ASSESSING THE KNOWLEDGE, ATTITUDE AND PRACTICE OF FAMILY PLANNING AMONG MALE POPULATION IN INARUWA MUNICIPALITY OF EASTERN NEPAL

Background : Family planning allows individuals and couples to anticipate and attain their desired number of children, spacing and timing of their births. It is achieved through use of contraceptive methods. A man’s perspective on the family planning methods and services is essential on his family health. The study aimed to know about knowledge, attitude and practice of family planning methods in male (Rickshaw puller) of Eastern Nepal and to know their reasons for not using the family planning. Methods: A descriptive cross-sectional study was done in Inaruwa municipality. Total of 400 male rickshaw puller samples were taken. Knowledge, attitude and practice on contraceptives were evaluated with the help of a predesigned questionnaire. Descriptive analysis was done by using SPSS 11.5software to obtain frequencies and percentages. Results: Out of 400 interviewed, 366 were interviewed with 92% response rate, the mean age was 36.54 years, and 92.7% said they heard about Family planning method. Health worker was the main Source of family planning information. Regarding the attitude of the Male respondents, 83.1% supported the concept of family planning; only 33.9% said they had used a male contra -ceptive, 46.7% of the respondents said the males didn’t practice the family planning methods on themselves because of the work load. Conclusions: Majority of the respondents knew about family planning methods but only a few agreed to have used them. The main reason for men lagging behind could be that the burden of work due to which contraception in a family is taken up by females.


INTRODUCTION
Contraception is one of the adjacent determinants of fertility and the most important interpreter of fertility transition. The determinants of fertility in developing societies are influenced by the demand for a certain number of children, their survival and assessment of their survival. Within the context of these factors, people evaluate availability and cost of fertility regulating mechanisms. 1,2 As fertility trends decline it have significant role in decreasing in infant, child, and maternal mortality. Women spend decreasing proportions of their lifetimes giving birth and caring for young children. 3 Since the 1994 International Conference on Population and Development (ICPD), and the 1995 UN World Conference on Women, interest in men's involvement in reproductive health has increased. There has also been a shift in objectives of male participation and concerns, from increasing contraceptive use and achieving demographic goals to achieving gender equality and fulfilling various reproductive responsibilities. 4,5 Male involvement helps not only in accepting a contraceptive but also in its effective use and continuation. 5 Spousal communication on contraception and reproductive goals suggests that the couple has an egalitarian relationship. 6 Studies have shown that couples who discuss the number of children they desire or the use of family planning are more likely to use a contraceptive and achieve their reproductive goals. 3,6 The study aimed to know about knowledge, attitude and practice of family planning methods in male (Rickshaw puller) of Eastern Nepal and to know their reasons for not using the family planning.

METHODS
A cross-sectional study was conducted in Inaruwa Municipality among male rickshaw puller. According to their union organization, there were approximately 400 rickshaw pullers registered in their union. So, census method was used for sample size calculation. The semi-structured questionnaire was used as tools for data collection. The questionnaire was developed in English which was translated in local language and interviewed. Prior to interview, questionnaire was pretested in Jhumka Municipality. The questions included socio-demographic variables such as caste, age, religion, type of family, education status, level of education, marital status, etc. Variables regarding the knowledge such as knowledge about family planning methods, source of information, etc, attitude such as support the concept of family planning, preference to permanent sterilization, appropriate age of marriage etc. and practice such as use of contraceptive, desired level of child spacing etc. of the family planning methods were included. Inform written consent was taken from all the study subjects. Confidentiality was maintained and those who did not give consent were excluded. To assure data quality, the questionnaire was pre-tested before the commencement of the research. Every day, the collected data were entered in Microsoft Excel 2007 and analyzed using SPSS 11.5. Descriptive Statistics as percentage, mean, standard deviation, were calculated and for inferior statistics chi-square test was used to see association between contraception use in Future after desire gender.

RESULTS
In our study we try to find the knowledge, attitude and practice of family planning among male rickshaw pullers. Total sample size was 400, but 366 were interviewed with 92% response rate. Majority were belonged to 31-45age group with average age of 36.42 years (SD= ±10.791) of which 81.4% were Hindu. Most of the respondents had a joint family (61.5%). About92% of them were married. The mean age of marriage was found to be 20.31 years (SD= ±2.661). Majority were illiterate (Table 1), and they were married for more than 15 years. Mean age at marriage was 20.31 yrs withSD±2.661 and majority had more than one child.  (Table 2), our study showed that majority had heard about family planning method and its type, source of information were health workers and friend circles, about 77% had had heard about condoms, about 58% knew about male contraception. When we asked the aboutadvantage and disadvantages of family planning methods most of them expressed that it helps to prevent birth control and prevent from STDs. most of them told that it is uncomfortable to use as disadvantages of male contraception. respondents expressed that the males didn't practice the family planning methods on themselves because of the work load, 79.5% of them recommended family planning methods to other people. On the practice side the respondents, only about 34% had ever used family planning methods. When we asked about the methods used by their couples, about 35% answered most of their couple had minilab operation. About 34% expressed that they send money to buy contraception methods.  Table 4 showed the association between desire number of children and plan to use of contraception, which showed 38.4% will be using family planning methods in near future after having both gender children, 38.4% will never use anyfamily planning methods in near future. It was found that 15.7% will be using family planning methods in near future after male child and 29.5% will be using family planning methods after female child. It was found that desire of male child has significantly difference to use contraception use rather than female child.

DISCUSSION
Family planning is a part of the lifestyle of couples that pertains to planning their family size, the time and occurrence of childbirth and prevention of unwanted pregnancies. Contraceptive methods and services are mainly focus on women; men are normally the primary decision makers on family size and their partner's use of family planning methods. 7,9 There was an active involvement of the health workers in these areas (Inaruwa and Jhumka) such that 4 out of 10 respondents came to know about family planning through health workers. About 92.7% of the total respondents interviewed knew about family planning out of which 60.3% of the respondents knew how to use a male contraceptive, study from Ethiopia 10 and Zimbabwe 11 showed similar finding to our studies. In context to BurkinFaso 12 79% of the respondents knew about family planning and used these methods mostly for birth spacing purpose rather than birth control, 90% recognized at least one method of family planning and 2/3 have heard about condom out of which half the men did know enough about how to use contraceptive. Also in Agra 5 less than 50% knew how to use male contraceptives. This revealed that majority of the population interviewed had knowledge of family planning despite the high levels of illiteracy thus supporting the fact that health workers have a major role in spreading the message of family planning even in low socioeconomic strata of Inaruwa and Jhumka.
Majority of the people interviewed in our study who used male contraceptives, they expressed that it is used for birth control. Similar studies in male adolescents 13 revealed that most of them used male contraceptives to prevent unwanted pregnancies and very few knew about venereal diseases.
In our study, 83% of the respondents supported and approved the concept of family planning where as in Zimbabwe 11 it was found to be 83.5% and 99% in Gaza. 14 Also 80% of them approved discussion about family planning with their partners which is more than that in Zimbabwe 11 where 57% of the respondents discussed with their partners reflecting better relations and understanding among the couples on the concerns of family planning in our study area.
Out of 366 of the respondents interviewed 64.8% suggested that both husband and wife should decide about family planning. Similar study in Zimbabwe 11 revealed 48.3% of the respondents said that male must decide about family planning methods to be used.
In our study, 33.9% of the respondents have used male contraceptives in their lifetime which is still lower than that in Zimbabwe11 80.6%and greater than that in Burkin Faso 12 which is 19%. In our study we found that about 9.6% of the respondents are currently using male contraceptive methods which is quite low as compared to study done in Agra 5 , Makwanpur 15 and Ethopia 10 but slightly higher than that in Burkina faso study. 12 In Inaruwa and Jhumka 35% of the wives of the respondents have already done sterilization and 80.9% of the respondents preferred for permanent sterilization which is comparatively better in comparison to results of similar study conducted in Makwanpur 15 where 69.6% had undergone vasectomy and 86.8% of their partners used contraceptives.
In our findings of the research strongly reflect that despite the presence of adequate knowledge and positive attitude towards male contraception there is minimal use of male contraception. Reason for non-accepting family planning method by male population wasis due to work load, felling of weakness if used. It was also found that majority of the respondents associated the use of condoms with practice of paid sex which could be a major source of information bias about use of condom in this research.
In similar studies in Pakistan 16, the reasons for lesser use of male contraceptives were fear of side effects like causation of impotence, backache, headache and infection by condoms and vasectomy. Having both gender child (male& female) will i.e. 38.4% be using any Family Planning methods in near future. A study done in Nepal, 17 showed that a strong propensity to have at least 1 or 2 sons among Nepalese men although they express not wanting to have more children.

CONCLUSION
It can be concluded that although almost all respondents knew about at least one contraceptive method, and there was strong association between knowledge and the use of contraceptive methods.

ACKNOWLEDGEMENT
This Research study was not an outcome of a single day or the product of a single mind. It has been completed with the suggestions, guidance and help of many people.First of all, we wish to express our sincere gratitude to School of Public Health and Community Medicine, B.P. Koirala Institute of Health Sciences for providing us an opportunity to carry out this research study.
And students MBBS batch 2010 (Abhinay Choybay, Ashish Kumar, Dipendra Rai, Nisij Shrestha, Prajwal Dahal, Sharjeel Shamsi, Swarup Sharma Rijal, Tushar Jha, Rajendra Basnet, Ujjwal Das, Vijay Deo) and all the respondents that their kind cooperation and willingness to participate in the study. Finally, we would like to thank all who have directly or indirectly contributed to bring up this research study in this form.