Attitudes toward and Use of Knowledge about Family Planning among Ghanaian Men RHODA ADWOBA AKAFUAH MARIE-ANTOINETTE SOSSOU University of Kentucky, USA
This study examines knowledge of and attitudes about family planning and its use by a convenience sample of men in Ghana. It considers sociocultural factors such as spousal communication and cultural misconceptions about family planning that contribute to the low level of male involvement in use of contraceptives by men in Ghana. The findings indicate that demographic factors such as education, religion, types of marital relationship, and exposure to mass-media education have significant effects on the participants’ increased knowledge, changing attitudes, and practices of family planning and reproductive decision-making. The study identifies sociocultural misconceptions resulting from lack of knowledge and education as the main deterrents for the use of different family planning methods including vasectomy. The study calls for further research and male-friendly programs that would clarify myths surrounding the use of contraceptive devices, their benefits and effects on the physiology of the users. Keywords: family planning, contraception, spousal communication, population, vasectomy, male, Ghana
This study examines knowledge of and attitudes about family planning and its use by a convenience sample of men in Ghana. It considers sociocultural factors such as spousal communication and cultural misconceptions about family planning that contribute to the low level of male involvement in use of contraceptives by men in Ghana. The findings indicate that demographic factors such as education, religion and types of marital relationship and exposure to mass-media education have significant effects on the participants’ increased knowledge, changing attitudes, and practices of family planning and reproductive decision-making. The study identifies sociocultural misconceptions resulting from lack of knowledge and education as the main deterrents for the use of different family planning devices including vasectomy. The study calls for further re-
Rhoda Adwoba Akafuah, Department of Pediatrics, University of Kentucky; Marie-Antoinette Sossou, College of Social Work, University of Kentucky. Correspondence concerning this article should be addressed to Marie-Antoinette Sossou, PhD., College of Social Work, University of Kentucky, 655 Patterson Office Tower, Lexington, KY 40506. Electronic mail:
[email protected] International Journal of Men’s Health, Vol. 7, No. 2, Summer 2008, 109-120. © 2008 by the Men’s Studies Press, LLC. http://www.mensstudies.com. All rights reserved. jmh.0702.109/$12.00 DOI: 10.3149/jmh.0702.109
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AKAFUAH AND SOSSOU search and male-friendly programs that would clarify myths surrounding the use of contraceptive devices, their benefits and effects on the physiology of the users. Introduction Population growth continues to undermine economic and social development efforts in Ghana. In 1960, the population of the country was 6.7 million, and by 1984, it had increased to 12.3 million. The 2000 population census indicated that there were 18.9 million people living in Ghana (Ghana Trend Report, 2005). In 1967, the country adopted its first comprehensive population policy due to rapid population growth and high fertility rates. In 1994 a new population policy replaced the old one with the commitment of reducing population growth from its present level of 3 percent to 2 percent per annum. The policy has the intention of increasing family planning practice among the citizens in order to attain a balanced economy as well as to achieve a middle-income status and standard of living in the country (Adlakha, 1996). Traditionally, reproductive decision-making within the Ghanaian family rests not only with the married couple but also with other members of their extended family and lineage members (Nukunya, 1992). However, the consequences of the decision on family size rest squarely on the woman, as she is usually responsible for the care of the offspring of the marriage. As a result, family planning programs and reproductive health issues and services have tended to be directed solely to women (Bleek, 1987). Estimates from the 1998 Ghana Demographic Health Survey (Ghana Statistical Service, 1999) indicated that modern contraceptive prevalence doubled from 5 percent in 1988 to 10 percent in 1993, and increased to 13 percent by 1998 with a steady increase in the use of oral and other contraceptives including condoms. According to Becker and Costenbader (2001), contraception is now predominately female-oriented, and because only women give birth, fertility surveys have questioned only women given their stake in terms of risks of pregnancy and childbirth. However, in Ghana, men still play an important role as the major decision-makers in the family, politics, social and economic policies, and religion, as well as being the custodians of the interests of their families’ lineage and communities. Even given these crucial roles played by men, less attention has been paid to their sexual and reproductive health needs and involving them in the sharing of responsibilities between them and their wives as equal partners (Ndong, Becker, Haws & Wegner, 1999). According to these authors, while there are many maternal-and-child health and women’s health centers in both the public and private sectors, there are no equivalents that solely target men’s needs. The potential positive role of men as equal partners in family planning has often been ignored due to the one-sided emphasis on women and the assumption that men hold negative attitudes toward family planning practices (Ratcliffe, Hill, Dibba & Walraven, 2001). The exclusion of men from family planning programs also means their unintentional exclusion from education regarding sexuality, fertility, anatomy, contraception, and the prevention of transmission of HIV/AIDS and other sexually transmitted diseases (STD). 110
GHANAIAN MEN A number of studies support the one-sided nature of family planning services in Ghana. Pool (1970) conducted an exploratory analysis of social change and interest in family planning in Ghana. The majority of the respondents in this study were women (N = 5,700) from both rural and urban areas, with 91 percent of the rural respondents and 63 percent of urban respondents being in some form of traditional marital union with men. The men were not included in the study, however. The Ghana Trend Report (2005) shows that contraceptive knowledge among Ghanaian women has been moderately high since the early 1980s with exposure to family planning messages provided by the media. The report indicates the percentage of women’s knowledge of all methods of contraception, including male condom use and male sterilization, increased from 35 percent in 1993 to 51 percent in 1998. In addition, the report shows that 25 percent of married women are currently using a family planning method without any reference to their spouses’ involvement (Ghana Trend Report, 2005). The Ghana Demographic and Health Surveys of 1993, 1994, and 1998 also reported only on Ghanaian women’s fertility and use of contraception without the inclusion of the men in the surveys. For example, the 1998 Ghana Demographic and Health Survey interviewed 4,483 women aged 15 to 49 years from 6, 003 households about their fertility, use and knowledge of family planning, child health, nutrition and mortality, breastfeeding and maternity care, and awareness of AIDS and STD. Again there were no data on the men’s involvement in family planning services (Ghana Statistical Service, 1999). There is however a growing recognition in Ghana that men play a significant and influential role in reproductive decision-making and family planning practices. According to Piotrow & Rimon (1997), many family planning managers have seen men as obstacles to women’s use of contraception due to power differentials, conflicting gender roles, and lack of economic resources, and these factors have prevented many women from effectively negotiating use of contraceptives and safer-sex practices with their male partners. Qualitative research finds the macho stereotype of men the barrier that prevents men from learning more about family planning (Piotrow & Rimon, 1997). Ngom (1997) analyzed data from demographic and health surveys of Ghana and Kenya and concluded that married men in both countries have high levels of unmet need for family planning that are comparable to, although slightly lower than those for women. In Ghana, 4,488 women aged 15-49 and 943 husbands were interviewed. The results indicated that 24 percent of married men who did not want to have more children were not using any modern contraceptive method, an indication of a high level of unsatisfied demand for family planning among men in Ghana (Ngom, 1997). Given this situation, the main purpose of this study is to examine knowledge of and attitudes toward family planning among men in Ghana as well as the extent to which they put their knowledge to use. Study Area The study was carried out in a town called Dunkwa-on-Offin, which is located in the Upper Denkyira District of Ghana and is one of the twelve districts of the country’s Central Region. Dunkwa-on-Offin covers an area of about 1500 square meters and is 111
AKAFUAH AND SOSSOU about 155 kilometers from Cape-Coast, the capital city of the Central Region. The town was selected because it was once a mining town that drew people from different areas of the country. It is therefore predominantly a migrant worker population (110,655 people according to the 2000 population census of Ghana). Dunkwa-on-Offin is well known for it steady population growth and its people represent a fair sample of the Ghanaian population, in terms of representation of ethnic backgrounds, religions and level of education. Until the current study, no family planning study had been conducted in Dunkwa-on-Offin. Methodology Sampling Design and Data Collection The Dunkwa-on-Offin District has five sub-districts. Each sub-district is made up of smaller communities scattered throughout the sub-districts, and these sub-districts are easily accessible. Within these sub-districts medical assistants manage health centers, which are visited by patients on local market days. Convenience samples of 40 men were selected at each health center (N = 200 between 19 to 65 years [M = 26.5]). Most of the interviews were conducted at the health centers. The data collected included with a demographics survey and a face-to-face interview. An interview guide was used to elicit personal information on the men’s knowledge, attitudes and intentions regarding the practice of family planning. For the purpose of this study, family planning was defined as ways in which couples can delay the next pregnancy or avoid having children if they are not ready to have them. The interview guide also explored the various family planning methods participants knew and used frequently. In addition, knowledge about previous use and current use of family planning services was also explored. Finally, other related matters, such as issues of communication and obstacles to effective spousal communication about reproductive decision-making and choices were also explored. Since this study was exploratory and the sampling was non-random and convenient, no significant statistical analysis or cross tabulations were carried out. The analysis simply indicates the percentages of the participants’ responses to their knowledge of family planning, current use of contraceptive practices, their previous use, and the intention of men to use them in the future. Demographic characteristics of religion, education, and marital status are shown in the tables presented below. Findings All of the participants knew something about family planning and were able to explain what they understood by the term. The majority (44%) were married. Sixteen percent were single men who planned to marry in the near future. 22% were miners. 18% were cocoa farmers. Twenty-two percent were unskilled, and 25 percent were professionals (teachers, hospital staff, police officers and local business executives). 112
GHANAIAN MEN Education seemed to be the highest influence on men’s knowledge and attitude towards family planning. In this study, 96 percent of the men had had some form of formal education, which included middle school, secondary and post-secondary education. Religion also played a role in influencing contraceptive use among the participants. The vast majority of men interviewed (about 81 percent) were Christian (mostly Protestant). The majority (75 percent) were in monogamous marital relationships. The others were single (16 percent) or in polygamous marriages (6 percent). Influence of Socio-Demographic Characteristics Table 2 gives a profile of the characteristics of the participants’ use of family planning services. The findings reveal that socio-demographic characteristics of age, education, religion and occupation and type of marital relationship played a major role in influencing men’s behavior concerning the use of family planning services in Ghana. The same characteristics influenced previous, current and the probable future uses of family planning services. The major family planning devices and services used by the participants in this study were the condom and natural family planning methods practiced by their wives or partners such as breastfeeding, the rhythm method, and at times the withdrawal method. Inter-group comparisons indicate that the prevalence rate of contraceptive use among men aged 20-29 years was at 69 percent compared to 11 percent for men aged 50-65 years. The results indicate that education, religion and marital relationship (which in this study refers to the practice of monogamy), are among the main factors that influenced the use of contraception among those interviewed. The majority of the participants (83.9 percent), who had had at least secondary school and post-secondary education, indicated that they had previously used a means of contraception, mostly the condom. Eighty-six percent of the group indicated they were currently using contraceptives and 64.9 percent of this educated group expressed the intention of using contraceptives in the future as compared to men with just primary education and those with no formal education. Interviews indicated that the decision-making process to use a family planning method is partially based, first, on acquiring knowledge of the available method, then learning about the merits of the method. The participants then form an attitude about the method and finally make a decision whether to adopt it. Use of family planning is a result of a long decision-making process based on knowledge and education about the benefits and the side effects of a particular device. Accordingly, the safest family planning device for most participants who indicated using family planning was the condom, pills and injections for their spouses. The educational background of the participants determines the willingness of men to use a family planning method in the future. Clearly, education has a positive role in influencing the use of a family planning method in the future. The findings show that 86.8 percent of the research participants who identified themselves as Christian had previously used a contraceptive, 85.2 percent are currently using contraceptives, while 113
AKAFUAH AND SOSSOU Table 1 Demographic Information of Participants Characteristics
n
%
Age (years) Under 20 20-29 30-39 40-49 50-65
22 79 55 27 17
11 39.5 27.5 13.5 8.5
Marital status Married Cohabiting Divorced/separated/widowed Single
88 70 10 32
44 35 5 16
Types of marriage Monogamy Polygamy
150 12
75 25
Education Primary Pre-secondary Secondary Post-secondary No education
38 74 42 38 8
19 37 21 19 4
Occupation Business/Professional Skilled labor Unskilled labor Farming
50 52 44 36
25 26 22 27
162 8 2
81 4 15
Religion Christianity Muslim Traditional N = 200 / 100%
86.7 percent of the same group expressed the intention of using contraceptives in the future. Muslim and traditional believers expressed a different outlook. Another significant factor that influences the participants’ involvement in family planning is their marital relationship or status. The study reveals that 87.2 percent of the men who had previously used any form of family planning were involved in monog114
GHANAIAN MEN Table 2 Demographic Characteristic and Family Planning Usage DemoNumber of Family planning usage graphic respondents characteristics Previous Never Current use used use
Age < 20 20-29 30-39 40-49 50+ Total
22 79 55 27 17 200
Communication on Future use
Number Contraof ceptive children use
5 74 42 27 16 164
17 5 13 0 1 36
4 68 37 26 11 146
13 77 46 25 10 171
0 8 26 16 8 58
1 15 37 17 9 79
143 10
6 3
127 12
137 13
55 3
75 4
11 164
27 36
7 146
21 171
0 58
0 79
Education Primary 37 Secondary 119 Post-secondary 37 No education 7 Total 200
21 104 33 6 164
16 15 4 1 36
20 89 33 4 146
21 111 33 6 171
9 30 15 4 58
10 49 17 3 79
Occupation Farmer 37 Business man 15 Professional 35 Skilled laborer 51 Unskilled laborer 45 Unemployed 17 Total 200
24 11 24 60 34 11 164
13 4 11 -9 11 6 36
20 8 23 58 30 7 146
31 10 29 47 38 16 171
9 5 7 14 22 1 58
14 2 12 25 24 2 79
Religion Christian Muslim Traditionalist Non-attendant Total
144 7 1 12 164
18 1 1 16 36
128 6 1 11 146
145 6 1 13 165
50 1 0 5 56
67 3 0 7 77
Marital Relationship Monogamy 149 Polygamy 13 Single/divorce/separated/ widowed 38 Total 200
162 8 2 28 200
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AKAFUAH AND SOSSOU amous marital relationships and 86.9 percent of this group were currently using family planning. Finally, 80.1 percent of those in this category expressed the intention to use family planning services in the future. Participants involved in polygamous or other non-binding sexual relationships had quite different attitudes. Knowledge about Family Planning Services The use of any family planning method depends on the person’s knowledge of the different family planning methods available and the willingness of both spouses to participate in the family planning program. In order to determine the interest of the participants in the subject of family planning, the study sought to establish participants’ general knowledge about the various family planning methods they were familiar with and used regularly. All participants indicated that they had heard about family planning services and were able, in general terms, to explain their understanding of the concept of family planning and its main purposes. The most common knowledge they had about family planning was that “the practice of family planning helps to space and reduce the number of children couples want to have and it enable families to plan and cater for a small family size.” The mass media were credited as the main source of knowledge about family planning methods and services. In the study, 62 percent of the participants identified newsprint, television and radio as their sources of knowledge. In Ghana, the radio has become a very effective tool for communication due to the proliferation of FM stations in most cities and towns throughout the country. These stations are noted for transmitting numerous educational programs in different local languages to their listeners. About 26 percent of the participants mentioned family planning and health service providers as another source of their knowledge. In addition, 13 percent of participants mentioned churches, their wives, friends and neighbors as sources of their knowledge about family planning services. It is evident that decisions to use family planning could also be initiated by significant others including spouses, relatives, friends and neighbors. Thus social networks played a crucial role in fertility decisionmaking. About 50 percent of the participants mentioned the condom as the most common and popular modern family planning device that they were familiar with. About 20 percent were familiar with oral or other forms of medical contraception. The natural family planning method of abstinence and the withdrawal or rhythm method seemed to be also common (about 30 percent across all age categories). The least known and less popular devices were spermicidal substances, vasectomy, tubal ligation and Norplant. The use of permanent family planning methods, such as vasectomy for men and tubal ligation for women, was very limited among the participants. Paucity of knowledge about the use of vasectomy as a family planning method could be due to lack of adequate education about the procedure and the unavailability of the service at the main government hospitals in the study area. There is also a misconception among many men and women that once a man has had a vasectomy, it is impossible for him to have an erection. The reluctance to use 116
GHANAIAN MEN permanent family planning methods implies that contraception among men is motivated more by the desire to space births or to avoid contracting a sexually transmitted disease (STD) rather than discontinuing childbearing. A few participants believed that having vasectomy would prevent men from having more children in case they were to lose their children through accidental death. This confirms the general understanding that childbearing is the overriding consideration in the adoption of contraception in most of sub-Saharan Africa (Mbizvo & Adamchak, 1991; Ezeh, 1993). Spousal Communication Factors Decisions about using family planning practices and fertility control measures (limiting the number of children a woman should have) are not entirely individual decisions. Spousal communication between a husband and wife has been found to be a prime indicator of the extent of knowledge and acceptance of family planning practices that couples will be willing to adopt and use (Sharen & Valente, 2002). The participants in this study were involved in discussions about their inter-spousal communication patterns concerning family planning. According to most of the participants, the discussion of the number of children a couple should have is considered a taboo and culturally unacceptable. Participants believe that children are gifts from God and their numbers should not be negotiated. However, it appears that a higher percentage of men are willing to discuss contraception use rather than the number of children they want to have with their wives. For example, it was indicated (Table 2) that communication among spouses with regard to the number of children to have and the use of contraceptives increased progressively with the husband’s educational level and was also more common among men with professional and business occupations. Inter-spousal communication was also more common among participants who were Christian and those in monogamous relationships. For example, 29 percent of participants with secondary and post-secondary education, 37 percent of those in monogamous marital relationships, and 31 percent of those who claimed to be Christian indicated they talked to their spouses about the number of children they wanted to have. Concerning contraceptive use, 51 percent of men in monogamous relationships, 40 percent of the educated participants, and 42 percent of the Christians also indicated that they discussed the use of contraceptives with their spouses. It is obvious that spousal communication is a key factor in the adoption and sustained use of family planning because such discussions allow couples to exchange new ideas and clarify information, which might change some wrong beliefs about the use of some family planning devices. Open communication between couples about family planning also provides couples with an opportunity to discuss family size preferences and the means to achieving them. Obstacles to Spousal Communication Despite the evidence that supports the benefit of spousal communication with regard to reproductive decision-making, lack of communication about family planning 117
AKAFUAH AND SOSSOU between partners is also a major hindrance to men’s interest in family planning programs. In this study, it was observed that lack of education and misconceptions about undocumented side effects of some of the devices deter many men from practicing family planning. Other obstacles cited by some of the participants for their lack of interest in family planning included shyness with regards to female service providers. Some participants simply considered visiting a family planning center as a waste of time. Another barrier was language, especially for the elderly and illiterate participants. Some men were embarrassed to discuss sexual issues with female service providers. Others had to have the discussion in their local language rather than a foreign language such as in English. Discussion The factors that influence men’s interest and involvement in contraception use in Ghana include education, effective mass media dissemination of information, spousal communication, religion and the practice of monogamous marital relationship. The findings indicate that at least a majority of the men interviewed in this study had some knowledge of family planning and contraception use. Positive expression of the intention by the participants to use modern family planning contraceptives suggests how to plan for future demands for contraceptives and to provide a distribution system to facilitate access to services and supplies. The study also indicates that the participants demonstrated a remarkable willingness to use a family planning method in the future. This could be due to their exposure to local family planning services and health educational programs provided by the health department in the study area. However, in practice, not all of the positive intentions can translate into action. Hence planners should be cautious about people’s intentions for future use of a family planning method. The study also found a high level of spousal communication among participants who were educated, Christian and in monogamous relationships regarding issues such as the number of children they wanted to have and also the use of contraceptives. The younger group of men should be targeted for effective communication campaigns and educational programs, and family planning services should be made available and accessible to this group in the future. Adult education programs in local languages should also be used to inform older men and uneducated groups as well as those involved in the practice of polygamy. The high involvement of participants who identified themselves as Christian and used some form of family planning services could be attributed to the active involvement of the Christian Council of Ghana which promotes family planning program in the country. For example, the Christian Council, which is made up of Protestant churches and other Evangelical Christian groups, has been actively involved in developing and promoting family planning programs and organizing services for their church members and the general public since the program was introduced in Ghana (Buor, 1996). The apparent low use of contraceptives among participants who identified them118
GHANAIAN MEN selves as Muslim and traditional believers could be attributed to misconceptions about traditional religious beliefs and lack of adequate knowledge about the services. The study also revealed that most participants were not very familiar with or misinformed about modern family planning services such as vasectomy and tubal ligation. Misunderstandings about alleged side effects of these processes were common. There is the need for intensive couples’ education, including counseling and open discussions of these issues by expert physicians to help couples and individual users understand the benefits and actual side effects of such procedures. On the whole, the study indicates that men are interested in learning about sexual matters and contraception, hence effective and sensitive communication programs using local stories, peer educators and audio and video equipment should be developed and made easily available to both married and unmarried men, as well as other groups such as elderly and uneducated men. Conclusion It is evident that men’s support and participation in family planning are essential to the ultimate success of any reproductive health initiative in Ghana. Hence, men need to be involved in addressing the reproductive health needs of their spouses and partners within their rights as husbands as well as consumers. As husbands and fathers, men should be educated to become more aware of their partners’ sexual and reproductive needs and concerns to help them become more sensitive and understanding of the physical, emotional and psychological needs of their spouses and children. Once educated, they would influence public attitudes toward family planning programs and could become peer-educators of their fellow men. As leaders, they could shape public policies that address the appropriate reproductive health and sexual needs of both men and women. Mass-media channels such as radio, television and newspapers should be made to target and also educate men by including health information during breaks in events such as sporting events, films, popular theater, and music. These programs should encourage men’s participation and their willingness to open up to and communicate with their spouses, peers, and health care providers about their sexual needs and services. Culturally, it is difficult for men to seek family planning services from women. Therefore male service providers should be trained and employed to provide family planning and reproductive health services to their fellow males. Male service providers should be able to attend to men’s needs and concerns without compromising women’s control over reproductive health decisions or perpetuating existing unequal gender roles. Finally, there is the need for human social service providers to advocate for change in the social norms that govern male behavior in sexual relationships and parenthood by incorporating male involvement in the overall planning of reproductive health programs. This could be done through inclusive parental involvement in childbirth and parenting programs, increased access to condoms and vasectomy services, involve119
AKAFUAH AND SOSSOU ment of the private sector, workplace initiatives, targeting the adolescent male audience, and promoting effective family-friendly communication between couples and within the family as a whole.
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