Background

Males’ involvement in family planning (FP) improves uptake and continuity of FP services by women [1]. Males’ involvement in FP is used to describe men who participate in using FP methods and or have discussions, support, and approve the utilization of FP methods by their wives [2,3]. Evaluation of earlier studies shows that males’ involvement in FP led to increased contraception uptake and important factor in improving maternal and child health outcomes [4,5]. Some studies have revealed that the relationship and communication between couples are significantly associated with better decision-making concerning contraceptive use, family size, birth spacing practices, breastfeeding, and prenatal care, all of which are critical for maternal and child health [4,5]. However, several FP programs are primarily targeted at women only [1,6].

In most developing countries, especially in the African communities, the decision-making process of a family is largely influenced by the males [1,7,8]. Evidence exist that males may be interested in FP, however, their understanding of FP is limited, making it challenging for them to discuss FP with their wives effectively [9–11]. Getting males to understand and participate in FP services and programs may significantly remove spousal barriers faced by women in the use of FP methods. FP and contraception are often regarded as women’s business by males and addressing this perception is important to achieve the Sustainable Development Goals, particularly Goal 3 (Good Health and Wellbeing) [12,13].

In Uganda, the total fertility rate (TFR) stands at 5.4 children per woman, with women in rural areas more likely to have more children than their counterparts in urban areas [14,15]. The contraceptive use prevalence rate (CPR) is 39%, and the use of modern contraception is higher among women in urban areas (41%) than among women in rural areas (33%) [14,15]. Although the statistics demonstrate that urban dwellers have better access to modern contraceptives than rural dwellers, this may not be entirely true because of the varied living conditions that exist between formal and slum settlements in the urban areas. About 60% of Uganda’s population is slum dwellers with the Nkwakwa Division having the largest proportion of urban populations in slum conditions [16,17]. As typical of a slum settlement, about 16 and 27% of the population of the Nkwakwa Division live 5 km or more to the nearest public health facility [16,17]. Significant disparities in FP and contraceptive use among the urban rich (48.5%) and the urban poor (21.9%) exist in Uganda [18]. Generally, the unmet need for FP exceeds 33% [19], which is higher than the national target of 10% [20] and the demand for FP services among poor households ranged between 56% in 2006 and 65% in 2016 [21].

The role of males as heads and key decision makers of the family in the African context [1,7,8] can be leveraged and maximized to address the high TFR and low contraceptive use in Uganda and slum areas. However, males’ involvement in FP services remains low (40%) in Uganda [22] and the current understanding of male involvement in FP and contraceptive use among slum dwellers has not been fully explored. The understanding of males’ interest in FP and their influence on women’s use of available FP methods and contraception has broader implications for service uptake and changes in service delivery. To address this gap, we assessed the factors that influence males to get involved in FP in Nakawa, Uganda. The Ugandan Ministry of Health and other agencies in FP and contraception will benefit from the findings of this study in the design of FP interventions that target and support urban slum settings.

Aim

To explore reasons for male involvement in FP in Nakawa Division, Kampala, Uganda, using a qualitative study technique.

Methods and materials

Results

Sociodemographic characteristics

A total of 40 male participants were recruited for the interviews. Most of the participants were in the age groups of 26–30 (27.5%), married (75.0%), and practised monogamous marriage (85.0%). Forty-five per cent (45.0%) of the participants and their female partners (27.5%) had secondary education. About 75.5% of the participants were Christians and urban dwellers (47.5%) (Table 1).

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Table 1. Sociodemographic characteristics.

https://doi.org/10.1371/journal.pgph.0003207.t001

Themes and subthemes.

Five major themes emerged from the data included males’ knowledge of FP and contraceptives, utilisation of contraceptives, perception of males’ roles in FP, health facility-related factors and the community perceptions of males’ participation in FP (Table 2) demonstrating factors that impact males’ involvement in FP and contraceptives use.

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Table 2. Themes and subthemes generated from interviews.

https://doi.org/10.1371/journal.pgph.0003207.t002

Discussion

The study explored the determinants of males’ involvement in FP and contraception and found that FP and contraceptive knowledge, socioeconomic factors, perception of men’s role, health facility and health professional-related factors impact men’s involvement in FP. Knowledge is an essential factor in individuals’ decisions on practices. It is therefore vital that males who are major stakeholders in FP and contraceptive use [2,26,27] have significant knowledge of FP services and contraception. Indeed, in this study, males’ knowledge of FP and contraceptives was significant. This finding is important due to the study setting, which is predominately a slum area. Promoters of FP and contraceptive use can capitalize on the findings to design interventions to increase male involvement in FP services in slum areas. Generally, literature demonstrates that knowledge of FP and contraception among males is universal [6,28–31]. However, some previous studies have reported poor knowledge of FP and contraception. For example, Kaida et al. ⁹ and Sileo et al. [32] reported that males have limited knowledge of FP and contraceptives in Mpigi and Butambala Districts, Uganda. Similarly, Mustafa et al. [33] reported that males have limited knowledge of FP and contraceptives in Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. This underscores the importance of continuous education and promotion of FP services among males to address the significant amount of misinformation that appears to impact men’s involvement in FP. Levels of male’s knowledge of FP and its impact on their involvement have been widely reported in the existing literature [2,34,35]. The findings suggest that FP practitioners must devise strategies to provide males with adequate quality information that equip them enough to stimulate their interest in FP, as minimal misinformation can derail a moderate positive impact, which appears to be the case in this study.

The perception of FP as a female activity makes it critical for health professionals to act in ways that motivate males and dissuade their erroneous perceptions with negative implications for involvement in FP, thus encouraging them to participate in FP activities. However, as shown in our findings, the healthcare environment can make it impossible for males to access the correct information on FP. It may discourage them from getting involved in its use. Therefore, health professionals’ attitudes towards males on FP issues must be well investigated. Areas of gaps in practices that promote male involvement relative to health professionals are harnessed to facilitate male involvement in FP to the extent that the benefits of male involvement in FP can be derived to the benefit of maternal and child health. Besides, health workers are unfriendly, discouraging males from involvement; other studies suggest that some health workers lack the requisite skills and knowledge to provide FP methods and counselling services [36–38]. Therefore, assessing health professionals’ knowledge and skills and providing them with such skills and strategies for getting males involved could significantly contribute to male involvement in FP services. Due to the perception of FP as a female activity, there are limited male-focused discussions on FP, creating a gap in how they could be involved, thereby limiting their involvement. Whilst it may be essential to have interactive information sessions for males and females together on FP, it may be helpful to identify males who may want personal privacy in discussing FP issues. Thus, gender-focused FP service may be essential. Males could be advocates for FP if they are strategically and adequately engaged in FP services [26,27]. There is a need for couple-based approach [32] to FP service provision, including creating male-friendly FP clinics in Uganda and globally, cannot be overemphasised as other studies, Dral et al. [39] and Kassa et al. [2] reported findings consistent with our study.

Adopting the all-inclusive approach to FP services could also be essential in addressing real and perceived issues, such as the side effects of contraceptives and misconceptions males may hold. In our study, participants indicated some effects of contraceptives, including bleeding, dizziness, menstrual disorders and losing or gaining weight as reasons for not encouraging FP usage. Although the latter is true, educating both males and females on how to prevent or minimise the potential side effects of FP services and contraceptive use could contribute to male involvement and promotion of the latter. Other participants also hold misconceptions and beliefs, such as contraceptive use promoting promiscuity and extramarital relationships among women, making them resist the use of contraceptives. Side effects, misconceptions, myths and beliefs about FP have been reported by other studies [2,13,40]. Indeed, the evidence that these factors contribute to males’ low promotion of FP has also been reported [10,41]. However, evidence suggest that these factors can be addressed by empowering males to promote FP services. For instance, multiple studies have shown that education positively predicts FP usage and involvement among males [2,8,42]. Therefore, targeting males for FP services early through incorporating FP into formal and informal education systems, creating male-friendly FP service centres, and using the Ugandan media space could allow us to increase male involvement in FP. Indeed, our study showed that participants with the most misconceptions, beliefs and myths that deter the promotion of FP services are young uneducated males between the ages of 20 and 30. Nonetheless, education of males on FP services, such as the exact types and methods of contraception, side effects and how to prevent or manage them, the benefits of FP and male involvement and how services are structured, could help attract male involvement. To address the misconceptions, beliefs and myths on FP and contraceptives, Ghulam et al. [33] study recommended the use of males with adequate training and knowledge of FP and contraceptives. The study emphasized the need to make available such males in the communities to inform other males about the benefits of FP and contraception [33]. This is because, males serving as FP and contraceptive promoters are more likely to positively influence other males to be involved in FP services.

Furthermore, while there is a perception that FP is a woman’s business [13], some of the participants in our study acknowledged that they were responsible for making it possible for their female partners to access FP services. For example, other studies [8,43] have also reported that while some males may not directly engage in FP services, they support females financially to obtain transport to the health facilities and to purchase FP services. However, males’ involvement in FP services goes beyond financial support. It involves understanding how FP services work, spousal communication on FP and accompanying partners to FP service centres [13,42–44]. However, some of our study participants were uninterested in accompanying their female partners to FP service centres. However, some service providers views seem to suggest that women whose partners supported their decisions and accompanied them to the FP clinic are happier than others who come to the service centres alone. Another study in Uganda showed that some women support the idea of their male partners accompanying them to FP service centres [32]. The study indicated that the females were of the view that couple-based FP services increases the quality of emotional care, joint decision making and tangible support offered by their male partners. From the perspectives of the males, the study emphasized that attending FP service centres is to primarily acquire insights on women’s reproductive health issues, make better decisions with their wives regarding pregnancy and FP and to consent to the use of FP methods by their wives [32].

Interestingly, others indicated that the presence of their male partners at the FP clinics adds an extra cost to FP services. This assertion has been reported in another study in Uganda [32]. Generally, males have financially supported their female spouses to procure FP services [13,45]. However, some providers may leverage on the male presence to add other services and backdoor payments for the male spouse to pay and may serve as a barrier to male involvement in FP and contraception as has been reported in other maternal healthcare services [46]. These factors asserted by our participants are critical to discouraging male involvement in FP and contraception. Healthcare providers should consciously create an environment that is welcoming for male participation in FP. It is equally essential for the Ugandan health authorities to provide in-service training on good clinical practice, such as client care and tailored FP services that will involve couples. Multiple studies have reported on health facility-related factors influencing male involvement in FP. Such factors include the behaviour of health workers, long waiting times and an unconducive environment for male involvement in FP [37,38]. A study in Uganda reported that health workers are harsh towards male teenagers seeking FP consultation and services [36]. As indicated earlier, acting friendly towards the male, providing them with the requisite knowledge and enabling their understanding of the FP services is critical.

Community and individual perceptions and cultural practices influence male involvement in FP. Our participants indicated that the perceptions and some sociocultural inclinations of the community, such as social stigma, discourage them from being actively involved in FP. This is consistent with studies elsewhere highlighting sociocultural beliefs as determinants of male involvement in FP for their female partners [35,47,48]. Some participants in our study who indicated having accompanied their female partners to FP clinics have suffered social stigma from some community members. Religion has been a major factor determining individuals’ uptake of FP services [49,50], and our participants equally reported this as a barrier to engaging in FP and contraceptive use. Although religion-related discourses could be very contentious, understanding how to apply deliberate behavioural communication change processes to develop individuals’ interest in practice could be explored. Indeed, there could be FP and contraceptive options that may not go against an individual’s religious beliefs. Exploring communities’ and individuals’ religious stances and juxtaposing them with FP interventions could contribute to finding common ground for male involvement in FP services. Again, an alternative like faith-based advocacy initiatives can be employed to address the cultural and religious barriers to FP and contraceptive use [51,52]. Studies have shown that faith-based organizations and religious leaders can be engaged and serve as advocates for FP services, policy and funding [51,52]. They need to be given the adequate knowledge, training and support based on strong evidence on FP to effectively play the role of FP advocates [51,52].

Community sensitisation activities on FP are of the essence to addressing community-level challenges to FP use and male involvement. Opinion leaders in the community, including traditional and religious leaders, should actively be engaged in promoting FP. Likewise, male-domineering groups could be targeted for FP public health education and promotional purposes. Generally, undertaking longitudinal action research with young couples at the commencement of their reproductive life may be expensive but effective way of promoting male involvement and facilitating the uptake of FP services. Such research could demonstrate the processes and benefits of FP on whole family, serving as a health and developmental intervention.

Conclusion

The determining factors for male involvement in FP include; an understanding of FP, side effects of FP and contraceptive methods, tagging FP and contraceptive methods as women’s business and misconceptions and myths about FP and contraceptives and associated costs of FP and contraceptives. The perception of the role males plays in FP, such as providing financial support towards FP and not a responsibility to accompany female partners to FP clinics. The community variables for male involvement in FP included negative community perceptions of FP and religious beliefs. There is a need to develop an influential FP health promotional policy and implementation strategy to sensitise and address the barriers to male involvement in FP initiatives in Uganda.

Implications

The need for interventions that target male partner involvement in FP and contraception to promote better contraceptive use and birth spacing and minimise the complications due to poor birth spacing has been supported by our study. Although the factors show that simple interventions are required to facilitate male involvement, implementing such interventions may not be as simple, considering that most factors appear to be value-laden. Therefore, whilst health professionals could initiate simple activities such as being friendly and providing male-centred information, further research may be a starting point to understand how underlying value-based factors could be tackled. As demonstrated, efforts to promote formal education and introduce FP ideas early may also improve male involvement in FP. However, enrolment issues may require policy changes to facilitate it. Perhaps satellite FP clinics that are easily accessible to men as clients and female partners may benefit the course of male involvement in FP.

Limitations

The study was limited to males and did not solicit the views of females. Therefore, some side effects of contraception asserted by our participants that their female partners suffered could not be verified. Again, the study was geographically limited to the Nakawa Division, and therefore, the use of the findings must be contextualised. Similarly, the study used FGDs to conduct the interviews among male participants and may have limited the illumination of some detailed perspectives.

Supporting information

Acknowledgments

Our deepest gratitude goes to Pan African University, University of Ibadan, Ugandan National Council for Science and Technology, The District Health Office of Nakawa Division and Kampala Capital City Authority for facilitating this study. Finally, our special thanks go to all respondents and data collectors in this study.