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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 8  |  Page : 1055-1062

Which men have better attitudes and participation to family planning services? A study in primary care settings from Northern Turkey


1 Departent of Public Health, Hitit University, Çorum, Turkey
2 Department of Public Health, Faculty of Medicine, Erciyes University, Kayseri, Turkey
3 Department of Medical Education, Faculty of Medicine, Erciyes University, Kayseri, Turkey

Date of Acceptance19-Mar-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Assoc. Prof. G Yilmazel
Department of Public Health, Faculty of Health Sciences, Hitit Universiity, Çorum
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_352_17

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   Abstract 


Background: Turkey is the third most populous country of the European region located at the crossroads of Asia, Europe, and the Middle East. In Turkey, approximately 2 million pregnancies occur every year. Half of the pregnancies are involuntary, and five out of every 100 pregnancies end with wanted abortion. There are limitations in access to modern methods in the north of Turkey. This study was aimed to determine the factors associated with better attitudes and participation to family planning (FP) services in primary care settings from Northern Turkey. Materials and Methods: This cross-sectional study, based on primary care settings, was conducted in the Middle Black Sea Region of Turkey with 400 married men. Male attitudes and participation were measured by a questionnaire form. Chi-square testing and logistic regression analyses were applied. Results: We found that male participation was present in 302 participants (75.5%), and 363 participants (90.8%) approved the use of FP. Male participation was significantly different by age, occupation, education, marriage age, spouses' education and occupation, and attitudes towards FP. Based on multivariate analysis, male participation was significantly associated with spouses' level of education, employment status, currently using FP, and the perception of spousal communication. Conclusion: Better participation existed among participants with higher educated spouses, employed spouses, current users of FP, and the better self-perception of communication.

Keywords: Attitudes, family planning, male, participation


How to cite this article:
Yilmazel G, Cetinkaya F, Nacar M, Baykan Z. Which men have better attitudes and participation to family planning services? A study in primary care settings from Northern Turkey. Niger J Clin Pract 2019;22:1055-62

How to cite this URL:
Yilmazel G, Cetinkaya F, Nacar M, Baykan Z. Which men have better attitudes and participation to family planning services? A study in primary care settings from Northern Turkey. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 21];22:1055-62. Available from: http://www.njcponline.com/text.asp?2019/22/8/1055/264409




   Introduction Top


Turkey is the third most populous country of the European region located at the crossroads of Asia, Europe, and the Middle East.[1] Besides having a young population, the total population was 78.741.053 by the year 2015. Half of the population are male, and the percentage of married men is 63.9%. It is estimated that the total population will reach 93,475.575 by 2050 according to the projections of Turkstat.[2] In Turkey, approximately 2 million pregnancies occur every year. Half of the pregnancies are involuntary, and five out of every 100 pregnancies end with wanted abortion.[3] Regional differentiation in the level of fertility is evident. The lifestyle shows similarity in the majority of metropolitan areas in Western countries. The slum areas of Metropolitan cities and the rural areas of the country have a more traditional lifestyle. There are limitations in access to modern methods in the north of Turkey. The prevalence of modern methods was in the low rate (42.3%) and the traditional methods were in the high rate (33.1%) in the north of Turkey.[3],[4]

FP is a dynamic part of reproductive health that requires the use of regular and continuous contraceptive methods, and its success depends on the males' participation. Males enter into this process by taking the responsibility with their spouses, by using contraceptives for themselves (condom, vasectomy) and by encouraging their spouses to use it.[5] In developed as well as developing countries, the participation of men in FP services is not at the desired level.[6],[7] Turkey has social and cultural variety and embodies modern and a traditional lifeline.[3] The fact remains that males are the head in 85% of the households in Turkey,[3] and they are basic decision-makers on contraception and fertility-related preferences as in the world.[8] In Turkey, male participation in family planning (FP) is not at a sufficient level, and also regional disparity is in existence.[3],[8] Studies regarding this area documented lower participation and acceptable attitudes from the countries in Southern Asia (Pakistan, India, Bangladesh), Sub-Saharan Africa (Ethiopia, Kenya, Nigeria), and the Middle-East (Iran, Jordan).[9],[10],[11],[12],[13],[14],[15],[16] In Turkey, prior studies have noted quite different patterns and regional variations. A study from the northern part of the country [17] indicated adequate participation, while a study from the eastern [18] part revealed lower participation and a moderate attitude and another study from the south-eastern area reported lower participation and a negative attitude.[19]

Traditionally, men are known for their decision-making roles. A primary concern of men is eliminating the barriers of contraception use. Roles of men can be defined within the scope of gender equality focusing on key fields that include sharing the burden of children care, supporting the mental health of women, preventing sexually transmitted infections by regular condom use, facilitating the accessibility, availability, and continuity of services for women in the new global agenda.

This study was aimed to determine the factors associated with better attitudes and participation to FP services in primary care settings from Northern Turkey.


   Materials and Methods Top


Study design

This cross-sectional study based on primary care settings was conducted in an urban area of Çorum city. Çorum is a province which is remarkable for the Hittite Archaeology and is established in the Middle Black Sea Region in North of Turkey. The city has a large industrial estate. Most members of the population are civil servants, artisans, and workers. According to the Turkish Statistical Institute (Turkstat) data for 2014, the estimated population in the center of Çorum was 275.610 where 106.167 (38.5%) being males aged ≥15, of which about 62.376 (58.8%) were married.[20]

Study site

This study was carried out from April to June 2015 at the two primary care clinics. Primary health care services are provided through 20 family health centers (FHC) and one community health service. General practitioners work in FHC, and approximately 3000 − 4000 people are registered to each practitioner list.

Recruitment of participants

In Turkey, marriage is the beginning of a socially accepted cycle for giving birth, so contraception use is not common among unmarried men.[3],[21] The study population consisted of 2283 married men dwelling in two FHC areas' urban region of the Çorum. Assuming that the prevalence of male participation was 55% in Turkey, estimated sample size at a 5% level of significance, and 80% power would be 389. Sampling was conducted during the day as the centers only operated during these practice hours. Recruitment started from 8 am to 5 pm on weekdays. Married literate men between the ages of 25 − 64, Turkish speaking, with spouses aged between 15 and 49, with at least one child due to determine fertility features were included in the study. Illiterate men, and men with visual and speech impairment, or with a psychiatric disorder, were excluded from the process. Men involuntary for participation in the study were not included. The study was continued with 400 married men. Interviews were arranged by ten trained male nursing students in private rooms at both the FHC; verbal and written consent was also obtained. In a a half-hour interview, participants were asked face to face. Participants were informed that we were studying, how husbands' look at contraception methods and how they displayed attitudes towards and participation in decisions related to FP.

Measures

A two-phased interview questionnaire was prepared to question about the socio-demographic characteristics, features related to reproductive health, attitudes towards, and participation in FP service. The questions were developed after the literature review. Before the study, the questionnaire was piloted with ten married men. For the purpose of participation, participants were asked “Have you ever participated in family planning services with your wife at least one time? − answers as “yes and no”. The section on attitudes contained thirteen questions, some of the statements required a two-choice answer, i.e., yes, no and some of them required a three-choice answer, i.e., agree, disagree, and have no idea. Example questions in order to identify attitudes of the men were: Should only women take the responsibility of family planning? The content validity of questions regarding attitudes and participation was assessed by experts on gynecology.

Independent variables

The respondents were divided into three age groups (≤34 years, 35 to 49 years, and ≥50 years). The level of education completed by the respondents was categorised into literate, primary school, secondary school, or high school and university. Occupations were grouped as: worker, civil servant, and other (farmer, sales, and self-employed). The level of spouses' education was divided into literate, primary school, secondary school or high school, and university, and occupation of spouses grouped as: civil servant, house-wife, and other (farmer, worker, and self-employed).

Dependent variable

The respondents were divided into two groups according to whether they were or were not participated in reproductive health. Male participation in reproductive health was defined as at least accessing reproductive health care services with their spouse.

Statistical analysis

Data management and analysis were performed using SPSS software for Windows (version 22). The associations between the variables were determined using the χ2 test and logistic regression. Bivariate analyses were performed for male participation (dependent variable) and each independent variable. Logistic regression analysis was used to determine the factors that affect men's participation in FP service. The P values were considered as significant at the level <0.05.

Ethical approval

The study was carried out in accordance with the Declaration of Helsinki, and ethic committee approval was given by the Erciyes University Ethic Committee.


   Results Top


A total of 400 respondents were enrolled in this study. The response rate was 83.3%. [Table 1] reports demographics and reproductive characteristics with attitudes towards FP of population. Their age ranged between 25 and 64 years with the mean 36.2 ± 10.6 years. Nearly 40.0% had university degrees, and the main job of men was civil servant (44.3%). Approximately, half of those reported that their spouses had education under the level of high school, and two-thirds of the respondents (64.5%) said that their spouses were a housewife. The mean age of the first marriage was 24.0 ± 3.4 years. The average number of living children per man was 2.3 ± 1.6, and the average desired number of children was 2.8 ± 1.05.
Table 1: Demographic and reproductive characteristics with the attitudes towards family planning among men

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Among men, 75.5% said that they participated in FP service with their spouse. The majority of respondents reported that they approved the use of FP methods. The most common reason for approval was for limiting birth. Male-specific effective method usage was low, and women mostly shouldered the responsibility for using contraception. As can be seen from [Table 1], a number of issues were identified to not approve FP methods. Four reasons (have no knowledge, being sinful, disadvantages, no accessibility) were a considerable amount of handicaps signified by 26.5% of the respondents. [Table 2] reports analysis of comparing the demographics/attitudes of the male population to participate in FP. Participation in FP service was present in 302 participants (75.5%). Younger participants (<35 years of age) had the highest participation in FP service. Participation decreased with age. Education and occupation were also associated with participation. The lowest participation was present among those with < high school completed, and the highest participation was present among civil servants. Participants who married after the age of 24 had higher participation than others. Spouses' education level and occupation were associated with the participation. Participation was more frequent in those with higher education and in civil servants. Among participants, who perceived responsibility, making decisions, and exchanging ideas on contraception as together had higher participation. Conversely, participation of those who had bad spousal communication and those with negative attitudes on FP services were less frequent.
Table 2: Analysis of comparing the demographics/attitudes of the male population to participate in family planning

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[Table 3] lists the factors selected for the model with the estimated odds ratios (ORs) and 95% confidence intervals (CIs). The multilevel logistic model for male participation showed that the probability for participation was significantly higher among spouses with university educated (OR, 3.81; 95% CI, 1.02 −7.26), employed (OR, 4.58; 95% CI, 0.48 −8.83), and among men those with current users of FP (OR, 3.11; 95% CI, 1.35 −7.15) and men with a good spousal communication (OR, 1.78; 95% CI, 0.99 −2.85).
Table 3: Factors associated with male participation, odds ratios (ORs), and 95% confidence intervals (CIs)

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   Discussion Top


This study was designed to assess the factors associated with attitudes and participation to FP services of literate married men in primary care settings in a Northern city of Turkey where it has not previously been studied.

Our study showed that men participation was present in three out of the four participants (75.5%). Based on the multivariate analysis, male participation was significantly associated with the level of education, occupation status, currently using FP, and the perception of spousal communication.

The current study confirms previous studies that have shown an association between socio-demographic characteristics, attitudes, and male participation. Evidence suggests that several factors influence male participation in FP services. Educational status, occupation, currently using FP, discussing FP with their wife, spousal communication, approve FP methods, support the use of FP, and encourage the use of FP were the consistent variables with other research.[22],[23],[24],[25],[26] What is interesting in this study is that male's education and occupation didn't influence the participation decisions in FP.

The most important relevant finding with previous studies was that of the high approval of FP.[22],[27],[28] Contrary to prior Turkish studies, this study reflects the positive and supportive attitudes towards FP especially in terms of participation and decision-making.[27],[29] It can thus induce that quantum leaps related to social and health transformations make a great contribution from men's perspective in Turkey.

Attitudes and participation of men in FP have been documented in previous studies from different nations.[14],[15],[30] The findings in most studies have met on common ground that males' participation is poor, although attitudes are positive and acceptable.[14],[15],[30] In this study, a higher proportion of FP method responsibilities belonged to women. From another aspect, husbands also had an intolerable rate of sharing the responsibility by using effective (condom and vasectomy) methods which were similar with other Turkish studies.[17],[21],[27],[31],[32],[33] Women carry the burden of FP still in Turkey, as so around the world.[12],[13] This result can originate from a patriarchal family structure and strong cultural effects in Turkey. One remarkable finding was that most of the participants approved FP methods to limit births instead of spacing births. This rather contradictory result may be caused by a knowledge gap on the intended purpose of FP. However, this is actually conflicting with many other studies from other regions, such as Sub-Saharan Africa.[12] Men are probably considering the FP as a family size reduction method because of economic imperatives. Anecdotally, 13.3% of the men had no information about why they didn't use FP. Taken together, these results suggest that a lack of knowledge and awareness were important problems for modern contraception, and more education is needed on the importance of birth spacing.

One anticipated finding was the influence of the spouses' demographic characteristics (education level and occupational status) on male participation. Although female characteristics are a major area of interest within the field of male attitudes, few have investigated the autonomous factors of women.[34] Our findings are evidence that male participation in FP services is significantly associated with women's characteristics. A possible explanation for this might be that gender indicators such as education level and occupational status can shape males' attitudes positively via the empowerment of women.

Several limitations may restrict the broader application of this study. The study sample was sequentially selected, but only reflects one city in northern Turkey. Participants were selected from a primary care setting. The major limitation of this study is the absence of unmarried and divorced men. Since the study was limited to husbands, it was not possible to verify their information without their spouses.


   Conclusion Top


Men had positive attitudes towards FP with high rates related to participation. Better participation existed among participants with higher educated spouses, employed spouses, current users of FP, and better self-perception of communication.

Practice implications

Women education and labor force participation are important for male participation in family planning (FP). Better educated women's husbands tend to be more participator in FP. Husbands married with women skilled labour tend to be more participator in FP.

Policies and programs are needed to the extent and impact of male participation. Education of women and opportunity for employment are especially important. Also, health professionals should focus on couple-oriented educations and epidemiological research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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