Husband's Knowledge and Involvement in the Reproductive Rights of Women in Harar, Eastern Ethiopia

Aminu Mohammed Dire Dawa University Tadesse Alemayehu Haramaya University College of Health Sciences: Haramaya University College of Health and Medical Sciences Assefa Desalew (  assefad100@gmail.com ) Haramaya University College of Health Sciences: Haramaya University College of Health and Medical Sciences https://orcid.org/0000-0001-6065-0708 Yalelet Belay Dire Dawa University Alekaw Sema Dire Dawa University Adera Debella Haramaya University College of Health Sciences: Haramaya University College of Health and Medical Sciences Yadeta Dessie Haramaya University College of Health Sciences: Haramaya University College of Health and Medical Sciences


Introduction
Reproductive rights are the rights of an individual to decide and choose about reproduction free of discrimination, coercion, and violence [1,2,3]. The mid-1990s marked an important milestone internationally regarding the roles and responsibilities of men in the reproductive right of women [4,5]. Before this time, relevant policies, programs, and strategies were exclusively focused on women and promoted their roles in improving reproductive rights. The Cairo International Conference on Population and Development (ICPD), was the rst global initiative that urged for extending the focus beyond women and emphasized the shared responsibility of men [1]. Subsequently, more initiatives began to target men in programs related to reproductive health including World Health Organization (WHO) and other international organizations [1,2,3].
Globally one-third of women experience intimate partner violence (IPV) [6]. These violations are a serious public health concern throughout the world, but it's notably present in low and middle-income countries (LMICs) particularly in Sub-Saharan Africa including Ethiopia, where 38.83% of the women abused by their intimate partner [7,8,9,10,11,12,13]. Women's reproductive right needs due attention because of its violence happens worldwide and it is a serious challenge for the health of women [1,7,14].
However, the lack of partners' knowledge of reproductive rights is among the factors related to IPV [15,16]. The violence is related to physical, sexual, psychological, emotional, and access to reproductive education, and family planning [14]. Decrease utilization of women's healthcare services, unintended pregnancies, pregnancy-related symptom distress (antenatal, intranatal and postnatal depression), inadequate prenatal care, induced abortion, and sexually transmitted infections were the most frequent adverse maternal health-related outcomes after IPV during pregnancy that results in a high burden of maternal morbidity and mortality [14,17,18,19,20,21,22,23].
Available evidence indicated that maternal health outcomes in LIMCs are related to the inadequacy of husbands' knowledge and involvement related to reproductive rights, lack of reproductive education, and spousal discussions which are the main cause of violations in reproductive rights [22,24,25,26,27,28,29]. Likewise, major contributing factors related to male partners' involvement in partners' reproductive rights are accessibility and utilization experience of reproductive health services, lack of spousal discussions on reproductive health and transportation access, and time to reach a health institution [30,31,32].
To achieve the Sustainable Development Goals (SDGs), the United Nations agenda related to gender equality, and empowering all women which is important to ensure universal access to sexual and reproductive rights for women seated for 2030 [1]. Likewise, the Ethiopian minister of health set seven strategic directions to prevent women's reproductive and human rights [6,33]. Appropriately and effectively promoting the involvement of men in the protection of women's reproductive rights requires an understanding of the current status of husbands' knowledge and involvement helps to set important programs and interventions on maternal healthcare needs in general and respecting women's reproductive rights in particular. There is a paucity of data related to husbands' knowledge and involvement and associated factors on women's' reproductive rights in eastern Ethiopia. Therefore, this study aimed to assess husbands' knowledge and involvement in women's reproductive rights and associated factors in Harar, eastern Ethiopia.

Methods And Material
Study setting and design A community-based cross-sectional study was conducted in March 2020 in Harari Regional State, eastern Ethiopia which is located 526 km from Addis Ababa, the capital city of Ethiopia. The region had an estimated 226,000 population with 125,000 urban and the remaining were rural populations [34]. This region is structured with 9 woredas (districts), six urban and 3 rural, and comprises 19 city kebeles (smallest administration unit) and 17 rural kebeles. We included all married male partners who have lived in Harar city. However, male partners who were severely ill and not living in the city during the study period were excluded.
Sample Size and sampling procedure The sample size was determined using a single population proportion formula considering the following assumptions; 5% level of signi cance (α = 0.05), 95% CI, a design effect of 1.5, and a proportion of 50% (to obtain maximum sample).
Therefore, the nal sample size for this study was 633 and 10% a non-response rate. n= . The multi-stage sampling technique was used to select 4 districts using simple random sampling. Then from the selected district, we had selected 2 kebeles from each district using a simple random sampling technique. After that, we had distributed the sample to selected 8 kebeles based on proportionately allocated sample size. Finally, we had employed required study subjects using a systematic random sampling technique. A sampling interval (k) of 5 was used for each kebeles to select male partners, where the rst eligible man was selected using the lottery method.

Data Collection Methods
Data were collected using a pretested structured questionnaire adapted from different studies [15,35] and modi ed to make inline with the local context. The questionnaire was translated from English into local languages (Affan Oromo and Amharic). Then, it was translated back into English to maintain consistency. The questionnaire contained three parts; socio-demographic characteristics, husband's knowledge, and involvement related to reproductive rights and reproductive health-related questions. Through face-to-face interviews, eight diploma nurses and midwives were collected the data, and two supervisors checked and monitored the data collection process daily. Regarding knowledge of reproductive rights, husbands who scored above the mean score value in the 11 knowledge measuring questions (each correct answer has a score = 1, wrongly answered and do not know response scores = 0) were considered knowledgeable. Likewise; Husband involvement was de ned as partners' current support or help to his partner in use or exercising of her reproductive rights. We used 7 questions to assess husbands' level of involvement in partners' reproductive rights (each correct answer a score = 1, each wrongly answered and do not know response score = 0). Overall current involvement in partners' reproductive rights was categorized as good (score ≥ mean) and poor (score < mean) [35].

Data Quality Control
Two days of training was given to all the data collectors and supervisors. A pretest was carried out on 5% (Hakim district not included in the nal sample) of the total sample size before the actual data collection. Based on the ndings of the pretest, modi cations to the questionnaire were made. The data collection process was closely supervised, and the completeness of each questionnaire was checked by the investigators and the supervisors daily. During data cleaning, a logical checking technique was employed to identify errors Finally, double data entry was performed to check the consistency of the data.

Data Processing and Analysis
The data were coded and entered into Epi Data Version 3.1 and exported to the Statistical Package for Social Sciences (SPSS) Version 22 statistical software for analysis. Univariate analysis was used to describe the frequency distribution of each variable. The outcome variables were coded as "1" for knowledgeable and good involvement, whereas "0" for not knowledgeable, and poor involvement of husbands. The association between the outcome variables and independent variables was analyzed using a logistic regression model. Covariates with a P-value ≤ 0.25 were retained and entered into the multivariable logistic regression analysis using a forward stepwise approach. Multi-collinearity was checked to see the linear correlation among the independent variables by using variance in ation factor (> 10) and standard error (> 2) and goodness-of-t was checked by Hosmer-Lemeshow test (> 0.05). Adjusted odds ratio (AOR) with 95% con dence intervals (CI) using a p-value < 0.05 was considered a statistically signi cant association with the outcome variable.

Sociodemographic Characteristics
A total of 611 study participants were included, yields a response rate of 96.5%. The age of respondents ranged from 20 to 79 (mean ± SD = 44 ± 13.79) years. Two hundred fty-two (41.2%) participants were employed. One hundred eightythree (30.0%) husbands had a secondary and above level of education. More than four-fth (84.1%) of the respondents used social media, of which nearly three-fourth (75.3%) used more than one social media weekly. Despite, 513 (82.3%) respondents have lived near to the health facilities which is less than 30 minutes, the majority (91%) of them reported that no access to reproduction education (Table 1).

Knowledge of husbands about Partners' Reproductive Rights
The mean Knowledge score was 5.64(SD ± 1.65) with a minimum and a maximum score of 2 and 10 respectively. Accordingly, 48.3% (95%CI: 44.5-52.2) of the husbands were knowledgeable about the reproductive rights of their wives ( Fig. 1). Participants were asked whether married women and men have equal reproductive rights and two hundred sixtyone (42.7%) of them responded correctly. More than two-thirds (68.2%) of husbands agreed that all married women must be free to enjoy and control their sexual and reproductive life as shown in (Table 2). Husband Involvement in Partners' Reproductive Rights The magnitude of the husbands' who had good involvement in partners' reproductive rights was 40.1% (95% CI: 36. . The mean score of involvement was 3.53 (SD ± 1.65) and their minimum and maximum scores were 1 and 7 respectively. The majority (70.0%) of study participants did not support the use of contraceptive methods for their partners, and 328 (53.7%) husbands did not support reproductive education access to their partners. However, 346 (56.6%) participants support partners to use reproductive services like prenatal care, facility-based delivery, and postnatal care as indicated in (Table 3).

Factors Associated with husband Knowledge in Partners' Reproductive Rights
In the multivariable logistic regression analysis, the use of social media, discussion on reproductive health, and type of nearby health facility were found to have a signi cant association with husbands' knowledge on the reproductive rights of their partners. Male partners who used social media were nearly 5 times (AOR = 4.97, 95% CI: 2.79-8.85) more likely to be knowledgeable than their counterparts. Partners who had an open discussion on their reproductive health were 2 times (AOR = 2.33, 95% CI: 1.60-3.39) more likely to be knowledgeable on partners' reproductive rights than those partners who did not have a discussion. Moreover, male partners who had nearby a hospital (AOR = 3.21, 95% CI: 1.23-8.36), and health post (AOR = 2.86, 95% CI: 1.20-6.94) were approximately 3 times more likely to be knowledgeable on partners' reproductive rights compared with their counterparts as shown in (Table 4).

Discussion
In United Nations 2030 Agenda for Sustainable Development, the international community has established the SDGs and set the target for countries to reduce maternal mortality ratio to less than 70 per 100,000 live births by 2030 [36]. Ethiopia has already declared its commitment to achieving the SDG targets. This implies that Ethiopia will need to signi cantly accelerate the progress rate. Expanding initiatives to include husbands and promoting their involvement in reproductive health could be considered as an important strategy for adaptation in this regard.
This study demonstrates that husbands' knowledge and involvement is a key factor in the protection of women's health. In this study, 48.3% (95% CI: 44.5-52.2) of husbands are knowledgeable about the reproductive rights of their partners.
This nding was in agreement with a study conducted in northern Ethiopia (Shire town, 47.1%) [37]. This consistency might be related to the fact that there is a community health development army and HEWs are almost similar in the country in which they are doing health promotion, awareness creation, and the development of social media access. This nding was lower than studies conducted in Ghana (53.8%) [16], Southern Ethiopia (Wolyta sodo, 54.5%) [15], Northern Ethiopia (Gonder, 57.7%) [38]. However, this nding was higher than studies conducted in India (9.1%) [35] and northwest Ethiopia (Adet Tana Haik, 25.96%) [39]. This disparity might be because of the differences in the socio-economic, cultural, religious, and level of education and awareness.
Regarding husbands' involvement, 40.1% (95% CI: 36.2-44.0) participants had good involvement in partners' reproductive rights. This nding was in line with studies conducted in Bangladesh (40%) [22], southern Ethiopia (Bale zone, 41.4%) [24], and Afar, Ethiopia ( 42.2%) [29]. This consistency might be related to the fact that there is a rising development intervention in many of these countries like community health promotion, awareness creation, and the development of social media access. However, this nding was lower than studies conducted in Tanzania (50.6%) (28) and Nepal (57.6%) [40]. But higher than a study conducted in Ethiopia (Harar, 19.7%) [21] This disparity might be differences in study times, and socio-demographic characteristics level of implementation in the above-mentioned countries.
In this study, the use of social media, discussions on reproductive health, and type of nearby health facility were factors associated with husbands' knowledge. Male partners who used social media were almost ve and two times more likely to be knowledgeable and involved in partners' reproductive rights compared to those partners who did not use it. This nding was in line with a study conducted in Bangladesh [22,41]. The possible explanation might be that a continuous and multidimensional community awareness through media, particularly on human rights, empowering women, and individual rights that can change the perception and knowledge of individuals [6,22].
Moreover, male partners who had a hospital and health post nearby were almost three times more likely to be knowledgeable on partners' reproductive rights. This might be health facility access can result in changing the perception, belief, health norms, and practice of individuals. [16,38,42]. Furthermore, male partners who had discussed reproductive health were two times more likely to be knowledgeable and involved in practicing partners' reproductive rights of women. This nding is in agreement with studies conducted in Bangladesh [22]), India [43], and Kenya [44]. This can be explained by the fact that knowledge gained through experience sharing during the discussion can increase the knowledge in reproductive rights [14,38,44].
Male partners aged 40 to 49 years were almost two times more likely to be involved in partners' reproductive rights. This nding is in line with a study conducted in Ghana [11]. This might imply that in this study majority were of maturity age and their level of education was secondary and above might increase their involvement in partners' reproductive rights.
As per this study, male partners' educational levels, occupation, having access to reproductive education, and experience of using reproductive services was not statistically signi cantly associated with husbands' knowledge and involvement in partners' reproductive rights. This was contrary to studies conducted in India [35], Bale Zone, Ethiopia [24], Arbaminch, Ethiopia [45], and Bangladesh [22] and southern Ethiopia [15]. The reason for the difference might be a disparity in the study sample and community health Nurses in India and Health Extension Workers in Ethiopia play a pivotal role in this di culty [3,14,25].
The study has some limitations: First, the cross-sectional nature of the study temporal relationship may not be assured. Second, it used self-reporting (interview response), which might have a social desirability bias. Some questions also required participants to recall, which could have affected the results. But efforts were made to manage through training of data collectors, and supervisors on how to approach respondents, interviewing male partners privately, and close supervision.

Conclusion
Less than half of the husbands were knowledgeable and involved in the protection of partners' reproductive rights. The use of social media, type of nearby health facility, and spousal discussion of reproductive health showed a signi cant association with husbands' knowledge on partners' reproductive rights. Having spousal discussion, the experience of reproductive service use, social media use, and age (40- and con dentiality issues. Informed written consent was obtained from all participants. Furthermore, con dentiality was assured throughout the process.

Consent to publish
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