Male involvement in sexual and reproductive health in the Mendi district, Southern Highlands province of Papua New Guinea: a descriptive study

Whilst global recognition of the importance of male involvement in sexual and reproductive health (SRH) emanated from the 1994 International Conference on Population and Development held in Cairo [1], it is a relatively new concept in Papua New Guinea (PNG). In PNG women have been the principal targets of sexual and reproductive health services over the past decades and men’s participation has been minimal. In rural areas, where more than 80% of the population live, the availability of quality sexual and reproductive health services for men is inadequate. Service utilization for SRH services has been low. National annual average figures for 2006–2010 for family planning (couple protection rate per year) were 83/1000 women, antenatal coverage 67% and supervised deliveries less than 50% [2]. This is reflected in very high maternal (733/100,000 live births^a) infant (56.7/1000 live births) and neonatal (29.1/1000 live births) mortality rates [3].The highest maternal death rates have been reported from the highlands region. The majority of maternal deaths are preventable with access to services.

A preliminary, smaller and unpublished study in the Southern Highlands by the first author strongly suggested that lack of male involvement and support for utilization of safe motherhood services is seen by women as a barrier to accessing services. (Project for Diploma of Public Health, University of Papua New Guinea 2010). The Southern Highlands Province has experienced an increase in sexually transmitted infections (STIs), including HIV/AIDS, suggesting poor male involvement in HIV/AIDS and STI prevention. HIV prevalence in PNG is currently estimated at 0.92% with a preponderance of females [4]. Heterosexual sex is by far the commonest mode of transmission [5]. HIV and STIs are more easily transmitted from men to women than women to men [6, 7]. Women in PNG are at risk of contracting STI and HIV because of cultural and social norms by which wives cannot decline sexual intercourse with their husbands nor can they insist that their partners use condoms. Whilst there are differences between some aspects of HIV/AIDS in different countries it is almost certain that in PNG as in Sub-Saharan Africa the majority of HIV positive women have been infected by their stable partners [8]. Whilst pregnancy child birth and the rearing of children as well as domestic chores are regarded as women’s responsibilities husbands play a pivotal role in decision making within the home and obtaining their involvement in and support for interventions to improve sexual and reproductive health for themselves and their wives is critical [9, 10].

A holistic approach is required. If men are involved and supported as equal partners better outcomes in sexual and reproductive health indicators, such as contraception acceptance, safer sexual behaviours, use of reproductive health services and reduction in SRH related morbidity and mortality, can be expected [11]. Results from Ghanaian [12] and Indonesian [13] studies demonstrate that a program that focuses on improving men’s knowledge of SRH for themselves and their partners is likely to be more effective than one that targets women. Involving men in SRH requires in-depth knowledge and understanding of men’s sexual and reproductive health perspectives [14, 15]. This study aimed to explore and assess the knowledge, attitude and role of men from the Mendi district of Southern Highlands province in regards to antenatal care, supervised birth, family planning and prevention of HIV/AIDS/STI and to assess the service providers’ capacity to involve men in its programmes.

In this prospective descriptive study data collection came from three sources; individual interviews with married men, interviews with health workers and focus group discussions with village leaders.

The study population was married men between the ages of 15–44 currently residing in a household with their wife/wives and who had fathered at least one child. (In this context a wife is defined as a woman living with a man in a non-casual relationship which is accepted within the local culture).

Council wards were selected by the lucky pick technique [16]. The names of all the council wards in each of the three Local Level Government areas were written on individual papers which were folded and put into the respective area box. Following mixing ten wards were selected from each box [16]. For each of the 30 selected wards, a list of men conforming to the selection criteria was provided by the local health workers and 7 men from each ward were selected using the same technique. In-depth structured interviews of the 210 selected men, using a pretested questionnaire were conducted by trained research assistants.

Data regarding service factors were collected from officers in charge of six district health facilities using semi-structured, self-administered questionaries to capture information on the types of SRH services offered at each health facility, whether those services were targeted at men or women, and the health workers’ views and experiences of working with men. Purposive sampling was used to select Officers in Charge (OICs) known to have broad knowledge and experience in all aspects of health care delivery in their establishment. The questionnaire was distributed to the participants and the researcher explained the instruments and clarified any misunderstandings while the respondents answered the questions.

Two focus group discussions were held with 12 village leaders from Upper Mendi and Lai Valley local level government areas to seek views on specific issues and to validate findings from the individual interviews. Purposive sampling was used in the selection of participants who had different leadership roles but possessed similar social and cultural backgrounds, were well acquainted with the social and health issues in their respective communities and had comfortably engaged in dynamic discussions. A Digital Voice Recorder was used in recording all the discussions. The principal investigator moderated the FGD while one of the research assistants did manual recording.

Quantitative data from individual interviews were processed and analysed using the Epi Info (version 3.5.1) computer program. A descriptive analysis was performed for each variable. Chi-square or Fisher exact test was performed to explore the relationship between selected variables.

Qualitative data from individual interviews, self-administered questionnaires and FGDs were processed and analysed using thematic analysis following the model described by Parahoo [17] and the standard coding procedure outlined by Strauss and Corbin [18]. Open and axial coding strategies were applied in identifying major themes and sub themes that emerged from the interview data. The major themes for each variable were then summarized in master sheets indicating frequency of responses for each category. Data from non-participant observations and informal discussions were summarized and analysed manually. Main themes were identified. The data from the FGDs were transcribed into a note book. All recorded discussions were transcribed into Pidgin and then translated into English. This was done by the principal investigator and research assistants after each discussion. Only notes relevant to the study were transcribed and summarized in themes and used for examining relationships with other variables. Issues felt to be important which surfaced in the discussion surrounding each theme were identified and written in narrative form.

Ethical Clearance to conduct this study was obtained from the University of Papua New Guinea (UPNG) School of Medicine and Health Sciences, Research Committee. Informed consent was obtained from study participants, who were assured of confidentiality which was ensured by the use of anonymous questionnaires. Verbal consent was also sought from the respective community leaders prior to the focus group discussions.

Illiteracy, inadequate knowledge, cultural factors and lack of appropriate services were found to have negatively influenced male participation in SRH. It was widely considered that pregnancy, child birth and rearing of children are solely the role of women. Priority for many men was given to social obligations in order to gain recognition and maintain their status in the community. Though men are not direct beneficiaries of safe motherhood services, their understanding and participation and support is crucial in order for women to access basic reproductive health services. Whilst many other factors contribute to SRH and Child Health indicators the low level of male involvement is a major determinant.

In many societies in PNG, including those in the study district, the patriarchal structured society, in which gender rights strongly favour men, predominates. Traditionally men have been and still are the principal decision makers in social, economic and political aspects of family and village life. In most societies gender determines the roles and responsibilities of men and women and these cultural factors were found to significantly influence men’s sexual and reproductive behaviour and attitudes in this study. Many men in our study considered safe motherhood to be women’s responsibility. Lauglo noted that understanding gender systems benefits from examining the relationships between men and women as well as their respective roles [19]. This is important when developing interventions where gender norms are a barrier but change is only likely to occur with improved education and with efforts to encourage male involvement in all aspects of reproductive health.

In the study area, as in many other parts of PNG, societal norms (taboos) prohibit males from assisting and witnessing births and some men indicated that the presence of male health workers at a delivery facility was a reason for their wives to deliver in the village. Health authorities have tried to ensure that every facility has female staff, but this has not always been possible in isolated areas.

Men’s literacy, even when loosely defined as self-reported ability to read and write - was strongly associated with their knowledge of SRH issues, discussion with their wives, and with their wives’ utilisation of SRH services. The wives of the respondents who were knowledgeable about ANC and supervised births were more likely to access these services than were those of many of the men who were unaware of their importance (p < 0.001). These findings were similar to studies from India [20] and Nepal [21] where men who received antenatal education provided better support to their wives, which led to increased ANC attendance and health facility delivery.

Although many men had heard about FP, only a small proportion of participants and their wives were using contraceptives. Many were unaware of the importance and benefits of family planning. Factors such as wanting more children and fear of religious condemnation and of partners having extra marital relationships hindered couples from accessing contraceptives. Many who would have benefited from the use of condoms did not access them due to misunderstanding of their dual functions as contraceptives and as.a means of disease prevention.

Vasectomy as a form of family completion was not known by the participants in the study and few knew of tubal ligation. Many expressed an interest in vasectomy and wanted more information on the method. Counselling and quality services associated with strong information and sensitization campaigns on vasectomy were proven to be successful in African countries [22] and vasectomy programmes have been well accepted in some areas of Papua New Guinea [23].

Men’s perspectives on FP in this study are similar to those reported from Nigeria where men allowed women to negotiate future FP contraceptives only after bearing the required number of children [24]. This could be due the misconception that female methods result in permanent sterilisation and family planning education should target such issues. In many rural areas, it is difficult to maintain contraceptive continuity, especially with short term methods. Methods such as IUDs and implants are more suitable for women in these rural areas, but are not widely available in PNG.

Spousal communication is important in family planning. Condoms, periodic abstinences and withdrawal require communication and negotiation between partners to be used effectively [25]. Our study found that men sometimes deliberately avoided discussions when wives tried to raise the issues. Absence of spousal discussion makes it difficult for women to negotiate contraceptive use, a common determinant discovered in many reproductive studies [22]. Spousal discussion is likely to increase with improved education of both males and females and with improved male involvement in SRH services.

Involving men, and obtaining their support and commitment to family planning, is of crucial importance. PNG cultural gender roles are similar to those in many African [22] and Indian [26, 27] societies where men are responsible for decisions on fertility and contraceptive use. The husband’s support is a good predictor for future practice and continued use of FP methods [22].This suggests the need for couple centred family planning and reproductive programs. Janine reported from a study in Indonesia that couple centred approaches to FP are viable in patriarchal societies [28].

The risk of contracting HIV among women in a non-high risk group has been found to be largely determined by their male partner’s behaviour [29]. In PNG it is assumed that most transmission is from husbands to wives. Thus engaging men more extensively in HIV prevention is likely to reduce women’s risk of HIV infection [30]. Most participants were aware that HIV/AIDS is transmitted during sexual intercourse with an infected person and they were familiar with the prevention strategies of one sexual partner and avoiding prostitutes. Knowledge of prevention of HIV through the use of condoms was acknowledged by many but did not necessarily translate into safe sex behaviour. Half of those that had sexual relationships with non-cohabiting partners did not use condoms. Such behaviour poses risks for wives who, owing to cultural norms, are not able to negotiate safe sex.

Domestic violence may result when the HIV status of women is disclosed to husbands, especially when the husband is negative [31]. It is important for both partners to know their HIV and VDRL status so that appropriate care can be sought from service providers and so that steps to prevent Mother to Child Transmission can be taken. Unfortunately HIV and VDRL screening are not widely available outside of main centres of PNG.

Men’s understanding of HIV infection and their attitudes towards prevention are key factors in containing the disease and in preventing infection of their wives and children. Most study respondents have stable family lives but some occasionally exhibit high risk sexual behaviour. Many indicated that they would be afraid to disclose their HIV/AIDS status to their wives or others if they were found to be positive.

The understanding that HIV/AIDS is a deadly disease for which there is no cure had apparently prompted some men to change their sexual behaviour. They wanted to be faithful to their wives. However many of those in a polygamous marriage did not view this as a threat to HIV/STI transmission but as a positive solution to reducing the risks of contracting HIV/STI infections. A Kenyan study showed that behavioural change messages directed at women had a low potential for preventing STIs and HIV/AIDS [32]. Such programmes directed at men are more likely to impact their attitude and sexual behaviour.

The concept of male involvement in SRH is still largely underdeveloped in PNG. Services currently available for men at rural health facilities are inadequate. In most health facilities there is no involvement of men in Safe Motherhood programmes. Many health workers are uncomfortable working with male clients in SRH programs due to lack of appropriate knowledge and skills. Condoms are often not readily available and even if they are the fact that they are often distributed by female health workers is a barrier to access. The study found that although men were willing to participate in SRH activities the environment was not conducive to their involvement.

The association between men’s literacy and their wives‘SRH practices was striking. Whilst much focus is put on the importance of female education in improving health outcomes the education of males is also clearly important. Literacy enables access to information relevant to health. It is important that education on issues of sexual and reproductive health be included at all levels, beginning at primary school.

Inadequate knowledge, cultural factors and lack of appropriate services adversely affect men’s involvement in their wives’ and their own sexual and reproductive health. Implementing the following recommendations is likely to improve men’s involvement and consequently improve the sexual and reproductive health of their wives and their communities.

^aThere has been debate as to the accuracy of this figure but even if the more recent estimate of 250/100 000 (2008 adjusted estimate from Unicef State of the World’s Children 2012) is more accurate it is still alarmingly high.