Factors associated with low male partners’ involvement in maternal and child health services in Suba sub county, Western Kenya

Objective: Male involvement (MI) in maternal and child health (MCH) services such as pre-conception care, antenatal care (ANC), prevention of mother-to-child transmission (PMTCT) of HIV, skilled delivery is an integral intervention that improves MCH outcomes. Suba sub County in western Kenya has the highest prevalence of HIV in Kenya. Moreover, data is skewed on men’s knowledge and perceptions regarding their involvement in MCH services. Methods: This mixed method cross-sectional study, collected data using questionnaire among 354 male participants, and conducted 4 focus group discussions (FGDs) and 6 key informant interviews (KIIs). STATA version 11 was used for quantitative data analysis. The thematic content analysis was used to analyze qualitative data. Results: The majority of the participants (52.3%) were aged >30 years, 44.9% had primary level of education and 63.1% engaged in fishing activities. About 54.5% of the participants were not aware of the Ministry of Health’s effort to enhance men’s attendance to MCH clinics, while men’s age, various cultural taboos and provider’s attitude were perceived as influencing MI in MCH services. Overall 16.3% of the participants were involved in MCH services. Health worker provider’s attitude towards men (OR 0.5, 95% Cl 0.3 to 0.8), men’s preferred time of attending MCH clinic (OR 6.7, 95% Cl 1.1-43.5), the frequency of men accompanying spouse to MCH clinic (OR 0.1, 95% Cl 0.04-0.3), duration taken to reach MCH clinic (OR 5.6, 95% Cl 1.3-24.6), use of family planning methods (OR 0.36, 95% Cl 0.18-0.72) and awareness about the methods used to reduce HIV mother to child transmission (MTCT) (OR 35, 95% Cl 0.19-0.65) were independently associated with men’s attendance of the MCH clinics. Conclusion: Significantly there was low male involvement in MCH services (16.3% compared to the > 30% targets by Kenya PMTCT guidelines, 2012) in this high HIV prevalent region. Enhanced dissemination and awareness creation on the importance of MI in MCH services could improve male involvement

and Development, which urged interventions that take to account men's shared responsibility in improving MCH. Since the increased focus on male involvement, the role of men in maternal health has been seen as the missing link in improving maternal and child health indicators (Kululanga et al., 2011). Studies on male participation in MCH services showed significant positive impact on the household (Gungor & Beji, 2007;Alio et al., 2010) including better decision-making on health for the couple and children, increased disclosure of HIV status with increased likelihood to adopt low risk behaviors, better adoption of HIV of prevention practices including PMTCT and increased compliance to family planning and infant nutrition (Ditekemena et al., 2012;Comrie-Thomson et al., 2015;Brubaker et al., 2016). Some studies have found that health interventions that target and involve men are strongly associated with enhanced and better birth outcomes and increased use of skilled maternal healthcare services (Nanjala & Wamalwa, 2012;Nkuoh et al., 2010). This includes safer birth practices, family planning, HIV prevention, birth preparedness, emergency obstetric access, emotional support and partner communication Yargawa & Leonardi-Bee, 2015).
Although male involvement in reproductive health issues has gained more visibility, gender beliefs still define roles and influence how maternal health issues are approached in many parts of the developing world (Yargawa & Leonardi-Bee, 2015). Further, MI in MCH services still remains a challenge because of the poor or lack of awareness and perceived cultural practices and taboos (Kwambai et al., 2013;August et al., 2015;Yargawa & Leonardi-Bee, 2015). This study sought to assess men's involvement in MCH services, their knowledge, perceptions and correlates for their involvement Suba sub county in Homabay County hardest hit counties with highest prevalence of HIV in western Kenya.

METHODOLOGY Study design and sample collection
This mixed method cross-sectional study enrolled consenting men aged (18 years), with least a child aged below 5 years old or a pregnant wife (s) and natives of Suba. For structured interviews, using the Lemeshow et al. (1990) formula for estimating the population proportion with specified relative precision and setting  at 0.05, and a 30% prevalence of male involvement in MCH (PMTCT guideline, 2016), a total of 354 men were recruited to achieve 0.95 power. These men were chosen from Suba, Nyamarandi and Sumba west community units respectively with already assigned community health volunteers and linked to Suba sub County Hospital.

Data Collection
The structured interviews were conducted by Community Health Volunteers who identified the men to be interviewed from their households. The participants were screened for eligibility, consented then interviewed, in a private and confidential place.
A total of 4 FGD were conducted to explore further the levels of male involvement, knowledge and perception and associated factors in this region. Twelve (12) adult men were randomly selected from the three (3) Community Units, consented and enrolled in two (2) FGDs composed of six men each. A similar process was applied for the two (2) FGDs composed of six (6) female adults each. The FGDs were conducted at an agreed time, date and location. Using an FGD guide, an experienced moderator, assisted by a note-taker, conducted these discussions in the Dholuo language. The FGDs lasted approximately 45 minutes and were recorded on tape.
Interviews with six (6) key informant including, health professionals, religious and tribal leaders, and wellregarded women in the community are experienced in MCH were conducted to confirm and clarify any pending or new issues captured in the questionnaires and FGDs. Key informant interviews have been shown to provide a valuable foundation for a broader understanding of contextual matters relevant to the issues being explored (Bernard, 1994). The key informants were selected based on their position of leadership, either formal or informal, in the community and their ability and willingness to discuss issues surrounding MI. In addition, key informants were those observant, articulate and available for multiple interviews of varying duration on an assortment of topics related to the study.
was maintained by assigning all participants with a unique identification number and all paper research records stored in a locked cabinet stationed in a secured restricted room.

Statistical analysis
Quantitative data was analyzed using STATA version 13.1 (Stata Corp LP, College Station, TX, USA). Descriptive statistics frequency (%) and mean was used to express quantitative data. The overall MI in MCH services was determined for all participants. In bivariate analyses, odds ratios (OR) and 95% confidence intervals (CI) for the association between MI in MCH services and socio-demographic, household demographic, knowledge and perception characteristics were calculated using Poisson regression. In multivariate analyses, a manual backward elimination approach was used to reach the most parsimonious model including factors that were associated with MI in MCH services among men in Suba sub County at the significance level of P ≤ 0.05.
The qualitative data (FGD and KII) were subjected to a thematic content analysis. This approach entails the categorization of recurrent data collected under thematic areas (Green & Thorogood, 2010). The analysis was done using Nvivo 8 Table 1 summarizes the characteristics of the study population. Analyzable data were available for 352 out of the 354 (99.4%) response rate. The majority of the participants 52.3% were aged 30 years, 44.9% had primary education, 49.4% were of Suba ethnic community, 85% were Christian. Further, the majority of participants when combined engaged in fishing activities including; 79 (22.4%) were fish traders, 59 (16.8%) were fishermen and 11(3.1%) boat owners, 92.6% were married.

Men's knowledge on MCH services
The study showed that 54.5% were not knowledgeable on the MOH effort to enhance men attendance to MCH clinics, 42.9% accompanied their spouses to clinic more than once and 45.2% stated four times as the recommended number of visits of ANC attendance. Concerning the services offered at ANC, the majority 42.6% stated HIV testing and counseling as well as immunization as the main services offered at the ANC clinic. Only 34.4% of these men were knowledgeable of the benefits of ANC clinics with 18.8% recognizing issuance of free mosquito while 15.6% stated that mothers are given mosquito nets, are tested and given appropriate drugs for prophylaxis as well as condoms are offered ate the ANC clinics. The majority 67.6% of men accompanied their spouses for HIV counselling and testing with spouse while 70.5% were knowledgeable on the methods to reducing HIV mother to child transmission. When probed about methods aimed at reducing PMTCT, 15.9% stated exclusive breast feeding while 22.7% stated a combination of methods exclusive breast feeding and uptake of ARV for mother and child. Different single or combination of responses concerning benefits of breastfeeding were reported; 24.4% stated that breast milk leads to healthier baby who are resistant to disease and ending up having strong bones while 20.5% stated combination of breast milk benefits including healthier baby resistant to disease, having strong bones and with fewer weight problems.
These men attributes concerning men's knowledge on MCH were confirmed both from FGD and KII. Men in this region were generally reported as lacking appropriate knowledge affecting the uptake of MCH services. One FGD 2 a male participant stated "I think most of them are ignorant on MCH services stating that it is not them get pregnant but the woman. So even if the woman tells him to accompany her to the clinic he doesn't see the need. Because it is the mother who is going to be tested, and it's the woman who will feel the pain and done for all those activities in the MCH. They don't have any knowledge about being involved in the MCH".

Men's perception on MCH services
Some of the men's perceptions of attributes affecting their involvement in MCH services included 52.8% reporting age as a key contributor to men's attendance of ANC clinic while 47.2% reported service waiting time was key on their MCH service involvement. Cultural and community taboos were also perceived to influence men involvement in MCH services. These cultural and taboos included, men household headship role and that child birth and pregnancies are women's affair; 19.9% of the participants stated that men are the head of the house and should spend time looking for food for family while 14.2% believed that men should not be involved in women's affair. The attitude of health provider was also sighted as key determinant in uptake of MCH by men. About 63.4% of the responded stated that provider's attitude influences male involvement in maternal and child services. Concerning income slightly over half of them 58.5% stated that income influenced male participation in maternal and child services. When asked about what clinical operation hours they would prefer for men to participate in maternal and child services, majority 79.5% preferred 8 to 12 am while only 2.6% had no time preferences.

Men's attendance in MCH clinic
The attendance of men in the MCH clinic was measured by asking men if they had ever accompanied their spouse (s) to PMTCT or ANC or MCH clinic. Only 58 (16.3%) men had ever accompanied their spouse(s) to these various clinics far below the average expectations (≥30%) by the ministry of health. Factors associated with men's attendance of MCH clinic MCH Knowledge as a factor Table 2 summarizes Men's Knowledge factors associated with attendance of MCH clinic. In bivariate analysis, male participants who were more likely to accompany their spouses to MCH clinics were knowledgeable of the MOH effort to enhance men attendance to MCH clinics (OR 10, 95%Cl 3.3-30.5, took 30 minutes (OR 5.6, 95%Cl 1.3-24.6), 30 to 60 minutes (OR 7.5, 95%Cl 1.7-32.1) and more than 60 minutes (OR 7.9, 95%Cl 1.8-33.7) to attend any MCH, stated thrice (OR 3.3, 95%Cl 1.3-9.1) and fourth (OR 3.4, 95%Cl 1.4-8.1) as the recommended number of time for the ANC attendance. Further, participants who stated HIV counseling and Testing and Immunization (OR 8.8, 95%Cl 1.2-64.5) and HIV testing, Immunization and Malaria prophylaxis (OR 8.3, 95%Cl 1.1-64.5) as some of the services obtained from the ANC clinics as well as participants who had ever gone for HIV counselling and testing with spouse (OR 1.9, 95%Cl 1.6-3.9) were more likely to attend MCH clinic together with their wives. On the other hand, male participants who less likely to accompany their spouse to any MCH clinic if; they had previously accompanied their spouse In multivariate analysis, awareness of MOH effort for men to accompany their spouse (s) to MCH clinic, number of time accompanied spouse to MCH clinic, time taken to accompany spouse for the MCH clinic, use of family planning methods, place of last child delivery and awareness about the methods used to reduce HIV mother to child transmission were independently associated with men's attendance of the MCH clinics.

MCH perception as a factor
As shown in Table 3; in bivariate analysis, male participants were more likely to accompany their spouses for MCH services if: they had no specific preferred time for clinic operation hour in maternal and child services (OR7.6, 95%Cl 1.4-40.3). On the other hand, participants were less likely to accompany their spouses for MCH clinic if they did not agree that the provider's attitude influences male involvement (OR 0.5, 95%Cl 0.3-0.8). In multivariate analysis, provider's attitude and preferred time of clinic operation hour for MCH services were independently associated with men's attendance of the MCH clinics.

Male involvement in MCH clinics
To our knowledge, this is among the first studies on men's MCH clinics attendance and the role of knowledge and perception on MCH clinic attendance in Suba sub-county. Male attendance in maternal and child health encompasses the way men accept and indicate support to their partners' needs, choices and rights including using contraception and their own reproductive and sexual behavior to promote observance of human rights and the need to enforce equity (Kaida et al., 2010). In our context, male attendance implied accompanying the spouse to MCH clinic to seek for medical intervention and to give birth. In the current study, men's MCH clinic attendance was reported at 16.3% which was way below the average male involvement in PMTCT in Kenya with the guidelines recommending at least ≥30% male involvement (Odeny et al., 2013). Other studies have reported varying levels of male involvement in their spouses MCH clinics attendance. Higher attendance rates have been reported in southern Ethiopia, 53% of men were involved in a PMTCT program (Tilahun & Mohamed, 2015). In Ghana, Craymah et al., (2017) reported 35%, 44%, and 20% men accompanied their partners to antenatal care, delivery, and postnatal care services, respectively. In Uganda Tweheyo et al., (2010) reported 48% of men accompanied their partners during delivery. In South Africa Matseke et al., (2017) reported a 44.1% male involvement in MCH clinical activities. In Ethiopia, 20.9% of men had high involvement index in prevention of mother to child transmission of HIV/AIDS (Amano & Musa, 2016). Lower male involvement has been reported in Uganda only 6% of male partners were found to be consistently involved in MCH services (Tweheyo et al., 2010) while in Rwanda, the well-intended initiative of male partner involvement that recommend women seeking maternal and child to be accompanied by a male partner has been interpreted as an obligation is proving to be counter productively causes delays or excludes women whereas supportive men are turned away from further health consultations (Pafs et al., 2015).
The reasons for the relatively low rates of men involvement in MCH clinics can be attributed to the fact that in many countries, sexual and reproductive health programs and services are centered around women, with men often lacking information that could assist them in making decisions regarding healthy behaviors and the roles they could play to promote overall family health, including accessing HIV prevention, care and treatment services (WHO, 2016). Low levels of male partner involvement in maternal and infant health and PMTCT are also partly attributed to traditional gender norms prevalent in patriarchal societies, which make involvement by men in such issues a challenge (van den Berg et al., 2015; Matseke et al., 2017).

Knowledge as a factor associated with Male involvement in MCH clinics
Although, half of participants (54.5%) were not aware of the MOH effort to enhance men attendance to MCH clinics, awareness of this effort was associated male attendance of MCH clinic. Studies have shown that low levels on the guidelines regarding the MI in MCH affect the overall involvement. In Tanzania, August et al., (2015) the low level of knowledge on the importance of involvement in MCH and guideline related to MCH such as birth preparedness and complication readiness, affected the overall male attendance of the MCH clinic. Similarly, in Malawi, Aarnio et al., (2013) showed that men would only promptly seek care in a health facility if a woman had severe bleeding, convulsions or swelling of hands and feet. The fact that men play a 'gatekeepers' role in health care in maternal and child health is not disputed, the lack relevant knowledge in maternal and child health can be a significant barrier to their involvement (August et al., 2015). These findings call for urgent efforts train men on the importance of their involvement in matters dealing with maternal health. The number of times accompanied spouse to MCH clinic was a key factor that determined overall male involvement in MCH clinics. Men's awareness on the importance of ANC is a major driver for not only in the attendance but for support of their spouses while attending. Previous studies have shown that men are responsible for their decisions that directly impact on women and child health (Eliason et al., 2013). From the FGD and KII, the knowledge on the importance of ANC was discussed.
In FGD 3 a concerning ANC, the following was reported "I think most of men are ignorant; most of them view it that it is not them who is pregnant but the woman. So even if the woman tells him to accompany her to the clinic he doesn't see the need. Because it is the mother who is going to be tested, and it's the woman who will feel the pain and done for all those activities in the MCH. They don't have any knowledge about being involved in the MCH". Another FGD participant was however preview to the importance of ANC and stated as follows '……. What I can add is that conceiving takes two people, so the best thing is that from the first day at ANC, it is proper for both the man and the woman to go together. Am saying that because if they go together, they can get to know their status, that if it happens that either is infected with HIV it eases the situation especially because the man can support the woman. And even if they are both infected, both of them can be helped through enrolling in care. Even through care in case of positive result, the unborn baby can be rescued from contracting the HIV infection. But in case the results are negative, it gives joy knowing when a woman is expecting a baby and is happy, she will give birth to a healthy child" Time taken to accompany spouse for the MCH clinic was an independent crucial factor determining their involvement. Studies have shown men as the family bread winner and the time spent at the MCH clinic tended to be in contrast with the men's timing for getting source of income (Odeny et al., 2013). In our study knowledge and the use of family planning methods was associated with men's MCH clinic attendance. Studies have shown that the lack of knowledge by men related to family planning services including the desire to have more children and lack of knowledge about contraceptive use, determines men's attendance of MCH clinics (August et al., 2015). The place of last child delivery and knowledgeable about the methods used to reduce HIV mother to child transmission were also important factors associated with men's attendance of the MCH clinics. This finding supported by Tweheyo et al., (2010) who showed that once men felt they knew more about antenatal care, they felt more driven to accompany their spouses.

Perception as a factor for male involvement in MCH clinics
Provider's attitude was an independent perception factor associated with men's attendance of the MCH clinics. Studies have highlighted the importance of health personnel and hospital environment as key determinate to men involvement in MCH services. Health system's policy (that advocates for male involvement) contrast sharply with the reality. The unwelcoming hospital environment is characterized by lack of privacy, absence of facilities in which men would be comfortable, apparent neglect by healthcare providers, lack of communication and near-total exclusion of men "who are willing to be involved" from healthcare issues of their spouses at this critical time (August et al., 2015).
Time preferences of clinic operation hour for MCH services were independently associated with men's attendance of the MCH clinics. Generally, clinic waiting time has been reported as a major hindrance to male involvement in MCH clinic. This was reinforced in by one of the FGDs in which one participant had this to say; '………. most of the mothers that come here, their husbands are fishermen, so they go to work at night and come back around 10.am, and 10.am the mother is already here at the clinic unaccompanied by their spouses……' (FGD3 for men). Our study is consistent with the findings of Adeleye & Chiwuzie, (2007) in Nigeria which showed that 74.6% men were not willing to participate in a PMTCT programs by accompanying their wives to antenatal clinics because they are often too busy. Further, confirmed by Theuring et al., (2009) who reported long waiting time as a major deterrent to MI in MCH clinics. No wonder majority of men in this study preferred to accompany their spouses to MCH clinic between 4-8 pm than between 8am-12 pm, a time in the morning hours corresponding to time when men were engaged in other activities that would bring income to the family for survival.
One of the major strengths of this study is the ability to contribute to wealth of knowledge by showing that men involvement in MCH clinics though low can be improved by addressing the associated factors not only in this region but in Kenya as a whole. The study also showed the potential association between awareness of health ministry's guidelines, history of male involvement in MCH clinics, time taken to MCH clinic, preferential time for clinic operation, use of family planning methods, place of last child delivery, provider's attitude and hour and awareness about the methods used to reduce HIV mother to child transmission and the associated with men's attendance of the MCH clinics. However, some of the limitation to our assessment needs to be pointed out: Firstly, cross-sectional nature of our study only allowed us to describe associations between men MI and MCH clinics, not a causal conclusion. Such outcomes can be confirmed in a longitudinal study. Secondly, report shows that about 16.3% men accompanied their spouses to MCH clinic, we may not have captured the true MI in MCH clinics in this study. These limitations notwithstanding, our findings indicate men are involved in MCH services and enhance dissemination and awareness creation on the importance of MI in MCH services could improve male involvement.