period of study. You went from being strangers to practically family-I love you guys.

I sincerely acknowledge all the participants who were part of this study together with the many acquaintances whose help enabled me to complete the research on time. Thank you for allowing me into your community to carry out this research and rendering your valued time to participate in this research.

ACRONYMS AND ABBREVIATIONS

AIDS: Acquired immune deficiency syndrome

ANC: Antenatal Care

FIGO: International Federation of Gynecology and Obstetrics

HIV: Human immunodeficiency virus

ICM: International Confederation of Midwives

IHPM: Institute of Health Policy and Management

IHSU: International Health Science University

MoH: Ministry of Health

PMTCT: Prevention of Mother-to-Child Transmission

SRH: Sexual and Reproductive Health

UBOS: Uganda Bureau of Statistics

UNDP: United Nations Development Programme

UNFPA: United Nations Population Fund

UNICEF: United Nations Children's Fund

WHO: World Health Organization

OPERATIONAL DEFINITIONS

Antenatal care according to WHO constitutes screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes, providing therapeutic interventions known to be effective; and educating pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them.

Attitude is the way males think, feel or behave towards their involvement in ANC.

Culture in this case refers to the characteristics of a particular group of people or society, defined by everything from language, ideas, beliefs, values, customs, religion, cuisine, social habits, music and arts.

Environment in this case will include the social, political or economic conditions that influence behavior.

Involvement in this context will mean to take part in or to make somebody take part in the ANC program. It will include active participation through attending ANC with the partner.

Knowledge refers to the information, understanding and skills that were gained through education or experience that supports or deters the involvement of males in ANC.

Lifestyle is a collection of related behaviors that go together to form a pattern of living.

Men in this case refer to adult male respondents aged 18 years and more, in a sexual relationship and working in the informal sector or lower class of employment.

TABLE OF CONTENTS

DECLARATION ...... i

APPROVAL ...... ii

DEDICATION ...... iii

ACKNOWLEDGEMENT ...... iv

ACRONYMS AND ABBREVIATIONS ...... v

OPERATIONAL DEFINITIONS ...... vi

TABLE OF CONTENTS ...... vii

LIST OF TABLES AND FIGURES ...... xii

ABSTRACT ...... xiii

CHAPTER ONE: INTRODUCTION ...... 1

1.0 Introduction to the study ...... 1

1.1 Background to the study ...... 2

1.2 Background to the study area ...... 4

1.3 Problem statement ...... 5

1.4 Research objectives ...... 6

1.4.1General objective ...... 6

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1.4.2 Specific objectives ...... 6

1.5 Research questions ...... 7

1.5.1General question ...... 7

1.5.2 Specific questions ...... 7

1.6 Significance of the study ...... 8

1.7 Conceptual Framework ...... 9

CHAPTER TWO: LITERATURE REVIEW ...... 10

2.0 Introduction ...... 10

2.1 Proportion of men involved in antenatal care services (ANC) ...... 10

2.2 Individual factors that influence men’s involvement in antenatal care services (ANC) ...... 12

2.3 Men’s level of knowledge on antenatal care services (ANC) ...... 14

2.4 Healthcare service factors that influence men’s involvement in antenatal care services (ANC)

...... 15

CHAPTER THREE: METHODOLOGY ...... 18

3.0 Introduction ...... 18

3.1 Study design ...... 18

3.2 Population ...... 18

3.3 Sources of data ...... 19

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3.4 Sample size determination ...... 19

3.5 Sampling procedure ...... 20

3.6 Study variables ...... 21

3.6.1 Dependent variable ...... 21

3.6.2 Independent variables ...... 21

3.7 Data collection techniques ...... 21

3.8 Data collection tools ...... 22

3.9 Data management ...... 22

3.10 Data analysis ...... 23

3.11 Quality control measures ...... 23

3.12 Ethical issues ...... 24

3.13 Limitation of the study ...... 24

CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION OF RESULTS ...... 25

4.0 Introduction ...... 25

4.1Descriptive results of the demographic information/ profile of the respondents...... 26

4.2 Male involvement in ANC in Kibuli, Makindye Division...... 28

4.2.1 Descriptive results of the individual characteristics influencing male involvement in

ANC in Kibuli, Makindye Division...... 30

4.2.2 Descriptive results of the level of knowledge on ANC influencing male involvement in

ANC in Kibuli, Makindye Division...... 33

4.2.3 Descriptive results of the healthcare service factors influencing male involvement in

ANC in Kibuli, Makindye Division...... 36

4.3 Statistical associations of the factors influencing male involvement in ANC in Kibuli,

Makindye Division...... 38

CHAPTER FIVE: DISCUSSION OF FINDINGS ...... 41

5.0 Introduction ...... 41

5.1 The proportion of men involved in antenatal care services (ANC) in Kibuli, Makindye

Division...... 41

5.2 The individual factors that influence the involvement in antenatal care services (ANC) among men in Kibuli, Makindye Division...... 43

5.3 The level of knowledge on antenatal care services (ANC) among men in Kibuli, Makindye

Division……………………………………………………………………………………..……45

5.4 The healthcare service factors that influence the involvement in antenatal care services

(ANC) among men in Kibuli, Makindye Division...... 47

5.5 Limitations ...... 48

CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS ...... 49

6.0 Introduction ...... 49

6.1 Conclusions ...... 49

6.2 Recommendations ...... 50

6.3 Areas of further study ...... 51

REFERENCES: ...... 52

APPENDIX: ...... 59

LIST OF TABLES AND FIGURES

Tables

Table 1: Demographic information/ profile of the respondents ...... 26

Table 2: Descriptive results of the individual characteristics influencing male involvement in

ANC in Kibuli, Makindye Division ...... 30

Table 3: Descriptive results of men’s level of knowledge on ANC ...... 35

Table 4: Descriptive results of the healthcare service factors influencing male involvement in

ANC ...... 36

Table 5: Statistical associations of the factors influencing male involvement in ANC...... 38

Figures

Figure 1: Male involvement in ANC among 240 men in Kibuli, Makindye Division...... 28

Figure 2: Descriptive results of the level of knowledge on the definition of ANC ...... 33

Figure 3: Descriptive results of the level of knowledge on the importance of male involvement in their partner’s health...... 34

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ABSTRACT

Background: Worldwide, male attendance of skilled ANC and delivery care remains a challenge to safe motherhood. About 210 million women become pregnant each year with 30 million (15%) developing complications, resulting into over half a million maternal deaths (De Bernis L, et al.,

2003). Developing countries account for more than 99% of all maternal deaths; with about a half occurring in sub-Saharan Africa, and a third in South Asia (WHO,2007; UNICEF, 2008). There is also slow progress towards achieving the fifth Millennium Development Goal (MDG) in developing countries (AbouZahr C, 2003).

Male involvement in reproductive health has recently been promoted as a promising new strategy for improving maternal and child health (UNFPA, 2000).

Main objective: To assess the factors influencing men’s involvement in antenatal care services

(ANC) in Kibuli, Makindye Division, Kampala District.

Methodology: A descriptive cross sectional study was conducted using semi-structured questionnaires. The study was conducted among 240 adult men, in a sexual relationship, with at least one child that were residing or working in Kibuli’s informal sector. They were chosen using stratified sampling and simple random sampling and consented to participate in the study.

Data was collected at a specific point in time without follow up and then analyzed to facilitate in the description of men’s involvement in antenatal care services in Kibuli.

Results: The proportion of men that were involved in ANC in Kibuli, Makindye Division was

147/240 (61.25%). Level of education (P=0.007), Tribe (P=0.015), and Occupation (P=0.0018), were found to be associated with male involvement in ANC. Men that reported knowing the importance of male involvement in their partner’s health (P= 0.000), knowledge on the definition of ANC (P= 0.000) and knowledge on the recommended number of ANC visits (P=0.000) were more likely to be involved in ANC

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Conclusion: In this study the level of male involvement in Kibuli, Makindye Division, Kampala

District is low (61.25%) but still higher than what is reported from other studies from East Africa.

Male involvement in ANC was associated with a higher education level, one’s tribe, occupation status, knowledge of importance of male involvement in the partner’s health, the definition of

ANC and knowledge on the recommended number of ANC visits.

Among the health care system factors that were included in the study, none of the factors were found to be significantly associated with male involvement in ANC.

Recommendations: The study recommends that increase awareness of the importance of male involvement in ANC/PMTCT services. It is important that more information is provided to the public on how, why, when and where men can be involved when it comes to not only ANC but to their partner’s health in general. Through aggressive advertizing and sensitizing of the population using mediums suitable for both the literate and illiterate people like radio talks, television shows, mobile entertainment and educative shows together with other forms of media; people’s knowledge on male involvement in ANC should be able to increase.

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CHAPTER ONE

INTRODUCTION

1.0 Introduction to the study

Antenatal care is the complex of interventions that a pregnant woman receives from organized health care services. The number of different interventions in antenatal care is large and may be provided in approximately 12-16 antenatal care visits during a pregnancy thought the WHO recommendation for service delivery is at least 4 visits (Robert Byamugisha, et al., 2010).

The purpose of antenatal care is to prevent or identify and treat conditions that may threaten the health of the fetus, the newborn and or the mother and to see that each newborn child has a good start to life (Godlove N.N, et al., 2010).

Pregnancy is one of the most important periods in the life of a woman, a family and a society so extraordinary attention is given to antenatal care by the health care systems of most countries

(Raymond Tweheyo, et al., 2010).

Globally, there has been increasing recognition that the involvement of men in Sexual and

Reproductive Health and service delivery such as ANC offers both men and women important benefits if men are involved not only as clients of Reproductive Health care but also as partners.

Such benefits may include improved family health, better communication between partners, joint and informed decision making within households,drawing attention to women’s rights, the achievement of some major development goals such as a decreased maternal mortality rate, an increased contraceptive prevalence rate and a reduction in the overall prevalence of HIV/AIDS.

Male partner attendance of skilled Antenatal Care (ANC) is beneficial to improving maternal outcomes. This study intends to investigate the factors influencing male partner attendance of skilled ANC in a peri-urban community.

This chapter describes the background of the study, the background to the study area, the problem statement, research objectives, research questions, justification or significance of the study, limitations to the study and the conceptual framework.

1.1 Background to the study

Worldwide, male attendance of skilled ANC and delivery care remains a challenge to safe motherhood. About 210 million women become pregnant each year with 30 million (15%) developing complications, resulting into over half a million maternal deaths (De Bernis L, et al.,

Maternal mortality reduction remains a great concern, for nearly all developing countries with broad-based population pyramids, Uganda in particular (MoH, 2004). In most rural areas of sub-

Saharan Africa, poor maternal health remains a major issue since health facilities do not provide a full range of primary health care services, undermining access to reproductive health services, including basic and comprehensive Emergency Obstetric Care (EmOC) services (Tawiah, 2011;

Magadi et al., 2003; Monir et al., 2009; Pearson et al., 2005; Lester et al., 2010). For instance, approximately all Level II health centres in Uganda do not provide maternity services. Many

women lose their lives in the process of procreation. Every year, more than half a million women die from pregnancy-related causes and majority of these deaths occur in sub-Saharan Africa.

Every minute, at least one woman dies from pregnancy and childbirth globally (WHO, 2003;

UNICEF, 2005; Awusi et al., 2009). On average, in developing countries, a pregnancy is 18 times more likely to end in the women's death than in developed countries.

Uganda continues to have one of the highest maternal and child mortality worldwide, with an estimated Maternal Mortality Ratio (MMR) at 435/100,000 and child mortality at 137/1,000 live births (UBOS, 2006). The Ugandan government has prioritized reproductive health strategies which focus on accelerated reduction in maternal mortality and severe morbidity related to pregnancy and childbirth.

Male involvement in reproductive health has recently been promoted as a promising new strategy for improving maternal and child health (UNFPA, 2000). Men, particularly husbands, often act as gatekeepers to their wives’ and family’s health-seeking behaviors and utilization of health services (Piet-Pelon, Rob & Khan, 1999; UNFPA, 2000). Men can also act as supportive caretakers and promoters of family health (Carter, 2002; UNICEF, 1994; Blanc, 2001). While men’s roles in fertility-related decisions are substantial, the role of male partners in other reproductive health behaviors remains largely unknown (Dudgeon & Inhorn, 2004; Becker &

Robinson, 1998; Robey, Ross & Bhushan, 1996).

Even though it is widely recognized that there is limited research on the role of male involvement during pregnancy (Roth DM, et al., 2001; Alio AP, et al.,2009; Katz DA, et al., 2009), there are promising links to beneficial effects as some few prospective studies and literature reviews have

successfully demonstrated that prenatal male involvement is associated with beneficial health outcomes such as; higher first trimester ANC visits, abstinence from smoking and alcohol consumption (Alio AP, et al.,2009; Martin LT, et al., 2007), and reduction in low birth-weight infants(Alio AP, et al.,2009; Hohmann-Marriott B, 2009).

Male involvement is also increasingly seen as beneficial for the whole family, helping to de- stigmatize HIV, increasing access to services, and providing information that heightens men's concern for the wellbeing of their pregnant partners and their support for safe births at health facilities. Reaching out to men also means reaching more community and household decision- makers, who may be convinced to accept and support PMTCT programs.

1.2 Background to the study area

Kibuli Hill lies 5.6 Km southeast of Kampala city and is one of the seven hills making up

Kampala, the capital city of Uganda.

Other nearby landmarks bordering Kibuli hill include; Kololo hill to the North, Nakawa and

Mbuya trading centre to the North East, Namuwongo area to the East, Muyenga Tank hill to the

South East, Kabalagala trading centre to the South, Nsambya hill to the South West.

At the top of Kibuli hill sits the most distinguished mosque in Kampala – The Kibuli Mosque. In

1930's, Prince Badru Kakungulu, from the Buganda Royal Family owned most of the land at

Kibuli hill. Later he donated some hectares to the Muslim community in Uganda to develop it and run several projects like schools, training colleges and universities, hospitals, several other income generating activities, etc.

The majority of the population in this area is therefore mainly Muslim with many economic activities and small businesses rooting in the informal sector. Kibuli is also a multi cultural society attracting many people of different origins and beliefs.

Makindye division has over 11 Health Centre IIIs that offer the ANC package together with other major hospitals of which Kibuli Hospital is inclusive. Save for the fact that Kibuli Muslim hospital is the major health facility in Kibuli, there is also a variety of other healthcare facilities present in the area that are usually smaller and privately owned but still frequently utilized by the population together with the Village Health Team members situated all over Kibuli.

Kibuli parish being a large area is distributed into 16 zones (Market A, Market B, Central, Agip,

Lubuga, Kisasa, Lubowa, Nakibinge, Kanakulya, Kitooro, Greenhill, Kigumba, Institute,

Kakungulu, Mosque, Kyeyune) each with its own local leader.

1.3 Problem statement

Couple-friendly reproductive health services and male partner involvement in women's reproductive health have recently gained considerable attention in many countries including

Uganda. And given the sensitive nature of gender roles and relations in many cultures, understanding the context of a particular setting, potential barriers, and attitudes towards a new intervention are necessary first steps in designing services that include men.

Efforts to involve males in reproductive health begun in the early 1970s, by making women- oriented family planning clinics more inviting to men. The intervention comprised an invitation letter delivered to the spouses of new antenatal attendees, and an information letter or leaflet concerning antenatal care.

Male attendance of skilled ANC is still a fairly new field to research in Uganda and the available estimates depict a low attendance averaging at 3% in 2006 (MOH, 2006). This data however, is based on health facility information systems that may be incomplete, irregular and mainly aimed at monitoring male attendance in the PMTCT programs.

Even if some interventions have been put in place to encourage male involvement in Family

Planning and PMTCT programs, little attention has been given to ANC.

With the increasing recognition that the involvement of men in Sexual and Reproductive Health

(SRH) and that service delivery such as ANC offers both men and women important benefits if men are involved not just as clients of Reproductive Health care but also as partners, reports still show that male involvement is still low.

It is for this reason therefore that there is need to assess the factors influencing men's involvement in antenatal care services (ANC) with a case study of Kibuli, Makindye Division, Kampala

District.

1.4 Research objectives

1.4.1General objective

To assess the factors influencing men’s involvement in antenatal care services (ANC) in Kibuli,

Makindye Division, Kampala District.

1.4.2 Specific objectives

i. To determine the proportion of men involved in antenatal care services (ANC) in Kibuli,

Makindye Division.

ii. To identify the individual factors that influence the involvement in antenatal care services

(ANC) among men in Kibuli, Makindye Division.

iii. To determine the level of knowledge on antenatal care services (ANC) among men in

Kibuli, Makindye Division.

iv. To identify the healthcare service factors that influence the involvement in antenatal care

services (ANC) among men in Kibuli, Makindye Division.

1.5 Research questions

1.5.1General question

What are the factors influencing men’s involvement in antenatal care services (ANC) in Kibuli,

Makindye Division, Kampala District.

1.5.2 Specific questions

i. What is the proportion of men involved in antenatal care services (ANC) in Kibuli,

Makindye Division.

ii. What are the individual factors that influence the involvement in antenatal care services

(ANC) among men in Kibuli, Makindye Division.

iii. What is the level of knowledge on antenatal care services (ANC) among men in Kibuli,

Makindye Division.

iv. What are the healthcare service factors that influence the involvement in antenatal care

services (ANC) among men in Kibuli, Makindye Division.

1.6 Significance of the study

While there is evidence that indicates that men can influence health care utilization during pregnancy and thereby the outcome of an obstetric emergency, few interventions have targeted men directly in ANC, birth preparedness or obstetric decision making, and randomized trials of the impact of involving men in such interventions are scarce. Most of the information available is of studies done on male involvement in PMTCT and not particularly ANC.

There are also mixed responses towards strategies to encourage male involvement in ANC and

PMTCT that may be attributed to a disparity in the understanding of the definition of male involvement between programmers and targeted program recipients.

It is therefore vital to carry out this study and add to the pool of knowledge in that area of study.

In addition, men’s knowledge towards involvement in antenatal care is not known yet it can determine the uptake of and compliance with a service or attract more users. This study will aid service providers to improve services so as to encourage men’s involvement in ANC not only in

Kibuli but also in other areas of Uganda.

As there is a need for programs to understand the prevailing perceptions towards the involvement of males in ANC in their communities, this understanding should enable programs to appropriately define and measure male involvement in ANC.

This study will also inform policy makers on factors influencing men’s involvement in ANC and eventually help in making recommendations on the male focused interventions for other ANCs.

1.7 Conceptual Framework

INDEPENDENT VARIABLES

INDIVIDUAL FACTORS DEPENDENT VARIABLE

Age

Marital status MEN’S INVOLVEMENT IN Number of children ANTENATAL CARE SERVICES Religion Actively attending Tribe ANC with partner Level of education

Occupation

Income levels

Cultural beliefs

LEVEL OF KNOWLEDGE HEALTH CARE ON ANC SERVICE FACTORS Meaning of ANC Accessibility

Recommended number of Client-provider relationship visits Waiting time Procedures involved Opening hours Importance of involvement in ANC towards women’s Long distance to health health facility

The conceptual framework above shows the independent variables that is, individual factors,

level of knowledge on ANC and health care service factors that influence men’s involvement in

Antenatal Care which is the Dependent Variable.

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents existing literature related to men’s involvement in antenatal care services from different writers and sources including peer reviewed journal articles and articles from organizations. It intends to highlight the existing information on the proportion of men involved in antenatal care services (ANC), men’s level of knowledge on ANC, the individual factors that influence men’s involvement in ANC and the other health care system factors that also influence men’s involvement in ANC.

2.1 Proportion of men involved in antenatal care services (ANC)

Study findings in Nepal showed that 39.3% of males accompanied their partners for ANC visits.

Previous findings suggested that providing information to male partners about attending antenatal care might increase their involvement, as well as greater preparedness in the case of pregnancy

(Dharma N.B, 2010). Unfortunately, according to most studies, male partner involvement in maternal and child health is still low in many countries.

Despite the several methods carried out since 2004 through the Men as Partners (MAP) program originally sponsored by the Action for West African Region (AWARE) Project to continually encouraged men to accompany their wife to ANC, the observed percentage of men participating in ANC/PMTCT activities has not exceeded 18.0%, which is consistent with findings of studies conducted in Cameroon, Ivory Coast, Burkina Faso, and other African countries (Godlove N.N, et al., 2010).

In South Africa, as in most other African countries, family planning, pregnancy and childbirth have long been regarded as exclusively women’s affairs. Men generally do not accompany their partners to family planning, antenatal or postnatal care services and are not expected to attend the labour or birth of their children. (Saiqa M, et al., 2005)

Across Tanzania, male involvement in reproductive and child health services is low, estimated at

5% and lower in urban areas.

Traditionally, pregnancy and ANC is believed to be a woman’s affair so fewer and fewer men consider accompanying their wife or partner to ANC because they feel that the provision of finance for ANC registration and delivery fees is their most important role in supporting their wife’s pregnancy.

In a study, conducted to establish determinants of male involvement in the PMTCT programme in Eastern Uganda, it was found that only 1 in 4 male partners were involved in the PMTCT programme. This level of involvement is low but higher than what is reported from other studies from East Africa (Farquhar C,et al., 2004). For example one study from Mulago Hospital in

Kampala, Uganda, showed that male participation in the PMTCT activities was low (16%)

(Farquhar C,et al., 2004; Byomire H, 2003) . Similarly, a study conducted at a Nairobi antenatal clinic, Kenya revealed that male partner participation in antenatal VCT with their spouses was low (15%) (Byomire H, 2003).

Male attendance of skilled ANC is a fairly new field to research in Uganda. The available estimates depict a low attendance averaging 3% in 2006 (MOH, 2006) but are based on health facility information systems that monitor male attendance in the PMTCT programme.

In 2008, the estimate for male attendance of skilled ANC in Gulu district was 18.4% having risen from about 3% in 2006 (Gulu, 2008). Of the total 23,408 pregnant women that were new ANC attendees in Gulu district in 2008, male attendance estimated at 18.4% varied by sub-county;

41.6% (1,107/2,746) in Aswa, 41.5% (2,529/6,264) in Omoro and only 5.0% (660/14,398) in the

Municipality (Gulu, 2008).

At Tororo hospital, in Eastern Uganda, between December 2004 and September 2005, only 2.8% of the male partners attending Antenatal care accepted the HIV test. Such low male partner involvement at ANC services is thought to contribute to poor PMTCT uptake.

Results in a cross sectional survey of 388 men done at Mbale district showed that the majority

(76%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. (Robert Byamugisha, et al., 2010)

2.2 Individual factors that influence men’s involvement in antenatal care services (ANC)

There are many socio demographic factors (individual factors) that influence knowledge, belief, values, and behavior towards men’s involvement in ANC. Even if knowledge on how male participation has been applied to national PMTCT programs worldwide is limited, the male partner plays an important role in women's reproductive health and improvement of PMTCT outcomes.

In South Africa, in the Zulu culture, it was previously unheard of for men to be involved in the care of their infant children; they are not permitted to see the mother or child for three months after the birth because this is thought to make the males ‘weak’. (Saiqa M, et al., 2005)

In Cameroon it was found that, men’s participation in ANC and PMTCT is affected by socio- cultural barriers centered in tribal beliefs and traditional gender roles (Godlove N.N, et al., 2010).

In Tanzania, the barriers said to inhibit male involvement in these services include lack of information, fear of HIV-test results, and limited time to spend at clinics. Other barriers often cited are social and religious norms that prohibit males from attending female health services and the widespread attitude that female reproductive health is not a male responsibility (Fhi360, viewed 26/4/2012).

A study in Ghana covering the period 1988 to 1998 reveals that the level of men’s education influences spousal fertility preferences. A husband’s level of educational attainment especially beyond primary level influences his wife to limit childbearing.

In dominant patriarchal cultures such as those found in Uganda and other parts of Sub-Saharan

Africa, men play an important role in determining what counts as a health care need for women; men are in control of almost all the resources in the family (Kasolo et al., 2000; Bawah et al.,

1999; Assfaw, 2010). Men and women, young and old, who are often inclined to customary beliefs, object to their wives going for antenatal care especially under skilled health providers.

Kaida et al. (2004, pp. 279-280) mentioned that in Uganda the cultural and religious background of an individual can have a significant effect on men’s attitudes toward family planning and reproductive health and that culture persuades the members of a society to act according to a tradition that has been in existence for generations.

In a cross sectional study in Eastern Uganda on the determinants of male involvement in the

PMTCT programs by Bio Med central in 2010, results showed that several of the men reported that due to their work nature as a result of their education, they did not have time to attend ANC with their partners since PMTCT programs are usually comprised of long waiting times.

2.3 Men’s level of knowledge on antenatal care services (ANC)

Socio-cultural belief systems, values, and practices also shape an individual’s knowledge and perception of health and illness/disease, together with health care seeking practices and behaviours (de-Graft Aikins, 2005; Caldwell J.C, et al., 1987; MoH, 2004; UNICEF, 2005).

As early as 2001, the World Health Organization (WHO) established proven safe motherhood interventions that are required at household, community and facility levels to enable every pregnant woman to have a safe pregnancy and childbirth, and to provide couples with the best chance of having healthy infants (Portela A, et al.,2003). The strategies include; providing skilled attendants to prevent, detect and manage the major obstetric complications, together with providing equipment, drugs and other supplies (WHO, 2004; MOH, 2006).

A few studies have found that facility interventions providing routine ANC have minimal beneficial effects to maternal health outcomes, creating a rationale for community-based

interventions for pregnant women where educational and support programs have been successful in increasing/improving skilled delivery, breastfeeding practices and postnatal attendance

(Belizan JM, et al., 1995; Hounton S, et al., 2009; Turan JM, et al., 2003). This reported success may be mainly attributable to spousal involvement, and not necessarily the community as a whole.

Also, many men are not aware of why they need to be involved in Sexual and Reproductive

Health (SRH), how they can be involved, and what services are available for them and their partners.

Men who are well informed about family planning are aware of their spouse’s wellbeing related to reproductive health. Men’s knowledge of family planning is important because they play a role as the chief decision makers in the family. The knowledge of particular importance to men includes receiving proper information about modern contraceptives that are available to be chosen in a family planning program for both husband and wife (Lasee A, et al., 1997).

Knowledgeable men are concerned about their wives’ health and during crucial periods like pregnancy especially, they accompany their wives to antenatal care clinics (Grady et al. cited in

Wegner et al. 1998, p. 38).

2.4 Healthcare service factors that influence men’s involvement in antenatal care services (ANC)

In many African countries, widespread testing of women for HIV infection remains an elusive goal, with their primary access to HIV testing and education occurring at antenatal care (ANC) visits and through Prevention of Mother-to-Child Transmission (PMTCT) programs. HIV testing of men also remains challenging, with an estimated 6.1% of men in Sub-Saharan Africa having

ever been tested for HIV and receiving the results. One strategy to increase HIV testing and counseling in men is to include male testing in ANC but barriers often prevent the inclusion of the woman’s husband in ANC/ PMTCT care. (Godlove N.N, et al., 2010)

Also according to PATH (1997), health systems factors have also been a major determinant of male involvement in ANC/PMTCT programs. It was noted that reproductive health services were designed to meet women and children’s needs so this results in men not considering these programs as a source of information and help for them. Furthermore, because the service providers are mostly females, they may be biased towards female related services.

Kamal, 2002 was of the view that men want to make use of the existing public health care facilities, but the way these facilities function is not conducive for their utilization because of the constraints related to time schedule, the attitude of the health care providers and the expenses involved.

In a study in Southern Ethiopia, it was suggested that the high levels of maternal mortality and morbidity in developing countries emphasized the need for antenatal care and availability of trained health personnel for all women during pregnancy, labor and delivery (Mekonnen.Y,

2003).

Numerous studies in Uganda and elsewhere in Sub-Saharan Africa (SSA) have identified physical or geographical access to health care as a major barrier affecting health care seeking behaviours of patients generally, and women’s reproductive health care seeking specifically

(Kasolo et al., 2000; MoH, 2004; GMOH, 1999).

In developing countries including Uganda, several factors impede accessibility, including cost of services, distance to health services, lack of available transportation, high transportation costs, poor road conditions and uneven distribution of health care facilities and lack of independence by women to make decision on matters that directly affect their health (Tawiah, 2011; Magadi et al.,

2003; Anarfi and Ahideke, 2006). All of these factors increase travel time and the difficulty in accessing health service facilities. In rural Uganda, physical accessibility and acceptability remains a significant challenge to health care service delivery.

The major factor consistently identified by all the focus groups in one of the studies conducted in

Eastern Uganda was rudeness and rough handling of the pregnant women by the health workers in the antenatal clinics. (Robert Byamugisha, et al., 2010)

A study by Asiimwe. K.J, (2010), found out that in western Uganda, the ability of a woman to afford ANC services has a significant association to the number of ANC visits she is likely to make. This echoes with studies elsewhere in the world that women having to take transport to

ANC facility, high fees for necessary but costly laboratory fees, drugs and consultation fees in case of private centres not serviced by government hospitals are averting to the utilization of maternal services as highlighted by Atuyambe et al., (2005).

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter is aimed at pointing out the ways through which the researcher carried out the study.

It contains details of the study design, study population, study variables, sample size determination, sampling procedure, data collection techniques and tools, quality control, data analysis and management, and ethical considerations.

3.1 Study design

A descriptive cross sectional study was conducted using quantitative methods of data collection.

Data collection was done at a specific point in time without follow up to determine the level of knowledge and the individual factors that influence men’s involvement in ANC.

The data was then analyzed to facilitate in the description of men’s involvement in antenatal care services in Kibuli.

3.2 Population

Target population: All men in Kibuli

Accessible population: All adult men of ages 18 and above in a sexual relationship, with at least one child, that reside or work in the informal sector of Kibuli

Study population: The study was conducted among adult men of ages 18 and above, in a sexual relationship, with at least one child, that were residing or working in Kibuli’s informal sector and consented to participate in the study.

3.3 Sources of data

The primary sources of data were adult men of ages 18 and above, in a sexual relationship, with at least one child, that were residing or working in Kibuli’s informal sector and consented to participate in the study.

The secondary sources of data were different websites, online journals, articles, and similar study reports done by individuals, private and public organizations in Uganda and other countries.

3.4 Sample size determination

Sample size was determined using Kish and Leslie formula (1965) for random sampling using single proportions as shown below;

Where; n = the required Sample size

Z = Standard normal value corresponding to 95% confidence interval = 1.96 e = Margin of error, 5% = 0.05 p = Estimated proportion of men involved in antenatal care services (ANC) = 0.184 (18.4%)

(Gulu, 2008) q = (1 - p) = Proportion of men that have not been involved in antenatal care services (ANC)

= (1 – 0.184) = 0.816

n = 230

To cater for non response, 5% of the estimated sample was added to get the final sample size.

= n + 5% non response

= 230 + 11.5

= 241.5

THEREFORE the sample size was 240 respondents.

3.5 Sampling procedure

The study units are adult male partners in sexual relationships with at least one child so that we can find out how many are or have ever been involved in ANC therefore answering Specific

Objective (i).

As Kibuli is administratively divided into 16 zones, after getting permission from the local authorities, stratified sampling and simple random sampling were employed in each zone to obtain the respondents.

After the area had been demarcated into zones, following the main routes in each zone, we systematically interviewed the first man we found that fit the inclusion criteria at every 5th workplace.

This system was duplicated in all 16 zones to make sure that 15 men were selected at random from each zone; until a final sample size of 240 respondents was reached.

Simple random sampling was used because it ensured that each member of the target population had an equal and an independent chance of being included in the sample.

3.6 Study variables

This included both dependent and independent variables, as described below:

3.6.1 Dependent variable

The dependent variable assessed was men’s involvement in ANC which in this context meant to take part in or to make somebody take part in the ANC program. It included active participation through attending ANC with the partner.

3.6.2 Independent variables

The independent variables to be assessed included the men’s level of knowledge on ANC

(meaning of ANC, frequency of attendance, procedure involved, importance of ANC towards women’s health), individual characteristics of the men (age, marital status, number of children, religion, tribe, level of education, occupation, income levels, cultural beliefs), together with the other health care system factors that also influence men’s involvement in ANC (accessibility, client-provider relationship, waiting time, opening hours, long distance to health facility).

3.7 Data collection techniques

After getting permission from the local authorities, stratified sampling and simple random sampling were employed in each zone to obtain the respondents.

After the area had been demarcated into zones, following the main routes in each zone, we systematically interviewed the first man we found that fit the inclusion criteria at every 5th workplace.

This system was duplicated in all 16 zone to make sure that 15 men were selected at random from each zone; until a final sample size of 240 respondents was reached.

A researcher administered questionnaire technique was adopted as some respondents in the community were illiterates and it also lowered the possibility of question misinterpretation by the respondents. The lead researcher and assistant researchers administered the questionnaires.

3.8 Data collection tools

Semi structured questionnaires containing both open and closed questions were developed and pretested. The data were collected through formal face-to-face interviews with the respondents.

We used researcher administered questionnaires which consisted of both closed-ended and open- ended questions to identify the proportion of men involved together with men’s knowledge regarding ANC and their involvement in their partner’s reproductive health.

In the semi structured questionnaires, respondents were asked exactly the same set of questions in the same sequence and the answers were recorded verbatim. This ensured uniformity of responses hence ease in data analysis.

3.9 Data management

Research assistants were trained in data collection techniques and supervised while collecting data. The submitted questionnaires were cross checked every day of data collection to make sure that they had been fully completed. The data collected was stored in a cupboard with a lock and key to ensure safety.

Data were coded and entered into Epi Info to ensure accuracy and to avoid duplication. It was then exported to Excel for cleaning by running frequencies to eliminate duplicated values and finally, it was exported to STATA for analysis.

3.10 Data analysis

ST ATA was used for analysis. The frequency, percentage as a descriptive statistics was used to describe background characteristics of respondents and establish relationships between variables.

The data was presented using bar charts and frequency tables.

Chi Square test was done to test for association between two variables. The strength of association was determined using the chi-square test for association and their associated P values.

Chi-square tests were used to test for either dependence or independence of male involvement on categorical variables. Statistically significant association was considered when P values for the

Chi-square tests were <0.05.

3.11 Quality control measures

The lead researcher identified 2 research assistants that were fluent and able to properly understand English and Luganda. They were trained in basic concepts of research, study objectives, interview techniques and correct recording of responses to ensure that questionnaire administration, data collection and recording are standardized.

Validity testing was done by pre-testing the questionnaires to ensure that the questions asked were not vague or ambiguous and to ensure that the questions were interpreted correctly.

Data collected were coded. Accuracy, consistency and correctness of each questionnaire was checked at the end of each day of data collection to avoid missing some important data which would distort the results.

The use of a relatively large sample size eliminated sampling errors. Also the use of the computer eliminated errors that would have been made if the analysis was to be done manually.

3.12 Ethical issues

 Approval was got at the university from the IHPM and the ethics and research committee

of the university and the Chair person of Kibuli.

 Informed, written consent of the respondents was got after a thorough explanation about

the research being conducted; directly before the interview.

 The respondents were clearly informed of the potential risks and benefits of the study and

their voluntary participation sought.

 Anonymity and confidentiality was observed by not requiring respondents to include their

names on the questionnaires and by keeping secret the information revealed by the

participants. Confidentiality is also guaranteed by using identification numbers on

questionnaires instead of people’s names.

3.13 Limitation of the study

The study was conducted in Kibuli parish so the findings from the study may not be generalized to other men in other settings due to different geographical, economic, social and cultural characteristics of the population. However the study findings are beneficial to the area of the study and other areas of similar settings.

CHAPTER FOUR

DATA ANALYSIS AND PRESENTATION OF RESULTS

4.0 Introduction

This chapter presents the analysis and interpretation of data on the study entitled “Factors influencing men’s involvement in Antenatal Care Services (ANC) in Kibuli, Makindye Division,

Kampala District”. The study population was 240 adult men of ages 18 and above, in a sexual relationship, with at least one child, that were residing or working in Kibuli’s informal sector and consented to participate in the study. Findings have been interpreted and arranged according to the study objectives. They have also been presented in form of texts, figures, tables, graphs and charts.

4.1 Descriptive results of the demographic information/ profile of the respondents.

Table 1: Demographic information/ profile of the respondents VARIABLE Frequency % AGE 18-24 35 14.58 25-34 112 46.67 35-44 61 25.42 45 and more 32 13.33 MARITAL STATUS Married 121 50.42 Cohabiting 62 25.83 Divorced / Separated 14 5.83 Polygamist 10 4.17 Visiting relationships 33 13.75 EDUCATON LEVEL Not educated 28 11.67 Primary 51 21.25 Secondary 92 38.33 Tertiary 69 28.75 RELIGION Catholic 62 25.83 Protestant 55 22.92 Muslim 87 36.25 Pentecostal 27 11.25 SDA 9 3.75 TRIBE Muganda 99 41.25 Mugisu 10 4.17 Mukiga 18 7.50 Munyankole 28 11.67 Musoga 21 8.75 Muteso 14 5.83 Mutoro 15 6.25 *Other 35 14.58 NUMBER OF CHILDREN 1 62 25.83 2-3 104 43.33 4-5 41 7.08 6 or more 33 13.75 OCCUPATION Employed 119 49.58 Self employed 112 46.67 Unemployed 9 3.75 NATURE OF OCCUPATION Transport 43 18.61

Construction 30 12.99 Food 18 7.79 Service 66 28.57 Vending 22 9.52 Trading 20 8.66 Business 32 13.85

*Respondents falling in Other in the category of tribe include: Mudokoli, Musamya, Mukonjo,

Mu luo.

As seen in Table 1 above;

The majority, 112/240 (46.67%) of the respondents were aged 25-34 years while the minority, 32

(13.33%) of the respondents were aged 45 years and above.

Similarly, a little over half 121/240 (50.42%) of the respondents were married followed by those,

62/240 (25.83%) that were cohabiting.

The bulk, 92/240 (38.33%) of the respondents had attended Secondary level, which is almost

three times the minority, 28/240 (11.67%) that were not educated.

The greatest part 87/240 (36.25%) of the respondents interviewed were Muslim and the least part

9/240 (3.75%) were Seventh Day Adventists (SDA).

Many of the respondents interviewed, 99/240 (41.25%) were Baganda followed by those in the

category of Other tribes 35/240 (14.58%) that includes the Badokoli, Basamya, Bakonjo and the

Luo.

Majority of the respondents 104/240 (43.33%) had 2-3 children followed by those 62/240

(25.83%) that had only 1 child.

Almost half of the respondents 119/240 (49.58%) were employed followed by those that were

Self employed 112/240 (46.67%) and lastly by the unemployed 75/240 (3.75%)

The mass 66/240 (28.57%) of the respondents interviewed worked in the Service industry (i.e.

Mobile money agent, Barber, Garden attendant, Car wash, Tailor, Cleaner, Radio repair, Phone repair, Laundry store, Shoe repair, Security guard/officer, Mechanic, Artist, Casual labourer,

Carrier, House help, Computer/printing services). While the smallest number of respondents,

18/240 (7.79%) worked in the Food industry (i.e Food vendor, Chapati maker/vendor, Restaurant worker, waiter, butcher, bar tender).

The majority 147/230 (63.91%) of the respondents that were interviewed made an average income more than 100,000 Ug Shs; followed by those 73/230 (31.74%) that made an average income of 50,000-100,000 Ug Shs and lastly those 10/230 (4.35%) that made an average income less than 50,000 Ug Shs.

4.2 Male involvement in ANC in Kibuli, Makindye Division.

Figure 1: Male involvement in ANC among 240 men in Kibuli, Makindye Division.

As shown in the Figure 1 above, 147/240 (61.25%) of men were involved in ANC in Kibuli,

Makindye Division while the minority, 93/240 (38.75%) of men were not involved.

4.2.1 Descriptive results of the individual characteristics influencing male involvement in ANC in Kibuli, Makindye Division.

Table 2: Descriptive results of the individual characteristics influencing male involvement in ANC in Kibuli, Makindye Division VARIABLE N (%) INVOLVED NOT CHI- P VALUE INVOLVED SQUARE AGE 18-24 35 (14.58) 18 (12.24) 17 (18.28) 25-34 112 (46.67) 77 (52.38) 35 (37.63) 6.084 0.108 35-44 61 (25.42) 32 (21.77) 29 (31.18) 45 and more 32 (13.33) 20 (13.61) 12 (12.90) MARITAL STATUS Married 121 (50.42) 76 (51.70) 45 (48.38) Cohabiting 62 (25.83) 40 (27.21) 22 (23.66) Divorced / Separated 14 (5.83) 9 (6.12) 5 (5.37) 2.985 0.560 Polygamist 10 (4.17) 4 (2.72) 6 (6.45) Visiting relationships 33 (13.75) 18 (12.24) 15 (16.13) EDUCATON LEVEL Not educated 28 (11.67) 11 (7.48) 17 (18.28) Primary 51 (21.25) 29 (19.73) 22 (23.66) 11.978 0.007 Secondary 92 (38.33) 55 (37.41) 37 (39.78) Tertiary 69 (28.75) 52 (35.37) 17 (18.28) RELIGION Catholic 62 (25.83) 44 (29.93) 18 (19.35) Protestant 55 (22.92) 32 (21.77) 23 (24.73) Muslim 87 (36.25) 50 (34.01) 37 (39.78) 8.058 Pentecostal 27 (11.25) 13 (8.84) 14 (15.05) SDA 9 (3.75) 8 (5.44) 1 (1.08) 0.089 TRIBE Muganda 99 (41.25) 71 (48.29) 28 (30.11) Mugisu 10 (4.17) 4 (2.72) 6 (6.45) Mukiga 18 (7.50) 7 (4.76) 11 (11.83) Munyankole 28 (11.67) 19 (12.93) 9 (9.68) 17.361 0.015 Musoga 21 (8.75) 15 (10.20) 6 (6.45) Muteso 14 (5.83) 5 (3.40) 9 (9.68) Mutoro 15 (6.25) 8 (5.44) 7 (7.53) *Other 35 (14.58) 18 (12.24) 17 (18.28) NUMBER OF CHILDREN 1 62 (25.83) 42 (28.57) 20 (21.51) 2-3 104 (43.33) 68 (46.26) 36 (38.71) 5.854 0.119 4-5 41 (7.08) 20 (13.61) 21 (22.58) 6 or more 33 (13.75) 17 (11.56) 16 (17.20) OCCUPATION Employed 119 (49.58) 80 (54.42) 39 (41.94)

Self employed 112 (46.67) 65 (44.22) 47 (50.54) 8.054 0.018 Unemployed 9 (3.75) 2 (1.36) 7 (7.53) NATURE OF OCCUPATION Transport 43 (18.61) 29 (20.0) 14 (16.28) Construction 30 (12.99) 19 (13.10) 11 (12.79) Food 18 (7.79) 11 (7.59) 7 (8.14) 0.864 0.990 Service 66 (28.57) 40 (27.59) 26 (30.23) Vending 22 (9.52) 13 (8.97) 9 (10.47) Trading 20 (8.66) 12 (8.28) 8 (9.30) Business 32 (13.85) 21 (14.48) 7 (8.14) AVERAGE INCOME PER MONTH <50,000 10 (4.35) 6 (4.17) 4 (4.65) 4.069 0.131 50,000 – 100,000 73 (31.74) 39 (27.08) 34 (39.53) >100,000 147 (63.91) 99 (68.75) 48 (55.81) *Respondents falling in Other in the category of tribe include: Mudokoli, Musamya, Mukonjo,

Mu luo.

As shown in Table 2;

The majority, 112/240 (46.67%) of the respondents were aged 25-34 years. The proportion of

men aged between 25-34 years that were involved in ANC was 52.38% (77/147).

Similarly, a little over half 121/240 (50.42%) of the respondents were married and the proportion

of these that were involved in ANC was 51.70% (76/147).

The bulk, 92/240 (38.33%) of the respondents had attended Secondary level. The proportion of

men that attended Secondary education and were involved in ANC was 37.41% (55/147). Level

of education (P=0.007)is associated with male involvement.

The greater part 87/240 (36.25%) of the respondents interviewed were Muslim and the proportion

of these that were involved in ANC was 34.01% (50/147).

Many of the respondents interviewed, 99/240 (41.25%) were Baganda. The proportion of these that were involved in ANC was 48.29% (71/147). Tribe (P=0.015) was found to be associated with male involvement in ANC.

Majority of the respondents104/240 (43.33%) had 2-3 children and the proportion of these men involved in ANC was 46.26% (68/147).

Almost half of the respondents119/240 (49.58%) were employed and of these, the proportion of men involved in ANC was 54.42% (80/147). It was found that occupation (P=0.0018) is associated with male involvement in ANC.

The mass 66/240 (28.57%) of the respondents interviewed worked in the Service industry (i.e.

Mobile money agent, Barber, Garden attendant, Car wash, Tailor, Cleaner, Radio repair, Phone repair, Laundry store, Shoe repair, Security guard/officer, Mechanic, Artist, Casual labourer,

Carrier, House help, Computer/printing services). The proportion of these that were involved in

ANC was 27.59% (40/145).

The majority 147/230 (63.91%) of the respondents that were interviewed made an average income more than 100,000 Ug Shs per month. The proportion of these men that were involved in

ANC was 68.75% (99/144).

4.2.2 Descriptive results of the level of knowledge on ANC influencing male involvement in ANC in Kibuli, Makindye Division.

Figure 2: Descriptive results of the level of knowledge on the definition of ANC

As seen in the figure above, the majority, 207/240 (86.25%) of men reported knowing what ANC is while 33/240 (13.75%) said that they did not know what ANC is.

With a P-value below 0.05, Knowledge of the definition of antenatal care (Chi=38.909, P= 0.000) was found to be associated with male involvement in ANC.

Figure 3: Descriptive results of the level of knowledge on the importance of male involvement in their partner’s health.

Although 86.25% of men reported to knowing the definition of ANC; from the figure above, it is noted that only198/240 (82.50%) knew that it is important to be involved in their partner’s health while 42/240 (17.50%) didn’t know it is important.

Knowledge on the importance of male involvement in their partner’s health (Chi=30.068, P=

0.000) was also found to be associated with male involvement in ANC.

Table 3: Descriptive results of men’s level of knowledge on ANC VARIABLE N (%) INVOLVED NOT CHI- P INVOLVED SQUARE VALUE What is the recommended number of ANC visits? 0 33 (13.75) 4 (2.72) 29 (31.18) 1 4 (1.67) 0 (0) 4 (4.30) 2 13 (5.42) 8 (5.44) 5 (5.38) 3 38 (15.83) 29 (19.73) 9 (9.68) 4 83 (34.58) 64 (43.54) 19 (20.43) 5 18 (7.50) 15 (10.20) 3 (3.23) 67.955 0.000 6 7 (2.92) 3 (2.04) 4 (4.30) 7 19 (7.92) 8 (5.44) 11 (11.83) 8 4 (1.67) 4 (2.72) 0 (0) 9 13 (5.42) 5 (3.40) 8 (8.60) 10 3 (1.25) 3 (2.04) 0 (0) 11 5 (2.08) 4 (2.72) 1 (1.08) Does your culture influence your involvement in ANC? Never 84 (35.00) 58 (39.46) 26 (27.96) 5.506 0.138 To a small extent 51 (21.25) 31 (21.09) 20 (21.51) To a great extent 43 (17.92) 27 (18.37) 16 (17.20) Always 62 (25.83) 31 (21.09) 31 (33.33) From Table 3, we noted that:

The largest number, 83/240 (34.58%) of men stated 4 visits as the recommended number of ANC visits and of these, the proportion that were involved in ANC was 19.73% (29/147). Knowledge on the recommended number of ANC visits (P=0.000); was associated with male involvement in

ANC.

Similarly, the majority, 84/240 (35.0%) of the respondents said that their culture never influenced their involvement in ANC. Of these, the proportion that was involved in ANC was 39.46%

(58/147).

4.2.3 Descriptive results of the healthcare service factors influencing male involvement in ANC in Kibuli, Makindye Division.

Table 4: Descriptive results of the healthcare service factors influencing male involvement in ANC VARIABLE N (%) INVOLVED NOT CHI- P INVOLVED SQUARE VALUE How far is it from your home to the nearest health centre? <5 Km 142 (59.41) 84 (57.53) 58 (62.37) 0.550 0.458 >5 Km 97 (40.59) 62 (42.47) 35 (37.63) How long did you wait to be attended to? <30 minutes 98 (40.83) 66 (44.90) 32 (34.41) 4.925 0.085 >30 minutes 98 (40.83) 60 (40.82) 38 (40.86) I don’t remember 44 (18.33) 21 (14.29) 23 (24.73)

How much did you pay to receive the services? Free 47 (19.58) 31 (21.09) 16 (17.20) <5,000 20 (8.33) 14 (9.52) 6 (6.45) 9.339 0.053 6,000 -10,000 40 (16.67) 18 (12.24) 22 (23.66) 11,000 – 15,000 36 (15.0) 18 (12.24) 18 (19.35) >15,000 97 (40.42) 66 (44.90) 31 (33.33) How do you rate the quality of service at the health facility? Good 136 (56.67) 89 (60.54) 47 (50.54) 2.510 0.285 Bad 27 (11.25) 16 (10.88) 11 (11.83) Fair 77 (32.08) 42 (28.57) 35 (37.63) As shown in Table 4 above;

More than half, 142/240 (59.41%) of the men reported the nearest health centre being less than 5

Km from their home. The proportion of those involved in ANC was 57.53% (84/147).

The largest number, 98/240 (40.83%) of respondents reported to have waited on average less than

30 minutes before being attended to. The proportion of these involved in ANC was 44.90%

(66/147).

More than three quarters, 97/240 (40.42%) of the men reported paying more than Ug Shs 15,000 to receive the services. The proportion of these who were involved in ANC was 44.90% (66/147).

More than half, 136/240 (56.67%) of the men interviewed rated the quality of service at the health facility as good and of these the proportion that were involved in ANC was 60.54%

(89/147).

VARIABLE N (%) If bad, give reasons Services were offered at a specific time 5 (18.52) Health workers attitude was poor 22 (81.48) Costly lab fees, drugs and consultation fees 21 (77.78) Lack of confidentiality 12 (44.44)

Out of the respondents that rated the quality of service they received at the facility as bad, 22/27 of them reported that the health workers’ attitude was poor, 21/27 faulted it to costly lab fees, drugs and consultation fees, 12/27 to lack of confidentiality and 5/27 to the fact that services were offered at specific time.

4.3 Statistical associations of the factors influencing male involvement in ANC in Kibuli, Makindye Division.

Table 5: Statistical associations of the factors influencing male involvement in ANC. VARIABLES ODDS 95% CI P- RATIO VALUE Level of Education: Not educated 1 Primary 2.037 (0.796 - 5.211) 0.138 Secondary 2.297 (0.967 - 5.458) 0.060 Tertiary 4.727 (1.855 - 12.047) 0.001 Tribe: Muganda 1 Mugisu 0.263 (0.069 - 1.003) 0.050 Mukiga 0.251 (0.088 - 0.713) 0.009 Munyankole 0.833 (0.337 - 2.059) 0.692 Musoga 0.986 (0.347 - 2.797) 0.979 Muteso 0.219 (0.067 - 0.711) 0.011 Mutoro 0.451 (0.149 - 1.360) 0.157 *Other 0.418 (0.189 - 0.924) 0.031 Occupation: Employed 1 Self employed 0.674 (0.394 - 1.152) 0.149 Unemployed 0.139 (0.028 - 0.702) 0.017 Do you know that it’s important to be involved in your partner’s health? No 1 Yes 7.187 (3.323 - 15.545) 0.000 Do you know what antenatal care is? No 1 Yes 16.199 (5.467 - 47.995) 0.000 What is the recommended number of ANC visits? 0 1 1 1 2 11.6 (2.511 – 53.578) 0.002 3 23.361 (6.461 – 84.472) 0.000 4 24.421 (7.625 – 78.218) 0.000 5 36.25 (7.163 – 183.458) 0.000 6 5.438 (0.876 – 33.756) 0.069 7 5.273 (1.318 – 21.094) 0.019 8 1 9 4.531 (0.981 – 20.929) 0.053 10 1 11 29 (2.558 – 328.713) 0.007

*Respondents falling in Other in the category of tribe include: Mudokoli, Musamya, Mukonjo,

Mu luo.

From Table 5, it is noted that;

A man's level of education was found to be a major influence in attendance of ANC. Men who attended Primary (OR= 2.037, CI= 0.796-5.211) and Secondary (OR= 2.297, CI= 0.967-5.458) level education were 2 times more likely to be involved in ANC than those that were Not educated. However, judging from their p-values (P= 0.138 and P= 0.060 respectively), these findings were not statistically significant. Those men that attended Tertiary (OR= 4.727,

CI= 1.855-12.047) level education were 4 times more likely to be involved in ANC than those that were Not educated. These findings were statistically significant (P= 0.001).

From our findings tribe did not seem to be a major factor influencing involvement of men in

ANC. Compared with the Baganda, men from the Bagisu tribe (OR= 0.263, CI=0.069-1.003,

P= 0.050), Bakiga (OR= 0.251,CI= 0.088-0.713, P= 0.009), Banyankole (OR= 0.833, CI= 0.337-

2.059, = 0.692), Basoga (OR= 0.986,CI= 0.347-2.797, P= 0.979), Bateso (OR= 0.219, CI= 0.067-

0.711,P= 0.011),Batoro (OR= 0.451, CI=0.149-1.360, P= 0.157) and Other tribes

(OR= 0.418,CI= 0.189-0.924, P= 0.031), were less likely to be involved in ANC but unlike results from the Bakiga, (P=0.009) the rest of the findings were not statistically significant as indicated by P values greater than or equal to 0.05.

Men that were Self employed (OR= 0.674, CI= 0.394-1.152, P= 0.149) and Unemployed (OR=

0.139, CI= 0.028-0.702, P= 0.017) were less likely to be involved in ANC than those that were

Employed. We see however that only the results from the unemployed (P= 0.017) were statistically significant.

Respondents that reported knowing the importance of male involvement in their partner’s health

(OR= 7.187, CI= 3.323-15.545, P= 0.000) were 7 times more likely to be involved in ANC than those that reported not knowing the importance of their involvement. These results were statistically significant.

A man's knowledge on the definition of ANC was found to be a major influence in attendance of

ANC. Males that reported knowing what antenatal care is (OR= 16.199, CI= 5.467 - 47.995, P=

0.000) were 16 times more likely to be involved in ANC than those that reported not knowing.

From our findings, compared with the men that reported the recommended number of ANC visits to be 0, 1, 8, or10; those that reported the recommended number of ANC visits as 2 (OR= 11.6,

CI= 2.511–53.578, P= 0.002), as 3 (OR= 23.361, CI= 6.461–84.472, P= 0.000), as 4 (OR=

24.421, CI= 7.625–78.218, P= 0.000), as 5 (OR= 36.25, CI= 7.163–183.458, P= 0.000), as 6

(OR= 5.438, CI= 0.876–33.756, P= 0.069), as 7 (OR= 5.273, CI= 1.318–21.094, P= 0.019), as 9

(OR= 4.531, CI= 0.981–20.929, P= 0.053), and as 11 (OR= 29, CI= 2.558–328.713, P= 0.007) were much more likely to be involved in ANC. But as indicated by P values greater than or equal to 0.05, results showing 6 and 9 were not statistically significant.

CHAPTER FIVE

DISCUSSION OF FINDINGS

5.0 Introduction

This chapter presents discussions of the findings of the study entitled “Factors influencing men’s involvement in Antenatal Care Services (ANC) in Kibuli, Makindye Division, Kampala District”.

This chapter is sectioned in line with the objectives of this study and includes a discussion in relation to various literacy reports, dealing with aspects raised in the discussion. A detailed discussion of the findings is indicated below:

5.1 The proportion of men involved in antenatal care services (ANC) in Kibuli, Makindye Division.

In this study, six in ten (61.25%) of the men were involved in ANC in Kibuli, Makindye

Division. In 2003, the Ministry of Health of Uganda introduced a policy advocating for HIV counseling and testing of all men together with their partners in Antenatal Clinic settings. This implies that male involvement in ANC in Kibuli, Makindye Division is still below the required standards.

Kampala, Uganda, showed that male participation in the PMTCT activities was low (16%)

(Farquhar C,et al., 2004; Byomire H, 2003) .

In this study, the prevalence of male involvement in ANC was associated with having a higher education level, one’s tribe, occupation status, knowledge of importance of male involvement in

the partner’s health, the definition of ANC and knowledge on the recommended number of ANC visits.

The findings in this study showed that male involvement in ANC was slightly higher than in the previous studies. This could most likely be because the previous studies were conducted when the population was not yet aware of the importance of male involvement in their partner’s health or when they did not see it as a priority.

The difference could also arise because this study was conducted in an urban area and the men in

Kibuli, Makindye Division probably hold a better chance of exposure to the ANC services.

Even with the increasing recognition that the involvement of men in Sexual and Reproductive

Health (SRH) and service delivery such as ANC offers both men and women important benefits if men are involved not just as clients but also as partners, reports still show that male involvement is still low.

This means that if male involvement in ANC continues at this trend, and given the sensitive nature of gender roles and relations in many cultures, understanding the context of a particular setting, potential barriers, and attitudes towards a new intervention will be close to impossible leading to a tremendous increase in mortality and morbidity of both mother and child, increased cost of treatment as well as decreased productivity.

5.2 The individual factors that influence the involvement in antenatal care services (ANC) among men in Kibuli, Makindye Division.

There are a number of individual factors that influence knowledge, belief, values, and behavior towards men’s involvement in ANC.

Among the individual factors studied, attending tertiary level of education was significantly associated with male involvement in ANC at all levels of analysis.

The odds of male involvement in ANC increase with increased education of the respondents, where those that had attended secondary and tertiary education were more likely to be involved as compared to those with no education. These findings were in disagreement with those done in

Eastern Uganda by Bio Med Central in 2010, where results showed that several of the men reported that due to their work nature as a result of their education or expertise, they did not have time to attend ANC with their partners. These results differ probably because the study sites and sample sizes used in both studies are different.

A study in Ghana covering the period 1988 to 1998 revealed that the level of men’s education influences spousal fertility preferences. A husband’s level of educational attainment especially beyond primary level influences his wife to limit childbearing.

It is generally true that men with higher levels of education are more informed and concerned about their partner’s health allowing them to get away from work and create time to attend ANC as recommended.

According to the study, tribe did not appear to be a major factor influencing male involvement in

ANC. This is in disagreement with the study by Kaida et al. (2004, pp. 279-280) that established

that in Uganda the cultural and religious background of an individual can have a significant effect on men’s attitudes toward family planning and reproductive health and that culture persuades the members of a society to act according to a tradition that has been in existence for generations.

This could be due to the fact that even if many people act according to a tradition, they are knowledgeable enough to know that not all traditions are right or beneficial to them or their loved ones.

Judging from the study findings, it was found that unemployed men were less likely to be involved in ANC than those that were employed. This is in deviation with the study done in

Eastern Uganda by Bio Med Central in 2010 where several of the men reported that due to their work nature, they did not have time to attend ANC with their partners as such programs are comprised of long waiting hours.

Another study in Tanzania, explained that some of the barriers said to inhibit male involvement in these services include lack of information, fear of HIV-test results, and limited time to spend at clinics. (Fhi360, viewed 26/4/2012).

This could be due to the fact that the unemployed men spend most of their time searching for jobs to support themselves and their families and currently do not see their involvement as a priority.

It could also be due to the fact that traditionally, men are the breadwinners in the home and therefore any work hours lost in a day are likely to cost the family much needed income.

Male involvement is increasingly seen as beneficial for the whole family, helping to de- stigmatize HIV, increasing access to services, and providing information that heightens men's concern for the wellbeing of their pregnant partners and their support for safe births at health

facilities. Reaching out to men of all calibers or standards also means reaching more community and household decision-makers, who may be convinced to accept and support PMTCT and ANC programs.

5.3 The level of knowledge on antenatal care services (ANC) among men in Kibuli, Makindye Division.

Men’s knowledge on ANC is vital because it helps them to better care for their partners during pregnancy. They would be able to differentiate between what is wrong or right as regards to their partner’s care.

In our study, men that reported knowing the importance of male involvement in their partner’s health were 7 times more likely to be involved in ANC than those that reported not knowing the importance of their involvement. This could be an outcome of the fact that many men are not aware of why they need to be involved in Sexual and Reproductive Health (SRH), how they can be involved, and what services are available for them and their partners.

These findings were not in line with another research conducted in Kayunga district on male involvement in ANC/PMTCT programs by Mary Duckti in 2010, where the results showed that men felt that pregnant women were a burben to them, and their demand to be accompanied to seek services was a violation of the male partner’s rights and that it showed a lack of respect for their men.

In this study, a man's knowledge on the definition of ANC was found to be a major influence in attendance of ANC. Males that reported knowing what antenatal care is were 16 times more likely to be involved in ANC than those that reported not knowing. These results were in agreement with a study conducted in Tanzania, which revealed that lack of information or knowledge hindered male involvement in ANC/PMTCT services (Theuring S et al.,2006)

There are also other aspects that shape an individual’s knowledge and perception of health and illness/disease, together with health care seeking practices and behaviours (de-Graft Aikins,

2005; Caldwell J.C, et al., 1987; MoH, 2004; UNICEF, 2005).

From our findings, compared with the men that reported the recommended number of ANC visits to be 0, 1, 8, or10; those that reported the recommended number of ANC visits as 2, as 3, as 4, as

5, as 6, as 7, as 9, and as 11 were much more likely to be involved in ANC. But as indicated by P values greater than or equal to 0.05, results showing 6 and 9 were not statistically significant.

These results are in line with the article that states, “Knowledgeable men are concerned about their wives’ health and during crucial periods like pregnancy especially, they accompany their wives to antenatal care clinics.” (Grady et al. cited in Wegner et al. 1998, p. 38).

Men who are well informed about family planning are aware of their spouse’s wellbeing related to reproductive health. This is important because they play a role as the chief decision makers in the family.

All these results imply that without emphasis on getting the population to know about the benefits of male involvement in ANC, many interventions will fail or continue with low levels of uptake, as mother and child mortality and pregnancy complications increase.

5.4 The healthcare service factors that influence the involvement in antenatal care services (ANC) among men in Kibuli, Makindye Division.

Among the health care system factors that were included in the study, none of the factors were found to be significantly associated with male involvement in ANC. This is in disagreement with a study done by PATH in 1997, where health systems factors were found to be a major determinant of male involvement in ANC/PMTCT programs. These results differ probably because most men do not consider these programs as a source of information and help for them reproductive health services as they feel the programs were designed to meet women and children’s needs. Furthermore, because the service providers are mostly females, they may be biased towards female related services.

The results of this study were also in disagreement with numerous studies in Uganda and elsewhere in Sub-Saharan Africa (SSA) that identified physical or geographical access to health care as a major barrier affecting health care seeking behaviors of patients generally, and women’s reproductive health care seeking specifically. This could be because the study sites, study population and sample sizes used in both studies are different.

Another reason could be that even if men want to make use of the existing public health care facilities, the way these facilities function is not conducive for their utilization because of the constraints related to time schedule, the attitude of the health care providers and the expenses involved.

This means that supporting community-based interventions may be more successful in increasing male involvement in maternity programs, improving skilled delivery, breastfeeding practices and postnatal attendance for pregnant women.

5.5 Limitations

The findings of this study are subject to some limitations as indicated below:

Being a researcher, it could be possible that the respondents provided me with information they thought I wanted to hear. Therefore the findings could be subjected to bias.

The findings may only be generalized to adult men of ages 18 and above, in a sexual relationship, with at least one child, residing or working in Kibuli’s informal sector.

CHAPTER SIX

CONCLUSIONS AND RECOMMENDATIONS

6.0 Introduction

This chapter presents the conclusions from the discussions of the findings as well as the recommendations of the study entitled “Factors influencing men’s involvement in Antenatal Care

Services (ANC) in Kibuli, Makindye Division, Kampala District”.

6.1 Conclusions

In this study of the factors influencing male involvement in ANC, results showed that the level of male involvement in Kibuli, Makindye Division, Kampala District is low (61.25%) but still higher than what is reported from other studies from East Africa.

A man's level of education was found to be of influence in attendance of ANC. Men who attended Tertiary level education were 4 times more likely to be involved in ANC than those that were not educated.

Men that were self employed and unemployed were less likely to be involved in ANC than those that were employed.

Men that reported knowing the importance of male involvement in their partner’s health were 7 times more likely to be involved in ANC than those that reported not knowing the importance of their involvement.

Having knowledge of what ANC is was found to be a major influence in attendance of ANC.

Males that reported knowing what antenatal care is were 16 times more likely to be involved in

ANC than those that reported not knowing.

Knowledge of the recommended number of ANC visits was significantly associated with high male involvement in ANC

Among the health care system factors that were included in the study, none of the factors were found to be significantly associated with male involvement in ANC.

6.2 Recommendations

The study recommends that increase awareness of the importance of male involvement in

ANC/PMTCT services. It is important that more information is provide to the public on how, why, when and where men can be involved when it comes to not only ANC but to their partner’s health in general.

Through aggressive advertizing and sensitizing of the population using mediums suitable for both the literate and illiterate people like radio talks, television shows, mobile entertainment and educative shows together with other forms of media; people’s knowledge on male involvement in ANC should be able to increase.

The government of Uganda and other stake holders should make an effort to start up more

Poverty eradication programs to allow men start up their own businesses. This could increase the odds of involvement in ANC among the men that were once unemployed or poverty stricken.

To increase male involvement and create a couple-friendly environment, this study recommends ensuring efficient health facility management and staff commitment to male involvement through meetings and workshops including Department of Health (DOH) officials at local, regional and national levels, as well as clinic managers and health care providers.

The Ministry of Health together with other stake holders should train health workers to be interactive and involve 2 way discussions for effective and comfortable communication about topics such as pregnancy, preparation of delivery, postnatal care, involving men in maternity, sexual health and basic counseling.

We also recommend that women be given an antenatal care booklet that reinforces the information given in the counseling session so they can read the book and share information and lessons learned with their partners.

Continuous support and mentoring should be given to further encourage men that are already involved in ANC by providing a platform for sharing lessons learned from individual men and peer support.

6.3 Areas of further study

 How women affect male involvement in maternity.

 Barriers of involving men in their partner’s health.

 Possible interventions to encourage male involvement in SRH not only as clients but also

as partners.

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APPENDIX:

I. A work plan for a study to assess the factors influencing men’s involvement in

antenatal care services (ANC) in Kibuli, Makindye Division, Kampala District.

ACTIVITY TIME (MONTH) RESPONSIBLE PERSON

Developing research topics and Aug. 2012 Researcher objectives

Approvals of research topic Sept. 2012 Supervisor

Developing a draft proposal Jan. 2013 Researcher

Developing a final proposal March. 2013 Researcher

Approval of proposal May. 2013 Supervisor

Selecting and Training research June. 2013 Researcher assistants

Pre - testing of tools June. 2013 Researcher / Research assistants

Data collection June. 2013 Researcher/Research assistants

Data analysis June. 2013 Researcher

Writing Report draft 1 July. 2013 Researcher

Writing Report draft 2 July. 2013 Researcher

Writing Report draft 3 Aug. 2013 Researcher

Writing final Report Aug. 2013 Researcher

Submission of Report to the Sept. 2013 Researcher University

II. Proposed Budget for a study to assess the factors influencing men’s involvement in

antenatal care services (ANC) in Kibuli, Makindye Division, Kampala District.

ACTIVITY QUANTITY UNIT NUMBER OF TOTAL COST COST TIMES

Training of Research 2 15,000 1 30,000 Assistants

Transport for Researcher 3 10,000 7 210,000 and Research Assistants

Lunch 3 5,000 7 105,000

Data Entry and Analysis 1 400,000 1 400,000

Printing and binding of 1 50,000 3 150,000 proposal

Printing and binding of 1 75,000 4 300,000 report

TOTAL 1,195,000