Abstract: This study was done to explore the effect of women`s group counseling on knowledge, attitude and practice of their husbands concerning family planning in Zahedan in 2002. A quasi-experimental study (before and after) was carried out. Forty-four married women with two or more children who had not used contraceptive methods were non-randomly selected from three Health Centers. Before intervention, women and their husbands were interviewed to complete a questionnaire to determine their educational needs, then the women attend three sessions in 5 8-9 member groups. One month after intervention they were asked to complete the same questionnaire and a check list was filled. The mean score, Standard Deviation (SD), paired t-test, Mc-nemar and Chi-square were used for analysis. The finding showed significant difference between the mean scores of knowledge (p<0.001) and attitude (p<0.001) of both of women and their husbands before and after intervention. Moreover, 43% of the couples used one of the modern contraceptive methods after intervention (p<0.00001). Statistic paired t-test with p<0.001 showed that the difference between the knowledge and attitude scores before and after the intervention is significant. Moreover, 43% of the couples used one of the methods after intervention (p<0.00001). According to the results, wives` counseling is recommended to enhance men involvement and to improve family planning programs.
INTRODUCTION
Reproduction is a dual commitment, but, so often in much of the world, it is seen as wholly women’s responsibility[1]. The role of men has always been considered to dominate in the decision-making process pertaining to women’s fertility and birth spacing[2]. The program for action globally endorsed at the International Conference on Population and Development (ICPD-94) emphasized the need for equity in gender relations, with a special focus on men’s shared responsibility and active involvement to promote reproductive and sexual health[3]. This has led researchers to redirect their attention to couples instead of individuals as the focus of such programs[4]. Therefore, concentration on men like women is obviously an inevitable necessity[5]. Getting men involved in the family planning programs will lead to an increasing in using contraceptive methods and consequently will improve the continuous use of the methods[6].
In many studies it was found that spousal communication about family planning should be developed as a component of family planning programs and spousal communication does, indeed, predict contraceptive behavior, even when other factors are controlled[7-10].
In other studies it was reported that women also perceive men’s participation in contraception as a support for them to use contraceptive methods that are highly efficient[11-12].
Research reports from Turkey and Senegal noted that the main factors affecting contraceptive use among men were misconceptions and concerns about health-related risks and for women, were discussion with their husbands about family planning[13,14].
One proper way for health workers to promote the women’s knowledge is consultation[15]. Because consultation is a way to help the person to make a conscious and voluntary decision about family planning[16].
According to one report from Turkey found that only 16% of the women decided about family planning methods and 23% of them were influenced by their husbands in selecting modern methods[17].
Research reports from India revealed that men have little information about reproductive health and women were depended on men about their health care decisions[18].
Results of a survey in order to study clinical trial in group counseling to change high-risk sex behaviors in men showed that after intervention, consulted group had compered to the control group changed their behaviors[19].
After 1988 in the Islamic Republic of Iran a national family planning programme was established which successfully led to a decline in the country’s total fertility rate[20]. The United Nations Fund for Population Activities (UNFPA) considers the Iranian family planning programme to be one of the world’s best functioning[21].
In some areas, however, social, cultural and religious institutions may be inhibiting the expansion of family planning[22] Sistan va Baluchistan Province has the highest population growth in the country and is considered a priority for family planning studies[23].
Since women are the main source of information for their husbands, in this study women group counseling and its effects on men participation and family planning were studied in order to find a proper way to increase male involvement in family planning.
MATERIALS AND METHODS
The province of Sistan va Baluchistan is located in the South-east of the Islamic Republic of Iran. There are 8 towns in the province and Zahedan, with a population of about 800000, is the capital of province. Large family are still popular in this area and the fertility rate and population growth rate (3.9 and 2.4%, respectively) are high compared with the Islamic Republic of Iran as a whole (1.9 and 1.1%, respectively). About 40% of couples use modern contraceptive methods. There are a variety of cultural, traditional, tribes and religions in the region that may affect how couples behave.
A quasi-experimental (before and after) study was conducted from April to May 2002 in Zahedan Urban Health Centers. The study focused on forty-four married women in reproductive age (15-49 years old). The women had at least two children and avoided use of modern contraceptive methods. At the first, women and their husbands, were assessed by a questionnaire to determine the educational needs, then they were divided into 5 groups based on their education level. Each group included eight or nine women who received group counseling within three sessions, each lasted 2 h during two weeks. The questionnaire consisted 15 demographic questions, 14 knowledge and 11 attitude questions. There was a checklist for assessing behavior. The multiple-choice questions were developed for knowledge which weighted based on their importance. The total score of knowledge was 62 which categorized into good, average, weak and very weak. The three-choice likert scale was applied for developing attitude questions with total score 33. The scores were categorized to positive attitude (more than mean) and negative attitude (less than mean). The purpose of the consultation sessions was to discuss about contraceptive methods and misconceptions, to analyze men’s opinions about family planning, to teach how women present the information to their husbands and how to develop men’s participation in family planning. The participants were received a pamphelet about contraceptive methods and communications. Evaluation of intervention was conducted one month later through completing the questionnaire and filling the checklist using documents in Health Centers. The mean score and Standard Deviation (SD) was used for descriptive analysis and paired t-test, chi-square and Mc-nimar for analytic analysis using SPSS package.
RESULTS
The mean age of the participants was 29±5.4 years and the mean age of their husbands was 37±6.4 years. Seventy-three percent were Baluch and Sunni and had primary education level. Sixteen percent had more than one wife. The average number of male and female children were 1.9±1.25 and 1.7±1.08, respectively. The mean age of the youngest child was 2.35±2.87 years. According to the occupation, 52.5% were employee, 43% had small business and 4.5% were unemployed (Table 1).
| Table 1: | Educational level of the participants and their husbands |
All women were housekeeper. The mean and SD of knowledge scores of women about family planning before and after intervention were 29.75±4.28 score and 51.91±5.29 score, respectively and for their husbands were 28.20±3.28 score and 41.15±4.35 score, respectively that in both the paired t-test showed a significant difference (p<0.001). Also, the mean and SD of attitude scores of women before and after intervention were 21.29±3.05 score and 24.68±3.09 score, respectively and for their husbands were 19.38±3.24 score and 23.45±3.35 score, respectively that in both the paired t-test showed a significant difference (p<0.001) (Table 2). After intervention 43% of couples used one of the modern contraceptive methods with a significant difference (p<0.00001). Before intervention women had the most interest in using pills (47.5%) and the least interest in using permanent methods (4.5%) and their husbands had the most interest for using pills by their wives (18%) and the least interest in using condoms (4.5%). After intervention pills and injectables, each with 13.5% were the most common and permanent methods (tubectomy and vasectomy) each with 2% were the least common methods that couples used.
DISCUSSION
This research was carried out to understand the ability of the women to improve their husband’s KAP regarding family planning issues.
| Table 2: | Knowledge and attitude scores of the participants and their husbands before and after intervention |
| Table 3: | The percentage of intent on using contraceptive methods before intervention and use of them after intervention among couples |
| 1- Oral Contraceptive Pill, 2- Intra Uterin Device | |
The findings showed a considerable improvement in husbands’ knowledge and attitude that reveals the effect of group counseling on women’s ability in transferring information to their husbands appropriately. The low level of knowledge and attitude of men and some women about contraceptive methods were the same a India and Palestine as they found that not only men had little information about birth spacing, but also did not take actions to improve their knowledge or usage contraceptive methods. Also, it revealed that men’s awareness of contraceptive methods might be high, but they did not know well how to use them[24,25].
Inter spousal communication has been demonstrated to predict contraceptive behavior[10]. Present study also supported this and suggests that it is imperative to focus on couples and inter spousal communication instead of women only for real change in fertility behaviors.
According to one report, it was revealed that to have an optimal using from reproductive health services, we need three levels of support (social, family and the spouse) and the level of spousal communication should be elevated by giving information, education and communication[26].
In present study, after intervention 43% of couples used one of the modern contraceptive methods. The female contraceptive methods such as pills and injectables were the commonest methods and male contraceptive methods also showed an increase.
According to one report in Uganda, it was explored that usage contraceptive methods among women shows a faster increase in comparison with men[27].
Generally, men do not take the responsibility of birth spacing as much as women do. Although there are negative attitudes and misconceptions toward contraceptive methods, the results of our study showed that we can increase the level of men’s knowledge, attitude and practice even among Sunni people who do not interest in use of contraceptive methods. Since, there are many social and cultural prohibitions against permanent contraceptive methods, we did not expect to have changes in using them, however, one tubectomy and one vasectomy among samples demonstrated great efficacy of program. Therefore, it is necessary to involve men in all reproductive health programs and it is most likely to have a positive effect on women and men’s reproductive health, knowledge, attitude and behaviors. So, policy makers should, increase male involvement in family planning programs through more family planning counseling for couples[1,28-33].
CONCLUSIONS
This study aimed to understand the role of the women to involve their husbands in reproductive health. The findings recommend that any investment in promotion of women’s communication skills and their KAP will be effective in family planning behaviors.
ACKNOWLEDGMENTS
We extend sincere thanks to the respondents who participated in the study. We also express thanks to all health workers who kindly helped us.