SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA DETERMINANTS OF MALE INVOLVEMENT IN ANTENATAL CARE IN THE BAWKU MUNICIPALITY, UPPER EAST REGION GHANA BY JAMBEIDU SIMON ATIIBUGRI (10293219) THESIS SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING JULY, 2017 Determinants of Male Involvement in Antenatal Care DECLARATION I Jambeidu Simon Atiibugri hereby affirm that the thesis is the product of my own research apart from the references of peoples ‘work and textbooks that have been acknowledged accordingly. This research was carried out under the supervision and guidance of Professor Ernestina Donkor and Dr. Florence Naab, all in the School of Nursing and Midwifery, University of Ghana. This research has not been partly or fully submitted for any other degree, neither has it been submitted concurrently in candidature for any other degree. Jambeidu Simon Atiibugri Signature………………… (Candidate) Date…………….. Prof. Ernestina Donkor Signature…………………..... (Supervisor) Date………………. Dr. Florence Naab Signature………………………. (Co-Supervisor) Date………………... i Determinants of Male Involvement in Antenatal Care DEDICATION I first of all dedicate this work to the almighty God for the strength and health granted me during this study period. I also wish to dedicate this work to my son Jambeidu Ivan Winogiti and my beloved wife Ngambire Clementia Lenye for their support and prayer that sailed me through this work. ii Determinants of Male Involvement in Antenatal Care ACKNOWLEDGEMENT I am thankful to God Almighty who gave me the grace and strength to carry out this research. I am exceedingly indebted to the staff and lecturers of the School of Nursing, University Ghana, Legon for their guidance and mentorship. I specially wish to express my greatest appreciation to my Supervisors, Prof. Ernestina Donkor (Dean) and Dr. Florence Naab whose tireless efforts, expertise and mentor’s that brought meaning to this study. In addition, I am grateful to the men who took part in this study. Lastly, I extend my gratitude to my parents, management of Bawku Presbyterian Hospital and the management of Vineyard Hospital whose diverse contribution and encouragement brought this work to reality. iii Determinants of Male Involvement in Antenatal Care TABLE OF CONTENTS Content Page DECLARATION.................................................................................................................... i DEDICATION....................................................................................................................... ii ACKNOWLEDGEMENT ...................................................................................................iii LIST OF TABLES .............................................................................................................viii LIST OF FIGURES ............................................................................................................. ix LIST OF ABBREVIATIONS .............................................................................................. x ABSTRACT .......................................................................................................................... xi CHAPTER ONE: INTRODUCTION ................................................................................. 1 1.1 Background ...................................................................................................................... 1 1.2 Problem Statement ........................................................................................................... 5 1.3 Purpose of the study ......................................................................................................... 7 1.4 Specific Objectives are to;................................................................................................ 8 1.5 Research questions ........................................................................................................... 8 1.6 Significance of the Study ................................................................................................. 8 1.7 Operational Definitions .................................................................................................. 10 CHAPTER TWO: LITERATURE REVIEW .................................................................. 11 2.1 Literature Search ............................................................................................................ 11 2.2 Foundation of Theoretical Framework: Ajzen (1991) Theory of Planned Behaviour ... 11 2.3. Empirical Literature Review ......................................................................................... 15 2.3.1 Overview of Male Involvement in Antenatal Care ..................................................... 15 2.4 Socio-demographic determinants of male involvement in Antenatal Care .................... 17 2.5. Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men Towards Male Involvement in Antenatal Care........................................................ 19 iv Determinants of Male Involvement in Antenatal Care 2.5.1 Attitude of Men towards Male Involvement in Antenatal Care .................................. 19 2.5.2 Subjective Norms of Men towards Male Involvement in Antenatal Care .................. 22 2.5.3 Perceived Behavioural Control of Men towards Male Involvement in Antenatal Care .............................................................................................................................................. 24 2.5.4 Behavioural Intentions of Men towards Male Involvement in Antenatal Care .......... 26 2.6 Pattern of Male Involvement in Antenatal Care ............................................................. 28 2.7 Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions .............................................................................................................................. 29 2.8 Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement in Antenatal Care. ........................................................................... 31 2.9 Predictors of Male Involvement in Antenatal Care ........................................................ 32 2.10 Summary of Literature Review .................................................................................... 34 CHAPTER THREE: METHODOLOGY ........................................................................ 35 3.1 Research Design ............................................................................................................. 35 3.2 Research Setting ............................................................................................................. 36 3.3 Target Population ........................................................................................................... 36 3.4 Inclusion Criteria ............................................................................................................ 36 3.5 Exclusion criteria............................................................................................................ 37 3.6 Sample Size and Sampling Technique ........................................................................... 37 3.7 Tool for Data Collection ................................................................................................ 38 3.8 Method of Data Collection ............................................................................................. 40 3.9 Data Analysis ................................................................................................................. 41 3.10 Validity and Reliability ................................................................................................ 43 3.11 Ethical Consideration ................................................................................................... 44 v Determinants of Male Involvement in Antenatal Care CHAPTER FOUR: FINDING ........................................................................................... 46 4.1 Socio-demographic characteristics of the respondents .................................................. 46 4.2 Knowledge Level of the Participants ............................................................................. 50 4.3 Attitudes of Men Involved in Antenatal Care ................................................................ 50 4.4 Subjective Norms of Men Involved in ANC .................................................................. 54 4.5 Perceived Behavioural Control of Men Involved in Antenatal Care ............................. 58 4.6 Behavioural Intentions of Men Involved in ANC .......................................................... 62 4.7 Patterns of Male Involvement in Antenatal Care ........................................................... 64 4.8 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male involvement in antenatal care...................... 66 4.9 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement in Antenatal Care ....................................... 67 4.10 Predictors of Male Involvement in Antenatal Care ...................................................... 68 4.11 Summary of Findings ................................................................................................... 74 CHAPTER FIVE: DISCUSSION OF FINDINGS........................................................... 76 5.1 Socio-demographic Characteristics ................................................................................ 76 5.2 Attitudes of Men Involved in Antenatal Care ................................................................ 78 5.3 Subjective Norms of Men Involved in ANC .................................................................. 80 5.4 Perceived Behavioural Control of Men Involved in ANC ............................................. 82 5.5 Behavioural Intentions of Men Involved in ANC .......................................................... 84 5.6 Patterns of Male Involvement in Antenatal Care ........................................................... 85 5.7 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male Involvement in Antenatal Care ................... 85 5.8 Relationship Between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement. ................................................................... 86 vi Determinants of Male Involvement in Antenatal Care 5.9 Predictors of Male Involvement in Antenatal Care ........................................................ 88 CHAPTER SIX: SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS .......................................................................................... 92 6.1 Summary of the Study .................................................................................................... 92 6.2 Implications of the study ................................................................................................ 93 6.2.1 For Midwifery Practice ............................................................................................... 93 6.2.2 For Hospital management ........................................................................................... 94 6.2.3 For Nursing/ Midwifery Research............................................................................... 94 6.3 Limitations ..................................................................................................................... 94 6.4 Conclusion ...................................................................................................................... 95 6.5 Recommendations .......................................................................................................... 96 6.5.1 The Ministry of Health ................................................................................................ 96 6.5.2 Christian Health Association of Ghana (CHAG) and The Ghana Health Service (GHS) ................................................................................................................................... 96 6.5.5 Nurses /Midwives Research ........................................................................................ 97 REFERENCES .................................................................................................................... 98 APPENDIX A -ETHICAL CLEARANCE ..................................................................... 114 APPENDIX B – INTRODUCTORY LETTERS ........................................................... 115 APPENDIX C – DEPARTMENTAL APPROVAL LETTER ..................................... 118 APPENDIX D– CONSENT FORM ................................................................................ 119 APPENDIX E- RESEARCH QUESTIONNAIRE ......................................................... 123 vii Determinants of Male Involvement in Antenatal Care LIST OF TABLES Table Page Table 4. 1: Socio-demographic Characteristics of Participants (N = 426) .............................. 48 Table 4. 2: Knowledge Level of Respondents ......................................................................... 50 Table 4. 3: Attitudes of Men Involved in Antenatal Care ........................................................ 52 Table 4. 4: Subjective norms of men involved in antenatal care ............................................. 56 Table 4. 5: Perceived Behavioural Control of Men Involved in Antenatal Care ..................... 60 Table 4. 6: Behavioural Intentions of Men Involved in Antenatal Care .................................. 63 Table 4. 7: Patterns of Male Involvement in Antenatal Care .................................................. 65 Table 4. 8: Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male Involvement in Antenatal Care ... 67 Table 4. 9: Relationship between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in antenatal care. ............................................. 68 Table 4. 10: Predictors of Male Involvement in Antenatal Care ............................................ 71 viii Determinants of Male Involvement in Antenatal Care LIST OF FIGURES Figure Page Figure 2.1 Conceptual Model: Theory of planned behaviour Framework (Ajzen, 1991) 12 ix Determinants of Male Involvement in Antenatal Care LIST OF ABBREVIATIONS ANC - Antenatal care HIV - Human immunodeficiency virus ICPD - International conference on population and development MDG - Millennium development goal PMTCT - Prevention of mother to child transmission SDG – Sustainable development goals STI - Sexually transmitted infections TPB - Theory of planned behaviour TRA - Theory of reasoned action x Determinants of Male Involvement in Antenatal Care ABSTRACT In our efforts to decrease maternal mortality and promote maternal health, male involvement has been identified as one of the factors that play a major role in places where the supremacy of decision-making in the family repose in the hands of men. Areas where male involvement in maternal health care is encouraged has observed an improvement such as family planning and exclusive breastfeeding. Maternal mortality in Ghana is still high and that led to the failure in the achievement of her millennium development goal five (5). One of the strategies that can be adopted to enhance the reduction of maternal mortality and to improve maternal health is male involvement in ANC. The study investigated the determinants of male involvement in ANC in the Bawku Municipality in the Upper East Region of Ghana using the theory of planned behaviour as a framework. A descriptive cross sectional quantitative study design was employed and data were gathered from four hundred and thirty nine (439) men who attended antenatal care clinic with their wives in four hospitals in the Bawku Municipality of Ghana. However, thirteen respondents were excluded in the data analysis due to missing data. Statistical Package for Social Sciences (SPSS) version 22.0 software was used in the data analysis. Descriptive statistics and inferential statistics such as Pearson r, Spearman Rho correlation analysis and multiple logistic regression analysis were the techniques employed in the data analysis. Finding indicates that the men in the study had good attitudes towards male involvement in antenatal care with a total mean (131.29, SD = 46.24), they had control over preforming antenatal care (95.34, SD = 37.47) and good intentions to involve in antenatal care (9.71, SD = 4.55). However, the men are influenced by the people they deemed important to them (low xi Determinants of Male Involvement in Antenatal Care social pressure) concerning involving in women antenatal care with a total mean of (79.73, SD = 46.42). There was moderate and positive significant correlation between attitudes, subjective norms and behavioural intentions of men and a significant positive but weak correlation was established between perceived behavioural control and behavioural intentions of men. The study also discovered a weak but positive significant correlation between men’s attitudes, subjective norms, behavioural intentions and male involvement in antenatal care. There was a very weak and positive significant correlation between perceived behavioural control and male involvement. Marital status, educational level, number of children, attitudes, subjective norms and behavioural intentions were the predictors of male involvement in antenatal care. However, perceived behavioural control was not a predictor of male involvement in antenatal care. The study findings have implications for midwifery practice, Hospital management, policy formulation and nursing /midwifery research. xii Determinants of Male Involvement in Antenatal Care CHAPTER ONE INTRODUCTION 1.1 Background Male involvement in antenatal care is when the male partner participates in the health care seeking behaviours of the pregnant partner. It includes seeking antenatal care together at the health facility, getting information from the health care provider, making decisions as partners, provide care and support to the pregnant woman, where to go and deliver, things she needs including the welfare of the woman and the baby before and after birth (Bhatta, (2013). Men as decision makers in most families and the kind of behaviour they exhibit towards maternal health has an enormous influence on maternal and neonatal health outcome. Globally, men play a pivotal role to ensure the welfare of women and children in the society (Morgan, 2016). The concept of male involvement in antenatal care is considered as a phenomenon being encouraged as an important component of World Health Organization (WHO) initiative for ensuring an out of harm pregnancy (Kululanga, Sundby, Malata, & Chirwa, 2012). This initiative appears to gain worldwide recognition after the 1994 International Conference on Population and Development (ICPD) held in Cairo, Egypt where 180 countries officially acknowledged the need for male involvement in women‘s reproductive health (Fincher, 1994). The conference suggested that special attempts should be made to put more emphasis on men’s responsibility and encourage their effective involvement in accountable sexual and reproductive behaviours. These encompasses parenthood, family planning, maternal and child health, prevention of sexually transmitted infections, prevention of unwanted and high- risk pregnancies, shared control and contribution of family income, children’s education, 1 Determinants of Male Involvement in Antenatal Care health and nutrition (International Conference on Population and Development Programme of Action. UNFPA - United Nations Population Fund, 1994). Since then male involvement in maternal issues has been intensified. Cases like HIV infections have also highlighted the need for men to take full-scale responsibility for their spouse’s sexual and maternal health care (Walston, 2005). In spite of the worldwide recognition of male involvement in maternal health issues, it appears many countries are yet to see more men in the antenatal care units with their women (Jennings et al. 2014; Tweheyo, Konde-Lule, Tumwesigye, & Sekandi, 2010) However, it is observed that, before the formation of the 1994 International Conference on Population and Development (ICPD) in Cairo, some of the high income countries such as United Kingdom had already made a move to involve men in antenatal care (Kululanga et al., 2012). Thus, the issue of male involvement during antenatal care is essential. Reports in some parts of the developed world suggested that men who are pushing for their involvement in antenatal issues encounter some challenges. As an attempt in some parts of Europe to involve males in pregnancy and childbirth shown that many men felt neglected and are inadequately informed about maternal issues because more interest is focused on women with insufficient space for men’s concerns to be addressed (Plantin, Olykoya, & Ny, 2011; Singh, Lample, & Earnest, 2014). Male involvement in antenatal care appears challenging in societies where culture and the role of masculinity are well-defined (Lewis, Lee, & Simkhada, 2015). In Nepal, the involvement of men in antenatal care, birth preparedness, exclusive breastfeeding and immunization for children indicated that, 39.3% of the men accompanied their wives to antenatal clinic, 26.9% had knowledge on danger signs of pregnancy and 53.7% prepared money down towards delivery, while 30.2% organized transport for their wives during labour (Bhatta, 2013). 2 Determinants of Male Involvement in Antenatal Care Promoting male involvement in antenatal care is considered as one of the key strategies to decrease the avoidable maternal morbidity and mortality across the globe (Jennings et al., (2014). Literature suggested that lack of proper and unprofessional antenatal care is identified every year as the third leading cause of maternal mortality worldwide with antenatal complications leading to chronic maternal morbidity (K. Singh, Bloom, Haney, Olorunsaiye, & Brodish, 2012a) .(Kavita Singh, Shelah Bloom, Erica Haney, & Comfort Olorunsaiye, 2012). Significantly, men are the decision determinants in the family in some of the traditional African settings and hence can motivate their female partners and escort them to antenatal care clinics, seek health information and assist them during the antenatal period (Bhatta, 2013). The most important determinant of male involvement in ANC is men’s knowledge of the importance of ANC (Tweheyo et al., 2010). According to Jennings et al. (2014), about 69% of pregnant women receive a minimum of one antenatal care (ANC) visit in sub-Saharan Africa, and approximately 44% receive a maximum antenatal care visit of four times. The same study also examined women empowerment and male involvement in antenatal care in selected African context that showed that about 45.7% of men in the study accompanied their partners to antenatal check-up only once. However, there were huge variations between the countries as Rwanda recorded the highest percentage of men who escorted their wives to antenatal care clinic with 86.8%, Uganda recorded 49.7%, whereas Burkina Faso, Mozambique and Malawi recorded 45.2%, 44.2%, and 41.0% respectively. Senegal and Zimbabwe had 32.0% and Burundi had the least with 18.2% (Jennings et al. 2014). This seems to suggest that male involvement in Africa appears to be low. Customs and gender segregation has been recognized as a factor that contributes to the low male involvement in antenatal care in Africa and Ghana is not an exception (Comrie- Thomson et al., 2015). These gender systems are social institutions that assign the social 3 Determinants of Male Involvement in Antenatal Care behaviours of men and women in society that suggest meaning and guidance with respect to men and women responsibilities, obligations and rights with regard to life (Kululanga et al., 2012). Lewis et al. (2015) also underscored the fact that, pregnancy and delivery in some parts of Africa are perceived as a female issue and gender can have an impact on the way male partners could participate in antenatal care. In African traditional setting, men determine the situations and control of sexual relations, family size, and whether or not their wives will make use of the health care services available at any given time (Lewis et al., 2015). Therefore, plans for including men in antenatal care services is essential as it would target building capacity on their knowledge about emergency obstetric conditions and involve them in birth plans and readiness for complications (Singh et al., 2014). Doe (2013) in Accra, Ghana, indicated that 81% of her study sample never escorted their women to antenatal care. This assertion suggested that though men are mindful of the significance of their women obtaining professional health care during pregnancy and delivery, majority of them reportedly do not always escort their women or inspire them to seek for ANC and delivery services in the health facilities (Ganle & Dery, 2015). Unfortunately, little is known in the upper East Region of Ghana that seeks to identify determinants of male involvement in antenatal care. The studies that have been done concentrated more on family planning with little focus on male involvement in antenatal care (Adongo et al., 2013; Achana et al., 2015; Apanga & Adam, 2015) The practice of male involvement in antenatal care is necessary in patriarchal societies like Ghana and for that matter the Bawku municipality to improve the health of expectant mothers and to reduce maternal morbidity and mortality. This study thus seeks to close the literature 4 Determinants of Male Involvement in Antenatal Care gap utilizing Icek Ajzen (1991) theory of planned behaviour constructs as a guiding framework. 1.2 Problem Statement Improving maternal and reproductive health continues to persist as a key challenge largely in low-income countries and particularly in the African sub-region (Zureick-Brown et al., 2013). In 2015, the maternal mortality ratio for the developing countries was 239 per 100,000 live births (Alkema et al., 2016). About 99% of these maternal deaths occur in low income countries for which Ghana is not exempted (WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015; Joharifard et al., 2012). Reports indicated that Ghana’s maternal mortality is 319 per 100,000 live births (WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015). Though Ghana appears to have made advances in reducing the maternal mortality, the fact still remains that Ghana’s progress is still less than optimal and much more need to be done. Ghana has been ranked 154 out 179 countries assessed in the 2015 annual states of the world mothers report which position the wellbeing of mothers in various countries (Kyei-Nimakoh, Carolan-Olah, & McCann, 2016). Similarly, the Family Health Division of the Ghana health service reports indicated that maternal mortality in Ghana is still shocking as Ghana recorded about 940 maternal deaths in 2014, 925 and 955 in 2015 and 2016 respectively (Ghana Health Service Annual Report 2016). Out of these maternal mortalities, the Upper East Region which the Bawku Municipality is inclusive have seen a considerable increase of maternal mortality ratio of about 90 to 110 per 100,000 live birth from 2015 to 2016 (Ghana Health Service Annual Report 2016) 5 Determinants of Male Involvement in Antenatal Care Reports also suggested that majority of these deaths affect women from the rural settings and among economically deprived communities (WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, 2015; Yargawa & Leonardi-Bee, 2015). This increasing trend poses a threat to the achievement of Ghana’s Sustainable Development Goal three target. Equally, as a rural community, the Bawku Municipality similarly experiences these unacceptable maternal deaths. Hence, tackling this maternal problem is pivotal for the achievement of the Sustainable development goal three target of reducing maternal mortality ratio to 70 deaths per 100,000 live births (Buse & Hawkes, 2015). This reduction may not be accomplished if men as decision makers and providers in most of the traditional Ghanaian communities and their influence in antenatal care as a key strategy for reducing maternal mortality are relegated (Acharya, Khanal, Singh, Adhikari, & Gautam, 2015; Bhatta, 2013). The men hold the social and economic power, and have an immense control over the timing and conditions of sexual intimacy, size of the family, medical, nutritional and when their partners should make use of available health care services or not. These responsibilities of the men will help reduce the three delays; delay in decision to look for care, delay in getting care and delay in obtaining care. The role men play through these three delays may help reduce maternal complications and increase safe delivery outcomes (Lewis et al. 2015). Research also indicated that male involvement in antenatal care has a positive impact on the pregnancy outcome of women and the unborn baby (Plantin et al., 2011). Despite all these benefits, a study in Kumasi, Ghana indicated that about 65% of the respondents never escorted their women to antenatal care which calls for concern. Equally, it was also found in Ablekuma South District in the greater Accra region of Ghana that out of 422 men in a study sample, only 24% (101) accompanied their partners to antenatal care once, 76% (319) never accompanied their spouses to ANC (Doe, 2013). These affirmations 6 Determinants of Male Involvement in Antenatal Care are not different from recent studies in the Upper West Region of Ghana that reported that, though women acknowledged the gains of male involvement in antenatal care, a greater number of them do not encourage male involvement (Ganle, Dery, Manu, & Obeng, 2016). Moreover, unpublished data from the Bawku Presbyterian Hospital in the Upper East Region of Ghana that serves about 60% of pregnant women in the Bawku municipality indicated that, out of 13,966 antenatal attendance recorded in 2013, only 706 men were involved. In 2014, out of 13,655 recorded antenatal attendance, 409 men were involved and in 2015 with a total number of 12,681 attendance, only 158 men were involved in antenatal care (Bawku Presbyterian Hospital Annual Report, 2015). However, most of the studies conducted within the sub-Saharan Africa, and Ghana for that matter, concentrated extensively on women perspectives on maternal health, and men who do not involved in their spouse’s antenatal care. Little studies is done on men who involved in their women’s ANC (Adelekan, Edoni, Olaleye, et al., 2014; Ganle & Dery, 2015; Ganle et al., 2016; Wai et al., 2015). Identifying and tackling the problems that militate against male involvement in ANC will help improve pregnancy outcomes and reduce maternal mortality. Although the problem of male involvement in antenatal care may be evident in some parts of Ghana, there have not been any identified studies on male involvement in ANC in the Bawku municipality. Thus, the need to examine the determinants of male involvement in antenatal care in the Bawku municipality using Icek Ajzen (1991) theory of planned behaviour as an organizing framework. 1.3 Purpose of the study The purpose of the study was to investigate the determinants of male involvement in antenatal care services in the Bawku municipality. 7 Determinants of Male Involvement in Antenatal Care 1.4 Specific Objectives are to; 1. Describe the attitude, subjective norms, perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care. 2. Describe the pattern of male involvement (behaviour) in antenatal care 3. Establish the relationship between attitudes, subjective norms, perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care 4. Establish the relationship between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement (behaviour) in ANC. 5. Determine the predictors of male involvement (behaviour) in antenatal care. 1.5 Research questions 1. What are the attitudes, subjective norms, perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care? 2. What are the patterns of male involvement in antenatal care? 3. What are the relationships between attitudes, subjective norms, perceived behavioural control and behavioural intentions of men regarding male involvement in antenatal care? 4. What are the relationships between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in ANC (behaviour)? 5. What are the predictors of male involvement in antennal care? 1.6 Significance of the Study The findings of the study will describe the determinants of male involvement in antenatal care in the Bawku Municipality. The findings may serve as the basis for designing suitable programmes aimed at improving male involvement in antenatal care that could help reduce 8 Determinants of Male Involvement in Antenatal Care maternal morbidity and mortality. With the nature of the population in the Bawku municipality, the findings may further help provide a clue to policy makers with respect to the level of male involvement in antenatal care and appropriate interventions obtained. The findings of the study may be used by the Ghana Health Service, the Bawku Municipal Health Management Team, and other interested organizations for educational purposes and to help enhance midwifery practice. These findings may also contribute to existing knowledge and as well provide a foundation for future research. 9 Determinants of Male Involvement in Antenatal Care 1.7 Operational Definitions Involvement: being part of antenatal care and making decisions. Male: Refers to a man of 18 years and above. Male involvement in antenatal care services: Male involvement in antenatal care service is when a man discusses antenatal care issues with the wife and they make decisions together as a couple and follow each other to seek antenatal care services. Attitudes: Refer to the degree to which an individual has positive or negative feeling of the behaviour of interest. Subjective norms: Refers to an individual socio-cultural belief or social pressure about what people who are considered important in society thinks about a certain behaviour. Perceived behavioural control: Is the perception of an individual whether performing a behaviour will be difficult or easy. Behavioural intentions: Is the individual’s plans or decisions to perform a specific behaviour. Behaviour: The way men act towards women’s antenatal health care issues 10 Determinants of Male Involvement in Antenatal Care CHAPTER TWO LITERATURE REVIEW This chapter consists of reviewed literature on male involvement in antenatal care, and examines the determinants of male involvement in antenatal care. Icek Ajzen’s (1991) theory of plan behaviour was adapted as a framework for this study. 2.1 Literature Search The literature on male involvement in antenatal care was reviewed from the following databases; Cinahl, Ebscohost, Google Scholar, Google, Wiley’s online, PubMed and Science Direct. The reviewed literature focused on current publications on the topic been investigated. However, some few older literatures were used for the purposes of the theoretical literature, relationships between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in antenatal care. 2.2 Foundation of Theoretical Framework: Ajzen’s (1991) Theory of Planned Behaviour There are many behavioural theories that could be used for various studies such as the theory of reasoned action and health belief model. However, for the purpose of this study, the Ajzen’s Theory of Planned Behaviour (TPB) as seen in figure 2.1 below was considered appropriate for the study because of its specific perceived behavioural control construct, and this was used to achieve the study objectives. 11 Determinants of Male Involvement in Antenatal Care Figure 2.1 Conceptual Model: Theory of planned behaviour Framework (Ajzen, 1991) ATTITUDES (Behavioural beliefs x outcome evaluations) SUBJECTIVE NORMS BEHAVIOURAL BEHAVIOUR (Normative beliefs x INTENTIONS motivation to comply) PERCEIVED BEHAVIOURAL CONTROL (Control beliefs x influence of control) This theory focuses on theoretical constructs regarding the individual motivational components as the basis of the possibility of predicting a behaviour. TPB is widely accepted as an excellent predictor of a behaviour and behavioural intentions, that is determined by attitude concerning the behaviour and social normative perceptions about it (Ajzen, 1991). The TPB by default is an extension of the theory of reasoned action (TRA) with perceived control over the performance of the behaviour as an additional construct. Ajzen and Fishbein proposed the theory of reasoned action (TRA) in 1967. This theory was used for attitude researches. Later, it was discovered that the theory of reasoned action components were not sufficient to predict behaviour that is under volitional control because behaviour appeared not to be hundred percent optional and under control. As a result, Ajzen and Driver (1991) decided to add perceived behavioural control to TRA to explain where one may not have a complete external control of behaviour. When this was added, the Theory was then modified 12 Determinants of Male Involvement in Antenatal Care to the theory of Planned Behaviour. Based on this that the researcher adapted the theory of planned behaviour for this study. Literature in this contemporary times has acknowledged the theory of planned behaviour as one of the effective method of predicting behaviour (Akulume & Kiwanuka, 2016; Harwood, 2011; Kalolo & Kibusi, 2015; Lawton, Ashley, Dawson, Waiblinger, & Conner, 2012; Tengku Ismail, Wan Muda, & Bakar, 2016). Ajzen described attitude as the one that is determined by the individual’s beliefs with respect to the outcomes or benefits of carrying out the behaviour (behavioural beliefs), weight by evaluations of the outcomes or benefits. Hence, any man who holds a firm belief that involving in the partner’s antenatal care will result to a positively valued outcome; he will have positive attitudes towards antenatal care involvement. However, if a man holds a strong belief that, involving in spousal antenatal care will result in a negative outcome, he will portray a negative attitude towards antenatal care involvement and will hesitate to get involved in the care (Ajzen et al., 1991). Subjective norms are controlled by normative beliefs, that is whether performing a behaviour will be accepted or approved by respected individuals and society or not, weight by the individual motivation to comply with the respected individuals in society. A man who believes that some particular respected persons or society supports involvement in antenatal care is motivated and may hold a positive belief about male involvement in antenatal care (subjective norms). Equally, if a man believes that society or significant others do not support or accept male involvement in antenatal care, he will not be motivated to involve in antenatal care. Whiles any man who has little motivation to comply with respected individuals or society will portray a relatively neutral subjective norm. Perceived behavioural control was added to the Theory of Reasoned Action to explain the external factors beyond the individual control that may influence intentions and behaviour. 13 Determinants of Male Involvement in Antenatal Care Perceived control is influenced by the beliefs about the existence or nonexistence of difficulty or easiness to perform a target behaviour weighted by their perceived power control factor to perform the behaviour. If a man perceived that, he has the power to involve in the partner’s antenatal care without any difficulties, he will be influenced to get involved in the care. However, if he is convinced that there are difficulties or impediments in involving in women’s antenatal care, he will not be influenced to involve in the care. An individual’s perception of control over behavioural performance, collectively with intention, is likely to directly affect the behaviour especially when perceived control is a correct evaluation of the real control of the behaviour, and when perceived control effect diminishes, the behavioural intentions become the predictor of behaviour (‘Madden, Ellen & Ajzen, 1992). The theory of planned behaviour again suggests that perceived control could autonomously determine behavioural intention along with subjective norms and attitude towards the behaviour. Therefore, making attitude and subjective norms constant, an individual’s perception of the difficulty or easiness of performing a behaviour will influence the person’s behavioural intention. The TPB and TRA accept a causal relationship that connects behavioural beliefs, normative beliefs and control beliefs to behavioural intentions and behaviours through attitudes, subjective norms as well as perceived behavioural control. However, the intra relationship between attitudes, subjective norms and perceived behavioural control were not within the scope of this study. According to Sumangla (2015), intention and behaviour functions as a result of three simple factors, and these are attitudes, subjective norms and perceived behavioural control. Factors like demographic and environmental characteristics are believed to work within the model constructs and may not independently added to describe the possibility of performing a behaviour (Ajzen, 1991). 14 Determinants of Male Involvement in Antenatal Care 2.3. Empirical Literature Review The remaining section of this chapter focuses on significant studies on male involvement in antenatal care. Literature was reviewed from unpublished and published journal articles in Ghanaian context, Africa and the World. The relevant literature that was reviewed in the area of male involvement in antenatal care was organized based on the construct of the theory of planned behaviour (Ajzen, 1991) as follows: Overview of male involvement in antenatal care. Socio-demographic determinants of male involvement in antenatal care. Attitude, subjective norms, perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care. Pattern of male involvement in antenatal care Relationship between attitudes, subjective norms, perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care Relationship between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in antenatal care Predictors of male involvement in antenatal care 2.3.1 Overview of Male Involvement in Antenatal Care The concept of male involvement differs within the context in which it is used and the meaning varies from one literature to another. However, the term used in this context refers to men’s behaviour of taking part or being responsible for their spousal antenatal health issue. These include accompanying their wives to antenatal care (ANC), do birth plans, support 15 Determinants of Male Involvement in Antenatal Care them, encourage them as well as assist in decision-making to promote maternal health (Bhatta, 2013). This form of behaviour fosters good communication, understanding and negotiations. According to Roseman & Reichenbach (2010) male involvement in antenatal health issues is the method of social and behavioural modification which is required by males to show enough and accountable responsibility with respect to maternal health care with the aim of safeguarding the welfare of women and children and preventing maternal and infant mortality and morbidity. The idea of male involvement in antenatal care has been encouraged as an important component of World Health Organization (WHO) plans for ensuring safe pregnancies(World Health Organization, 2015; Kululanga et al., 2012). It does not depict male supremacy or downgrading of females. Indeed, male autonomous decision-making appears to decrease antenatal care enrolment among pregnant women (Story & Burgard, 2012). A study indicate that male involvement in antenatal care is considered as having a beneficial impact on utilisation of antenatal care services and a significant reduction of pregnancy and delivery related complications (Yargawa & Leonardi-Bee, 2015). This implies that men owe it an essential duty to involve in making sure that, their pregnant spouses obtain the best of care throughout their pregnancy period. Studies suggested that both males and female partners are all in support of male involvement in antenatal care service (Mullany 2006). However, Ganle et al. (2016) in Ghana indicated that majority of female do not actually encourage male involvement. Moreover, it was also reported that there was little knowledge about pregnancy among men that served as a challenge for their full participation. Most maternal health education is usually done at the antenatal care units Kululanga et al., (2012). Hence, when male partners are captured in that clinical tutorials, it broadens their minds on the value of antenatal care that enables them assist and inspire the females to visit antenatal care clinics. It further indicated that when couples are educated together at the antenatal 16 Determinants of Male Involvement in Antenatal Care clinic, they understand and can memorize the information than when they receive the tutorials solo. In examining men’s awareness on birth preparedness, Nasreen et al. (2012) found that there was little level of knowledge on the part of men regarding antenatal care as 13.1% planned for emergency transportation and 0.7% received advice on pregnancy complication. In the case of Kakaire et al. (2011), 42.9% of the males accompanied their partners to antenatal care, 25% assisted in domestic chores while 25.7% provided money for transport and hospital care. According to Nanjala & Wamalwa (2012), about 53.7% of the women in their study wanted their husbands to accompany them to hospitals to seek antenatal care, while approximately 72% wanted their husbands to organize money to enable them access health care. The theory of planned behaviour upon which this study is grounded on explained four main constructs that could predict behaviour of which demographic characteristics run through all the constructs (Ajzen 1991). 2.4 Socio-demographic determinants of male involvement in Antenatal Care Various determinants have been found to have effects on male involvement in antenatal care. These may include the age of a man, the marital status, occupation, religion and educational level. Literature suggests that these distinctive individual characteristics influence the degree of male involvement in antenatal care (Byamugisha, Tumwine, Semiyaga, & Tylleskär, (2010). In Sub-Saharan Africa, Ditekemena et al. (2012) submitted that older aged men were found to be involved more in their spousal antenatal care than the younger age group. The proportion of male involvement in spouses’ antenatal care increases between the ages of twenty to forty years (Nkuoh, Meyer, Tih, & Nkfusai, 2010). Again, Byamugisha et al. (2010) investigated 17 Determinants of Male Involvement in Antenatal Care the influences of male involvement with regard to the prevention of mother-to-child transmission of HIV using a cross-sectional survey design. It was found that majority (51%) of the respondents were between the ages of 25 to 34 years. Studies further revealed that men who were married to one woman or cohabiting were more involved in antenatal care (Nkuoh et al., 2010; Ditekemena et al., 2012). Similarly, previous studies found that majority of the participants who took part in a study conducted in Uganda involving 154 respondents were cohabiting or married (Kabagenyi et al., 2014). This indicates that male involvement in antenatal care is considered important to married/cohabiting couples. Moreover, differences in religious background may also contribute to the level of male involvement in antenatal care. Byamugisha, Tumwine, Semiyaga, & Tylleskär (2010) in their studies, held the view that majority of Muslims were found to involve in antenatal care than other religions. The study additionally revealed that men who have acquired secondary level of education were observed to have a high male involvement in antenatal care. Again, it was noted that males who have acquired higher education were twice more frequently involved in their spousal antenatal health care than those who have obtained less education (Ditekemena et al. 2012; Wai et al., 2015). This suggests that the better the level of education, the more the involvement. A study by Akinpelu & Oluwaseyi (2014) established that level of education has a significant effect on the extent of male involvement in antenatal care. This was also suggested by Nanjala and Wamalwa (2012) who reported that male partners who attained some basic level of education understand the complications associated with unskilled delivery better than those who are not educated. Education therefore, makes men to abandon the negative attitudes and cultural beliefs that may affect their antenatal care involvement and adopt positive behaviours. It is also suggestive that, men who attained a high level of 18 Determinants of Male Involvement in Antenatal Care education have gained some employment that may help them make money to assist pay their spouses antenatal care bills hence tend to involve in antenatal care. Previous studies in Uganda reported that males who achieved secondary or higher level of education, have higher antenatal care involvement than those with lower educational level (Tweheyo et al. 2010). The population of this study was made up of males from peri-urban setting that perhaps have more educated men and workers than the rural areas where majority of the population is not educated. Probably, if this had been conducted in a rural setting, the findings would have been different. Other related studies have also shown that majority of the men who were involved in maternity care were public service workers and Businessmen. In addition, a study conducted in selected rural districts of Bangladesh (Nasreen et al. 2012), examined males’ knowledge in maternal, neonatal and child health and discovered better male involvement in some of the selected study areas which they attributed to education. The nature of occupation may influence one’s involvement in antenatal care. Studies suggested that male partners type of occupation has an effect on his contribution in assisting his wife during antenatal care period (Mildred Nanjala, 2012). Contrary to this assertion, Akinpelu & luwaseyi (2014) argued that the occupation of men has no significant influence on their participation in antenatal care services. 2.5. Attitude, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men Towards Male Involvement in Antenatal Care. 2.5.1 Attitude of Men towards Male Involvement in Antenatal Care The level of knowledge and attitude of men may be controlled by so many determinants. However, male’s awareness and perception regarding their spouse’s pregnancy requirements define the magnitude of which men involve themselves in antenatal care. According to 19 Determinants of Male Involvement in Antenatal Care Onyango, Owoko & Oguttu (2010), there are a lot of positive rewards if men are involved in pregnancy associated matters. The understanding of men or false impressions about their spouse‘s antenatal health influence the level at which they will act financially, physically, and emotionally with respect to the antenatal care needs of their spouse’s. Many of the antenatal associated issues women are encountering could be avoided if male partners were provided with the requisite knowledge and skills about women antenatal or maternal health issues (Jooste & Amukugo, 2013). Attitude can either be positive or negative as far as male involvement in antenatal care issues is concerned (Akinpelu & Oluwaseyi, 2014). As a result, the individual’s perception about the benefits of the outcome of a behaviour may influence his attitude either negatively or positively. A study by Olugbenga-Bello (2013) indicated that majority (93.4%) of the respondents were aware of antenatal care. On attitudes concerning male involvement in antenatal care, 63.8% of the respondents were of the view that, men should escort their partners to antenatal care services while 24.0% of the respondents stated that they ever accompanied their wives to antenatal care. However, a study by Dumbaugh et al. (2014), in Ghana also revealed that majority of the men felt assisting in spouse’s maternal and neonatal care is mostly offered by colleague women. Although they felt they are still partners, men are usually not involved in supportive responsibilities. The same study noted that men viewed their role during pregnancy as providers and decision-makers. Despite the fact that majority of the respondents believed pregnant women should not be involved in hard work, a small number reported to have supported their partners only in the third trimester. Also, previous research pointed out that, a greater proportion of males believed their friends and families will make a mockery of them 20 Determinants of Male Involvement in Antenatal Care when they are aware they (men) are involved in women’s antenatal care activities (Nanjala & Wamalwa, 2012). Therefore, it is imperative that they should not involve in such activities. Similarly, a study in Nigeria indicated that 40.8% of the participants said skilled delivery would ensure women deliver safely whereas 39.2% suggested that, it would help prevent maternal complications. The study further to indicated that majority (93.1%) supported the care during pregnancy and 85.1% promoted family planning. The same study established that, 43.4% of the respondents had negative attitudes and 56.6% had positive attitudes concerning maternal health care (Olugbenga-Bello, 2013). Moreover, a study by Vermeulen et al. (2016) in Tanzania using a mixed method observed that despite the use of Traditional birth attendances (TBA’S) in deliveries, men also trust that health facilities should be well equipped, and with efficient staff. Some of the men see it as a duty to escort their spouse to ANC whereas others believe male involvement in ANC only comes to play when the woman encounters certain prenatal difficulties. Some men stressed on health facilities being far from them and others did not know that they are supposed to accompany their spouses to antenatal care. Few of the men indicated that, the possibility of being tested HIV as the reason for them not attending antenatal care with their spouses. A qualitative study conducted in Osogbo Nigeria revealed that an enormous number of the men recognised it was good to escort their partners to antenatal care. Most of the men understood that they ought to go to antenatal care with their spouses because they impregnated them and others indicated that doing this would enable them render monetary support, and provide a sign of true love to their spouses. The study further noted that going to the antenatal clinic with their spouses will help them learn more about antenatal care activities (Adelekan, Edoni, & Olaleye, 2014). 21 Determinants of Male Involvement in Antenatal Care Iliyasu, Abubakar, Galadanci & Aliyu (2010) in northern Nigeria and Bhatta (2013) in Nepal suggested that majority of the participants in their study claimed to have saved money towards their women pregnancy, delivery and hospital expenses. It is during this period in antenatal care that expectant mothers are educated on birth preparedness and complication readiness. 2.5.2 Subjective Norms of Men towards Male Involvement in Antenatal Care Traditions, cultural beliefs, and separation of gender responsibilities by relatives and friends in society during pregnancy period have a significant influence on men’s involvement in antenatal care (Nyondo, Chimwaza, & Muula, 2014). Antenatal care (prenatal and intrapartum care) has always been considered as a female related issue in many cultural divides in Africa including both educated and non-educated. As a result, the attention has always been on women with men being sidelined. Thus, men are usually not required to go to antenatal clinics with their wives because it appears to be the duty of mother-in-laws and colleague women and not men (Kwambai et al., 2013). However, Men’s involvement in antenatal care in recent times has a significant impact in decreasing maternal morbidity and mortality and also serves as a means of inspiring husbands to assist in women’s pregnancy care from conception to delivery ( Singh et al., 2012; Jennings et al., 2014; ). The amount of male involvement in antenatal care could demonstrate the discrepancies among various societies and communities. There may be several determinants that could influence the level of men’s behaviour towards antenatal care. Some of these determinants may emerge from significant people in society like peers, friends, family, health care workers, opinion leaders and politicians. These individuals can either approve or disapprove health associated behaviours (Tweheyo et al., 2010). 22 Determinants of Male Involvement in Antenatal Care Nanjala & Wamalwa (2012) examined the determinants of male partner involvement in skilled attendants using a cross- sectional study design with a sample size of 380 men with their wives. they observed that, socio-cultural determinants such as gender roles and taboos have a positive effect on male involvement in assisting their wives to gain access to professional delivery services. In their study, it was suggested that about 33% of the respondents indicated that, babies delivered newly by their wives must be indoors for three days when they are boys, and when they are girls two days before they are brought out after having the outdooring ceremony. Forty-four percent of the respondents said that delivery is a woman’s responsibility that does not necessitate men’s involvement. The same study further indicated that majority of the men had little information about pregnancy and childbirth associated complications. About 48.2% (83) of the men also stated that their colleagues would mock them and consider them as being controlled by their spouses if they were spotted escorting their wives to a health centre for antenatal care services. Thapa & Niehof (2013), in their study on Women’s autonomy and husbands’ involvement in maternal health care in Nepal with a sample size of 341 women discovered that men complained of fear of social humiliation, and therefore feel shy to support their wives. This is because of the traditional and cultural beliefs that do not represent a positive value on husbands who assumed a caring responsibility during spousal antenatal period. Some of the societal customs demoralize men who make an attempt to get involve in their wife’s antenatal care to the extent that, those men feel timid to openly take part in their partner’s antenatal care (Thapa & Niehof 2013). Mullany, Becker, & Hindin (2007) explored barriers and attitudes about promoting husbands’ maternal health involvement. Findings revealed that societies coined some phrases or idioms for those husbands who are found involved in their wife’s antenatal health care. They call 23 Determinants of Male Involvement in Antenatal Care those husbands “swasniko mutma bageko” or a “man who has been captured by the urine of his spouse”. Meaning men who attend to their wife’s needs and follow them instead of pursuing their own desires. These findings support the findings of Audet et al. (2016) in Mozambique, who reported that most of the men who escort their spouse’s to antenatal care are dishonored in their communities and are made to feel they are controlled by their wives. The study further indicated that friends and relatives viewed those men as jealous and weak men. These forms of behaviour tend to discourage men from part taking in their women’s ANC care activities. In addition, previous researchers found that men see themselves as financial providers and decision makers. For instance, Wai et al. (2015) in Myanmar found that majority (81.7%) of their study sample saved money for pregnancy and delivery purposes. Men often consider antenatal care activities as a woman’s responsibility and some felt they are not comfortable associating themselves with women in the antenatal care unit. Nevertheless, the study did not look at men who were married but were not yet having children. Recent and earlier studies also noted that the aged men were not encouraging male involvement in antenatal care (Mullany et al., 2005; Vermeulen et al., 2016). 2.5.3 Perceived Behavioural Control of Men towards Male Involvement in Antenatal Care The ability of a man to be able to get involved in his wife’s antenatal care or the presence of other factors that may make it difficult or easy could influence the man positively or negatively as regards to his involvement in antenatal care. However, he may decline participation if he realises that, there are certain obstacles impeding his efforts to participate in the care (Ajzen, 2015). 24 Determinants of Male Involvement in Antenatal Care A couple of factors have been reported in the literature as being responsible for determining male involvement in antenatal care. To demonstrate, Mullany (2006) outlined the restrictions of husbands by health facility policies to involve them in their partner’s antenatal care. The researcher looked at the obstacles and attitudes concerning supporting partners’ involvement in maternal health care. Findings indicated that respondents expressed their disappointment with the hospital authorities for not including them in their wife’s antenatal care. Some of the husbands emphasized that when they take their partners to the hospital, they cannot even ask questions and when the women are admitted, they are not allowed to enter into the ward. Some of the respondents who were maternal health providers admitted that inadequate staff, nonexistence spaces, time and privacy issues were the reasons why men are not included in both antenatal and delivery care services. This appears to stress the fact that, the impoliteness and inflexibility of health workers during antenatal care has contributed to low patronage of male involvement in antenatal care (Nanjala & Wamalwa, 2012). In Eastern Uganda, a cross sectional survey examine the factors of male involvement with regard to prevention of mother-to-child transmission of HIV with 422 men. This was accompanied by a focus group discussion, and findings suggested that there are numerous health system associated factors that affect male involvement in antenatal care. The study reported that antenatal care staff do not permit males to enter into the antenatal care units with their wives and charge unnecessary fees that make it very difficult for the male partners to pay leading to their difficulty in coming to the antenatal care units with their spouses. Another cultural limitation that impedes men participation in antenatal care services was the fact that men believed, it is not traditionally right for them to accompany their wives to antenatal clinic and some men indicated that though they see their wives’ private parts at home, when they get to the antenatal care units, it becomes a different thing. Therefore, it is better allowing the women to go alone (Byamugisha et al. 2010). Byamugisha et al. (2010) 25 Determinants of Male Involvement in Antenatal Care also noted that, some of the health system factors are obstacles that impede male involvement in antenatal care. They observed that, the midwives handle pregnant women badly at the health facilities during pregnancy examination and are not polite towards clients. Previous research also indicated that long hours of queuing in the antenatal clinics waiting to be attended to also deter men from involving in their spouse’s antenatal care as men always want to be served fast so they will go back to their work place (Adelekan, Edoni, & Olaleye, 2014a). Recently, literature also indicated that most men claimed, they are not involved in antenatal care because of long distances from the health facilities to their houses, lack of enough facilities to accommodate men who participates in ANC services, insufficient staff to attend to them and also as a result of high cost of antenatal services (Nyandieka et al., 2016; Vermeulen et al., 2016). Kwambai et al. (2013) in their qualitative study in western Kenya also suggests that men claimed they are willing to involve themselves in ANC if only they and their wives will be given priority first before those women who come without their husbands. This behaviour of men appears to explain the fact that men see themselves to be too busy at work site trying to put food on the table and will not like to waste much time at ANC units. 2.5.4 Behavioural Intentions of Men towards Male Involvement in Antenatal Care Behavioural intentions embody the individual readiness or plan to carry out a specific behaviour and this is influenced by certain factors that inform the individual that, performing this behaviour will result in a positive or negative outcome. When the outcome of the behaviour will be negative, the individual will rescind his intention to perform the behaviour but when the outcome will be positive, the individual will intend to perform the behaviour (Ajzen, 1991). 26 Determinants of Male Involvement in Antenatal Care Sekoni and Owoaje (2014) identified certain factors that may contribute to men’s intention to get involved in pregnancy decision making. In their study with 259 men, they realized that most of the respondents were not aware of the danger signs of pregnancy. Only 10% (26) of the respondents viewed obstructed labour as an antenatal care issue, 11.6% (30) of the respondents said haemorrhage, 12.7% (33) sepsis, absence of fetal movement 19.9% (51), and abnormal position 21.6% (56) as the danger signs of pregnancy. Whereas 43.6% (113) considered hypertension, 29.7% (77) anaemia and 18.1% (47) were not able to state any danger sign of pregnancy. Overall, majority of the respondents lack the knowledge of danger signs of pregnancy that will help them make the right intention to involve in their partner’s antenatal care decision making. However, 68.0% of the respondents reported that, in an event where their expectant wives need to look for hospital care, the decision will be made by them and 4.6% said it will be a shared decision making. These findings also buttress the findings of Singh, Lample, & Earnest (2014) in their pilot study on male involvement in maternal care that found that majority of the men were interested in escorting their wives to antenatal care. However, some of the men justified why they do not make their intentions to go to antenatal clinics with their wives, citing traditions as a basis where their fathers and ancestors did not escort their mothers to antenatal care. For that reason, same should be applicable to them. Significantly, the results indicated that men intent to be happy allowing women to be in charge of their pregnancy care issues including husbands who think they are the decision makers of the family. These men only acknowledge the importance of antenatal care to the women and urge them to go for antenatal care but did not deem it mandatory themselves accompanying their spouses to antenatal care. Moreover, some of the men felt they just do not have time to go to antenatal clinic with their wives. Lewis et al. (2015) in their study revealed that men perceived antenatal care services as the duty of the woman’s mother, sisters, friends and mother-in-laws and that men are not 27 Determinants of Male Involvement in Antenatal Care culturally allowed to engaged in women activities. This study was done using a qualitative approach with few sample size. Hence, findings could be attributed to the methodological approach of the study. 2.6 Pattern of Male Involvement in Antenatal Care The pattern of male involvement in antenatal care is necessary as far as antenatal care is concern. This helps brings to bear the frequency and times that males engage in women antenatal care. The WHO new ANC model suggested that pregnant women should have a minimum of eight antenatal contacts in other to improve fetal and maternal outcomes (Tunçalp et al., 2017). A study have revealed that 94% of women made at least four visits to antenatal clinic in Uganda (Kakaire et al., 2011). While in Bangladesh, it was reported that about 58% of women were found to have made antenatal visit once (Story & Burgard, 2012). Some of these women attendance at antenatal care facilities are influenced by their husbands’ decision making responsibilities regarding antenatal care and their command of resources needed for antenatal care visit (Jennings et al., 2014; Nasreen et al., 2012). In addition, Kashitala et al. (2015) in their retrospective study with secondary data found that of the total number of respondents who attended ten different hospitals in Zambia only 11% of the women were accompanied by their husbands. With regard to male involvement in antenatal care, literature on a demographic and health survey in some African countries (Jennings et al., 2014) indicates that 45.7% of the men went with their partners for antenatal care services. This was also varied between countries as Rwanda recorded the highest (86.8%) of male involvement in antenatal care, Uganda had 49.7%, Burkina Faso had 45.2%, Mozambique had 44.2%, Malawi had 41.0%, Senegal and Zimbabwe recorded 32% and the 28 Determinants of Male Involvement in Antenatal Care lowest country was Burundi with 18.2%. This suggests that male involvement in antenatal care is not the same in every country. Again, previous studies observed that among 171 males who took part in a study, 43.3% ever escorted their spouses to the antenatal clinic once ((Nkuoh et al., 2010). Similarly, it was noted by Mullany, Hindin, & Becker (2005) in a study that, 40% of women were escorted by their spouses to ANC and about 75% reported making health decisions with their husbands. Relatedly, a study in Nigeria noted that 24.0% of the respondents escorted their spouses to ANC. The results also showed that, 53% had poor involvement whilst 46.4% had good involvement (Olugbenga-Bello AI, 2013). Also a study conducted in Ghana reported that out 422 respondents in a survey, only 24,0% of the respondents accompanied their spouses to antenatal care (Doe, 2013) . Similarly, recent qualitative study in the upper west region of Ghana indicated that although men recognized the worth of male involvement in antenatal care during pregnancy and delivery and its implications, majority of the men do not actually involve unless there is an impending complication issues (Ganle & Dery, 2015). 2.7 Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions Attitudes towards an intention is an assessment of the individual as to whether the outcome behaviour will be favourable or not (Ajzen & Driver, 1991). A study on young men intention to talk about birth controls with spouses suggested that attitudes of men was positively associated with their intentions (Masters, Morrison, Querna, Casey, & Beadnell, 2017). Earlier studies have also shown that Male involvement in antenatal care faced a lot of social pressure in some communities. For instance, in rural Mozambique Audet et al. (2015) in their qualitative study observed that men who support their wives during pregnancy including 29 Determinants of Male Involvement in Antenatal Care escorting them to antenatal clinics suffer ridicule from peer groups. This societal behaviour appears to discourage many men from engaging in women’s antenatal care activities. The study also found that offering emotional, clinical or physical support to an expectant partner denotes the feebleness of men. Some peers felt that you have become a slave to your wife if you are seen escorting her to antenatal care clinic or the man is being jealous. The same study indicates that others think the man has no say in the house and “that it is as if he were a chair at home, that the wife sits on top of (P6). The negative cultural believes, social pressure and too much submission to the elderly can influence male involvement in antenatal care. A study in family planning indicated that there was a positive relationship between young men subjective norms and their intentions to discuss family planning (Masters et al., 2017). This suggests that when subjective norms increase, young men intention to discuss family planning also increases. Similarly other researchers also established that there is a significant effect of cultural norms and male involvement in maternal health (Idowu, 2013). A qualitative study in Kenya reported that the high fees charged by health providers are associated with the difficulty of men involving in their spouse’s maternal health care (Nyandieka et al., 2016). Similarly, literature also found that there is a significant positive association between perceived behavioural control and men intention to support breastfeeding (Harwood, 2011). This means that when the men perceived behavioural power improve there will be a corresponding improvement on men intention to support breastfeeding practices. Similarly, researchers in related study as reported that perceived behavioural intention was significantly positive and strongly correlated with women intention to practice exclusive breastfeeding in Malaysia (Tengku Ismail et al., 2016). 30 Determinants of Male Involvement in Antenatal Care 2.8 Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement in Antenatal Care. It is widely a known fact that attitudes influence the kind of behaviour people portray in every sector of their lives. It aids the individual to evaluate ideas, objects or events and act positively or negatively towards the performance of the behaviour of interest (Ajzen, 1991a). As such, positive attitudes may lead to positive behaviour and negative attitudes results to negative behaviour. A study assessing the attitudes and practice of males towards antenatal care with a sample size of one hundred and twenty (120) men indicate that there was no significant influence found between men’s attitudes and their participation in antenatal care (Akinpelu & Oluwaseyi, (2014). This corroborates other researchers who contended that though men had favourable attitudes towards male involvement in antenatal care their involvement appeared low (Theuring et al., 2009). This throws more light no the fact that there are factors influencing their participation. Indeed these findings are not different from a recent related study that also suggest that attitudes have a significant weak positive association with women’s behaviour to practice exclusive breastfeeding (Tengku et al., 2016a). Undeniably, these findings are not in segregation with researchers in other disciplines that reported that there was a positive significant relationship between attitudes and behaviour (Kalolo & Kibusi, 2015). Furthermore, subjective norms appear to be associated with male behaviour. For instance, Tengku Ismail et al., (2016) in their study indicated that subjective norms were positively and significantly associated with women breastfeeding exclusively. Other qualitative studies Nyandieka et al. (2016) and Vermeulen et al. (2016) indicate that a majority of their respondents affirmed it is not easy to involve in women antenatal care activities because of long proximity from their localities to the antenatal care clinics and unnecessary fees charges on antenatal care services. Though these researchers did not 31 Determinants of Male Involvement in Antenatal Care measure relationships, one could imagine that these factors have an influence on male involvement in antenatal care that will have the potential of lowering male involvement in ANC. This also supported that of Tengku et al. (2016) who suggest that perceived behavioural intentions positively and significantly related to exclusive breastfeeding behaviour among women in Malaysia. Additionally, behavioural intentions come to play when the individual makes decision to perform a certain behaviour. Good intentions are sometimes formed when the evaluation of the benefit is positive and bad intentions are made when the outcome is negative (Ajzen, 1991a). Related literature has been established regarding the relationship between intentions and behaviour. A study by Masters et al. (2017) on birth control noted that there was a significant relationship between men’s intention to confer with their spouses on birth control behaviour. Tengku et al. (2016) also contended that there was a positive significant relationship with behavioural intentions and breastfeeding behaviour. 2.9 Predictors of Male Involvement in Antenatal Care Male involvement in antenatal care is widely known as a behavioural modification that men need to adopt to show their social responsibility as partners in their women’s pregnancy (Fincher, 1994). There are copious factors that influence male involvement in antenatal care. These may include socio-demographic factors, knowledge and attitude towards pregnant spouse’s antenatal needs and social pressure or socio-cultural determinants. Studies indicate that the individual socio-demographic characteristics can be associated with the kind of involvement men offer to their spouses during antenatal care (Ditekemena et al., 2012). Also, Wai et al. (2015) suggested that the introduction of maternal health education had a significant relationship with male involvement in antenatal care. Their study also noted that 32 Determinants of Male Involvement in Antenatal Care age and occupation were not significantly related to men involvement in antenatal care. The findings could have differ if they had used a qualitative approach. A related study on prevention of mother to child transmission of HIV by Byamugisha et al. (2010) also observed that men who achieved senior high school level and above were two times likely to engage in antenatal care than those who obtained less education. However, the same study reported that socio-demographic variables like age, religion and area of residence were not associated with male involvement in PMTCT. The same way, Rahman, Islam, Mostofa, & Reza, (2015) confirmed that married men with age 25 to 34 were 1.33 times more likely to involve in antenatal care than those that were married newly and below 20 years old. Mostly those who are grown are always eager to have children and that sometimes make them accompany their spouses to antenatal clinic. A study in Myanmar also reported that number of children of a man is related to neonatal and maternal health care (Ampt et al., 2015). Meaning those men who have children are more likely to involve in maternal care that includes antenatal care, delivery and post-natal care. The same study also found that positive attitudes concerning male participation were more likely to show an increase male participation in neonatal and maternal care. In China, a study by Hongwei Wan, Sujitra Tiansawad, Susanha Yimyam, & Punpilai Sriaporn, (2015) on the determinants of exclusive breastfeeding reported that attitude is a significant predictor of exclusive breastfeeding behaviour among young female Chinese. It was established in that study that attitudes accounted for 6.3% of exclusive breastfeeding behaviour. Subjective norms, on the other hand, are essential for male involvement in antenatal care. Related study in Tanzania indicated that subjective norms or social pressure significantly predicted condom use behaviour (Asare, 2015). These findings are indeed not disconnected 33 Determinants of Male Involvement in Antenatal Care as it has been suggested that gender roles do not permit men to engage in antenatal care involvement. And that the man’s responsibility during antenatal care is to make decisions and provide money to the woman and remain at his work place (Lewis et al., 2015; Singh et al., 2014). The cracks of Singh and his friends is that their study could not capture a large sample size. In addition, recent studies in Mozambique suggested that socio-cultural factors affect men involvement in antenatal care negatively (Audet et al., 2016). 2.10 Summary of Literature Review The literature indicated that male involvement in antenatal care has been acknowledged globally as a significant strategy for improving women’s antenatal health and prevention of maternal and neonatal morbidity and mortality. The literature demonstrated that areas of maternal health where men are involved, always had positive outcome and where they are less involved, the outcome becomes deplorable. In spite of the empirical underpinnings, the literature connotes that, it is challenging to achieve a satisfactory amount of male involvement in antenatal care. This is because it is being influenced by several determinants such as the individual characteristics like age, educational level including societal determinants, traditions and cultural influence, the individual intentions, personal and systemic impediments. The literature suggested that there is low male involvement in antenatal care in Ghana. However, the male involvement situation cannot be determined in some parts of Ghana and the Bawku Municipality for that matter. Even the few studies conducted in this area in other parts of Africa and the world; there is little empirical evidence that these studies have used the theory of planned behaviour model as an organizing framework. Thus, there is a literature gap, which serves as an impetus for the investigation of the determinants of male involvement in antenatal care. 34 Determinants of Male Involvement in Antenatal Care CHAPTER THREE METHODOLOGY This section presents a description of the research methodological approach that was used to achieve the study objectives. It provides detail description of the research design, research setting where the study was conducted, target population, inclusion and exclusion criteria, and sample and sampling technique. The chapter also gives an overview of the data gathering tools, data gathering procedure, data analysis, validity and reliability, ethical clearance and limitations of the study. 3.1 Research Design The study applied a quantitative study technique using a cross sectional survey design to examine the determinants of male involvement in antenatal care in the Bawku Municipality in the Upper East Region of Ghana. A cross sectional study provides a ‘picture’ of the outcome the study and the characteristics related to it at a given point in time (Levin, 2006). According to Parahoo (2006), a quantitative method of research develops from the belief that human events can be researched empirically. A quantitative study employs a stable design that already organizes the research questions and a comprehensive approach of data gathering and analysis (Babbie, 2007). A descriptive cross sectional survey was applied to investigate and describe the relationships between determinants of male involvement in antenatal care within an interested population (Levin, 2006). This approach permits the collection of unique data that enhances the generalisation of result (Polit & Beck, 2010). 35 Determinants of Male Involvement in Antenatal Care 3.2 Research Setting The study was conducted in four health facilities that provide antenatal care services within the Bawku Municipality. These facilities include Bawku Presbyterian hospital, Mognori health centre, vineyard Hospital and Bugri health centre. These four health facilities were selected using a simple random sampling technique from the four sub-districts in the Municipality which served as clusters. The Municipality is among the thirteen Metropolitan, Municipal and District Assemblies in the Upper East Region of Ghana. The Municipality has a total land area of 247.23720 sq.km with a total population of 98,538 people representing 9.4% of the population of the Upper East Region of Ghana. The population constitute 47,254 males, 51,284 females and 36.4% of the population is Rural and 63.6% Urban (GSS, 2013). The Municipality has four sub- districts, twenty electoral areas and shares its boundaries with Pusiga District to the North, Binduri District to the South, Garu-Tempane District to the East and Bawku West District to the West respectively (GSS, 2013). The Municipality is largely served by the Bawku Presbyterian Hospital, seven health centres, four public clinics, five private clinics, twelve CHPS centres, one private laboratory and fifty chemical stores (BMA, 2016). 3.3 Target Population The population of interest for this study consisted of men who accompanied pregnant women to seek for antenatal care services in the selected health facilities in the Bawku municipality. 3.4 Inclusion Criteria The inclusion criteria were men 18 years and above who accompanied pregnant women to antenatal care units to seek for antenatal services irrespective of whether they were their wives or not, and were currently staying in the Municipality and consented to the study. 36 Determinants of Male Involvement in Antenatal Care 3.5 Exclusion criteria Men 18 years and above who accompanied pregnant women to the antenatal clinic seeking antenatal care services, but their women were ill or suffering from co-morbidities at the time of the study were excluded. In addition, men who do not stay in the Municipality at the time of the study were also excluded. 3.6 Sample Size and Sampling Technique The Bawku Municipality has a total male population of 47,254 and a population of males between the ages of fifteen years and above is 26,852 which was the only available age limit data that was close to eighteen years (GSS, 2010). By using the age limit that was close to eighteen years and above data, the total number of males between the ages of fifteen years and above in the Municipality as the accessible population and an alpha level 0.05, the sample size was calculated using the Yamane (1967) simplified sample size formula as follows: N n = 1 + N (e)2 Where n = the sample size N = the population size e = the significant or alpha level When this formula was computed with the above sample where: N = 47,254 and e = 0.05 26852 Then n = = 399 I + 26852 (0.05)2 37 Determinants of Male Involvement in Antenatal Care The sample size was calculated to be 399 but 10% was added to take care of the bias and non – responses. The total sample size then became 439 respondents. The four sub-districts of the Municipality were served as clusters and simple random sampling technique was used to select one health facility from each of the clusters that provide antenatal care services. Convenience sampling technique was used to recruit respondents who were conformed to the inclusion criteria, and agreed to take part in the study from the selected health facilities within the clusters. This technique was employed because the target population was scares, and using any random sampling technique, the researcher might not have gotten the required sample size for the study hence convenience sampling technique was used. Though convenience sampling technique was used, due diligence was done during the data collection process to minimize biases. As a quantitative study, the largest sample size should be selected to enable a good representation of a target population to facilitate generalisation of the results (Suen, Huang, & Lee, 2014; Polit & Beck, 2013). 3.7 Tool for Data Collection Instruments for research are measurement tools structured to obtain data on the study from respondents. These were questionnaires, that the researcher used to collect data in the survey. Babbie (2007) maintained that, structured questionnaires are the best reliable methods of collecting data using survey designs. As a result, standard tools were considerably modified to fit the objectives and the study methodology, and were used for the data collection. The adaptation of the instruments featured terms like ‘male involvement’ in place of behaviour. The questionnaire consisted of six sections as indicated in appendix E. Section A was made up of the socio-demographic characteristics, section B constituted the theory of planned behaviour questionnaire on attitude, section C subjective norms, section D perceived behavioural control, section E 38 Determinants of Male Involvement in Antenatal Care behavioural intentions and section F behaviour. All measured male involvement in antenatal care. The attitudes scale was used to seek information about the attitude of men with regard to antenatal care involvement. It was measured by eight items, with seven bipolar Likert’s scale response. Higher score (+3) indicates good attitudes (positive attitudes) and lower score (-3) indicates bad attitudes (negative attitudes). The subjective norms scale was employed to obtain information about the effects of social pressure concerning male involvement in antenatal care. The scale was measured by eight items with seven bipolar Likert’s scale response with the least score (-3) represented lower social pressure (negative subjective norms ) and higher score (+3) indicates high social pressure (positive subjective norms). The perceived behavioural control measurements contained six items with seven bipolar Likert’s scale where higher score (+3) depicts high level of control (positive perceived behavioural control) towards performing male involvement in antenatal care and lower score (-3), epitomised lower level of control (negative perceived behavioural control) . These items were used to elicit data on men’s control power with respect to male involvement in antenatal care. The behavioural intentions scale was used to solicit the men’s behavioural intentions to accompany their wives to antenatal clinic the next visit. It was measured by two items with seven bipolar Likert’s scale response where higher score (+3) signifies good behavioural intentions (positive behavioural intentions) and lower score (-3) means bad behavioural intentions (negative behavioural intentions) about male involvement in antenatal care. The behaviour (male involvement) scale was employed to establish whether the men have ever been involved in women antenatal care and the frequency of their involvement. The 39 Determinants of Male Involvement in Antenatal Care behaviour scale was measured by two items with a categorical yes or no response for the first one, and continues response for the follow up question. 3.8 Method of Data Collection Following clearance to conduct the study from the Institutional Review Board (IRB) of the Noguchi Memorial Institute of Medical research (NMIMR) of the University of Ghana, and an introductory letter from the School of Nursing to the management Board of the selected health facilities within the Bawku Municipality and the permission granted, the researcher went ahead to collect data. Four research assistants were trained, one per each health facility to help the researcher in the data collection process after the approval was granted from the IRB and the various hospitals. They were taken through skills of communication and ethics in research. They were also educated on how to administer the questionnaire more especially in the local languages. Those who could not understand English, research assistants were employed to translate to them in the language they understood and the response ticked appropriately by the research assistants. Certificate teachers were the minimum qualification for persons that were selected as research assistants. Health professionals were not included because their presence might lead to distortions or bias in the respondent’s response. Respondents for the study were contacted individually at the various antenatal care units and those who voluntarily consented to the study received the explanation of the purpose, nature and confidentiality of the study as well as the right to withdraw from the study. A consent form was given to those who consented to the study to sign to confirm their readiness before they took part in the study. Appropriate place and time was sought from each of the respondents, and the questionnaire was administered accordingly. Each respondent answering 40 Determinants of Male Involvement in Antenatal Care the questionnaire spent about 20 – 30 minutes. To ensure anonymity and confidentiality, names and personal identification information of the respondents were not written on the questionnaire form. 3.9 Data Analysis The data collected from the field was entered into a computer and analysed using the Statistical Package for Social Sciences (SPSS) version 22.0 analysis software. The study required description and predictions of actual behaviour, hence items determining direct attitude, subjective norms and perceived behavioural control were exempted (Holst & Iversen, 2012). The data cleaning was done and the variables were examined by descriptive statistics. The mean age and modal age were also determined. Before the data analysis, the attitudes, subjective norms and perceived behavioural control variables were prepared in harmony with Ajzen’s (2006). The salient beliefs were multiplied by the outcome evaluation to form an expectancy value as suggested by Francis et al. (2004). For instance, respondents answered the likelihood of them involving in antenatal care, after which they were asked to evaluate the same item scaling from extremely good to extremely bad. The items of the attitudes were recoded from a bipolar scale -3 to +3 to a unipolar scale 1 to 7 so that higher score represents positive attitudes towards male involvement in antenatal care. For every behavioural belief, the belief score with the likely/unlikely scale was multiplied by the outcome evaluations scores with extremely bad/extremely good scale and the products were summed to form the overall attitude score and the total attitude mean score was determined to be 196. A median split of the maximum attitudes score was calculated and a total mean score of 98 and above depicts high (positive) attitudes and a score below 98 represents low (negative) attitudes concerning male involvement in antenatal care. 41 Determinants of Male Involvement in Antenatal Care The items of the subjective norms items were also recoded from bipolar -3 to +3 to unipolar 1 to 7 so that higher scores depict greater social pressure to perform male involvement in antenatal care. The normative belief score on “I should/I should not” scale was multiplied with the “not at all/very much” scale. The products were summed to form the overall subjective norm score, and the total subjective norms mean score was calculated. A median split of the maximum score was calculated and a total mean score of 98 and above represents positive subjective norms and a score below 98 indicates negative subjective norms towards male involvement in antenatal care. Perceived behavioural control items were also recoded from a bipolar -3 to +3 response to a unipolar 1 to 7 making higher scores denotes greater amount of control towards male involvement in antenatal care. The perceived control belief score with the strongly agree/strongly disagree response were multiplied by the much difficult/much easier scale. The products resulted were summed across the beliefs to form the overall perceived behavioural control score and the total perceived behavioural control mean was calculated. A median split of the maximum score was calculated and an overall perceived behavioural control mean score of 73 and above depicts high (positive) control and a score below 73 represents low control over the performance of male involvement in antenatal care. The behavioural intentions items were summed and the total mean score was calculated. A total behavioural intentions mean score of 7 and above represents positive behavioural intentions and a score below 7 indicates negative behavioural intentions Descriptive statistics were generated and used to describe the findings while Pearson correlation analysis was conducted to establish the relationships between attitudes, subjective norms, perceived behavioural control and behavioural intentions as these were measured in an interval scale. The data was then ranked and Spearman rho correlation was carried out to 42 Determinants of Male Involvement in Antenatal Care ascertain the relationship between the attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in antenatal care. Binary logistic regression analysis was carried out to determine the factors that predict male involvement in antenatal care. The data of the outcome variable (dependent variable) was measured in two levels (dichotomous) that is Yes or No responses and these were used to run the binary logistic regression. There was no high intercorrelations among the predictors. Hence, the data met the basic assumptions for a non-parametric analysis. 3.10 Validity and Reliability Validity of a questionnaire is the ability of which an instrument is able to measure what it is expected to measure (Polit & Beck, 2010). The instruments should deal with all the problems of the study. The most often issue being reported in most literatures are the face validity and content validity (Parahoo, 2006). The standard instruments that was adapted for the study was developed based on the theory of planned behaviour constructs and was used to study online course adoption in public relations education and hence was deemed valid (Knabe, 2012). This theory of planned behaviour instruments have also been used for other related researches in social sciences and health disciplines and thus are considered valid and reliable (Muhindo et al., 2015; Harwood, 2011; Peltzer, Jones, Weiss, & Shikwane, 2011). The theory of planned behaviour constructs was used to cover the content area of the study and the data collection tools described all the variables under investigation. According to Roberts, Priest & Traynor (2006), reliability is mostly concerned about ensuring that, the method of data collection leads to consistency of results. The Cronbach’s alpha coefficient of the adapted instrument was reported as attitudes 0.61, subjective norms 0.83, perceived behavioural control 0.81 and behavioural intention 0.98, these were within acceptable level for adaptation (Knabe, 2012). To ensure reliability, the instruments were pre- tested with 20 males in Pusiga District Health Centre to help identify and modify errors in the 43 Determinants of Male Involvement in Antenatal Care instruments and the Cronbach’s alpha for the pre-test was calculated as follows; Attitudes 0.68, subjective norms 0.76, perceived behavioural control 0.60 and behavioural intentions 0.92. The instruments were also reviewed by expects to determine its appropriateness. The main study Cronbach’s alpha were recoded as; attitude 0.74, subjective norms 0.76, perceived behavioural control 0.62 and behavioural intentions reported 0.90. Abramson, Dawson, & Stevens, (2015) suggested that a Cronbach’s alpha of 0.70 is considered acceptable. However, the low perceived behavioural control Cronbach’s alpha 0.62 was still used because, indirect measures are usually not evaluated using internal consistency criterion since individuals can have negative and positive beliefs towards the same behaviour (Francis et al., 2004). 3.11 Ethical Consideration Ethical consideration is the most essential part of research that seeks to protect the human respondents during the research process. Grounded on this, ethical approval was obtained from the Institutional Review Board of the Noguchi Memorial Institute of Medical Research of the University of Ghana as seen in appendix A. Permission was also obtained from the management of the selected health facilities where the study was conducted before men attending ANC with pregnant women were recruited for the study. The purpose for the study, confidentiality and the right to be part of the study or withdraw from the study without consequences was explained to respondents and written and verbal consent was obtained. The respondents were made to understand that, answering the questionnaire takes 20 to 30 minutes. Consent forms as contained in appendix D were given to the respondents who voluntarily consented to the study to sign and those who could not sign, thumb printed before the questionnaires were administered (Shrader-Frechette, 1994). 44 Determinants of Male Involvement in Antenatal Care The respondents were assured of no harm related to the study and all data collected was treated with utmost confidentiality. To ensure anonymity, identification of data and names of respondents were not written on the questionnaire forms (Edginton et al., 2012). 45 Determinants of Male Involvement in Antenatal Care CHAPTER FOUR FINDING This chapter presents results of the study that are organised according to the study objectives. The first section describes the socio-demographic characteristics of the respondents, and the remaining sections report the results in line with the research objectives. Out of the total number of respondents (439) who participated in the study, 426 questionnaires were fully completed and fit for analysis representing 97.0% response rate. 4.1 Socio-demographic characteristics of the respondents Majority of the participants (51.4%, n = 219) were within the ages of 21 – 30 years. The mean age was 30.7 (SD = 5.8) with a modal age of 30 years. A greater proportion of the participants (90.6%, n = 386) were married while those who were single constituted 6.8% (n = 29). The rest 2.6% (n = 11) were either separated or divorced. In addition, more than half of the participants (68.1%, n = 290) were married to one wife each and only 3.5% (n =15) of the participants were having three or more wives. Approximately 51% (n =217) were Muslims, 38.7% (n = 168) were Christians and 1.4% (n = 6) were either not practising any religion, or do not belong to any of the three major religions in Ghana, and 39.2% (n = 167) were from the Kusasi tribe. Moreover, less than half of the participants that constituted the majority (28.6 %, n = 122) had tertiary education whilst a small proportion 11.3% (n = 48) obtained primary level of education. Interestingly, an equal number of the participants 27.2% (n = 116) which form the largest percentage were public servants and businessmen respectively whereas 9.2% (n = 39) being minority representing other occupations like masons, carpenters and students. Less than half (47.4%, n = 202) which forms a greater part of the participants were from Bawku town and a few of the respondents (20.2%, n = 86) were from the villages within the 46 Determinants of Male Involvement in Antenatal Care Bawku municipality. About half (50%, n = 214) of the respondents reported that was their wife’s first pregnancy. Furthermore, a majority of the participants (57.3%, n = 244) who took part in the study reported not having children yet. Table 4.1 below presents the details of the socio- demographic characteristics of the respondents. 47 Determinants of Male Involvement in Antenatal Care Table 4. 1: Socio-demographic Characteristics of Participants (N = 426) VARIABLES FREQUENCY (N) PERCENT (%) Age group 20 and below 16 3.8 21-30 219 51.4 31-40 173 40.6 41 and above 18 4.2 Total 426 100.0 Marital status Single 29 6.8 Married 386 90.6 Separated/divorce 11 2.6 Total 426 100 Number of wives One 290 68.1 Two 82 19.2 Three or more 15 3.5 Others 39 9.2 Total 426 100 Religion African traditional religion 38 8.9 Christianity 168 38.7 Islam 217 50.9 Others 6 1.4 Total 426 100 Ethnicity Kusasi 167 39.2 Moshie 84 19.7 Mamprusi 38 8.9 Busangas 94 22.1 Others 43 10.1 Total 426 100 48 Determinants of Male Involvement in Antenatal Care Educational level Primary 48 11.3 J H S 80 18.8 SHS 92 21.6 Tertiary 122 28.6 Illiterate 84 19.7 Total 426 100 Occupation Businessman 116 27.2 Public servant 116 27.2 Farming 115 27.0 Private practitioner 40 9.4 Others 39 9.2 Total 426 100 Place of residence Bawku town 202 47.4 Outskirt town 138 32.4 The village 86 20.2 Total 426 100 Number of wife One 214 50.2 pregnancies Two 105 24.6 Three 75 17.6 Four and above 32 7.5 Total 426 100 Number of children One 97 22.8 Two 52 12.2 Three 14 3.3 Four and above 19 4.5 No child 244 57.3 Total 426 100 Mean age 30.7 Modal age 3 0 SD 5.8 49 Determinants of Male Involvement in Antenatal Care 4.2 Knowledge Level of the Participants As shown in Table 4.2, 51.4% (n = 219) of the respondents ever heard of male involvement in antenatal care whereas 48.6% (n = 207) never heard of male involvement in antenatal care. This suggests that nearly half of the respondents who accompanied their wives to antenatal care during the time of the study did it without much information about male involvement in antenatal care. Table 4. 2: Knowledge Level of Respondents Variable Frequency (N) Percent (%) Have you ever heard of male involvement in ANC No 207 48.6 Yes 219 51.4 Total 426 100 4.3 Attitudes of Men Involved in Antenatal Care The Ajzen (2006) theory of planned behaviour model indirect questionnaire for attitudes demands that, the behavioural beliefs score should be multiplied by the outcome evaluation score. As a result, item (questionnaire) one was multiplied by item five, item two with six, three with seven and four with eight as shown in appendix (E). The product sums of these pairs were used to compute the total mean score and standard deviation of attitudes of men involved in ANC. The results indicated that the total mean score of men involved in ANC was high (131.29, SD = 46.24), suggesting that the respondents in this study had positive (good) attitudes towards male involvement in ANC. 50 Determinants of Male Involvement in Antenatal Care The results also demonstrated that of the 426 participants who took part in the study, 77% (n = 328) representing majority had positive attitudes whereas 23% (n = 98) had negative attitudes towards male involvement in antenatal care. The results based on the attitudes items suggested that a large proportion (78.9%, n = 336) of the men reported that involving in their wife’s ANC would allow them understand more danger signs and pregnancy complications. As a result, 88.0% (n = 375) of the participants agreed that it is good to know about the danger signs and complications of pregnancy. About 90.4% (n = 385) constituting majority held the view that, their involvement in ANC would be appropriate for their wife’s safe delivery. Additionally, 85.5% (n = 364) of the respondents agreed that involvement in ANC regularly could enhance their chances of seeking early obstetric intervention for their wives, whereas majority (88.9%, n = 379) alluded to the fact that it is good to seek for obstetric intervention during ANC. Moreover, 86.1% (n = 367) forming majority of the respondents reported that, if they accompany their wives to ANC regularly, they would prepare ahead of their birth and more than half (55.2%, n = 235) indicated that preparing ahead of birth during ANC is good. The details are indicated in table 4.3 below. 51 Determinants of Male Involvement in Antenatal Care Table 4. 3: Attitudes of Men Involved in Antenatal Care Attitudes and its Characteristics Mean and standard deviations of paired items Frequency(N) Percent (%) Mean SD Total mean and standard deviation 131.289 46.24 Positive attitudes 328 77 Negative attitudes 98 23 Total 426 100.0 My involvement in Unlikely 69 16.2 my wife ANC regularly would allow me Neither understand more likely 21 4.9 danger signs and nor pregnancy unlikely complications Likely 336 78.9 total 426 100.0 Understanding Bad 26 6.0 more danger signs and pregnancy complications is Neither 25 5.9 good nor bad Good 375 88.0 Total 426 100.0 My involvement in ANC would be Unlikely 26 6.0 appropriate for my wife safe delivery Neither 52 Determinants of Male Involvement in Antenatal Care likely 15 3.5 nor unlikely Likely 385 90.4 Total 426 100.0 my involvement in Bad 66 15.5 ANC that would ensure my wife safe delivery is Neither 60 14.1 good nor bad Good 300 70.4 Total 426 100.0 My involvement in Unlikely 38 8.9 ANC regularly could enhance my chances of seeking Neither for early obstetric likely 24 5.6 intervention for my nor wife unlikely Likely 364 85.5 Total 426 100.0 Seeking for early Bad 26 6.1 obstetric intervention is Neither 21 4.9 good nor bad Good 379 88.9 Total 426 100.0 if I accompany my wife to ANC 53 Determinants of Male Involvement in Antenatal Care regularly, I would Unlikely 34 8.0 prepare ahead of her birth Neither likely 25 5.9 nor unlikely Likely 367 86.1 Total 426 100.0 Preparing ahead of Bad 170 39.9 birth is Neither good 21 4.9 Nor bad Good 235 55.2 Total 426 100.0 Higher mean score indicates positive attitudes of men involved in ANC 4.4 Subjective Norms of Men Involved in ANC According to the Ajzen theory of planned behaviour (2006) model indirect questionnaire, normative beliefs score should be multiplied by the motivation to comply score and the resulting sum constitutes the subjective norm score. Based on this, item (questionnaire) one was multiplied by item five, item two with six, three with seven and four with eight as shown in appendix (E). The product sums of these pairs were used to compute the total mean score and standard deviation of the subjective norms of men involved in ANC. The findings revealed that the subjective norms total mean score of men involved in ANC emerged low suggesting that the respondentshad negative subjective norms towards involving in their spouse’s antenatal care. 54 Determinants of Male Involvement in Antenatal Care The results further revealed that, of the total number that participated in the study, 35.7% (n = 152) of the participants had positive subjective norms whilst 64.3% (n =274) had negative subjective norms towards male involvement in ANC. As illustrated in table 4.4, the findings imply that more than half (54%, n = 230) of the participants admitted that their clan head (family head or parents) think they should not accompany their wife’s to ANC regularly. Similarly, 61.3% (n = 261) constituting majority agreed that when it comes to ANC involvement, they will do much of what their family head thinks they should do. Furthermore, slightly more than half (54.7%, n = 233) held the view that, their co-workers think they should be involved in their wife’s ANC decision making regularly. A high proportion (52.2%, n = 222) suggested that they will do much of what their co-workers think they should do when it comes to ANC involvement. A large percentage (70.8%, n = 301) reported that their working peers think they should save money for their wife’s ANC whereas more than half (53.3%, n = 227) of the men in the sample stated that their opinion leaders in their community think they should accompany their wife’s to ANC. The details are presented in Table 4.4 below. 55 Determinants of Male Involvement in Antenatal Care Table 4. 4: subjective norms of men involved in antenatal care Subjective Norms and its Frequency Percent Mean standard Characteristics (N) (%) deviation of paired items Mean SD Total mean and standard deviation 79.73 56.42 Positive subjective norms 152 35.7 Negative subjective norms 274 64.3 Total 426 100.0 My clan head (family head or parents) think that……. I should 230 54 accompany my wife to ANC not regularly Neither I 30 7 should nor I should not I should 166 39 Total 426 100.0 When it comes to ANC involvement, how much do you want to do what your family head thinks you should do Not 142 33.4 Neither not 23 5.4 nor much Much 261 61.3 Total 426 100.0 My co-workers think that ….. involve in my wife ANC I should not 175 41.1 decision making regularly Neither I 18 4.2 should nor I should not I should 233 54.7 Total 426 100.0 56 Determinants of Male Involvement in Antenatal Care When it comes to involving in your wife ANC, how much do I should not 182 42.8 you want to do what your coworkers think you should do Neither not 22 5.2 nor much much 222 52.0 Total 426 100.0 My working peers within the I should 90 21.1 community thinks …. save Not money for my wife ANC regularly Neither I 45 8.2 should nor I should not I should 301 70.8 Total 426 100.0 When it comes to saving money for your wife ANC, how much Not 160 37.6 do you want to do what your working peers think you should do Neither not 28 6.6 nor much Much 2 38 55.9 Total 426 100.0 The opinion leaders of my I should not 141 33.1 community think…accompany my wife to ANC Neither I should nor I 58 13.6 should not I should 227 53.3 426 100.0 57 Determinants of Male Involvement in Antenatal Care Total When it comes to Not 258 57.1 accompanying your wife to ANC, how much do you Neither not 24 5.6 Nor much want to do what your opinion Much 244 37.3 leaders think you should do total 426 100.0 Higher mean score indicates positive subjective norms of men involved in ANC 4.5 Perceived Behavioural Control of Men Involved in Antenatal Care As indicated in table 4.5 below, the indirect questionnaire according to Ajzen theory of planned behaviour requires that the control belief should be multiplied by the influence of control to form the perceived behavioural control score. Grounded on this, item one was multiplied by item four, two with five and three with six. The products sums were used to determine the total mean and standard deviation of the perceived behavioural control of men involved in ANC. The outcome illustrated that the perceived behavioural control total mean score was high 95.34 (SD 37.47). This implies that the participants had greater control over the performance of male involvement in ANC. A large proportion (71%, n = 304) of the participants in this study had positive perceived behavioural control (high control) over the performance of male involvement in ANC whilst 28.6% (n = 122) had negative perceived behavioural control (lower control). The results of the perceived behavioural control also revealed that 88.1% (n = 375) of the respondents indicated that, they expect their health institutions would have ANC infrastructure, necessary space and close proximity to encourage them involve in ANC. Also, an impressive proportion (70.4%, n = 300) suggested that appropriate ANC infrastructure, 58 Determinants of Male Involvement in Antenatal Care necessary space and close proximity would make it easy for them to accompany their wives to ANC. Additionally, a greater percentage (86.4%, n = 368) indicated that they expect their health institutions would offer services to couples first before women who come alone for them to involve in ANC. And more than half (62.7%, n = 267) indicated that offering services to couples first before women who come alone would make it easy for them to accompany their wife’s to ANC the next visit. Furthermore, a significant proportion of the participants (78.6%, n = 335) suggested that they expect their health institutions would offer professional advice and support on ANC to enable them accompany their wife’s to ANC the next visit. In terms of ranking, the expectation that health institutions would have ANC infrastructure, necessary space and close proximity was the highest (88.1%) followed by the expectation that their health institutions would offer services to couples first before women who attended ANC without their husbands (86.4%). These findings suggest that these items are the most significant perceived behavioural control factors that may enhance male involvement in ANC. 59 Determinants of Male Involvement in Antenatal Care Table 4. 5: Perceived Behavioural Control of Men Involved in Antenatal Care Perceived behavioural control Mean and and its characteristics standard deviation of paired items Frequency(N) Percent(%) Mean SD Total mean and standard deviation 95.34 37.47 High control 304 71.4 Lower control 122 28.6 Total 426 100.0 I expect that my health institutions would have ANC Disagree 3 1 7.3 infrastructure, necessary space and close proximity to encourage male involvement in ANC Neither 20 4.7 agree nor disagree Agree 375 88.1 Total 426 100.0 Appropriate ANC infrastructure, necessary space and close Difficult 76 17.8 proximity would make it ….. for me to accompany my wife to ANC the next visit Neither difficult 50 11.7 nor easy Easy 300 70.4 Total 426 100.0 I expect that my health Disagree 44 10.3 institutions would offer services to couples before women who came alone for me to involve in Neither 14 3.3 ANC agree nor disagree 60 Determinants of Male Involvement in Antenatal Care Agree 368 86.4 Total 426 100 Offering services to couples Difficult 96 22.5 before women who come alone would make it …….to accompany my wife to ANC the next visit Neither difficult 63 14.8 nor easy Easy 267 62.7 Total 426 100 I expect my health institutions would offer professional advices Disagree 65 15.3 and support on ANC for me to accompany my wife to ANC the next visit Neither agree nor 26 6.1 disagree Agree 335 78.6 Total 426 100.0 Professional advice and support Difficult 83 19.5 on ANC would make it Neither 42 9.9 difficult nor easy Easy 301 70.7 Total 426 100.0 Higher mean score indicates positive perceived behavioural control (high control) of men involved in ANC 61 Determinants of Male Involvement in Antenatal Care 4.6 Behavioural Intentions of Men Involved in ANC The total mean score of the behavioural intentions was high (9.71, SD 4.55). This demonstrates that the men in the study had good intentions about male involvement in ANC. Additionally, the results indicated that majority (74.4%, n = 317) of the participants had positive behavioural intentions towards male involvement in ANC whiles 25.6% (n = 109) had negative behavioural intentions. The findings further suggest that more than half of the men in this study (64.5%, n = 275) reported that they have decided to accompany their wives to ANC the next visit. Also, a large section of the participants (67.3%, n = 287) constituting majority agreed that they are determined to be involved in their wives ANC decision making. This is demonstrated in table 4.6 below. 62 Determinants of Male Involvement in Antenatal Care Table 4. 6: Behavioural Intentions of Men Involved in Antenatal Care Behavioural intentions and Frequency (N) Percent (%) Mean SD its characteristics Total mean and standard deviation 9.71 4.55 I have decided to accompany False 126 29.6 my wife to the next ANC visit Neither true 25 5.9 nor false True 275 64.5 Total 426 100.0 I am determined to involve in my wife ANC decision Disagree 117 27.5 making Neither agree 22 5.2 nor disagree Agree 287 67.3 Total 426 100.0 Good behavioural intentions 317 74.4 Bad behavioural intentions 1 09 25.6 Total 426 100.0 63 Determinants of Male Involvement in Antenatal Care 4.7 Patterns of Male Involvement in Antenatal Care The second objective was to describe the patterns of male involvement in antenatal care. As demonstrated in Table 4.7 below, majority (53.1%, n = 226) of the respondents in this study have never accompanied women to antenatal care before while less than half (46.9%, n = 200) ever accompanied their spouses to antenatal care. Among those who ever escorted their spouses to ANC, 25.3% (n = 110) of them ever accompanied their spouses one to three times. A greater number of the study population never accompanied their women to antenatal care before the study. This suggests that though all the respondents accompanied women to antenatal care during the time of the study, it was the first time many of them got involved in their wife’s antenatal care. 64 Determinants of Male Involvement in Antenatal Care Table 4. 7: Patterns of Male Involvement in Antenatal Care VARIABLE FREQUENCY PERCENT (N) (%) Have you ever involved in your woman to ANC YES 200 46.9 NO 226 53.1 TOTAL 426 100 If yes how many times One to three 110 25.3 Four to six 88 20.9 times Seven to 2 0.7 nine times missing 226 53.1 TOTAL 426 100 65 Determinants of Male Involvement in Antenatal Care 4.8 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male involvement in antenatal care The correlation analysis was conducted using the Pearson’s Product-moment correlation to establish the relationship between attitudes, subjective norms, perceived behavioural control and behavioural intention of men involved in antenatal care. The findings indicated that there was a significant and moderately positive correlation between attitudes and behavioural intentions (r = .438, p < .001). This implies that an increase in attitudes (good attitudes) leads to an increase in behavioural intentions of men towards male involvement in antenatal care. Similarly, there was a significant but moderately positive relationship between subjective norms and behavioural intentions (r =.421, p < .001), suggesting that an upsurge in subjective norms (positive social pressure or beliefs) lead to an increase in behavioural intentions with regard to male involvement in antenatal care. Perceived behavioural control also showed a significantly weak and positive association with behavioural intentions (r = .226, p < 001). This finding suggest that an increase in perceived behavioural control of men leads to an improvement in behavioural intentions of men towards male involvement in antenatal care. The details of the correlation between attitudes, subjective norms, perceived behavioural control and behavioural intentions are indicated in table 4.8 below. 66 Determinants of Male Involvement in Antenatal Care Table 4. 8: Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male Involvement in Antenatal Care VARIABLES BEHAVIOURAL INTENTIONS r p- value (2 tailed) N Attitudes 0.438 < .001 426 Subjective norms 0.421 < .001 426 Perceived behavioural control 0.226 < .002 426 Criterion level 0.05 4.9 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement in Antenatal Care Spearman’s rho correlation was performed to determine the relationship between attitudes, subjective norms, perceived behavioural control, behavioural intentions and men involvement in antenatal care using a sample size of 426 men. The results revealed that there was a weak but significant positive relationship between attitudes and male involvement in antenatal care (rs = .257, p < .001). This implies that an increase in attitudes of these men leads to an increase in male involvement in antenatal care. That is to say, an increase in positive attitudes will better improve male involvement in antenatal care. Similarly, there was a significant weak and positive correlation between subjective norms and male involvement in antenatal care (rs = .242, p < .001), suggesting that an improvement in subjective norms of the men leads to an increase in male involvement in antenatal care. 67 Determinants of Male Involvement in Antenatal Care Furthermore, perceived behavioural control was very weak with significant positive association with male involvement in antenatal care (rs = 0.159, p < .001). This indicates that an increase in perceived behavioural control leads to an increase in the performance of male involvement in antenatal care. Behavioural intentions also demonstrated a significant positive but weak correlation with male involvement in antenatal care (rs = 0.261, p < .001). This shows that an increase in behavioural intentions leads to an increase in male involvement in antenatal care. Details are illustrated in table 4.9 below. Table 4. 9: Relationship between attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement in antenatal care. VARIABLES MALE INVOLVEMENT IN ANC rs p- value (2 tail) N Attitudes 0.257 <.001 426 Subjective norms 0.242 < .001 426 Perceived behavioural control 0.159 <.001 426 Behavioural intentions 0.261 <.001 426 Criterion level 0.05 4.10 Predictors of Male Involvement in Antenatal Care As noted in table 4.10 below, a multiple binary logistic regression analysis was conducted to determine the predictors of male involvement in antenatal care (dependent variable). All the socio-demographic variables were first computed to determine their individual significance on male involvement in antenatal care. Those variables that were not statistically significant at P < 0.05 level in the bivariate analysis were exempted in the first logistic regression model. 68 Determinants of Male Involvement in Antenatal Care As seen in model one, marital status, religion, educational level and the number of children (p < .05) were statistically significant on male involvement in antenatal care. The odds ratio for those who were married/cohabiting increase by .206, indicating that men who are married or cohabiting were .206 times less likely to accompany their wife’s to antenatal care than those that were separated or divorced. However, there was no significant difference between single men and those that were separated or divorced which is the reference category. Even though religion was statistically significant, there were no differences between African traditional religion, Christianity, Islam and other religions. In terms of educational level, the odds ratio of men who obtained SHS education and involved in antenatal care increased by 2.885. This implies that men with SHS level of education are 2.885 times more likely to be involved in ANC than men who are illiterates. The results further revealed that men’s educational level (tertiary) is significantly related to male involvement in antenatal care (p < .05), suggesting that, men who attained tertiary education are 2.415 times more likely to involve in women’s antenatal care than illiterates. However, significant differences were not found between those who obtained primary education, JHS and men who are illiterates. In addition, number of children was significantly associated with men accompanying their wives to ANC p < .05. This implies that men who have children were1.331 times more likely to involve in their wife’s antenatal care. Nevertheless, the socio-demographic variables (marital status, religion, educational level and number of children) significantly predicted 12% of variance in male involvement in antenatal care [R²= .121, x² (10) = 11.967, p < .001]. In the second model, attitude was added to the socio-demographic variables that were significant in the first model and they jointly accounted for 19.9% of male involvement in antenatal care [R² =.199, X² (11) = 68.902, p < .001]. It was observed in model two that as 69 Determinants of Male Involvement in Antenatal Care the odds ratio of attitudes scores increases, men are 1.013 times more likely to involve in ANC. Attitudes explained 2.3% of male involvement in antenatal care in the model. Furthermore, when subjective norms were added to socio-demographic and attitudes variables in the third model, the subjective norms independently accounted for 3.6% of variation of male involvement in antenatal care, odds ratio 1.007. In addition, as subjective norms scores of men increases odds ratio 1.007, the likelihood of men involving in women ANC too increases. In other words, as the subjective norms of men increases, men are 1.007 times more likely to involve in ANC. The socio-demographic variables, attitudes and subjective norms collectively accounted for 23.2% of male involvement in antenatal care [R2 = .232, x2 (12) = 81.165, p < .001]. As shown in model four, whilst the behavioural intentions score increases, men are likely to involve in ANC by 1.113 times. This indicates that men who have positive (good) behavioural intentions are 1.113 times more likely to accompany their wife’s to antenatal care. Finally, marital status, educational level, number of children, attitudes, subjective norms and behavioural intentions were the main predictors of male involvement in antenatal care. They collectively and significantly accounted for 26.7% of male involvement in antenatal care. [R²= .267, x² (8) =95.046, p < .001]. However, perceived behavioural control was not a predictor of male involvement in antenatal care. 70 Determinants of Male Involvement in Antenatal Care Table 4. 10: Predictors of Male Involvement in Antenatal Care 95% C.I. for Predictors EXP(B) B S.E. Wald Sig. Exp(B) Lower Upper MODEL 1 Marital status 6.012 .049 Separated/divorced (Ref) - - - - - - - M arried/cohabiting -1.581 .806 3.849 .050 .206 .042 .999 Single -.494 .664 .552 .457 .610 .166 2.244 R eligion 9.632 .022 O ther religions (Ref) - - - - - - - African traditional religion .109 .925 .014 .906 1.115 .182 6.836 Christianity -.286 .871 .108 .742 .751 .136 4.141 I slam .447 .863 .269 .604 1.564 .288 8.496 Educational level 18.542 .001 Illiterate (Ref) - - - - - - Primary .556 .384 2.094 .148 1.743 .821 3.702 JHS -.120 .341 .124 .725 .887 .455 1.729 SHS 1.059 .343 9.513 .002 2.885 1.471 5.656 Tertiary .882 .320 7.574 .006 2.415 1.289 4.524 Number of children .286 .095 9.094 .003 1.331 1.105 1.602 No children (Ref) - - - - - - - Model 1 summary: R² = .121, x² (10) = 11.967, p < .001 MODEL 2 Marital status 7.186 .028 71 Determinants of Male Involvement in Antenatal Care Married/ cohabiting -1.728 .853 4.104 .043 .178 .033 .945 Single -.517 .719 .516 .472 .596 .146 2.443 Religion 5.875 .118 African traditional religion .152 .962 .025 .874 1.164 .177 7.666 Christianity -.290 .906 .102 .749 .749 .127 4.423 Islam .307 .898 .117 .732 1.360 .234 7.906 Educational level 13.891 .008 Primary .377 .400 .890 .345 1.459 .666 3.195 JHS -.198 .357 .310 .578 .820 .408 1.650 SHS .970 .357 7.368 .007 2.637 1.309 5.313 Tertiary .645 .337 3.664 .056 1.906 .985 3.688 Number of children .276 .100 7.694 .006 1.318 1.084 1.602 Attitudes .013 .002 25.892 .000 1.013 1.008 1.018 Model 2 summary: R² =.199, X² (11) = 68.902, P < .001 MODEL 3 Marital status 7.929 .019 Married/cohabiting -2.010 .865 5.401 .020 .134 .025 .730 Single -.763 .725 1.108 .292 .466 .113 1.930 Religion 4.872 .181 African traditional religion -.104 .967 .012 .914 .901 .135 5.993 Christianity -.405 .910 .199 .656 .667 .112 3.965 Islam .147 .901 .027 .870 1.158 .198 6.766 Educational level 13.336 .010 Primary .548 .408 1.801 .180 1.730 .777 3.851 72 Determinants of Male Involvement in Antenatal Care JHS -.120 .365 .109 .741 .887 .434 1.812 SHS 1.026 .365 7.892 .005 2.790 1.364 5.709 Tertiary .605 .344 3.089 .079 1.830 .933 3.592 Number of children .258 .102 6.446 .011 1.295 1.061 1.580 Attitudes .009 .003 12.287 .000 1.009 1.004 1.015 Subjective norms .007 .002 11.947 .001 1.007 1.003 1.012 Model 3 summary: R²= .232, x² (8) = 10.590, p < .001 M ODEL 4 Marital status 9.150 .010 Married/ cohabiting -2.459 .896 7.539 .006 .086 .015 .495 Single -1.231 .756 2.650 .104 .292 .066 1.286 Religion 5.074 .166 African traditional religion -.160 .998 .026 .873 .852 .121 6.026 Christianity -.468 .946 .244 .621 .626 .098 4.003 Islam .109 .937 .013 .908 1.115 .178 6.993 Educational level 13.476 .009 Primary .517 .418 1.534 .215 1.677 .740 3.802 JHS -.135 .371 .133 .716 .874 .422 1.808 SHS 1.061 .375 8.025 .005 2.890 1.387 6.023 Tertiary .551 .353 2.430 .119 1.734 .868 3.466 Number of children .256 .103 6.151 .013 1.292 1.055 1.582 Attitudes .006 .003 5.012 .025 1.006 1.001 1.012 Subjective norms .005 .002 5.249 .022 1.005 1.001 1.010 73 Determinants of Male Involvement in Antenatal Care Behavioural intention .107 .029 13.193 .000 1.113 1.050 1.179 Model 4 summary: [R²= .267, x² (8) = 95.046, p < .001 Dependent variable: male involvement in antenatal care. Criterion level 0.05 4.11 Summary of Findings The study findings indicate that the mean age of the respondents was approximately 31 years and a modal age of 30 years. About 90.6% of the respondents were married whilst 2.6% were either divorced or separated, with 68.1% of them married to one wife each. More than half 51% were Muslims and 39.2% were from the Kusasi tribe. About 28.6% obtained a tertiary education while many of them 27.2% were public sector workers and businessmen whereas 9.2% represented other occupations. Majority of them 47.2% of the respondents were from Bawku town and half of the respondents’ wives were pregnant for the first time. The study additionally reported that 57.3% of the respondents were not having children and only one person 0.2% reported having eight children. The study unearths that 51.4% of the men in this study knew about male involvement in antenatal care and majority of the men were aware of the positive impact of male involvement in antenatal care. Of the number that took part in the study, majority 77% of them had positive attitudes towards male involvement in antenatal care. The men also exhibited high total attitudes mean value of 131.29 (SD = 46.24), suggesting that a large proportion of them had positive attitudes concerning male involvement in antenatal care. The respondents in this study were found to have presented low total subjective norms mean score of 79.73 (SD = 46.42), indicating the men had negative subjective norms towards involving in women ANC. It was also observed that, of the total number of respondents, 64.3% possessed negative subjective norms regarding male involvement in antenatal care. However, there appeared to be a sociocultural influence on male involvement in antenatal 74 Determinants of Male Involvement in Antenatal Care care. The study discovered that though the men were involved in ANC and were aware of the advantages of male involvement in ANC, many of them still depend on the subjective approval of their family heads/clan heads, coworkers, peers and opinion leaders to make their decisions. Furthermore, the study suggested a high perceived behavioural control total mean score of 95.34 (SD = 47), signifying that majority of the men had greater control over the performance of male involvement in antenatal care. It was also established that 71% of the men had positive perceived behavioural control on involving in their women antenatal care. However, 88.1% indicated that, if the health institutions have ANC infrastructure, required space and short proximity, they would involve in ANC. The study found that majority of the respondents had a positive behavioural intention towards involving in their women ANC with a high total mean score of 9.71 (SD = 4.55). Though the findings revealed that 74.4% had good behavioural intentions with regards to male involvement in ANC, about 53.1% never accompany women to ANC before. Furthermore, attitudes, subjective norms and perceived behavioural control were found to have significant relationships with behavioural intentions, whereas attitudes, subjective norms, perceived behavioural control and behavioural intentions were also significantly associated with male involvement in antenatal care. In the nutshell, the study found that sociodemographic variables (marital status, educational level, number of children), attitudes, subjective norms and behavioural intentions significantly predicted male involvement in antenatal care. They collectively explained 26.7% of male involvement in antenatal care. However, perceived behavioural control variable was not found to predict male involvement in ANC. 75 Determinants of Male Involvement in Antenatal Care CHAPTER FIVE DISCUSSION OF FINDINGS This chapter presents the discussion of the study findings. The discussion includes the socio- demographic characteristics of the respondents, their attitudes, subjective norms, perceived behavioural control, behavioural intentions and the behaviour of men with regards to male involvement in antenatal care. The discussions were made based on the reviewed empirical literature, and in line with the study objectives. 5.1 Socio-demographic Characteristics The study found that most of the respondents were between the ages of 21 – 30 years with a mean of 30.7 (SD = 5.8) and a modal age of 30 years. This means that most of the respondents were in their reproductive age. This finding is corroborated by previous studies Olugbenga-Bello et al. (2013) who reported that 62.2% of their respondents were within 20- 39 years. Furthermore, the current study findings revealed that majority (90.6%) of the respondents who took part in the study were married. This is in conformity with Kabagenyi et al. (2014) in Uganda who noted that married men were involved in women antenatal care. The current findings could be related to the fact that because they are married, they feel responsible for their women pregnancy. Moreover, an appreciable number of the men 68.1% (n = 290) were in monogamous family marriages. These findings were validated by a study in Cameroon, ( Nkuoh et al., 2010) who reported that majority of the men who participated in their study were those who married to one wife. It could be argued that those men who are from monogamous families tends to have more time for their partners and hence involve in their women ANC. However, it also suggest 76 Determinants of Male Involvement in Antenatal Care that this trend might alter as time goes on with most of the polygamous men getting involve in ANC. The study further ascertained that a considerable number of the respondents 50.9% (n = 217) were Muslims. The findings are consistent to Byamugisha et al. (2010) in eastern Uganda who reported that about half of the men in their study were muslims . These findings could be associated with the religious orientation of the study setting. Previous studies also found that individuals who attained Senior High School level of education and above were more involved in their women antenatal care than those who do not obtain formal education (Akinpelu & Oluwaseyi, 2014; Tweheyo et al., 2010; Wai et al., 2015). Their findings are in line with the current study which found that most of the respondents obtained tertiary education. It could be reasoned with the perception that those men who are well educated understand the rationale behind male involvement in antenatal care and will involve. Moreover, the study suggested that many of the respondents were public servants and businessmen (27.2%) respectively. These men are employed and earn salaries that could enable them to transport themselves to the ANC units and also enable them settle hospital bills and this could explain why these men are involved in their women’s ANC. This finding is supported by an earlier study Iliyasu et al. (2010) in Nigeria, where a greater percentage of the respondents who took part in their study were government employees and self-employed businessmen. Although the current study and that of Iliyasu et al. (2010) were conducted in different countries and cultural background, the similarities of the study methods could have attributed to the similarities in results as the current study utilized a quantitative design and Iliyasu et al. (2010) adopted a mixed method. 77 Determinants of Male Involvement in Antenatal Care 5.2 Attitudes of Men Involved in Antenatal Care Attitudes towards male involvement in antenatal care denote the level at which the individual holds a positive or negative assessment of a certain behaviour (Ajzen, 1991b). It informs the individual to exhibits either a positive or negative attitudes towards the targeted behaviour. In this study, it is found that the respondent’s attitudes towards male involvement in antenatal care are high (Mean =131.29, SD = 46.24), suggesting that the men had positive attitudes towards male involvement in antenatal care and may appear to be involved in their women antenatal care. This could be attributed to the fact that majority of the respondents in the study were educated and are exposed to information about the benefits of male involvement in ANC (Davis & Davis, 2010). This is in conformity with Kabagenyi et al. (2014) who contended that majority of the respondents in their study were educated. In addition, this study further found most of the men (77%, n = 328) exhibiting positive attitudes towards male involvement in antenatal care. The proportion of men with positive attitude in this study is consistent with that of Olugbenga-Bello et al.(2013) study in Nigeria which reported that about 56.6% of the participant’s in their study had positive attitudes towards maternal care. Even though their study found the respondents’ attitudes to be positive, it appeared lower than the current study findings, which is 77%. The study also found that majority of the respondents 78.9% reported that involving in women ANC will enable them recognize danger signs and pregnancy complications among their partners, suggesting that many of the men cannot identify danger signs of pregnancy. This findings were supported by Sekoni & Owoaje, (2014) who indicated that about 60.6% of their study respondents had little knowledge in danger signs in pregnancy. Also Olugbenga- Bello et al., (2013) indicated that many of the men stressed on the need to participate in antenatal care services to ensure adequate skilled care is rendered to their partners that will 78 Determinants of Male Involvement in Antenatal Care result in a healthy pregnancy and delivery outcomes. This could probably be due to the similarities in the study design. In Cameroon, Nkuoh et al., (2010) and (Adelekan, Edoni, Olaleye, et al., 2014) in Nigeria reported in their studies that, majority of their respondents indicated, it was good to accompany women to ANC. Though these researches used qualitative methods, their findings emerged to be consistent with the current study where majority 88.0% (n = 375) indicated that it was good to involve in antenatal care. Again, the current study unveiled that most of the men 90.4% (n = 385) suggested that involving in women ANC would be appropriate for their wives safe delivery. This is probably because of the increasing sensitization by health care providers on the need for male involvement in antenatal care that is in line with programmes strategies to include males in maternal health care (Roseman & Reichenbach, 2010; WHO Regional Advisers in Reproductive Health WHO/PAHO Meeting, 2002). Despite this sensitization, Sekoni & Owoaje, (2014) reported that a lesser proportion of men (48.3%) affirmed that antenatal care will enhance proper pregnancy care and safe delivery. This suggest the need for more sensitization on the importance of male involvement in antenatal care, although the current study revealed a higher proportion of men were aware of the importance of male involvement in ANC. Furthermore the study noted that a significant section of the participants (86.1%, n = 367) asserted that, going to ANC with their wives enable them to prepare towards delivery. This indication in the present study demonstrates how men prepare towards their wives pregnancy. These findings are in consonant with the findings of Iliyasu et al., (2010) in northern Nigeria where many of the respondents saved money during pregnancy for transportation and cost of ANC and delivery services. More recently, majority of the men in Nepal also saved money 79 Determinants of Male Involvement in Antenatal Care towards their women ANC and delivery services (Bhatta, (2013). This trend indicates how men are increasingly becoming more concern about their women ANC and delivery services. This could lead to an increase in male involvement in antenatal care. 5.3 Subjective Norms of Men Involved in ANC The current study discovered low subjective norms of the men towards male involvement in antenatal care (Mean = 79.73, SD = 46.42), suggesting that most of the men in this study had a negative subjective norms. This could be associated to the fact that many men in the traditional communities in Africa are not found to involve in pregnancy related issues. Corroborating this findins, Kwambai et al. (2013) contends that men believed antenatal care activities are mainly the responsibility of the women and not the men. Again, Audet et al. (2016) also purported that, most of the men who were found accompanying their spouse’s to antenatal care were humiliated in their communities and were made to feel those men are controlled by their wives. This belief deters most men who may have the interest to involve in their women antenatal care (Thapa & Niehof, 2013). Perhaps this might have contributed to the low subjective norms of the respondents in this current study since it was conducted in a rural area where these traditional beliefs are inherent. In addition, the current study also demonstrated a negative subjective norms among a greater percentage of the respondents, (64.3%, n = 274). This implies that majority of the respondents in this study still have socio-cultural beliefs of seeking approval from their significant others before involving in women antenatal care. With this revelation it appears the men believed that antenatal care is the responsibility of the women, their friends, rivals and not necessarily for men (Ditekemena et al., 2012). These findings are in conformity with prior study which suggested that men believed it is a tradition given to them by their fore fathers not to accompany women to antenatal care which they find it difficult to alter (Singh., 2014). 80 Determinants of Male Involvement in Antenatal Care Moreover, most of the respondents (54%, n = 230) in this study were found to have stated that their clan heads or family heads believed they should not accompany their wives’ to ANC. This implies that elderly men might have been influenced by socio-cultural believes and do not support male involvement in antenatal care. In line with this findings, Mullany., (2006) in Nepal, and Singh et al., (2014) in Uganda reported that aged men discourages the younger ones against ANC involvement. And that they believed their customs does not permit them to escort their spouses to ANC. Singh et al., (2014) further indicated that respondents believed their fore fathers gave birth to so many children without accompanying their wives to ANC but pregnant women in this contemporary times wants their husbands to support them in antenatal care. This believe discourages men from accompanying their women to ANC that could possibly explain why the men in this study exhibited negative subjective norms. Furthermore, the current study found 54.7% (n = 233) of the respondents confirmed their co- workers approved of them involving in ANC regularly. This implies that the respondents are encouraged by their working colleagues to take part in their women antenatal care. Perhaps this could be linked to the educational exposure of the people in the study area. However, the present study findings conflicts with findings in Erstwhile study Mullany, (2006) which suggested that people in certain societies mock at men who accompany their wives to ANC clinics. Similar findings were also reported by Audet et al., (2016) who purported that some of the people felt if a man escorts his spouse to ANC he becomes a slave to the woman. This can be attributed to the socio-cultural orientation of the respondents. The present study also observed 70.8% (n = 301) of the respondents indicated their working peers believed they should save money for their spouse’s ANC and 55.9% (n = 238) of the men in this study held the view that they will do what their working peers think they should do. This suggests that majority of the men in this study will save money towards their women 81 Determinants of Male Involvement in Antenatal Care antenatal care, indicating that men see themselves as providers in the family. This agrees with that of Dumbaugh et al., (2014) findings that reported that men are described as breadwinners and decision determinants when it comes to women antenatal health. The same study stated that the responsibility of a man in the house is to provide funds and preside on decisions concerning the health of the woman and children. The current finding is also supported by a study in Myanmar Wai et al., (2015) which reported 81.7% of their study sample purported to have saved money towards their spouses pregnancy and delivery. Though men provide money for their wives ANC upkeep, there is evidence that this may not translate into men accompanying their women to antenatal clinics. According to (Nyondo, Chimwaza, & Muula, 2014b), men often make decisions and provide funds for their wives antenatal upkeep but they really did not deem it necessary to accompany their spouses to antenatal care. 5.4 Perceived Behavioural Control of Men Involved in ANC Perceived behavioural control is an essential part of determining behaviour as it represents the belief power that hinders or enables the individual to execute a targeted behaviour (Ajzen, 2015). In this study, the men were found to demonstrate a high perceived behavioural control with regards to male involvement in antenatal care (mean = 95.34, SD = 37.47), suggesting that the men believed they have the control power to involve in women antenatal care activities. The findings could be attributable to the fact that the respondents were those who involved in their women ANC. Contrary to these findings Byamugisha et al., (2010) reported that their respondents identified disrespect, poor handling of expectant mothers and men been prevented from entering into the antenatal units as the factors making it difficult for them to accompany their spouses to antenatal care. The same study noted that men believed they are busy looking for money and 82 Determinants of Male Involvement in Antenatal Care that they do not even have the money to fare the two of them to the ANC unit. The contradictory findings could perhaps be related to the methodological approach of the current study. Also greater proportion (71%, n = 304) of the respondents in this study were found to have positive perceived behavioural control towards male involvement in antenatal care. This suggest that most of the men in this study have the control to involve in their women ANC without difficulties. Inconsistent with the current findings, Adelekan et al. (2014) in Nigeria inferred that prolong waiting hours at the health facility and high ANC bills makes it difficult for them to involve in women antenatal care. Other researchers, Vermeulen et al., (2016) also noted that unavailability of transport and far distances to the ANC clinics makes it difficult for them to accompany their spouses to antenatal care. The positive perceived behavioural control of the men in the present study could be associated with the quantitative nature of the study. Further, most (88.1%, n = 375) of the respondents in this study indicated that health facilities should have ANC infrastructure with enough space to accommodate males, and the facilities should be close to the respondents houses to enable them participate in antenatal care. Again, 70.4% (n = 300) of the men reported that close proximity to ANC facilities will make it easy for them to involve in antenatal care. This findings is not surprising as distance to health facilities is a hindrance to health care utilization (Robert Stock, 2011). These findings conform with that of Nyandieka et al., (2016) who reported that the nature of the antenatal care clinics where there is insufficient space to accommodate men and their women and paucity of staffs makes it challenging for men to involve in their women antenatal care. In furtherance, the present study also found 86.4% (n = 368) of the men wanted their health institutions to provide ANC services to them and their women first before women who come 83 Determinants of Male Involvement in Antenatal Care without their husbands. This means that the men in this study do not want to waste much time in the antenatal clinics. This validates the study of (Kwambai et al. 2013) who suggested that most men in their study believed they will involve in women ANC if only they will be considered first in the ANC unit before those women who are not escorted by males. This goes to attest the fact that men are busy and will prefer fast antenatal care services (Byamugisha et al., 2010). 5.5 Behavioural Intentions of Men Involved in ANC The behavioural intentions of men are key in male involvement in antenatal care as it connotes the men decisions to perform a specific behaviour (Ajzen, 1991b). The study revealed that the men exhibited high behavioural intentions towards male involvement in antenatal care (mean = 9.71, SD = 4.55), indicating that the men in this study had positive behavioural intentions towards male involvement in antenatal care. This could perhaps be attributed to the fact that most of the respondents in this study are educated and are sensitize on the importance of male involvement in antenatal care. It could also be due to the positive attitude found in the study. This study finding further highlighted 74.4% (n = 317) of the men in this survey had positive behavioural intentions towards male involvement in antenatal care, suggesting that the men have the intention to accompany their spouses to antenatal care. This could be due to the fact that all the respondents in this study are those who involved in ANC. The study additionally showed that 64.5% reportedly have decided to accompany their wives to antenatal care the next visit. This means the men really have planned to involve in their women antenatal care which is different from the findings of Lewis, et al, (2015) who established that pregnancy and delivery issues are considered as women domain, especially a 84 Determinants of Male Involvement in Antenatal Care responsibility of the woman’s sisters, friends, mother and mother-in-law’s and not for men. The present study approach might have attributed to the disparities in findings. 5.6 Patterns of Male Involvement in Antenatal Care The study was also intended to establish the pattern of male involvement in antenatal care. Findings showed that only 46.9% (n = 200) of the men in this study ever accompanied their women to ANC and about 25.3% (n = 110) ever accompanied their women to ANC one to three times. Suggesting that though all the respondents were involved in their women ANC at the time of data collection, less than half of the men ever accompanied their women to ANC. This indicate that there is a trend of improvement in male involvement in ANC. This agrees with earlier research findings (Bhatta, 2013; Olugbenga-Bello et al., 2013). The present study findings are also supported by previous researchers who indicated that, of 2007 pregnant women attended ten different Hospitals in Zambia, only 11% of them were escorted by their husbands during antenatal care appointment (Kashitala et al. 2015). Even though many women prefer their partners escorting them to antenatal care services, more men still find it difficult going to the antenatal clinic with their wives (Yende, Van Rie, West, Bassett, & Schwartz, 2017). 5.7 Relationship between Attitudes, Subjective Norms, Perceived Behavioural Control and Behavioural Intentions of Men towards Male Involvement in Antenatal Care Behavioural intentions is grounded on attitudes which is determine by behavioural beliefs of the individual (Ajzen, 2015). This study found a positive significant relationship between men attitudes and their behavioural intentions (r = 0.438, p < .001), suggesting positive attitudes of men is associated with good behavioural intentions. Attitudes appear to be a basis for behavioural intentions (Lawton et al., 2012). 85 Determinants of Male Involvement in Antenatal Care Furthermore, the present study ascertained a significant positive correlation between subjective norms and behavioural intentions. This means high level of subjective norms amongst men is related with good behavioural intentions of men. Studies have demonstrated that subjective norms (positive subjective norms) are associated with behavioural intentions (Akulume & Kiwanuka, 2016). This appears consistent with the theory of planned behaviour that states that subjective norms is related to behaviour through behavioural intention (Ajzen, 1991). Moreover, perceived behavioural control was found in this study to have significant positive correlation with men behavioural intentions. Studies also indicates that perceived behavioural control has a positive correlation with behavioural intentions (Tengku Ismail et al., 2016). Even though perceived behavioural control is associated with behavioural intentions of men in this study, it was not found to be a significant predictor of male involvement in antenatal care in the logistic regression model. 5.8 Relationship Between Attitudes, Subjective Norms, Perceived Behavioural Control, Behavioural Intentions and Male Involvement. According to Ajzen, (1991) theory of planned behaviour, attitudes, subjective norms, perceived behavioural control has a relationship with behavioural intentions to perform a behaviour. This present study findings showed that there was indeed a positive significant association between men’s attitudes and male involvement in antenatal care (r = 0.257, p < .001). This finding agrees with the assumptions of the theory of planned behaviour which states that attitudes has a relationship with behaviour (Ajzen, 1991). However, findings of other studies have contradicted the assumption of the theory and what have been reported in the recent study. According to Tsehay, (2014), attitudes were not found to be significantly associated with male involvement in antenatal care. 86 Determinants of Male Involvement in Antenatal Care In addition, subjective norms are considered as the individual views of whether people who are deemed important to them approves or disapprove a certain behaviour (Ajzen, (1991). The current study indicated that subjective norms were found to have a positive significant association with male involvement in antenatal care (r. = 0.242, p < .001). That is to say, subjective norms have a positive influence on male involvement. The current study findings concurs with the perception that subjective norms is a major concern in most societies (Lewis et al. 2015; Singh et al. 2014;Thapa & Niehof, 2013). Moreover, perceived behavioural control is describes as the individual perception of whether performing a behaviour needs much effort or not (Ajzen, 1991). This study found that perceived behavioural control of men have a positive significant relationship with male involvement in antenatal care (r. = 0.159, p < .001). Thus, when men realized that performing male involvement in ANC is not difficult they will be eager to involve. In a related study where theory of planned behaviour was used, perceived behavioural control was found to have an influences on an individual behaviour (Tengku Ismail et al., 2016). In conformity with this findings other researchers Nyandieka et al., (2016) and Vermeulen et al., (2016) reported that a greater numbers of the men claimed it is difficult to involve in their women antenatal care activities because of far distances from their locations to the antenatal care facilities and cost of antenatal care services. Though these researchers did not measure relationships, one could envisage that these factors have an influence on male involvement in antenatal care that will have the potential of lowering male involvement in ANC. The present study also found behavioural intentions to have a significantly positive relationship with male involvement in ANC (r. = 0.261, p < .001). This could be as a result of the fact that behavioural intentions are an inspiring factor of behaviour (Ajzen, 1991). In addition, Ajzen (1991) indicated that behavioural intentions has a relationship with a behaviour of interest. 87 Determinants of Male Involvement in Antenatal Care 5.9 Predictors of Male Involvement in Antenatal Care Logistic regression analysis was conducted and the findings indicate that socio-demographic characteristics, attitudes, subjective norms and behavioural intentions collectively explained 26.7% of male involvement in antenatal care [R²= .267, x² (8) =95.046, p < .001]. Evaluation of the variables individually also indicate that marital status, educational level, number of children, attitudes, subjective norms and behavioural intentions were the significant predictors of male involvement in antenatal care. In terms of marital status, men who are married/cohabiting were less likely to accompany their spouses to ANC compared to those who were divorced or separated. This could be attributed to the fact that because these men are divorced or separated they want to accompany women to antenatal care in order to win their heart. Despite the fact that these men were less likely to accompany their women to ANC in this study, Rahman et al. (2015) in their study reported that married men were more likely to escort their partners to ANC. This could be linked to the socio-cultural context of the respondents. Additionally, the present study revealed that men who obtained senior high school level of education, were more likely to accompany their women to ANC than illiterate men. This could suggests that educated men may be exposed to knowledge and information and will do away with the negative attitudes and cultural beliefs and accompany their women to antenatal care (Davis & Davis, 2010). This corroborates with prior researchers from Bangladesh. Rahman et al. (2015), and Uganda Byamugisha et al. (2010), who reported that men’s level of education is a predictor of male involvement in ANC. Ditekemena et al. (2012) also affirmed that men who had 8 years and above of education were more likely to involve in women ANC than those having less than 8 years of education. This could perhaps be 88 Determinants of Male Involvement in Antenatal Care attributed to the exposure these men had about the outcome of male involvement within or outside the hospital through electronic media as a result of the education. Moreover, African men value children very much and will be responsible to ensure the safety of their women and children (Amos, 2013). In this study it is observed that men who have children were more likely to accompany their women to antenatal care. This suggests that men who have children understands the importance outcome of male involvement in antenatal care and will accompany their spouses to ANC. These findings are found to be consistent with Ampt et al., (2015) study who indicated that there was a significant relationship between number of children and male involvement in maternal care. However, these findings are not universal as Wai et al., (2015) reported that having more children were negatively related with males accompanying their women to antenatal care. This could be associated with the geographical context of the study area as the current study was conducted in a rural setting. Positive attitudes appear to be the driving force that influences the behaviour of many individuals. In this study men who had positive attitudes towards male involvement in ANC were more likely to accompany their spouses to ANC. This was reflected in the current study when majority 77% (n = 328) of the respondents had positive attitudes towards male involvement in antenatal care. Nevertheless, these findings are in contrast with a study of an earlier researcher who observed that men’s attitudes had no significant association with male involvement in antenatal care (Akinpelu & Oluwaseyi, 2014). The large sample size nature of the current study could be attributed to the disparities in findings. Additionally, the present study found that men with positive subjective norms are more likely to involve in their spouse’s antenatal care. Recent study also indicated that subjective norms is a predictor of behaviour (Kalolo & Kibusi, 2015). 89 Determinants of Male Involvement in Antenatal Care This finding is in conformity with a qualitative study in Mozambique Audet et al., (2016) who found that socio-cultural taboos and social pressures negatively affects male involvement in antenatal care. The same study noted that men believed it is culturally unacceptable for males to escort their partners to antenatal care, and that it demonstrates lack of control on the part of the man as the head of the family. Most men believed that antenatal care is a female obligation and that it is embarrassing to go to such environments (Kidero, 2014). This could have possibly led to the reflective low subjective norms of the respondents in this study. In addition, the study also highlighted that men who had higher behavioural intentions were more likely to accompany their wives to ANC. Generally, before an individual could perform any behaviour the person must have a positive or high behavioural intention about that behaviour. Consistent with the theory of planned behaviour, behavioural intention is an immediate precursor of behaviour (Kiriakidis, 2015). Interestingly, the perceived behavioural control was significantly associated with male involvement in antenatal care but did not emerge as a significant predictor of male involvement in the logistic regression model. In summary, the study established that most of the respondents have positive attitudes, negative subjective norms, positive perceived behavioural control and positive behavioural intentions towards male involvement in antenatal care. Though the men had goods scores on subjective norms, the total subjective norms appeared low. This indicates that the men are affected by their subjective norms. The findings additionally indicated that to improve male involvement in antenatal care the subjective norms of men need to be looked at. In harmony with the theory of planned behaviour, all the model constructs significantly predicted male 90 Determinants of Male Involvement in Antenatal Care involvement in antenatal care with the exception of perceived behavioural control which the theory suggest may not have a relationship with behaviour. 91 Determinants of Male Involvement in Antenatal Care CHAPTER SIX SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS This chapter reports the summary of the whole study, discusses implications, limitations, conclusion, and provide recommendations based on the study findings. 6.1 Summary of the Study The health of every pregnant woman is key to the development of any nation. Thus, the study investigated the determinants of male involvement in antenatal care in the Bawku Municipality, Ghana. Quantitative study method using a cross sectional survey design was employed to gather data from 439 respondents in the Bawku Municipality of Ghana. A structured questionnaire was used for data collection. Statistical Package for Social Sciences (SPSS) version 22.0 was used to analysed the data. The relationship between attitudes, subjective norms, perceived behavioural control and behavioural intentions were tested using Pearson Product Movement Correlation (Pearson’s r), the relationship between men attitudes, subjective norms, perceived behavioural control, behavioural intentions and male involvement was tested using Spearman Rho Correlation and binary logistic regression used to establish the predictors of male involvement in antenatal care. The findings indicated that the men had high attitudes towards antenatal care with a total attitudes mean score of 131.289 out 196 (SD = 46.24), high perceived behavioural control total mean score 95.34 of 147 (SD = 37.47) and high behavioural intentions towards male involvement in antenatal care with a total mean score of 9.71 (SD = 4.55). This implies that the men had positive attitudes, perceived behavioural control and behavioural intentions towards male involvement in antenatal care. However, the subjective norm total mean score 92 Determinants of Male Involvement in Antenatal Care was low 79.73 of 196 (SD = 56.42), indicating that the men had negative subjective norms. Again, about 53.1% (n = 226) never accompanied their spouses to ANC before. The study established a moderate positive but significant correlation between attitudes and behavioural intentions, subjective norms and behavioural intentions and a weak and positive association between perceived behavioural control and behavioural intentions of men towards male involvement in antenatal care. The study also found a weak but positively significant relationship between men’s attitudes, subjective norms, behavioural intentions and male involvement in antenatal care. In addition, the study also established a positive but very weak significant relationship with perceived behavioural control and male involvement in antenatal care. The men’s socio-demographics (marital status, educational level, number of children), attitudes, subjective norms and behavioural intentions were the predictors of male involvement in antenatal care. These results are consistent with the theory of planned behaviour constructs that are used to predict behaviour. Except the perceived behavioural control construct that had a significant relationship with the men’s behavioural intentions and male involvement in antenatal care but did not significantly predict male involvement in antenatal care. Based on the findings, the theory of planned behaviour is useful in predicting male involvement in antenatal care. 6.2 Implications of the study The study findings have implications for midwifery practice, the Hospital management, policy formulation and nursing /midwifery research. 6.2.1 For Midwifery Practice The findings revealed that about 86.4% of men wanted to be seen at the antenatal clinic first with their spouses before those who come without men accompanying them. This means that the men do not understand the rules of the health care delivery system. Therefore, the 93 Determinants of Male Involvement in Antenatal Care midwives need to encourage the men and explain to them to understand the right for equal treatment for all clients and the rule for first come, first serve. However, the men should be made to understand that priority would be place on clients who needs emergency attention. 6.2.2 For Hospital management The study found that about 88.1% of the respondents prefer the antenatal care units to have more space to accommodate them, and the facilities should be close to them to enable them participate in their women ANC. This means that the health facilities in the Bawku Municipality do not have enough space to accommodate men who accompany their spouses to the antenatal clinic. This has the tendency of deteriorating the existing low male involvement in antenatal care in Ghana. Thus, the various Hospital management boards in the Bawku Municipality need to expand their antenatal care units in order to accommodate the pregnant women and their spouses. This will help improve male involvement in antenatal care. 6.2.3 For Nursing/ Midwifery Research The hub of human knowledge and evidence oriented practice is empirical research. Midwives are required to be research centred in order to detect major problems of pregnant women and their men. The training the midwives have obtained in rendering antenatal care services need to be complemented with research to enable them identify antenatal related issues and use scientific approach in dealing with the problems. Therefore, it is necessary for the midwives to conduct research on issues surrounding male involvement in antenatal care to unravel major barriers of male utilisation of antenatal care services. 6.3 Limitations The current study was conducted among men who accompanied their women to antenatal care clinic in four health facilities in the Bawku Municipality. Only one Municipality out of 94 Determinants of Male Involvement in Antenatal Care the two hundred and sixteen metropolitan, municipal and district assemblies in Ghana to identify the determinants of male involvement in antenatal care. As such these findings may not depict the entire men situation in Ghana. Another limitation of this study is that the study was a cross sectional survey as a result, the study cannot establish cause and effects. The study also used convenience sampling technique to select the respondents from the selected health facilities. Hence the findings may not reflect the views of the entire total population in the Bawku Municipality. The study used respondents aged 15years and above to calculate the sample size whilest the inclusion criteria was men 18years and above. Thus the sample size might have been over estimated. 6.4 Conclusion This study was the first to be conducted in the Bawku Municipality to establish the determinants of male involvement in antenatal care. Findings of the study indicated that the extent of male involvement in antenatal care in the Bawku Municipality is not the best. It revealed that men involving in women antenatal care services in the Bawku Municipality are faced with a variety of issues. Though the men attitudes, perceived behavioural control and behavioural intentions towards involving in women antenatal care were good, negative subjective norms, inadequate ANC space and long distances to the health facilities affected their involvement. Despite these challenges, the study established that there is a little improvement in the male involvement situation in the Bawku Municipality. However, for male involvement in antenatal care to fully improve in the Bawku Municipality, the negative subjective norms and the proximity to the ANC units issue should be addressed. This ultimately would translate into effective antenatal care and improved maternal health 95 Determinants of Male Involvement in Antenatal Care that will help reduce maternal morbidity and mortality and propel the achievement of the Sustainable Development Goals three (3) by the year 2030. 6.5 Recommendations Recommendations are made to the following institutions based on the research findings: The Ministry of Health (MOH), Ghana Health Service (GHS) and Christian Health Association of Ghana (CHAG), Nurse/ Midwives Researchers. 6.5.1 The Ministry of Health The Ministry of Health should consider:  Enacting policies that will include male compulsory involvement in women antenatal care.  Ensure that antenatal care clinics are constructed in a manner that there is enough space to accommodate both men and women to help scale up the level of male involvement in antenatal care.  Ensure antenatal care clinics are evenly distributed across the length and breadth of Ghana to accelerate easy access of antenatal care services to all men and their spouses. 6.5.2 Christian Health Association of Ghana (CHAG) and the Ghana Health Service (GHS) The CHAG and GHS should:  Enroll programmes that seeks to encourage male involvement in antenatal care  Develop a public sensitization programmes to help educate the public especially men on the importance of male involvement in antenatal care and the need to discard negative subjective norms regarding male involvement in antenatal care. 96 Determinants of Male Involvement in Antenatal Care 6.5.5 Nurses /Midwives Research Nurses and midwives should:  Use qualitative method to research on the determinants of male involvement in antenatal care.  Consider including both men and women in their future research to have a multifaceted view on male involvement in antenatal care. 97 Determinants of Male Involvement in Antenatal Care REFERENCES Abramson, J., Dawson, M., & Stevens, J. 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International Perspectives on Sexual and Reproductive Health, 39(01), 032–041. https://doi.org/10.1363/3903213 113 Determinants of Male Involvement in Antenatal Care APPENDIX A ETHICAL CLEARANCE 114 Determinants of Male Involvement in Antenatal Care APPENDIX B – INTRODUCTORY LETTERS 115 Determinants of Male Involvement in Antenatal Care 116 Determinants of Male Involvement in Antenatal Care 117 Determinants of Male Involvement in Antenatal Care APPENDIX C – DEPARTMENTAL APPROVAL LETTER 118 Determinants of Male Involvement in Antenatal Care APPENDIX D– CONSENT FORM 119 Determinants of Male Involvement in Antenatal Care 120 Determinants of Male Involvement in Antenatal Care 121 Determinants of Male Involvement in Antenatal Care 122 Determinants of Male Involvement in Antenatal Care APPENDIX E: RESEARCH QUESTIONNAIRE UNIVERSITY OF GHANA SCHOOL OF NURSING AND MIDWIFERY 123 Determinants of Male Involvement in Antenatal Care 124 Determinants of Male Involvement in Antenatal Care 125 Determinants of Male Involvement in Antenatal Care 126 Determinants of Male Involvement in Antenatal Care 127 Determinants of Male Involvement in Antenatal Care 128 Determinants of Male Involvement in Antenatal Care 129 Determinants of Male Involvement in Antenatal Care 130 Determinants of Male Involvement in Antenatal Care 131 Determinants of Male Involvement in Antenatal Care 132 Determinants of Male Involvement in Antenatal Care 133