H.R. Sadeghipour Roudsari,1 R. Sherafat-Kazemzadeh,1 M. Rezaeie1 and M. Derakhshan1
ABSTRACT This study was carried out in south-west Tehran province to assess the knowledge, attitudes and practices of men, Iranians and Afghan refugees, regarding reproductive health. A questionnaire was used for the assessment. Mean scores for knowledge, attitudes and practices for Iranians were 4.38/30, 13.89/20 and 12.99/31 respectively; for Afghans the scores were 3.79/30, 11.66/20 and 11.88/31. Although the scores in both groups were low, Afghans showed significantly lower scores for attitudes and practices. Access to reproductive health services was the same for both groups. Further scrutiny of men’s role in reproductive health, particularly social and cultural factors, is strongly recommended.
Connaissances, attitudes et pratiques des hommes iraniens et afghans concernant la santé génésique dans la province de Téhéran
RÉSUMÉ La présente étude a été réalisée dans la partie sud-ouest de la province de Téhéran pour évaluer les connaissances, attitudes et pratiques des hommes iraniens et afghans réfugiés en ce qui concerne la santé génésique. Un questionnaire a été utilisé pour l’évaluation. Les scores moyens des Iraniens pour les connaissances, attitudes et pratiques étaient de 4,38/30, 13,89/20 et 12,99/31 respectivement ; pour les Afghans, les scores étaient de 3,79/30, 11,66/20 et 11,88/31. Même si les scores dans les deux groupes étaient faibles, les Afghans avaient des scores significativement plus bas pour les attitudes et les pratiques. L’accès aux services de santé génésique était le même pour les deux groupes. Il est vivement recommandé d’examiner plus en profondeur le rôle de l’homme dans la santé génésique, notamment les facteurs sociaux et culturels.
1Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H.R. Sadeghipour:
Received: 07/07/03; accepted: 06/10/04
EMHJ, 2006, 12(6): 862-872
Introduction
The programme of action of the international conference on population and development in 1994 urged gender equality and equity and the empowerment of women [1]. Reproductive health is an essential part of this [2]. In response to global action plans adopted at the Cairo and Beijing conferences [1,3], initiatives have been implemented in many parts of the world concerning 4 main goals: to increase men’s awareness of and support for family planning; to increase men’s awareness of the need to safeguard the reproductive health of their partners and themselves, especially through prevention of sexually transmitted infection; to improve access to men’s contraceptive methods for couples who are interested in using them; and to improve men’s access to comprehensive reproductive health services [3,4].
There are several reports confirming the inefficacy of reproductive health programmes with regard to the role of men [1,5]. Needs assessments conducted in Kenya and Mexico showed that men’s attitudes towards reproduction was an important factor in efficacy of family planning [5,6]. In a survey conducted in Indonesia it was shown that neglecting the man’s role was the main cause of family planning failure, either in selection or continuation of contraception use [7]. On the other hand, lessons learned from successful men’s programmes around the world are publicized occasionally, especially in developing countries such as India, Bolivia, Indonesia and Mexico, where men’s positive attitudes and beliefs regarding reproductive health have led to successful programmes [7–11].
It is strongly believed that plans of action should be tailored according to specific local factors as the health concerns of men and women are different with regard to gender issues and according to the cultural and demographic circumstances of the specific region [10,11].
Family planning and reproductive health programmes in the Islamic Republic of Iran reduced the population growth rate in the country to 1.5% in 1996 and the maternal mortality rate has fallen below 100/100 000 live births since the implementation of these programmes [12]. The Iranian population is dominated by the youth reaching reproductive age (65.3% < 30 years according to National Research Centre and Ministry of Health and Medical Education statistics) and this makes it necessary to maintain the functionality of the present programmes and to assess emerging needs and current trends regarding this issue. There is a lack of information in the country about men’s reproductive concerns and their attitudes to female partners and their reproductive health.
In addition, there are more than 1 million Afghan refugees seeking asylum in the Islamic Republic of Iran. This imposes an excessive burden on the Iranian health system and is an important problem that needs to be addressed. The refugees often live in very poor socioeconomic conditions and their dwelling places are often unstable. Many are illiterate; many maintain unjustifiable beliefs regarding women and reproduction. The problems are pronounced in areas where large numbers refugees reside, south-west Tehran being one of those sites.
The attitudes and concerns of the refugees are expected to differ from those of native Iranians. There are numerous reports to health authorities describing reproduction rates, visits to the health centres and coverage of services delineating each indicator for both Iranians and Afghans. But there is ambiguity about attitudes to reproductive health, and especially the role of men, in this concern. Local reports to the authorities show weaker family planning achievement in those areas where Afghan refugees reside. In a study conducted in the south-west of Tehran province in 1997, total fertility rate among Iranians was 1.73 while in refugees it was 3.27. Other reproductive health indices such as contraceptive usage, gross reproductive rate and general fertility rate were significantly better among Iranians [13].
We conducted this study to assess the differences in knowledge, attitudes and practices regarding reproductive health issues in 2 groups, Iranian males and Afghan males. The information would be especially useful when designing further health programmes. Taking men’s role and cultural differences into account could lead to better performance.
Methods
Definition of terms
“Knowledge” means awareness, understanding and problem-solving capacity [14]. “Attitude” refers to inclinations to react in a certain way to certain situations, or to organize opinions into coherent and interrelated structures [15]. By “practice” we mean the application of rules and knowledge into action [15].
Study population
Two towns, Ahmad Abad and Chahardangeh, were selected for conducting the study on knowledge, attitudes and practices of males regarding reproductive health issues. The study was carried out from March 2001 to March 2002. The towns are located in the south west of Tehran province, where a large number of Afghan refugees reside. Aiming to test the hypothesis that the 2 groups show a significant difference in level of knowledge, attitudes and practices, the sample size was calculated according to the population of the towns and with a 95% confidence. A total of 247 Iranian and 231 Afghan males were included. The participants were recruited at their doorsteps from a list of addresses (456 Afghan families in Chahardangeh, 275 in Ahmad Abad; 2150 Iranian families in Chahardangeh, 2559 in Ahmad Abad) obtained from district health houses. Addresses were selected using random numbers tables and participants were recruited until we reached the sample size. Those who were absent from home (many were at work or back in their home country in the case of Afghans) were replaced by the next name on the list. All but 7 Iranians and 13 Afghans agreed to participate.
Questionnaire
We generated customized questions to assess knowledge, attitudes and practices towards reproductive health. The 54-item questionnaire contained questions which collected demographic data on the reproductive characteristics of men’s families, as well as separate closed questions for the knowledge, attitude and practice study. The multiple-choice knowledge, attitudes and practice questions were recoded by assigning scores to quantify the answers (Table 1). The maximum scores for knowledge, attitudes and practices were 30, 20, and 31 respectively. The questionnaire was reviewed by a group of family planning and reproductive health experts, and pilot tested on 20 adults for face and construct validity.
The study questionnaire was filled in through direct interviews. Eight interviewers, all health service providers, were fully trained by the research team to conduct face-to-face interviews. Before participating, each individual was fully informed about the goals and scope of the study and was assured of the confidentiality of all the information gathered, he was free to accept or reject taking part in the study.
Analysis
To compare the means of quantitative variables in the 2 groups, the t-test was used and for the differences of nominal variables (most demographic variables) the χ2 test was used. The statistical analyses were performed using SPSS, version 10.05.
Results
A total of 247 Iranian (51.7%) and 231 Afghan (48.3%) men were interviewed. From the combined group, 312 (65.3%) believed that family planning was the responsibility of both partners. Only 17 individuals (3.6%) could give a definition of family planning while 203 (42.5%) had no knowledge of the term.
The rates for acquaintance with contraceptive methods are tabulated in Table 2. The most recognized methods were oral contraceptives (70.7% of the respondents), and condoms (46.9%). Oral contraceptives had ever been used by 262 wives (54.8%).
Wives, friends and books were the sources of information most often cited by the men in our study (Table 2). Only 50 (10.5%) had ever attended a class on reproductive health issues. In case of emergency need for contraception, 429 (89.7%) had no idea of the possible measures which could be used: 18.2% stated their wives had had at least 1 unwanted pregnancy.
At the time of the study, 395 (82.6%) of the men we interviewed were using contraceptive methods: 43.1% used oral pills, 10.2% used condoms, 8.7% of their wives had had tubal ligation surgery and 7.5% used Norplant® (subdermal implants).
Among the 83 individuals who were not using contraceptives at the time of the study, in 28.9% it was because of the wife’s pregnancy, in 19.3% because they wanted to have a child, in 9.6% because of infertility, in 8.4% due to lactation and in 4.8% because the wives were post-menopausal. The rest did not identify their reasons for not using any methods—none cited religious issues, family opposition, personal resistance or difficulty in use.
Analysis
The findings on demography and knowledge, attitudes and practices scores for Iranians and Afghans were compared (Table 3). There was no significant difference in mean age at the time of the study and at the time of marriage between the 2 groups. For their wives, the difference in mean age at marriage and the age at first pregnancy was statistically significant. The indicators of socioeconomic status [monthly salary, ownership of a house, luxury items (e.g. refrigerator, mobile phone, car) and the crowding index] were significantly better for Iranians than for Afghans (P < 0.001 for differences of all indicators). Illiteracy and semi-
literacy rate was 50.2% among Afghans and 11.4% among Iranians (P < 0.001). For their wives the rates were 78.6% among Afghan women and only 13.0% among Iranians (P < 0.001). No Afghan wives and only 4.9% of Iranian wives were working outside the home (P < 0.001). There was no significant difference between the 2 groups (P = 0.242) with regard to reproductive health service delivery coverage, including education and provision of contraceptive drugs and devices.
Mean scores for knowledge, attitudes and practices in Iranians and Afghan refugees in our study sample are shown in Table 4. There was no statistically significant difference in the knowledge score between the 2 groups, but the scores for attitudes and practices were significantly higher in the Iranian men (P < 0.001).
Discussion
A review of studies on reproductive knowledge and beliefs among Iranian women revealed a relatively high level of knowledge of contraceptive methods and good attitudes, but studies on practices still showed low rates of use of contraceptive methods and a relatively high rate for unsuccessful use [5,11,16–20]. Published reports confirm a 70%–90% rate of acceptance of contraception and reproductive health topics, while the rate for contraception use was around 30% [20]. Around 20% of women clearly indicated the negative attitudes of their husbands as the reason for discontinuation of contraception [20]. Other studies found a 25% rate of unwanted pregnancy [21] and a rate of 42% for effective contraception [22]. It seems this negative attitude is another obstacle to effective use of contraception, continuous attendance to service delivery sites and proper usage of services. A number of international organizations have emphasized the important role of male partners in reproductive health issuse following the satisfactory results of several initiatives conducted in different countries concerning the involvement and support of male partners [8,9,23].
This study casts light on the current situation of reproductive health knowledge, beliefs and practices among male partners in the Islamic Republic of Iran. While a great amount of resources are dedicated to promoting family planning programmes designed for women, the role of men has been neglected. South-western Tehran province is a region where a great number of Afghan refugees reside, and previous studies have outlined the differences in reproductive health indices between the 2 groups [13]. This study investigated whether there are similar differences regarding male attitudes and beliefs.
Apart from economic markers and literacy grades, which showed large differences between the 2 groups, there was no significant difference for the coverage of reproductive health services provided by health centres. The health system basically tries to maintain equity in access to services. On the other hand, the reproductive demographic data showed significant differences for age of marriage, age of bearing the first child, and the number of children among women of the 2 groups, as well as literacy and crowding index; all of the indicators were better among Iranians. These differences might suggest different perceptions of gender and family life, but the information obtained in this study is not conclusive on this matter.
Men in both groups had very low scores for knowledge (< 5 out of a maximum of 30) about reproductive issues. This is not surprising considering the 10.5% rate of attending direct educational classes on reproductive health issues for the males in our study. A detailed look at the results shows that for every contraceptive method, men get acquainted with the concepts and methods through their wives rather than any educational programmes in their work place, the media or health centres. This communication of information is limited, however, since men showed very little knowledge on the issue.
Iranians had a significantly better attitude score. One should, however, bear in mind the influential role of culture and perceptions of sexuality and reproduction. Afghans have been reported to have a preference for larger families and consider the number of boys in the family as the major capital of a man [24]. They tend to esteem those who have more children, especially boys [24]. Although these types of cultural beliefs are also found among some families in the Islamic Republic of Iran, studies show that education for family planning, increasing the literacy rate and reducing economic difficulties have long been deterring Iranians from the tendency for having large families [20,21]. Nevertheless, the attitude scores of Iranian males were judged to be low, with a mean of 13.89 out of a maximum of 20.
Another issue to bear in mind is that Afghan refugees do not reside in one district for a long period of time. Migration and unstable living conditions can render any formal or informal education ineffective. If the education is transformed into action, repetition and perseverance, together with peer approval and encouragement are effective.
The scores for practices were statistically significantly different between the groups, being better for Iranians, but were still quite low.
Considering the very poor scores for knowledge in both groups, it is clear that the familiarity of women with family planning and their beliefs about this topic, and their determination to use contraception, together with their effectiveness in delivering the knowledge to their husbands is quite important for raising the practice scores because most of the contraceptive methods used by the clients of health houses actively involve women rather than men. The rate of use, and especially the high rate of failure, indicate a need for revision of the current education system.
Reproductive health services in the Islamic Republic of Iran face a major challenge in dealing with the Afghan refugees [13,22]. Although coverage by health centres and access of women to services was satisfactory, in practice it was ineffective and failure rates seemed high. Males play a dominant role in families of both groups, and their knowledge was defective. But when it came to attitudes, the second step before taking action, Iranians had better scores; they also had higher scores for practices. It is obvious that we need to plan a series of programmes for better cooperation and support from male partners for reproductive health. Providing educational materials tailored to the special needs of males may be the first step [25,26].
This study was not designed to determine the reasons for differences in knowledge, attitude and practice scores. Possible explanations are rooted in the difference in culture, as well as social and economic dissimilarities and the special characteristics of refugees. Further studies, preferably of a qualitative nature, will be necessary.
The limitations of this study should also be mentioned. The main problem in the course of the study was to locate Afghans for the interview. They often changed addresses, and were often difficult to trace. The interviewers spent much time reassuring them of the confidentiality and purpose of the study. Furthermore, the closed nature of the data-gathering tool (questionnaire) made inferences and justifications of the results rather inconclusive and the study illustrates a situation for which further investigation is required.
Acknowledgements
The authors would like to thank the health care staff in Ahmad Abad and Chahardangeh for the tasks of data collection and filling in the questionnaires by interviewing men. We would also like to thank Ms Zahedi for her kind contribution in the data entry process.
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