A Qualitative Endline Evaluation Study of Male Engagement in

eCommons@AKU eCommons@AKU

Population Health, East Africa Medical College, East Africa

7-2021

A Qualitative Endline Evaluation Study of Male Engagement in A Qualitative Endline Evaluation Study of Male Engagement in

Promoting Reproductive, Maternal, Newborn, and Child Health Promoting Reproductive, Maternal, Newborn, and Child Health

Services in Rural Kenya Services in Rural Kenya

Adelaide Lusambili

Stefania Wisofschi

Constance Shumba

Peter Muriuki

Jerim Obure

See next page for additional authors

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Part of the Maternal and Child Health Commons, and the Obstetrics and Gynecology Commons

Authors Authors

Adelaide Lusambili, Stefania Wisofschi, Constance Shumba, Peter Muriuki, Jerim Obure, Michaela Mantel,

Lindsay Mossman, Rachel Pell, Lucy Nyaga, Anthony Ngugi, James Orwa, Stanley Luchters, Kennedy

Mulama, Terrance J. Wade, and Marleen Temmerman

ORIGINAL RESEARCH

published: 08 July 2021

doi: 10.3389/fpubh.2021.670239

Frontiers in Public Health | www.frontiersin.org 1 July 2021 | Volume 9 | Article 670239

Edited by:

Samantha M. Harden,

Virginia Tech, United States

Reviewed by:

Bridgit Adamou,

University of North Carolina at Chapel

Hill, United States

Jackline A. Oluoch-Aridi,

University of Notre Dame,

United States

*Correspondence:

Adelaide M. Lusambili

[email protected]

Specialty section:

This article was submitted to

Public Health Education and

Promotion,

a section of the journal

Frontiers in Public Health

Received: 20 February 2021

Accepted: 06 May 2021

Published: 08 July 2021

Citation:

Lusambili AM, Wisofschi S,

Shumba C, Muriuki P, Obure J,

Mantel M, Mossman L, Pell R,

Nyaga L, Ngugi A, Orwa J,

Luchters S, Mulama K, Wade TJ and

Temmerman M (2021) A Qualitative

Endline Evaluation Study of Male

Engagement in Promoting

Reproductive, Maternal, Newborn,

and Child Health Services in Rural

Kenya. Front. Public Health 9:670239.

doi: 10.3389/fpubh.2021.670239

A Qualitative Endline Evaluation

Study of Male Engagement in

Promoting Reproductive, Maternal,

Newborn, and Child Health Services

in Rural Kenya

Adelaide M. Lusambili

, Stefania Wisofschi

, Constance Shumba

, Peter Muriuki

Jerim Obure

, Michaela Mantel

, Lindsay Mossman

, Rachel Pell

, Lucy Nyaga

Anthony Ngugi

, James Orwa

, Stanley Luchters

1,3,4

, Kennedy Mulama

Terrance J. Wade

2,5

and Marleen Temmerman

2,4,6

Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya,

Centre of Excellence in Women

and Child Health, Medical College, Aga Khan University, Nairobi, Kenya,

Aga Khan Foundation, Canada, Ottawa, ON,

Canada,

Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University,

Ghent, Belgium,

Department of Health Sciences, Brock University, St. Catharines, ON, Canada,

Department of Obstetrics

and Gynaecology, Medical College, Aga Khan University, Nairobi, Kenya

Background: Globally, male involvement in reproductive, maternal, newborn, and child

health (RMNCH) is associated with increased beneﬁts for women, their children, and

their communities. Between 2016 and 2020, the Aga Khan University implemented

the Access to Quality of Care through Extending and Strengthening Health Systems

(AQCESS), project funded by the Government of Canada and Aga Khan Foundation

Canada (AKFC). A key component of the project was to encourage greater male

engagement in RMNCH in rural Kisii and Kiliﬁ, two predominantly patriarchal communities

in Kenya, through a wide range of i nterv entions. Toward the end of the project, we

conducted a qualitative evaluation to explore how male engagement strategies inﬂuenced

access to and utilization of RMNCH services. This paper presents the endline evaluative

study ﬁndings on how male engagement inﬂuenced RMNCH in rural Kisii and Kiliﬁ.

Methods: The study used complementing qualitative methods in the AQCESS

intervention areas. We conducted 10 focus group discussions (FGDs) with 82 community

members across four groups including adult women, adult men, adolescent girls, and

adolescent boys. We also conducted 11 key informa nt interviews (KIIs) with facility health

managers, and sub-county and county ofﬁcials who were aware of the AQCESS project.

Results: Male engagement activities in Kisii and Kiliﬁ counties were linked to improved

knowledge and uptake of family planning (FP), spousal/partner accompaniment to facility

care, and defeminization of social and gender roles.

Conclusion: This study supports the importance of male involvement in RMNCH in

facilitating decisions on women and children’s health as well as in improving spousal

support for use of FP methods.

Keywords: male engagement, reproductive health, family planning, Kiliﬁ, Kisii, Kenya FP, Kenya

Lusambili et al. Male Engagement in Reproductive Health

PLAIN ENGLISH SUMMARY

Active engagement of fathers and overall spousal participation

in reproductive maternal and new child heath (RMNCH) is

associated with improved nutrition and improved decisions

and actions for the use of antenatal services (ANC), delivery,

and post-natal services (PNC). While research from low and

middle income countries (LMICs) has linked male engagement

projects to improved couple relationships, joint family decision

making, increased uptake of family planning (FP), and reduced

child mortality; however, male involvement and participation

in women’s health remains low in Sub-Saharan African (SSA)

settings. We conducted a qualitative evaluation to explore how

male engagement strategies inﬂuenced access to and utilization

of RMNCH services, following a 5-year intervention activity that

encouraged greater male engagement in RMNCH in rural Kisii

and Kiliﬁ, two predominantly patriarchal communities in Kenya.

We conducted 10 focus group discussions (FGDs) with the

community members across four groups including adult women,

adult men, adolescent girls, and adolescent boys. We also

conducted 11 key informant interviews (KIIs) with facility health

managers, and sub-county and county oﬃcials who were aware of

the project activities. We found that male engagement activities

in the two sub-counties were linked to improved knowledge and

uptake of FP, spousal/partner accompaniment to facility care,

and defeminization of social and gender roles. In conclusion,

male involvement in RMNCH is key as it is associated with joint

decisions on FP and child spacing with improved spousal support

for use of FP methods.

BACKGROUND

There is growing recognition of men as actors who inﬂuence

the health of women and children (

1, 2). Addressing gender-

based inequalities through enhanced women’s empowerment

demands that men act in a supportive role toward the realization

of women’s sexual and reproductive health (

1). International

research demonstrates that active engagement of men and overall

partner participation in reproductive, maternal, newborn, and

child health (RMNCH) is associated with improved nutrition and

improved decisions and actions for the use of ANC, delivery,

and PNC (3–13). Contrary to this, men’s disengagement has

been shown to have deleterious outcomes such as poor child

development, poor maternal and child mental health, and low

and delayed uptake of ANC services (11, 12).

Abbreviations: AKFC, Aga Khan Foundation Canada; AKU, Aga Khan

University; ANC, antenatal care; AQCESS, access to quality care through

extending and strengthening health systems; CHC, community health committee;

CHEW, community health extension workers; CHU, community health unit;

CHV, community health volunteer; FGD, focus group discussion; FP, family

planning; HF, health facility; HIC, high-income countries; KII, key informant

interview; LMIC, low- to middle-income countries; MERL, monitoring and

evaluation and research learning; MNCAH, maternal, newborn, and child health;

NACOSTI, national commission for science, technology, and innovation; PI,

principal investigator; PNC, post-nat al care; RMNCH, reproductive, maternal,

newborn, child, and adolescent health; SSA, sub-Saharan Africa.

Similarly, recent but limited research from LMICs such as

Bangladesh, Zimbabwe, Mozambique, and Tanzania has linked

male engagement projects to improved couple relationships, joint

family decision making, increased uptake of FP, and reduced

child mortality (

13–15). Despite these reported beneﬁts, male

involvement, and participation in women’s health remains low

in SSA settings (14). This lack of involvement and participation

is of particular concern in male dominated societies, like Kenya,

and threaten women’s autonomy and ne gatively impact health

seeking behaviors throughout pregnancy and delivery (16, 17).

In such contexts, men dete rmine under what conditions their

partners or spouses utilize health and FP resources and leave

women unable to make decisions about their own health

(2, 18, 19).

While one study conducted in Kenya found that men

were reported to be facilitators of positive behaviors by

encouraging wives and partners to attend ANC visi ts and facility-

based delivery services (

11); our previous study also identiﬁed

speciﬁc barriers to men’s pa rticipat ion in RMNCH including

gendered cultural norms such as the belief that pregnancy

is the sole responsibility of the woman, negative health care

worker attitudes toward male engagement and maternity, and

community health services infrastructures that are unsupportive

of men’s participation (19). As empowered women are more

likely to attend facility-based reproductive he a lth services,

utilize modern FP methods, and experience fewer pregnancy

complications, an increased emphasis on male engagement in

women’s h ealth will assist in preventing reproductive health

issues, increasing acceptance of contraceptive methods, and

empowering women’s decision making (20–22). As such, the

promotion of FP initiatives that involve men is key to addressing

barriers to men’s supportive participation in reproductive and

maternal health and has been linked to positive health outcomes

for women and children (23–26).

In an attempt to identify and address the barriers to

women’s access to RMNCH in rural Kenya, in 2015, “Access to

Quality of Care through Extending and Strengthening Health

Systems (AQCESS)” project, an RMNCH project funded by

the Government of Canada and Aga Khan Foundation Canada

(AKFC) designed and implemented a range of activities (Table 1)

in rural Kisii and Kiliﬁ counties, two predominantly patriarchal

communities in Kenya. The e valuation study was conducted

after a 4-year intervention with activities that promoted the

participation of men in RMNCH. This paper presents ﬁndings

from the end line evaluation study and focuses speciﬁcally

on understanding how male engagement strategies inﬂuenced

RMNCH services.

METHODS

Study Design

A qualitative study.

Study Setting

The evaluation study was conducted in Kiliﬁ (Kaloleni and Rabai

sub-Counties) in southeast Kenya and Kisii (Bomachoge Borabu

sub-County) in southwest Kenya where Aga Khan University

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Lusambili et al. Male Engagement in Reproductive Health

TABLE 1 | AQCESS interventions.

1. Using community health volunteers (CHVs), community health committee (CHCs) members, and community health extension workers (CHEWs), dialogues with

men and women were carried out quarterly in each of the 1 7 Community Health Units (CHU’s) on the importance of family planning. Dialogue sessions targeted

men and women of all ages. Men, including the heads of households, were recruited across the 17 CHU’s and from geographically disconnected villages.

Sessions, also known as dialogues, engaged women, men, and adolescents of both sexes. Discussions focused on the barriers to access and use of RMNCH

services, the importance of men supporting women in RMNCH, and the need for men and women to work together to improve health outcomes for their families.

2. All CHVs and CHC members were mentored by the AQCESS study team on gender equality in RMNCH with the ultimate aim of involving even those members

from hard-to-reach communities.

a. Mentorship trainings included information on how CHVs can reach out to men, talk to them, and empower them to support their spouses in RMNCH.

b. In addition, the AQCESS project team also conducted quarterly outreach through the health facilities in AQCESS catchment n areas. This outreach had a

health education component for health care workers on RMNCH and FP targeting both males and females attending facilities for care.

c. Facilities provided edutainment sessions on RMNCH targeting both males and females.

3. Project staff employed models that empowered CHVs/CHCs as change agents, which included training sessions on how to reach the heads of households,

Maternal, Newborn, Child and Adolescent Health (MNCAH), gender, and how to deliver and facilitate dialogues.

4. Project staff trained members of health facility committees with respect to challenges in RMNCH and gender responsiveness, speciﬁcally on male support, and

accompaniment for women attending facility care.

5. Project staff promoted gender empowerment through Ministry of Health forums and through the creation of gender champions with representatives from

community leaders, CHVs, CHCs, health facility committees, and county child and gender departments. The role of gender champions was to act as role

models and agents of change in challenging negative gender and social norms and supporting adoption of positive practices.

conducted a RMNCH intervention since 2015. Both Kiliﬁ and

Kisii are patriarchal communities and geographically dissimilar

rural counties in Kenya. Further details on social-cultural context

of Kiliﬁ can be found in our earlier research paper (

19).

Table 1 gives a summary of some of the interventions

that were led by the AQCESS project team to promote male

engagement. The interventions were implemented in these areas

over a period of 4 years and were nearing completion when

this study was conducted and a detailed description is provided

by Lusambili et al. (27). The male engagement strategies were

designed to change men’s behaviors and increase their support

toward women during pregnancy, ANC, delivery, and PNC. The

interventions also aimed to enable men to become change agents

in addressing socio-cultural and gender inequalities in Kisii and

Kiliﬁ counties.

Methods

The qualitative study assessment employed 10 FGDs with

82 participants and 11 KIIs across the two study sites. Key

informants who were aware of the AQCESS project in the past

1 year were purposively sampled by AQCESS project managers

for interviews. These included males and females at the county,

sub-county, and health facility (HF) levels.

Focus group dis cussions participants were recruited by

AQCESS project ﬁeld coordinators. Across the two sites, FGDs

were c onducted separate ly with female and male CHC members,

male and female adult community members, and female and

male adolescent community members. To qualify, participants

had to have lived in the AQCESS target areas for at least 1

year and have awareness of AQCESS male engagement activities.

While eﬀorts were made to secure as great a representation

as possible to ensure an unbiased and representative sample,

this was balanced necessarily by the need to be familiar with

or engaged in the AQCESS project. Adolescents were aged 15–

19 and included those who had been involved in AQCESS

gender forums.

The qualitative evaluation explored the observed beneﬁts

of male engagement, the perceived eﬀectiveness of male

engagement strategies in promoting RMNCH, facilitators and

barriers to male engagement, and the lessons learned for engaging

men in RMNCH. For this paper, we will focus on the evaluation

of th e beneﬁts of involving men in RMNCH activities.

Interview Process

Data collection was led by the study Principal Investigator (PI),

a qualiﬁed qualitative consultant, and a team of experienced

research assistants. Actual dat a collection commenced after

securing institutional approval from the Aga Khan University

(AKU) Kenya and National Commission for Science Technology

and Innovation (NACOSTI/P/19/2768) on December 3, 2019.

The research also sought consent from all participants and was

granted permission to carry out the resea rch from local HF

and CHCs.

Data was collected from January to March 2020 in the local

Swahili language. All the study participants were provided with

full disclosure and information regarding the purpose of the

study, including the beneﬁts and risks. They were also given

the opportunity to ask questions before, during , and after the

KIIs and FGDs. Focus group discussions for “women adult

community members,” “male adult community members,” “male

adolescents,” and “female adolescents” were facilitated separately

by a qualiﬁed facilitator and a note taker of the same gender.

Research assist ants were trained on the approved protocol

requirements and participants consenting processes prior to

performing data collection. Parental/guardian assent was sought

for adolescents <18 years of age. All participants provided

written consent prior to participating in the study. All KIIs and

FGDs were conducted in community spaces deemed convenient

and private for interv iewees to converse. Focus group discussions

consisted of 6–8 people.

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Lusambili et al. Male Engagement in Reproductive Health

Data Management and Analysis

All audio recordings from the collected interview data were

labeled and transferred to a secure laptop at AKU’s Monitoring

Evaluation and Learning Unit (MERL) and then subsequently

deleted from th e audio recorders. All reﬂective ﬁeld notes and

transcripts were stored on a password protected computer and

accessibility was limited to the study team. Further, transcripts

were anonymized by deleting any references to names and

additional identiﬁers to safeguard participants’ conﬁdentiality.

Translated and transcribed data was checked by the study PI and

study consultant who are Swahili native speakers.

To address reliability and validity, two qualitative researchers

read all the transcripts, coded them separately into NVivo 12 Data

Analysis Software (QSR International), and proceeded to identify

codes, categories, and themes with attention to contradictions

across the two sites and diversity of experiences, and to

perceptions and attitudes across the diﬀerent stakeholders. These

codes, categories and themes were compared and harmonized.

Additionally, the study PI randomly reviewed selected transcripts

and compared the ﬁnal codes, categories, and themes identiﬁed

by t h e two preceding coders.

Toward the end of March 2020 and early April 202 0, the

AQCESS research team held a workshop at both study sites to

validate the ﬁndings. The workshop, attended by all ﬁeld staﬀ,

local stakeholders, and the research team, conﬁrmed the observed

interventions as well as ﬁndings on the beneﬁts of involving men

in t he RMNCH activities.

RESULTS

Results from our endline evaluative study indicate that the

intervention may have shifted behaviors with regard to uptake

of FP, spousal support in RMNCH, and improved relationships

at t he household levels, as summarized below:

I. Improved knowledge and uptake of FP methods

II. Spousal accompaniment for antenat al care and facility-

based delivery

III. Shift in traditional social and gender norms

Improved Knowledge and Self-Reported

Uptake of Family Planning

Narratives from study participants suggest that AQCESS male

involvement strategies may have improved knowledge leve ls

among husbands and partners relating t o the beneﬁts of using

FP methods. The sensitization of husbands and wives together

on the importance of FP was central to shifting behaviors.

Findings revealed that male partners who were targeted during

the interventions no longer prohibited their wives from utilizing

FP methods. In addition, adolescents beneﬁted from early sex

education through sensitizations activities organized by AQCESS

staﬀ. Overall, male involvement strategies resulted in improved

relationships at the household level. These views were reported by

both men and women community members and HF managers.

Women Access Family Planning Without Fear

In Kiliﬁ, ﬁndings from separate FGDs for male CHCs and adult

female community members as well as KIIs with a facility healt h

manager suggest collaborative decisions in uptake of FP.

“. .. And even now when my wife is going to the hospital or doing

family planning it is easy because the man was the one tough

headed but now there are teachings, women can do family planning

without fear.”

FGD_Male CHC, Kiliﬁ

“. . . before it was very diﬃcult for a mother to go to the hospital

for family planning. Even other women used to plan without

informing their husbands; or if you tell your husband he would

even beat you, but now they understand, you can collaborate and

go together to do family planning.”

FGD_ Adult female community member, Kiliﬁ

“Something else about family planning, back then when you

would tell your husband you go for family planning, he would refuse

and now, because of the trainings, they accept to accompany us, and

we get educated together. And it’s going on well. . . ”

FGD_ Adult female community member, Kiliﬁ

“. . . now the women do not get frustrations when seeking for

services, like they don’t have to hide, they discuss with the partners

and they just come openly and say we decided.”

KII_Health Facility Manager, Kiliﬁ

In Kisii, however, similar but limited ﬁndings were reported from

a female adolescent FGD participant.

“It’s good because even men nowadays this issue of family planning

they don’t leave it to women alone. You ﬁnd now they discuss how to

get few children and they plan so they don’t leave it alone to women

to do family planning.”

FGD_ Adolescent female community member, Kisii

Adolescent Sex Education

Similarly, data also suggests that men’s support for and

engagement in FP training sessions may have improved

adolescent men’s knowledge of protective sex behaviors. In Kiliﬁ,

adolescent girls also indicated that they were educated during

forums organized by AQCESS on youth’s dangers and risks of

HIV contraction and methods for early pregnancy prevention

through the use of contraceptives.

In Kisii, for example, ﬁndings from the male adolescent

FGDs revealed that young boys may have been taught how

to use protection during sex by other men engaged in

AQCESS activities.

“. . . as we have been involved, they advise us on how we should be

staying and when any other youth gets to hear about something, let

me say about adult matters, and the young person wants to explore,

to know how they happens, but as we attend in the baraza [local

meetings] we are advised to wait until we are mature enough.”

FGD_Adolescent male community member, Kisii

“. . . taught how I can protect myself when in a relationship with

a lady and you are told to wait until you get mature, you get advised

by the doctors then agree on what to do.”

FGD_Adolescent male community member, Kisii

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Lusambili et al. Male Engagement in Reproductive Health

Similar ﬁndings were reported in Kiliﬁ from adult male

community members and adolescent female community

members. In the following quote for instance, an adult male

community member mentioned how they now take initiative to

impart knowledge on protected sex to the youths.

“. . . our youths used to be people that were walking idly but since

they were made aware of this issue [early sex] they got directions.

Because every time they got training there were lessons taught to

those especially about protective sexual practices if they had to have

sex. After being taught we go ahead and teach our youths that

whenever they get a partner they should not easily trust the partner

but if they happen to be in a hurry they should always use protection

before involving in sexual intercourse.”

FGD_Adult male community member, Kiliﬁ

“A while ago, you know some time back there was HIV/AIDS,

long ago there was no education about it, we had knowledge about

it, but we only knew that it is there and that we can get HIV/AIDS

through sex and we didn’t know any other ways. But now there

are professionals that have been chosen who tell the youth of all the

other ways you can contract HIV/AIDS . . . ”

FGD_ Adolescent female community member, Kiliﬁ

Additionally, female adolescents further reported how the

ACQCESS project may have impacted them to take up

contraception to prevent e arly pregnancies.

“Back then you would ﬁnd yourself at home idle you don’t have

work. So, you decide to ﬁnd someone to marry you. But since

this program came, AQCESS, it has taught us to avoid these

early pregnancies, through things like family planning, pills and

injections that you can take in order to avoid it.”

FGD_Adolescent female community member, Kiliﬁ

Joint Decision Making on Family Planning Linked to

Improved Relationships

Study participants reported that the use of FP had improved

relationships at the family level as husbands and wives have

become more united in joint decision-making regarding child

spacing. Men’s support in child care improved. Findings

from Kiliﬁ and largely from both adult female and male

community members give details about the shift in the behaviors

of men toward joint decision-making regarding FP. In the

following three quotes, adult female community members for

this study explain their frustrations before their husbands were

educated about FP compared to after the intervention, and

the changes they have seen since attending trainings through

AQCESS activities.

“First, I say thank you to AQCESS, I once gave birth to twins and

whenever I asked my hu sband to assist me with babies, he used

to refuse, but after attending these educative sessions, he helps me

carry them to the facility, they are healthy because of the knowledge

we gathered and I say thank you to this project.”

FGD_Adult female community member, Kiliﬁ

“As for me, what I have learnt is in involving men, its being

close to your husband, the kind of love that you share, then if

you would start considering issues to do with family planning

he will understand you, and planning on how to give birth to

children, kids will be educated well, you can bu ild a home, would

be having time to buying assets to put in your home, through doing

family planning.”

FGD_Adult female community member, Kiliﬁ

“Regarding the changes at the moment, its easier at the facility to

use those services because back then, men would completely refuse

but now I bring my husband, we are counseled well together and

we both understand even family planning is explained with him

around until I ﬁnish, that’s why we have improved because back

then we were so behind in family planning.”

FGD_Adult female community member, Kiliﬁ

In particular, men pointed out how joint family decision has

brought happiness in the home.

“. . . as for me, to add is that, emphasizing on the information about

family planning, it has brought happiness in homes because it has

a created a good relationship between the father, mother and that

child. . . . happiness can be found in those homes, people are staying

well and in an organized manner.”

FGD_Adult male community member, Kiliﬁ

“So right now, we are on the same path, there is peace in homes,

and marriages are being mended, things are being done without

opposition. To add on that, most marriages used to break because

the man did not know if the woman had done family planning,

because the woman did not involve him. So, he will be struggling

to get his wife pregnant but in vain because the woman did not

tell him, which later brings misunderstanding between them. As

my friend had said men have been involved and the ﬁeld doctors

have taught.”

FGD__Adult male community member, Kiliﬁ

In the same vein, scant ﬁndings from Kisii further report on the

impact of AQCESS in improving their knowledge about FP and

child spacing.

“. . . I would like to say thank you, because of the doctors from

AQCESS, because we have been involved in family planning. As

men, we never knew that once a woman delivered needed space,

rather we knew that we were to continue getting another child.

But we have now improved and we have been trained that after

a mother has delivered, she needs to be given more time as you have

agreed. You need to discuss together if it is two to three years to

enable the kid to grow and also to get enough money to feed and

educate the baby as well get suﬃcient time to advance in life.”

FGD_Male CHC, Kisii

The narratives from participants indicate that the male

involvement strategies to some extent may have increased

women’s agency in accessing FP services. This was largely

due to the creation of a supportive and enabling environment

resulting in a situation where men and women were able

to make joint decisions on FP and child spacing, and were

ultimately thriving in joyful and fulﬁlling relationships. Previous

clandestine use of modern FP methods due to fear of domestic

violence against women was reported to have been reduced

as a result of improved knowledge and support from male

partners. The quotes from male adolescents highlight that men’s

support for, and engagement in FP training sessions increased

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Lusambili et al. Male Engagement in Reproductive Health

their knowledge on protective sex behaviors identifying potential

generational diﬀerences.

Spousal Accompaniment for Antenatal

Care, and Facility-Based Delivery

Our ﬁndings across the two sites revea led that male involvement

strategies resulted in behavior change and positive practices

toward RMNCH as men became more responsible and

supportive partners in RMNCH issues. Participants from the

study sites reported observed changes in men’s behavior,

speciﬁcally they were seen accompanying their spouses to

RMNCH services. In Kiliﬁ, HF managers noted that they had

witnessed an increase in spousal accompaniment in the past

3 years.

“When AQCESS came nowadays we can see at least, let’s say in

a number of ten, ﬁve usually come with their male partners for

the services.”

KII_Health facility manager, Kiliﬁ

“. . . this is through the male accompanying their partners and

even allowing women to come for this service . . . and also for the

ante-natal clinics.”

KII_Health Facility Manager, Kiliﬁ

Similar sentiments were reported in Kisii among both female

and male CHCs members. Participants reported that, prior to the

intervention, spousal accompaniment was limited as men were

afraid to accompany their wives to attend facility care. Howe ver,

this improved following the AQCESS interventions.

“Men have become loving and caring, when he sees that his wife has

conceived, he treats her well and when it reaches the labor time, he

takes her to the hospital.”

FGD_Female CHC, Kisii

“To add on this, pre viously before AQCESS came in, like most

men would not bring their wives to the clinic but nowadays, if you

just stand outside a facility, you will ﬁnd a husband and a wife

together in the facility. . . ”

FGD_Male CHC, Kisii

“What I can add, nowadays if a woman is expectant, a man is

not afraid to take her to the hospital to deliver...”

FGD_Male CHC, Kisii

In Kisii, men were also observed to assist in taking their children

to the hospital and were now mindful of the health of their wives

and children.

“Even when taking their children to the hospital they take them both

[man and woman], so the father is concerned about the children.”

FGD_Adolescent female community member, Kisii

“. . . men have started to understand the care and health

promotions of the mother, children... Now there is this attitude

that it is the mother who is supposed to be responsible to ensure

good health of the baby, they have reached a point where they have

known that even the husband can bring the baby to clinic and they

have buried those bad attitudes of saying that clinic is only for

the mothers.”

FGD_Female CHC, Kisii

Participants reported behavior change in relation to the adoption

of positive RMNCH practices. These mainly manifested in

the form of spousal accompaniment for antenatal care and

facility-based delivery, which was not previously the case

due to lack of knowledge and negative gender norms and

sociocultural attitudes. Health facility managers, men, women,

and adolescents all echoed this change indicating that many male

partners exhibited improved attitudes and behaviors toward t heir

pregnant wives and young children. The men were described as

being caring, demonstrating concern about their children’s well-

being and health, and exemplifying support for their wives by

accompanying them to health facilities for antenatal care visits

and delivery.

Shift in Traditional Social and Gender

Norms

Men Now Perform Traditionally Feminized Roles

Findings chieﬂy from Kisii showed that male engagement in

RMNCH promotion shifted men’s views and practices in relation

to traditionally feminized roles as men began helping their wives

with h ousehold chores.

“Most of the time if we are pregnant they help us in doing house

chores.. . Now they don’t leave the work to us. They help out they

can do the laundry. If you have been told bed rest, he is the one does

that and things like that.”

FGD_Adult female community member, Kisii

“I would like to add that since they started to be involved, they

fetch water and bring it to the house they also help to carry the baby

when he’s crying and you’re doing something else. When it reaches

time to cook if you are cooking ugali [cornmeal] and the child is

asleep they help in cutting up the kales.”

FGD_Adult female community member, Kisii

“Mostly, from the question you asked, we as men, when my wife

is expectant, I can help her to do some house chores like cooking. But

previously, that was the work of a wife. She could even cook within

a day of delivery. But nowadays, through the public barazas, we as

men have been able to be enlightened.”

FGD_Adult male community member, Kisii

Similar but limited ﬁndings were reported in Kiliﬁ.

“But it’s like we were oppressing the women back then when we

left to them all those duties, but now there are changes, where the

husband also helps the women in like cooking and also helping

the children in bathing them, washing their clothes, those are the

changes that are existing now and they couldn’t be there, it’s through

AQCESS project and gender.”

FGD_Adult male community member, Kiliﬁ

Girls Go to School

In addition, involving men and training them on gender equality

allowed men in Kiliﬁ to reﬂect on discriminatory traditional

customs, guided them to denounce such practices and move

toward recognizing the importance of educating girls and

including t h em in the family inheritance.

“. . . When AQCESS was teaching us about gender, you know here

at home we had discrimination, my child couldn’t own my wealth

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Lusambili et al. Male Engagement in Reproductive Health

because we would say she would go to another homestead but we

saw it not right that the child is yours and. . . (Coughs)... You fail to

give her inheritance.”

FGD_Male CHC, Kiliﬁ

“We used to oppress our ladies by not taking them to school,

through AQCESS in the issue of gender we are now taking our girl

children to school, because back then we used to say a girl child is to

grow then get married and so was it.”

FGD_Male CHC, Kiliﬁ

Based on these narrati ves, male involvement was the key

ingredient that led to the positive changes realized. Participants

from both Kisii and Kiliﬁ acknowledged this approach in the light

of t h e positive returns it yielded.

“It is because majority of the Kisii man are the decision makers, so

if the decision maker is not involved in the health care of his family,

because many women are not the decision makers in this area, then

we may not have the desired change.”

KII_County oﬃcial, Kisii

“Yes, when they involved men was that, as you have put, it was

that, because automatically the catch and community of this area,

we call them the “Mwenye factor”, and if you didn’t involve their

men then you could not see their women.”

KII_Sub-county oﬃcial, Kiliﬁ

“In the past it was that whatever a man said was ﬁnal but

these days they agree together, the father gives his opinions and the

mother g ives her own opinions then they get the solution.”

FGD_Adolescents female community member, Kisii

In Kisii, customary laws that led girls to suﬀer by being

circumcised seemed to have shifted, improving girls’ health

and opportunities.

“When we explained to them that it is not good to circumcise a

girl child because you will cause trauma to her life because there

are so many diseases these days and you might not know how one

contracts a disease of any kind. So when we gave them those reasons

they were all happy and said that they no longer follow the analog

way, they follow the digital way, we will no longer follow our past

beliefs we will do according to the health because we have to follow

the health instructions and if we follow the analog things we will

cause injury to ourselves.”

FGD_Female CHC, Kisii

The narratives demonstrated a positive shift in social and

gender norms in the intervention communities. Men were

reported to be supporting their pregnant wives with household

chores, which were pre v iously considered part of women’s roles

and responsibilities. The project also helped to improve men’s

understanding of discriminatory practices against the girl child,

and allowed them to recognize the importance of according

them educational and inheritance rights, in contrast to the past

when they believed that a girl child was raised to be married

oﬀ and would not provide a good return on (educational)

investment. The mind-set shift due to the community level

dialogue sessions enabled t hese communities to respect the rights

of women and girls and make some commendable strides toward

gender equality.

DISCUSSION

This paper presents ﬁndings regarding the inﬂuence of

male engagement interventions on RMNCH in rural Kiliﬁ

and Kisii counties. Our results show that the AQCESS

male engagement interventions improved men’s knowledge

regarding the beneﬁt of FP, which allowed partners to access

FP without fear. Interventions also improved adolescents’

sexual education, spousal joint de c ision making and support,

and de-feminization of social and gender roles. The ﬁndings

also show that men’s involvement in RMNCH, i ncreases

their ability to inﬂuence adolescents to adopt protective

and mutually beneﬁcial sexual practices for them and

their partners.

The reported improvement in spousal support is a positive

ﬁnding demonstrating that the intervention inﬂuenced spousal

support for RMNCH in a positive way. Our ﬁndings, regarding

increased partner support, i mproved joint decision making

on FP and boosted happiness and peace at home, and are

consistent with other studies in both LMICs and high income

countries (HICs) (

3–6, 11, 14). These ﬁndings exemplify that it

is possible, through dedicated and contextualized interventions,

to change gender and social norms related to male involvement

in RMNCH. In addition, the progress on access to education for

girls illustrated the need for more targeted strategies from the

Kiliﬁ county government that may help to sustain these beneﬁts.

Encouraging more girls to continue to go to school could help

address the high rates of teenage marriages and pregnancies

plaguing the region (28).

There are several implications for policy initiatives based on

our ﬁndings. First, there must be strategies and guidelines to

speciﬁcally address increased male involvement in the delivery

of RMNCH programs. Secondly, metrics, evaluation frameworks,

and best practices should be developed a nd collected to measure

how well programs are doing in terms of ensuring that men

are involved in RMNCH programs including the use of key,

standardized indicators of male involvement. This will ensure

that t hese practices can be adapted and scaled across a wide range

of socio-cultural and geographic settings and particularly in

LMICs. Third, to encourage greater male participation, attention

should be paid to the infrastructure of RMNCH facilities similar

to that addressing disrespect ful maternity care (

19) such as

staﬀ training, addressing gender bias among staﬀ, and ensuring

that men feel welcome through things such as partner-friendly

promotional materials. Most importantly, emphasis should be

placed on building upon the set of positive strategies through

which programs can support male involvement as demonstrated

in this paper. This would ensure that all stakeholders in

the implementation sites design and embed complementary

strategies in their future policies that can assist in sustaining this

progress at the household, community, and national levels.

Consistent with previous work examining male participation

in RMNCH that ﬁnds positive eﬀects on child health and

mortality, maternal health, and improved couple relationships

(

3–15) our ﬁndings demonstrate the potential for further

research to deepen our understanding of the processes t hat

can sustain the beneﬁts of engaging men in RMNCH. For

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Lusambili et al. Male Engagement in Reproductive Health

instance, future longitudinal qualitative and quantitative follow-

up studies across the two sites could h elp us to understand

the extent to which such interventions are sustained after the

completion of the project. Research on the key inﬂuences of

men’s lack of support for RMNCH in diﬀerent age groups could

help policy makers identify gaps as well as develop targeted

tools and strategies to address and eliminate these barriers.

Lastly, a quantitative study with targeted questions on male

engagement and epidemiological outcomes related to RMNCH

has the potential to ﬁll in gaps not addressed by qualitative

research and assess whether these targeted interventi ons may

permeate the larger community.

STRENGTHS AND LIMITATIONS

This study and its results are supported by several strengths.

First, it used both FGDs and key-informant intervi ews as

data c ollection methods and had a diversity of participants

(CHCs, HF mangers, gender representatives, and both adult and

adolescent male and female community members) enabling the

researchers to have a deeper understanding of male-involvement

in the intervention catchment area. Second, while work has

been done in ot h er LMIC countries including Bangladesh,

Zimbabwe, Mozambique, and Tanzania (

13–15), this study

examined one of a few interventions addressing the challenge of

increasing male involvement in RMNCH projects that has been

evaluated scientiﬁcally in rural Kenya which is traditionally male-

dominated (2, 16, 17). L astly, the evaluation was conducted after

4 years of intervention, which was ample time for participants to

realize its beneﬁts.

The principal limitation of the study is that it includes only

participants who are familiar or involved with the interventions

and AQCESS ﬁeld staﬀ, which may have introduced bias in

their narratives, eﬀorts were made to ensure the community

focus group participants were representative of their respective

communities, However, being insiders, as participants they

may not have critically reﬂected on the beneﬁts or/and they

may have been prejudiced by their involvement with the

AQCESS project staﬀ, who also recruited them in the study.

Second, as a qualitative approach, we did not have control

over our interviewees’ narratives, and even though the project

staﬀ recruited interviewees who were conversant wit h AQCESS

projects, there are many other development programs in Kiliﬁ

and Kisii including projects ge ared toward reproductive health

that may potentially ﬂow over into these results. To minimize

this potenti al, it was necessary to recruit persons familiar with

AQCESS at the risk of recruitment bias identiﬁed above. The

extent to which all the beneﬁts reported by the participants are

attributable solely to AQCESS-speciﬁc interventions could be

further explored in non-AQCESS areas.

CONCLUSIONS

This study has shown that male involvement in RMNCH

is critical in facilitating decisions on women and children’s

health and in improving spousal support for the use of

FP methods. This indicates the importance of implementing

male-involvement focused interventions to enhance RMNCH

outcomes in settings with deeply entrenched patriarchal social

and gender norms. Similar programs that aim to increase

male involvement in RMNCH should systemati cally examine

how individual and community le vel factors inﬂuence male

involvement with in speciﬁc contexts in an eﬀort to further

program and policy development.

DATA AVAILABILITY STATEMENT

The datasets presented in this article are not readily available

due to the conﬁdential nature of the data. Requests to access

the datasets should be directed to Dr. Adelaide Lusambili

and Prof. Marleen Temmerman adelaide.lus ambili@ak u.edu

and [email protected].

ETHICS STATEMENT

The studies involving human participants were reviewed and

approved by National Commission for Science, Technology, and

Innovation (NACOSTI) (NACOSTI/P/19/2768) on 03/December

2019. Consent was sought from all the participants and in

the communities in which this study was conducted. Written

informed consent to participate in this study was provided by the

participants legal parents or next of k in.

AUTHOR CONTRIBUTIONS

AL: conceptualization, data collection, data analysis, supervision,

visualization, writing, and validation. SW: formal analysis,

writing, visualization, and validation. CS: interpretation,

writing, visualization, and validation. TJW: manuscript review,

interpretation visualization and validation. MT: overall PI of

the AQCESS implementation and the MERL Unit. All authors

contributed to the article and approved the submitted version.

FUNDING

AKFC and the Government of Canada (grant # 7540280)

supported this research as part of the Access to Quality Care for

Extending and Strengthening Health Services (AQCESS) project.

ACKNOWLEDGMENTS

We are grateful to all our partners and study participants in

Kisii and Kiliﬁ counties. We would like to thank the project

study managers-Lucy Nyaga and Kennedy Mulama. We thank

the MERL unit managers, Jerim Obure and Michaela Mantel for

supervision of the overall evaluation project and Anthony Ngugi

and James Orwa for protocol development. Further, we would

like to thank the qualitative consultant, Peter Muriuki and all

the research assistants. We are grateful to Prof. Stanley Luchters

for providing an enabling environment to write the manuscript.

Finally, we thank the Government of Canada and the Aga Khan

Foundation Canada for funding t hi s study.

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Lusambili et al. Male Engagement in Reproductive Health

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Conﬂict of Interest: The authors declare that the research was conducted in the

absence of any commercial or ﬁnancial relationships t hat could be construed as a

potential conﬂict of interest.

Mossman, Pell, Nyaga, Ngugi, Orwa, Luchters, Mulama, Wade and Temmerman.

This is an open-access a rticle distributed under the terms of the Creative Commons

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is permitted, provided the original author(s) and the copyright owner(s) are credited

and that the original publication in this journal i s cited, in accordance with accepted

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