Discussion

6.7.1. Knowledge and attitudes of focus group participants

The FGDs conducted as part of the formative research for this study revealed that participants’ attitudes resemble those described in other studies involving men in Burkina Faso (Drabo et al., 2015, Rossier and Hellen, 2014). It is not surprising that men have favourable attitudes towards skilled antenatal and delivery care, given that ANC attendance and facility delivery are high in Bobo-Dioulasso (Ministère de la Santé, 2015b). However, fears of the potential side-effects of contraception, such as infertility, persist even in this urban area, confirming the findings of the PopDev study (Drabo et al., 2015). In addition, that study also showed that some men oppose contraception because they believe that it may cause infidelity.

It has been suggested that religious and other cultural factors may play a role in explaining the low uptake of PNC in Sub-Saharan Africa (Warren, 2006). Participants in our FGDs mentioned the tradition based on which in Muslim families, mother and baby are expected to remain at home until the child’s naming ceremony, on the 7th day postpartum (Taverne, 2000). However, it is uncertain to what extent this tradition is still observed, and its impact would only be felt on the 6th day visit, but not on the 6th week visit. Rather, the most important finding seems to be that postnatal visits are not considered important when the woman feels well, and does not wish to start contraception, confirming existing evidence (Rossier and Hellen, 2014). As mentioned in Subchapter 1.2.1, postnatal home visits could be a solution to low uptake (World Health

123 Organization and UNICEF, 2009), but are far from widespread in Sub-Saharan Africa. In the meantime, raising awareness about the importance of PNC must remain the focus.

Some FGD participants expressed the view that RH care focuses on “women’s issues”, and therefore does not concern them, an opinion described in studies from other parts of Sub- Saharan Africa (Nkuoh et al., 2010, Ganle and Dery, 2015). However, the most strongly-voiced reason reported for low participation was that health workers were not welcoming to men. As mentioned above (see Subchapter 2.2), this problem has also been identified in the regional literature. Problems reported have included negative health worker attitudes, and of unit infrastructure not being welcoming to men or couples (Kaye et al., 2014, Kwambai et al., 2013, Nanjala and Wamalwa, 2012, Tadesse et al., 2004). Even in hospitals where men have been allowed to participate, tension with health workers has been reported (Kululanga et al., 2012a). This points to the need to educate health workers on how to interact with men and couples, which is an important component of our intervention. Overall, however, the most promising finding was that FGD participants displayed a willingness to become more involved in

maternity care. This is worthy of note, despite the fact that attendees were a self-selected group who had responded to our invitation. Male partners’ interest in participating in maternity care has also been reported in other countries, such as Malawi (Aarnio et al., 2013) and Tanzania (Mbekenga et al., 2013).

However, the findings also suggest that some men still hold patriarchal views of their own authority within their families, referring to themselves as head of the household, and appearing concerned about maintaining control over their female partners. In the Popdev study, some men seemed to interpret taking an interest in women’s health as checking that their wives took prescribed medication correctly (PopDev, internal communication). These controlling behaviours are a source of concern for male involvement programmes, as without appropriate mechanisms to tackle them there is a risk of reinforcing them. For this reason, we have included the promotion of communication and shared decision-making as a key component of this intervention.

6.7.2. The finalisation and implementation of the intervention

The FGDs and staff consultations constituted essential formative research, which was needed in order to ensure that the format, timing, location and other practical aspects of the finalised intervention were acceptable to men and couples. This iterative, collaborative process sought to ensure that the content of the sessions would be culturally acceptable and compelling (Panter- Brick et al., 2014). As far as possible, we also attempted to incorporate lessons learnt from past programmes and to avoid introducing men’s participation in ways that might not be acceptable in the local context (Susin and Giugliani, 2008, Comrie-Thomson et al., 2015a). For example, we did not incorporate male attendance at birth into the intervention because this would have

124 been an almost entirely new practice in this context, and because of practical reasons, in

particular the lack of space and privacy in PHC delivery rooms. We also decided not to focus on HIV/AIDS testing, because PMTCT is already abundantly discussed in health centres, and specific promotion initiatives exist. Furthermore, this is a very sensitive topic, and counselling couples on VCT and PMTCT requires a high degree of skill and tact. Providing this level of specialist training was beyond the scope of our study. However, it may be useful to include this topic in future male involvement interventions.

The first distinctive feature of this intervention is that it is facility-based. Out of the 37 male involvement intervention studies identified in Chapter 3 which focused on MNH or PPFP outcomes, only 15 included facility-based activities, and the rest were entirely community- based. Out of this subgroup, only Kunene’s study was set in Sub-Saharan Africa (Kunene et al., 2004). The inclusion of three sessions was fairly typical of other programmes, however only one other facility-based intervention offered a combination of group education and couple counselling sessions (Varkey et al., 2004). The other facility-based studies were almost equally split between those offering group education and those offering individual or couple

counselling, apart from the two studies of men as birth companions (Morhason-Bello et al., 2009, Ojengbede et al., 2009). Because it was necessary to avoid contamination between the study arms, certain formats described in the literature were not considered for inclusion in this intervention, such as multi-media and public entertainment, religious/community leader mobilisation, and home visits (see Subchapter 3.3).

Among the other studies involving facility-based group education, three provided this for men only, similarly to ours (Maycock et al., 2013, Wolfberg et al., 2004, Bich et al., 2014). All but one other study involving individual counselling received men and women together, like ours (Pisacane et al., 2005). Our study was similar to a few others in that it addressed a range of health topics during the sessions, including birth preparedness, danger signs, breastfeeding, PPFP and the role of the male partner (Varkey et al., 2004, Kunene et al., 2004, Turan et al., 2001). The other facility-based studies had a narrower focus on birth preparedness, PPFP or breastfeeding. Unlike several others, we did not give out written information in the form of leaflets, booklets or brochures as part of this intervention, partly because of the low level of literacy in the population, and partly out of the concern to avoid contamination between study arms. Our study used invitation letters for men, as done by Kunene (Kunene et al., 2004) and in the PMTCT literature (see Subchapter 3.3.5). In our case, additional phone calls were included. As most of the other facility-based studies took place in contexts where men take part in maternity care or at least accompany their female partners to facilities, men/couples could be easily be recruited during ANC or on the postnatal ward.

125 The session facilitators in our study were health workers, as was the case in most other facility- based studies. They received a day’s training on how to use the study materials and on the essential principles of couple counselling, plus on the job support. In some other studies the training period was longer, and also included technical updates on key topics (Kunene et al., 2004, Varkey et al., 2004). We did not provide these for a variety of reasons. Firstly, our budget was limited; secondly, staff in the study health centre already receive regular technical updates; and thirdly, they were already used to educating women on all the key topics addressed during the intervention. However, we did put supervisory measures in place in order to avoid problems such as a deterioration over time in the depth and range with which counselling topics were covered, which occurred in Kunene’s study (Kunene et al., 2004).

From a gender lens, I believe that this intervention includes both gender-accommodating and gender-transformative elements (Interagency Gender Working Group (USAID)). On the one hand, it certainly acknowledges that men are usually the gatekeepers and decision-makers in this setting, and seeks to harness their authority and use it in order to achieve beneficial outcomes for women and newborns. On the other hand, however, it also interrogates men explicitly about gender roles, and seeks to challenge prevailing attitudes and modify normative behaviour around communication and decision-making within couples. Furthermore, this intervention involves bringing men into what is perceived to be a women’s environment and involving them in conversations to which they are not usually exposed. By doing so, it also encourages all involved to critically re-examine the traditional notion of separate social roles and domains that are exclusive to men or to women (McAllister et al., 2012).

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7. PHASE 2: RCT PARTICIPATION AND BASELINE