Assessment of men involvement in family planning services use and associated factors in rural Upper West Region of Ghana

A cross-sectional descriptive study design was used to collect data from 200 respondents. Study respondents were selected through random cluster sampling.


Abstract Background
In low-and-middle come countries (LMICs) less attention is paid to men' involvement in Family Planning (FP)programs where public health o cials have advocated the involvement of men as a strategy for addressing the dismal performance of FP programs. The study assessed factors which promote or hinder the uptake of FP services among partners in a rural setting of northern Ghana.

Methods
A cross-sectional descriptive study design was used to collect data from 200 respondents. Study respondents were selected through random cluster sampling.

Results
The ndings showed that men partners' knowledge (95.5%) and approval (72.8%) of FP services were high. Approval of services was also con rmed by their men partners (75%). Mass media was the commonest source of contraception information (48.1%) with the radio (29.4%) being the most popular source. The ndings also indicated that men had a higher propensity (X 2 = 4.5534, p = 0.033) of supporting a FP method use. Women who reported that their spouse supported FP method use were more likely to use a contraceptive method (X 2 = 9.5223, P = 0.002) if their spouse supported FP method use (X2 = 9.5223, P = 0.002) and if their partners had some education (X2 = 14.1133, P = 0.000). Reasons for low contraceptive use were health risks, side-effects and socio-cultural norms.

Conclusion
Family planning programs need to include men at all levels of health promotion and education of FP programs to help reduce misconceptions about contraceptive Background Family planning services are critical to improving maternal and child health and reducing maternal and infant mortality [1]. Expanding the availability of FP services and working on the utilization of services in LMICs could avert up to 42% of maternal deaths [1,2] . Men are also recognized to be responsible for the large proportion of reproductive ill health suffered by their partners' use of FP methods [3]. Although contraceptive methods and services are frequently geared towards women, men are often the primary decision makers on family size and their partners' use of FP methods [4]. It is well documented that men's general knowledge and attitude about the ideal family size, gender preference of children, ideal spacing between child births, and contraceptive methods use greatly in uence women's preferences and opinions [3,5,6].
The 1994 Cairo International Conference on Population and Development recognized that men involvement in reproductive health issues is required and further work with men is needed for effective change [7]. The effects of men and the socio-cultural construction of masculinities on women's reproductive health outcomes are also recognized [8]. The World Fertility Survey showed that utilization of FP methods varied widely from 69% in south-east Asia to 11% in Africa 9. Evidence showed that there is high unmet need for contraceptive use in most developing countries and even higher In sub-Saharan African countries where the number of women with unmet need for modern contraception increased from 31 million in 2008 to 36 million in 2012 [9].
In Ghana, the focus of this study, knowledge of any contraceptive method is almost universal, with 98% of all women and 99% of all men knowing at least one method of contraception 10 and where 50% of all women reported having used a method contraception before [10]. However, according to the 2014 Ghana Demographic and Health Survey, only 27% of married women use FP with 22% using a modern method and 5% using traditional method [11].
Family planning in Ghana dates as far back as 1956 [12]. However, studies have shown that uptake of FP services in Ghana has not been encouraging and for that matter Tumu in the Sissala East District of the Upper West Region which experienced a decrease from 71.4% in 2011 to 50.7% in 2012 [13]. Family planning research in rural Ghana have been dominated by ndings almost exclusively from women studies.
Men especially in Ghana are seen to be the head of the home and in uence healthcare decisions of the entire household [14]. Studies have also shown an increase in contraceptive use in cases where men partners have been involved [4,15]. Men involvement helps not only in accepting contraceptives uptake but also its effective use and continuation [4,5,15]. However, men partners role in FP services promotion and uptake has often overlooked and neglected in LMICs such as Ghana. To ll this research gap, this study assessed factors that promote or hinder contraceptive uptake among women and their men partners in a rural district of the Upper West Region.

Study setting
The study took place in Tumu in the Sissala East District in the north-eastern part of the Upper West Region of Ghana. Tumu, the district capital is predominantly rural by nature, with majority (85 %) living in rural settings [16,17]. A large percentage (84%) of the population live below the poverty line [16,17]. A greater proportion (76%) of the population are being engaged in agriculture. It is predominantly Islam (88.0%) with Christianity being the largest of the minority (10%) followed by Traditional (1.4%) [16,17]. A greater proportion of the population (52.4%) has Some level of education [16].

Study Design
A cross-sectional descriptive study design was used for this study. An interviewer administered questionnaire consisting of both open and close-ended questions were administered by experienced research assistants to elicit the necessary information from the study population.

Sampling technique and sample size
The sample size for this study was determined using the Yamane method: p = margin of error (5%). A sample size of 386 was derived from the total population of 11,252.

Study population
The study population consisted of adult males and females aged 15 years and above who were either married or cohabitating. For this study, we aimed at recruiting 386 respondents but nally recruited 200 respondents due to nancial constraints.

Data Collection method
An interviewer administered questionnaire consisting of both closed and open-ended questions was used to assess the knowledge and use of FP services among partners. The study questionnaire was developed based on the objective of this study by the principal investigator. The questionnaire was administered by the rst author and other two experienced research assistants who understand the native dialect. It was administered in English and translated into the local dialect for those who could not understand or speak the English language. The data was administered among households in ve communities or clusters out of the ten in Tumu municipality. These communities were chosen using a simple random sampling method. Forty respondents were interviewed from each community. This method gave the individual an equal chance of being selected. Before permission was sought from respondents, the aim of the study was explained to each individual. They were also assured of con dentiality and privacy of information they will give. The questionnaires were pretested in a similar environment in the district.

Data management and Analysis
To ensure accuracy, data collected was checked and screened for completeness. The completed copies of the questionnaire were serially numbered coded and doubly entered and analyzed using Statistical Package for Social Scientists version 20.0. Bivariate and regression analyses were used to determine the associations between the outcome variables and a host of explanatory variables.

Results
Background characteristics of respondents Two hundred (200) respondents were interviewed for this study. The study involved 107 men representing 53.5% and 93 women representing 46.6%. Respondents' age ranged between 15-54 for men and 15-49 for women. In all, over seventy percent (76.5%) had some form of education ranging from primary to tertiary while (23.5%) had no education. All the respondents were involved in some kind of work with over sixty percent (66%) being artisans.
Knowledge of Family Planning.
Majority of the men respondents (95.5%) had heard of FP. Almost half of the respondents (48.1%) had information about FP via the mass media (Television, Radio and Newspaper) followed by friends (27.5%) and the health facility (23.5%) as indicated in Table 1. known and used was the condom (42.5%) followed by implants (32.0%) and the least known method being the foam tablet (7.0%) among men respondents. Men involvement in FP Over fty percent (52.2%) of the men respondents reported they or their partner were currently using some form of contraceptives to delay or avoid pregnancy. However only 36.4% of women reported they or their partner were currently using contraceptives to delay or avoid pregnancy. Majority of the men respondents (72.8%) approved of the use of FP methods by their partners, 75% of the women respondents also indicated their partners had approved of their use of FP. The ndings also indicate that men had a higher propensity of reporting FP use (X 2 =4.5534, p= 0.033). For the couples who did not approve of the FP methods, the reasons included: socio-cultural beliefs (31%), side effects (30.8%) and others (38.5%).

Decision making in FP use
We wanted to know from the women whether their partners support them in their desire to use contraceptives; 67.0% of the women answered in the a rmative and 33.0% answered in a negative.
Those who answered in the a rmative said their partners support them by providing money for transport to facility and/or for FP services, encouraging and accompanying them to the health facility. Women who reported that their spouse support FP use were more likely to use a contraceptive method (X 2 = 9.5223, P=0.002) compared to those who said no. Women who reported their partners had some education were also more likely to use a contraceptive method (X 2 =14.1133, P=0.000).
Generally, a greater proportion of men (77.6 %) intend using FP in the future. For those who answered in a negative, 19.1% said most of the contraceptives were designed to suit women and thought it was a woman's business. Nearly three quarters of women (73.4%) who ever used a FP method indicated their partner had a say in the decision to use. For the women interviewed,70.7% said they would still practice birth control irrespective of their partners' opinion while 23.9% would not use birth control if their partners were against it, 5.4% were however were not certain.

Discussion
This study assessed men partners knowledge and factors associated with use of FP services in Tumu in the Sissala East District of the Upper West Region of Ghana. The study identi ed several factors that in uence FP services use among partners in this setting. Our study demonstrated that despite the high knowledge of modern contraceptive methods among couples, use was low due to side effects and sociocultural norms. Men's attitude and social practice towards family planning methods also in uence the behaviour of their partners using contraceptives [18]. It is found elsewhere that the decision not to practice FP is men dominated and men are responsible for providing contraceptive decision when FP is practiced [19]. A major limitation facing low-and-middle come countries family planning promotion programs and population policy development on contraceptive behaviour is that men are always neglected [20].
Our study identi ed several factors associated with men's in uence in FP service utilization among their partners. Non-approval of family planning methods by men this study was attributed to perceived risks, side-effects and socio-cultural norms. Focus groups with men and women in rural Uganda have come out with similar ndings [4]. Contraceptive knowledge and use are shaped by the socio-cultural cultural environment as are personal attitudes and feelings about contraception. In rural settings in low-andmiddle income countries most men may be unwilling to have their wives adopt family planning, which they themselves have little knowledge about it. Evidence show that some oppose contraceptive use for reasons of tradition and religion which require men to maintain the honour and position of their extended family, village, religious group and social organization [21]. Studies have come with similar ndings in settings in rural northern Ghana [22,23]. The complex web of social and cultural factors impedes spousal communication regarding reproductive health issues and that discourages them to take their wives to health clinics to discuss family planning issues [20].
Several interventions can be used to address barriers in the uptake of family planning services in this setting. Family planning programs need to target men at all levels of health promotion and education with their partners to reduce misconceptions about family methods to increase acceptance [18]. Men's participation is crucial to help reduce misconception about side effects of contraceptive methods [18].
Therefore, family planning programs need to target men at all levels of the service. Their involvement will also lead to women's empowerment to increase effective contraceptive use and continuation to improve better health outcomes in reproductive health [24]. User experiences indicate that text messages provide a novel way to raise awareness, promote behaviour change and address myths and socio-cultural norms [25].

Limitations
This study has some limitations which need to be taken into consideration. The nding of this study cannot be generalized to the entire region of the Upper West region due to the small sample size. Despite the small sample size, views of groups of our respondents which comprised of married partners and those cohabitating, will not differ signi cantly from the rest of the entire population in the region. Also, this study provides vital insights for policy makers in Ghana and beyond who are working to improve sexual and reproductive health services for men and women. The need for future study to capture the perspectives of men and women on cultural factors in uencing PF services for policy.

Conclusions
Our study demonstrated high knowledge of FP among partners. However, use of modern contraceptives methods was low due to side effects and socio-cultural norms. Involving men partners in FP programs could give them accurate and complete information on contraceptive methods to help reduce misconception and increase uptake. Reproductive health programme designers, policy makers, and population researchers, health professionals need to incorporate the ndings into reproductive health programs to help address barriers to improve health outcomes among couples.

Consent for publication
All authors read the manuscript and approved it for publication.

Availability of data and materials
The dataset for this study is available on request from the corresponding author.

Competing Interests
None to declare

Funding
The authors received no funding for this work.

Authors' Contributions
"SAK conceived the study and conduced eld work. SAK and TA designed the study and performed the statistical analysis. ASL drafted the manuscript. SAK and TA reviewed the manuscript. All authors read and approved the nal manuscript"