The authors have declared that no competing interests exist.
Millions of children continue to miss immunizations each year despite global increases in financing and advances in vaccine technology. Male involvement in routine child immunization activities could improve and sustain coverage but is rarely emphasized in immunization programs or research. This study identified factors associated with male involvement in routine child immunization using the attitude, social influence and self-efficacy model.A household cluster survey was conducted among 460 fathers aged 18 years or more, with children aged 10-23 months. A semi-structured interviewer-administered questionnaire was used to collect data. Prevalence Risk Ratios (PRRs) were used to measure associations with level of involvement using generalized linear models with Poisson family, log link and robust standard errors in STATA 12. Our findings show that half (51%, 236/460) of the respondents were aged 25-34 years; 36% (166/460) had completed eight or more years of formal education. Although90% (415/460) of the respondents were willing to be involved, only 29% (133/460) were highly involved in routine child immunization. Highly involved fathers had a positive attitude towards involvement in routine child immunization (adj. PRR 2.3, 95% CI 1.18 – 4.98) and were ≥45 years adjusted prevalence risk ratio (adj. PRR) 2.0, 95% confidence interval (CI) 1.15 - 3.76. Traders had a lower involvement compared to those engaged in other occupations (adj. PRR 0.55, 95% CI: 0.37 - 0.82). In conclusion
Nearly 19 million infants worldwide did not complete their routine immunization schedules in 2014, more than 60% of these lived in 10 developing countries including Uganda
Interventions that generate demand for immunization services in developing countries have traditionally targeted women neglecting the involvement of men mainly due to the general belief that women are typically responsible for child immunization
Since the launch of the Global Vaccine Action Plan for 2011 to 2020
We conducted a household cluster survey in Hoima district, Western Uganda, between March and May, 2013. Hoima District is located 230km West of Kampala, the Capital City of Uganda. Hoima had a total population of 549,000 people, 106,000 of whom were aged under-five and 22,000 were infants. The annual population growth rate is 4.7%
Fathers who were at least 18 years old with children aged 10 to 23 months, and had lived in Hoima for at least a year prior to the survey were included in the study. The required sample size was 460 men using the formula by Bennett for sampling in cluster surveys, with the following assumptions; a two-sided test with a precision of 0.03, 80% power, 10 households per cluster, intra-cluster correlation of 0.1, and a design effect of 1.9 and 50% level of male involvement in routine child immunization
Multistage cluster sampling method was used to select study participants. In the first stage, five of 13 sub-counties in Hoima district were randomly selected using computer generated random numbers. In the second stage, two parishes from each of the five selected sub-counties were randomly selected (ten parishes in total). In the third stage, a list of all villages from each of the ten parishes was generated. A total of 46 out of 116 villages were then selected proportionate to the number of villages in each parish. Villages (lowest administrative units) were considered as clusters in this study. At the last stage, households were consecutively searched for eligible fathers. Ten fathers were interviewed in each village, selecting one respondent per household.
In each of the selected villages, a random starting point preferably a main junction in the village was identified. Then beginning with the house on the eastern side, data collectors moved from house to house looking for eligible respondents until the desired sample for the village was obtained.
In case a household did not have an eligible respondent, the respondent declined to participate, or was not at home at the time the house was approached for study inclusion, the next household was considered. In a household with an eligible man with more than one child aged 10-23 months or a polygamous man with partners each having a child in the 10-23 months age group; the male partner would be interviewed in reference to the youngest child in the age group. This last criterion was chosen to reduce recall bias for the study outcome.
The ASE model was originally developed for smoking cessation by de Vries et al
As shown in
The measurements used in this study were based on the ASE model described above. Data were collected through face-to-face interviews using a pre-tested structured questionnaire that was translated into Runyoro (local dialect) and back translated into English for consistence in meaning. We describe below the measurements used for this study; male involvement in routine child immunization, attitude, social influence and self-efficacy.
This was estimated based on an involvement index developed from five indicators: 1) if the male partner had taken their child for routine immunization, 2) had accompanied the partner for routine child immunization, 3) provided financial support for a child’s routine immunization visits, 4) discussed with the partner about the child’s immunization schedule, and 5) had participated in making a decision with partner to have a child immunized. Each indicator had an equal weight score of one. The involvement score of each respondent ranged from 0=no involvement to 5=involved in all five areas at least once. A total score of at least 4 was considered as high male involvement and ≤3 as low male involvement
A male partners' attitude was defined as his evaluation of merits and demerits of his involvement in routine child immunization (RCI)
Social influence was described as resulting from social norms in regard to male involvement in routine child immunization
Self-efficacy was defined as a father’s perceived ability to cope with barriers to their involvement in RCI
Data were coded, entered, cleaned and analyzed using STATA version 12.0. We computed prevalence risk ratios (PRR) as a measure of association between the outcome and independent factors (attitudinal, social influence and self-efficacy factors) using generalized linear model (GLM) with Poisson family and a log link with robust standard errors
Ethics approval was obtained from Makerere University School of Public Health Higher Degrees Research and Ethics Committee. Interviews were conducted only when written informed consent had been obtained from the study participants.
A total of 460 eligible respondents were approached for study inclusion and all were interviewed, representing 100% response rate. Respondents were aged between 18-72 years with a mean age of 32.3 years (SD=8.7). Half (51%, 236/460) of them were aged 25-34 years and only 36% (166/460) had completed 8 or more years of formal education. Most (77%, 353/460) respondents had four or less children, were in monogamous relationships (83%, 380/460); 41% (190/460) were peasant farmers, and 29% (135/460) were traders,
|
|
|
---|---|---|
|
||
18-24 | 74 | 16.1 |
25-34 | 236 | 51.3 |
35-44 | 98 | 21.3 |
≥45 years | 52 | 11.3 |
|
||
≤7 years | 236 | 51.3 |
>7 years | 224 | 48.7 |
|
||
Living with partner | 299 | 65 |
Married | 142 | 31 |
Separated | 19 | 4 |
|
||
Monogamous | 380 | 83 |
Polygamous | 78 | 17 |
|
||
≤5 People | 308 | 67 |
>5 People | 152 | 33 |
|
||
Peasant farmer | 190 | 41.3 |
Casual laborer | 83 | 18 |
Trader | 135 | 29.4 |
Formally employed | 52 | 11.3 |
|
||
Anglican | 184 | 40 |
Catholic | 155 | 33.7 |
Muslim | 59 | 12.8 |
Other | 62 | 13.5 |
|
||
≤4 | 353 | 76.7 |
>4 | 107 | 23.3 |
|
||
<12 | 69 | 15 |
12-17 | 232 | 50 |
18-23 | 159 | 35 |
|
||
Male | 222 | 48 |
Female | 238 | 52 |
Overall, 29% (132/460) of all respondents were highly involved in routine child immunization (RCI). The level of involvement varied by activity; for instance, most (76.1%, 350/460) respondents reported provision of financial support for the child’s routine immunization session(s), followed by accompanying the partner (61.5%, 283/460), discussing a child’s routine vaccination schedule with partner (57.8%, 266/460), and least involvement (18%, 84/460) was in taking their children for routine immunization,
|
|
|
---|---|---|
|
|
|
1. Did you ever take the child yourself for routine immunization? | 84 (18.3) | 376 (81.7) |
2. Did you ever accompany your partner for routine child immunization? | 283 (61.5) | 177 (38.5) |
3. Did you ever provide financial support for a child’s routine immunization? | 350 (76.1) | 110 (23.9) |
4. Did you ever discuss with your partner the child’s routine immunization schedule? | 266 (57.8) | 194 (42.2) |
5. Did you ever make a decision with partner to have the child routinely immunized? | 195 (42.4) | 265 (57.6) |
29% (132/460) of fathers were highly involved in RCI (participated in 4-5 indices) |
Overall, 87% (399/460) of respondents had a positive attitude towards involvement in RCI (Cronbach’s alpha correlation coefficient (α) = 0.8). The majority (87%, 401/460) agreed that male involvement in RCI was beneficial in terms of: sharing parental responsibility (60%, 275/460), showing love to partner (40%, 186/460), opportunity to receive child care education as a couple at immunization clinic (15%, 69/460), and help both parents plan and be better prepared for the next visit (9%, 42/460), and improve timely completion of routine child immunization schedule (12%, 55/460). Nearly all (90%, 415/460) respondents were willing to be involved in RCI and to encourage other men to be involved in RCI (88%, 405/460).
Most (73%, 334/460) respondents reported that it is mainly a woman’s responsibility to have a child immunized and only 3% (14/460) said it was mainly a man’s role. In terms of the key roles fathers thought other community members expected of them in RCI, 21% (95/460) reported taking the child for immunization, 34% (155/460) reminding partner of next visit and 45% (209/460) reported providing financial support.
Most men (68%, 313/460) reported encouragement for involvement in RCI mainly from their spouses (28%, 129/460). Respondents reported that other community members considered the act of male involvement in RCI as an expression of love for the wife and child (23%, 107/406), and as a way of a father showing a sense of responsibility for his family (50%, 230/460).
On the other hand; 23% (106/460) of respondents reported discouragement from involvement in RCI mainly from their peers (22%, 101/460). Their involvement was viewed by other community members as a sign of “weakness” for a man (34%, 157/460) and as having time to waste (4%, 19/460)
Overall, most (72%, 333/460) respondents had a high self-efficacy towards involvement in RCI (Cronbach’s alpha correlation coefficient (α) = 0.83).Key barriers to male involvement in routine child immunization (RCI) were: competing work demands (88.7%, 408/460), long waiting time at immunization clinics (43.3%, 199/460), considering routine child immunization as a woman’s responsibility (38.9%, 179/460), financial constraints (24.4%, 112/460), long distance to immunization facility (17.6%, 81/460), and perceived ridicule from peers (5.7%, 26/460). Nearly all fathers (90%, 395/460) expressed ability to cope with or overcome financial constraints; 79% (362/460) with long distance to immunization clinic; 76% (348/460) with ridicule from peers; 70% (321/460) with traditional gender roles, 67% (306/460) with competing work demands; and 56% (258/460) with long waiting time at immunization clinic.
Both univariable and multivariable level analyses are shown in
|
|
|
|
|
|
|||||||||
18-24 | 74 | 13 (17.6) | 61 (82.4) | 1 | 1 | |||||||||
25-34 | 236 | 72 (30.5) | 164 (69.5) | 1.74 (1.02 - 2.95) | 1.59 (0.53 - 2.72) | |||||||||
35-44 | 98 | 29 (29.6) | 69 (70.4) | 1.68 (0.94 - 3.01) | 1.58 (0.88 - 2.84) | |||||||||
≥45 years | 52 | 18 (34.6) | 34 (65.4) | 1.97 (1.06 - 3.66) |
|
|||||||||
|
||||||||||||||
≤7 years in school | 236 | 60 (25.4) | 174 (74.6) | 1 | 1 | |||||||||
≥8 years in school | 224 | 72 (32.1) | 152 (67.9) | 1.26 (0.95 - 1.69) | 1.33 (0.98 – 1.81) | |||||||||
|
|
|
|
|
|
|||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Farmer | 190 | 63 (33.2) | 127 (66.8) | 1 | 1 | |||||||||
Casual laborer | 83 | 22 (26.5) | 61 (73.5) | 0.80 (0.53 - 1.21) | 0.86 (0.57 - 1.30) | |||||||||
Trader | 135 | 25 (18.5) | 110 (81.5) | 0.56 (0.37 - 0.84) |
|
|||||||||
Formally employed | 52 | 22 (43.2) | 30 (57.8) | 1.28 (0.88 - 1.86) | 1.00 (0.66 - 1.50) | |||||||||
|
|
|
|
|
|
|||||||||
≤4 | 353 | 29 (8.2) | 250 (70.8) | 1 |
|
|||||||||
>4 | 107 | 103 (96.3) | 78 (72.9) | 0.93 (0.65 -1.32) |
|
|||||||||
|
|
|
||||||||||||
Male | 222 | 60(27.0) | 162 (73.0) |
|
|
|||||||||
Female | 238 | 72 (30.3) | 166 (69.7) | 1.12 (0.84 - 1.49) |
|
|||||||||
|
||||||||||||||
|
||||||||||||||
|
||||||||||||||
Yes | 401 | 122 (30.4) | 279 (69.6) | 1.79 (1.00 - 3.22) | 1.08 (0.60 - 1.95) | |||||||||
No | 59 | 10 (16.9) | 49 (83.1) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 310 | 103 (33.2) | 207 (66.8) | 1.72 (1.19 - 2.47) | 1.19 (0.77 - 1.84) | |||||||||
No | 150 | 29 (19.3) | 121 (80.7) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 415 | 128 (30.8) | 287 (69.2) | 3.47 (1.35- 8.95) |
|
|||||||||
No | 45 | 4(8.9) | 41 (91.1) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 405 | 124 (30.6) | 281 (69.4) | 2.10 (1.09 - 4.06) | 1.16 (0.46 - 2.93) | |||||||||
No | 55 | 8 (14.5) | 47 (85.5) | 1 | 1 | |||||||||
|
|
|
||||||||||||
Positive (yes to 3-4 indices) | 399 | 125 (31.3) | 274 (68.7) | 2.73 (1.34 - 5.57) |
|
|||||||||
Negative (yes to ≤2 indices) | 61 | 7 (11.5) | 54 (88.5) | 1 | 1 | |||||||||
|
||||||||||||||
|
|
|
|
|
|
|||||||||
Joint parental role | 112 | 44 (33.3) | 68 (20.7) | 1 | 1 | |||||||||
Man’s role | 14 | 3 (2.3) | 11 (3.4) | 0.55 (0.19 - 1.53) | 0.72 (0.29 - 1.95) | |||||||||
Mother’s role | 334 | 85 (64.4) | 249 (75.9) | 0.65 (0.48 -0.87) | 1.39 (0.96 - 1.75) | |||||||||
|
|
|
||||||||||||
Yes | 325 | 101 (31.1) | 224 (68.9) | 1.35 (0.95 - 1.92) | 1.18 (0.86 – 1.64) | |||||||||
No | 135 | 31 (23.0) | 104 (77) | 1 | 1 | |||||||||
|
|
|
|
|||||||||||
Yes | 106 | 32 (30.2) | 74 (69.8) | 1.07 (0.76 - 1.49) | 1.14 (0.80 – 1.62) | |||||||||
No | 353 | 100 (28.3) | 253 (71.7) | 1 | 1 | |||||||||
|
|
|
|
|
|
|||||||||
|
||||||||||||||
Yes | 258 | 85 (32.9) | 173 (67.1) | 1.42 (1.04 - 1.92) | 1.21 (0.90 - 1.63) | |||||||||
No | 202 | 47 (23.3) | 155 (76.7) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 348 | 107 (30.7) | 241 (69.3) | 1.38 (0.94 - 2.01) | 1.10 (0.66 - 1.51) | |||||||||
No | 112 | 25 (22.3) | 87 (77.7) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 321 | 96 (29.9) | 225 (70.1) | 1.15 (0.83 - 1.60) | ||||||||||
No | 139 | 36 (25.9) | 103 (74.1) | 1 | ||||||||||
|
||||||||||||||
Yes | 306 | 96 (31.4) | 210 (68.6) | 1.34 (0.96 - 1.87) | 0.93 (0.65 - 1.35) | |||||||||
No | 154 | 36 (23.4) | 118 (76.6) | 1 | 1 | |||||||||
|
||||||||||||||
Yes | 395 | 117 (29.6) | 278 (70.4) | 1.28 (0.80 - 2.05) | ||||||||||
No | 65 | 15 (23.1) | 50 (76.9) | 1 | ||||||||||
|
||||||||||||||
Yes | 362 | 107 (29.6) | 225 (70.4) | 1.16 (0.79 - 1.68) | ||||||||||
No | 98 | 25 (25.5) | 73 (74.5) | 1 | ||||||||||
|
||||||||||||||
High (yes to 4-5 SE factors) | 333 | 104(31.2) | 229 (68.8) | 1.42 (0.98 - 2.04) | 1.13 (0.78 - 1.63) | |||||||||
Low (yes to ≤3 SE factors) | 127 | 28(22.0) | 99 (78.0) | 1 | 1 |
This study identified factors associated with male involvement in routine child immunization (RCI). We found that, although 90% of men were willing to participate in RCI, only 29% were highly involved. High male involvement in RCI was more often among respondents that were 45 years or older and among those with a positive attitude towards involvement. Men engaged in trade as the main occupation were less involved.
Lower levels of male involvement have been reported in other child health programs such as the prevention of mother-to-child transmission of HIV (PMTCT) programmes in Uganda
In our study, a man's positive attitude towards involvement in RCI was associated with high involvement in RCI similar to findings from an urban Ugandan setting where attitude was the strongest predictor of health seeking behavior among men
Older fathers were more involved in routine child immunization consistent with earlier findings from a high income setting
Men whose main occupation was trade were significantly associated with lower involvement in RCI. Similar to findings from a PMTCT program in Eastern Uganda where men involved in occupations that kept them away from home for long hours were less involved in their child's health care
Our study developed a composite measure of male involvement using questions from published literature. The composite measure used here gives a broader understanding of indicators which interact in a complex manner to influence male involvement in RCI. In contrast, a few studies done on male involvement in RCI have used a single involvement indicator to measure male involvement
This study used five indicators to measure male involvement in routine child immunization (RCI) differing from other reports that use only one of the five indicators for male involvement. Overall, a small proportion of fathers were involved in RCI in this rural setting. And several factors associated with their involvement have been identified. For instance, men's positive attitude towards involvement in RCI was associated with higher male involvement. Interventions to improve men's attitude such as health education or peer education are needed to increase their involvement. These interventions need to be centered on the involvement of both parents in the health care of the family, in conjunction with local and policy-level changes that support an environment more conducive to men’s participation
This study was funded by the United States Agency for International Development (USAID) through AFENET/USAID/CDC Trainee Grants Program to improve immunization coverage, number AFE2012 RS-01. The funding agency was not involved in any of the research activities or in the writing of the manuscript. We thank the study participants, the research assistants, local council leaders, and the District Health Team.
Conceived and designed the experiments: CB JNB PO LA. Performed the experiments: CB JNB PO. Analyzed the data: CB JNB PO PW LA. Contributed reagents/materials/analysis tools: CB JNB PO PW LA. Wrote the paper: CB JNB PO PW LA.