Future husbands: predictors of young males’exposure to family planning messages in Ghana

Abstract A number of studies have concluded that weak involvement of men in family planning decision-making accounts for the low adoption in countries undergoing fertility transition. Programmes to incorporate men in family planning decision-making have largely focused on married men. However, given the pronatalist nature of such societies, family planning within marriage tends to be low. An alternative is to consider the involvement of unmarried young people. This paper assesses the exposure of young males’ to specific contraceptive messages and their predictors rather than channels. The study uses data from the 2003 round of Ghana Demographic and Health Survey, a nationally representative survey of people in their reproductive ages. Logistic regression was used to examine predictors of exposure to family planning messages. Generally, levels of exposure to messages on contraceptives were high. Messages which positioned family planning messages as beneficial to the individual had high levels of exposure. However, there were marked disparities in exposure to messages based on age, region and rural–urban residence, level of formal education, especially beyond the secondary level. The effect of education beyond the secondary level on exposure appeared more robust than any other socioeconomic variable. Given the multivariate nature of predictors of exposure, appealing and culturally acceptable messages through reliable mediums are likely to increase exposure and attract the attention of young men towards family planning messages. Keywords: exposure; contraceptives; messages; predictors; family planning; young males and Ghana Resume Un certain nombre d'etudes ont conclu que la faible implication des hommes dans la planification familiale de prise de decision des comptes pour la faible utilisation dans les pays en transition de la fecondite. Des programmes visant a integrer les hommes dans la planification familiale de prise de decision ont surtout porte sur les hommes maries. Toutefois, etant donne la nature de ces societes natalistes, la planification familiale au sein du mariage tend a etre faible. Une alternative est de considerer l'implication des jeunes celibataires. Cette etude evalue l'exposition des jeunes hommes »aux messages specifiques de contraception et leurs predicteurs plutot que les canaux. L'etude utilise les donnees du volet 2003 du Ghana et demographiques Enquete sur la sante, une enquete nationale representative de la population en âge de reproduction. La regression logistique a ete utilisee pour examiner les predicteurs de l'exposition aux messages de planification familiale. Generalement, les niveaux d'exposition aux messages sur les contraceptifs etaient eleves. Les messages dont positionne messages de planification familiale comme benefique pour l'individu avaient des niveaux eleves d'exposition. Cependant, il ya eu de fortes disparites dans l'exposition aux messages en fonction de l'âge, region et rurale-urbaine de residence, niveau d'education formelle, en particulier au dela du niveau secondaire. L'effet de l'education au-dela du niveau secondaire sur l'exposition apparu plus robuste que toute autre variable socioeconomique. Etant donne la nature multidimensionnelle des facteurs predictifs de l'exposition, attrayante et des messages culturellement acceptables, grâce mediums fiables sont susceptibles d'accroitre l'exposition et attirer l'attention des hommes jeunes vers des messages de planification familiale. Mots cles : exposition, les contraceptifs, les messages, les facteurs predictifs, la planification familiale, les jeunes hommes et le Ghana


Introduction
Over the years, the mass media has played a significant role in the dissemination of information on contraceptives to the general public in many societies.Considered to be a reliable medium for disseminating information, the mass media has been used to present and legitimise issues which were hitherto considered taboos, such as family planning and sexuality (Piotrow et. al., 1997;Hornik & Mc Anany, 2001), helping to make such issues discussible and to the extent of modelling words and terms to make discussions more lively and comfortable.
Available evidence suggests that exposure to the mass media and target audiences differ by location, community, country and the type of media.For instance, in Egypt and Turkey, television reaches almost everyone, making it a high-priority medium for most health messages (Piotrow et. al, 1997) and in countries such as Haiti, the radio and television are popular since family and friends watch television and/or listened to radio in groups (Piotrow et. al, 1997).In Peru, street theatre is used to confront difficult questions (Valente et al., 1995) while in Morocco male street performers (helaki) would not be a credible source of information about modern family planning (Berry, 1991).For persons who regularly pass by bill boards or use public transportation, such mediums may provide repeated exposure to messages which can lead to expected behavioural outcomes (McDermott & Albrecht, 2009).
The exposure of individuals to mass media messages affects their behaviour and intentions to use contraceptives (Bankole et al., 1996;Kincaid, 2000).A study conducted in Nigeria showed that the use of modern contraceptives was associated with exposure to media messages on family planning (Bankole et al., 1996).Also, there is evidence from Malawi to suggest that family planning messages and advertisements that prohttp://aps.journals.ac.za mote condom use have had a significant positive effect on the use of modern contraceptives (Cohen, 2000).Other studies have revealed that mass media campaigns are effective at different stages in the process of altering reproductive behaviour and intentions to using contraceptives (Agha & Van Rossem, 2002).
In Ghana, some studies have used cross sectional surveys, such as Ghana Demographic and Health Survey (GDHS) and other small scale surveys to examine the effects of mass media on contraceptives, and other behavioural outcomes (Olaleye & Bankole 1992;Parr, 2001;Kwankye & Augustt, 2007).Others too have sought to determine the extent to which community activities and traditional folk media can best reinforce modern health messages and practices (Piotrow et al., 1997).Yet, many of the studies on mass media exposure and contraceptive adoption in Ghana have focused on women or people in the reproductive ages (15-45 years).Very few of these studies have focused on the messages carried through the various mass media channels.It is imperative to note that exposure to channels may not necessarily lead to contact with the message of interest.Similarly, exposure to messages may not result in behaviour change.Nevertheless, exposure to messages comes closer to behaviour change than channels.For instance, Ayi et al. (2010) have reported that exposure to media adverts in Ghana have immense influence on adolescents2 use of medicines.
Although women bear children, the role men play in this process and the effects it has on women are substantial.
Studies in Ghana show that although husband's attitudes regarding contraceptives are not affected by those of their wife's, the attitudes of wives towards contraceptives are strongly influenced by their husband's attitudes which are often swayed by background characteristics such as education (Ezeh, 1993).On the other hand, however, the influence of men on reproductive decisions of women is not always that of absolute control (Coombs & Chnag, 1981;Bankole, 1995).Nonetheless, the exclusion of men from family planning programming does not only alienate men, but also has the potential of creating a suspicious atmosphere and tension between couples/partners.The refusal of husbands to allow their wives to use contraceptives is often borne out of suspicion of possible extramarital sexual relationships.Similarly, in indigenous patrilineal societies where high bride price payments signify a woman's requirements to bear children for a man, men have been found to be uncooperative in family planning discussions and subsequent adoption of family planning (Bawah et al., 1999).Furthermore, the available literature on Ghana particularly appears terse on unmarried adolescent males' (who are an embodiment in future decision-making on family planning matters) exposure to mass media channels as well as message content.A number of studies have concluded that weak involvement of men in family planning decision-making accounts for the low usage in countries undergoing fertility transition (see, for instance, Bawah et al., 1999;Hossain, 2003).Programmes that incorporate men in family planning decision-making have largely focused on married men.However, given the pronatalist nature of such societies, family planning within marriage tends to be low.An alternative is to consider the involvement of unmarried young people.For many years, fertility and family planning researches have focused on women.This situation has, however, not been able to produce the expected results partly, due to the fact that men and women do not necessarily share the same fertility goals and intentions (Ezeh, 1993;Bankole, 1995).
From the evidence available thus far, the depth of evidence on men's involvement in family planning in Ghana in totality is limited.But whereas relatively much is known about married men, there is little evidence about unmarried men between 15-24 years.With young people today spending much time in the classroom without corresponding increase in sex education, the mass media remain one of the most reliable mediums for communicating information on contraceptives to adolescents.The current study examines exposure to mass media messages rather than channels.This is aimed at identifying relevant factors that are imperative in designing messages on family planning for young people, especially males.Two specific objectives are addressed in this paper: identifying the levels of exposure of adolescents to specific messages on the Life Choices campaign and further assesses the predictors of adolescents' exposure to the messages.

Setting
The 2003 Ghana Demographic Health and Survey reports almost universal knowledge about contraceptives in Ghana; 98 percent of women and 99 percent of men knew at least one method of contraception.Modern methods are more widely known than traditional methods.Ninety-nine percent of all men know of a modern method compared to 80% who know of a traditional method.Male condom is the commonest among males (98%) and females (95%).The most popular contraception method, condom was highly (70%) used by sexually active unmarried men.With high access to the mass media, print and electronic, Ghana provides a good setting for examining the relationship between socio-demographic characteristics and exposure to specific mass media messages on contraceptives.At the moment, there are radio stations scattered all over the country (at least one government owned in each regional capital) with many privately operated ones.There are more than six television stations in the country and a lot in the print media.As a means of assessing the potential effectiveness of using the media to broadcast messages on such important topics such as reproductive health and HIV/AIDS, the 2003 GDHS collected information on respondents' exposure to both broadcast and print media.Access to these media channels, especially the broadcast media is generally high in Ghana, compared to the print media.Twelve percent of women and 28 percent of men read a newspaper at least once a week.Men are twice as likely as women to be exposed to all three media sources (23 and 10 percent http://aps.journals.ac.za respectively).Media exposure is higher among younger women (age 15-24) than older women (25 years and above).However, among men, exposure is lowest among those aged 15-19 years and highest among those aged 20-29 years (GSS et al., 2004).
The 2003 GDHS survey collected information from women and men about whether they had heard/seen specific radio adverts and slogans on family planning from the Life Choices campaign in the few months before the survey.The messages included the following: It's your life, it's your choice; Make the choice that is best for you; Contraceptives are safe and effective; and Obra ne wora bo 3 .This paper focuses on the determinants of young peoples' exposure to these specific messages (in the form of adverts/slogans) used for the Life Choices campaign as opposed to the channels used in the campaign.

Data and methods
The study uses data from the 2003 Ghana Demographic and Health survey, a nationally representative probability sample of 5015 men aged 15 to 59 years (GSS et al., 2004).This data provides extensive and quality data for this kind of analysis.The survey comes with a large number of variables for the comprehensive measurement of mass media exposure, knowledge of family planning methods, media channels, media messages and some behavioural variables.For this paper, a sample of 1787 males aged 15-24 years was used.The paper uses comparative analysis of background characteristics of respond-ents.To restrict our analysis to never married adolescents, approximately 10% of the sample with marital status other than never married was dropped from the analysis.Consequently, the results are reported on 1603 people.Four messages in the 'Life choices campaign are used; 'it's your it's your choice', 'make the choice best for you', 'contraceptives are safe and effective' and 'Obra ne wora bo'.These messages were carried through the radio, television, newspapers/magazines, posters, leaflets/brochures.Other means of delivering the messages were community meetings and health workers education.The outcome variable assessed was whether a respondent had heard/ seen any of the messages.To aid conceptualisation, four different independent models were constructed to account for the effects of background characteristics on exposure to each of the messages.The predictive variables used in the multivariate analysis (logistic regression) on exposure were age, ethnicity, region of residence, place of residence (urban-rural) and highest educational attainment.Logistic regression results are reported in odds ratios.

Descriptive results
Table 1 presents background characteristics of the young people used for this paper.The mean age of respondents was 19 years with 61.2% aged 15-19 years; the rest were aged 20-24 years.More than half (58.3%) of the respondents were resident in rural areas.Three 3. Obra ne wora bo is an Akan phrase that translates to "Life is how you make it."In terms of the Life Choices campaign, therefore, it implies "Your (reproductive) life depends on the choices you make."Akan is the dominant spoken language in Ghana http://aps.journals.ac.za of every five (63%) adolescent males in Ghana had had a secondary education by the end of 2003; attainment of tertiary education was far lower (2%) in spite of the investments in education in the country since the early 1990s.In terms of household wealth, the trends were close to the theoretical quintiles for evenly distributed populations; it ranges from 18% (middle) to 23% (poorest).The highest proportion of respondents (15%) were from the Ashanti region with the least (6%) being resident in the Central region.
The dominant ethnic group in Ghana is the Akans; they constituted about 42%.
The second principal group in Ghana, Mole-Dagbanis were just around 24%; Ga-Dangmes were in the minority (6%).The proportion of people aged 15-19 years exposed to the various messages on family planning ranged from 41%-66%.For instance, 62% of them had been exposed to the message 'contraceptives are safe and effective' whilst 66% were exposed to the message 'Obra ne wora bo'.Among the respondents aged between 20-24 years 75% had heard/seen the message titled 'it is your life it's your choice'.The message captioned 'contraceptives are safe and effective' was the message with the least exposure among both urban (61%) and rural (34%) adolescents.The most popular message among rural residents (57%) was 'Obra ne wora bo' while 'it's your life it's your choice' was more popular in urban (86%) areas.
It is generally believed that education increases people's curiosity and openness to new information around them.Respondents who had no education had low exposure to all the four messages (15%-24%).Wide variations are noted in exposure to the messages based on wealth index.As shown in Table 1, for each of the messages, exposure increased with increase in economic status.The message with the highest exposure among the poorest respondents was 'it's your life it's your choice' (37%); 'contraceptives are safe and effective' was less common (23%) in the same category whereas about 71% of the richest had been exposed to 'contraceptives are safe and effective'.Approximately 92% of richest respondents had heard/seen the message titled 'it's your life it's your choice' and 'Obra ne wora bo' respectively.Regional variations are also observed with respect to certain messages.Two out of the ten regions (Northern and Upper West) had disproportionately marginal levels of exposure to all genres of information on contraceptives.For instance, in the Northern region, only 3% had heard/seen the message 'make the choice best for you'.As is known, Ghanaians speak different languages but varied forms of Akan are the predominant ones with each variant almost understood by the other language group.'Obra ne wora bo' which is an Akan wise saying was expectedly familiar among residents in the Akan dominated regions; Western (89%), Central (84.5%),Eastern (89%), Ashanti (95%) and Brong-Ahafo (88%).Despite the fact that indigenous people of Greater Accra are not Akans, the 'Obra ne wora bo' message was also ordinarily in the region.The cosmopolitan nature of Accra (commercial and administrative capital which has led to a mixture of people with different backgrounds with many of them likely to be averagely fluhttp://aps.journals.ac.za ent in Akan) could account for this phenomenon.

Multivariate logistic regression results
This section addresses the second objective of the paper; effects (direct, strength and significance) of background characteristics on exposure to messages.As shown in Model I, respondents aged 20-24 years were approximately two times likely to have been exposed to 'it's your life it's your choice' (p<0.001).A similar pattern is observed in Model IV ('Obra ne wora bo'; p<0.001).The influence of education is visible at all levels of education, especially, as one went up higher on the educational system.The effects at primary, secondary and tertiary levels are however more remarkable with respect to the message titled 'make the best choice for you' (Model I).For example, tertiary education increased the probability of exposure to 'make the choice best for you' by about 21 times compared to those without formal education.Significant differences are noted between respondents at the highest quintile and exposure to all the messages.The probabilities were more pronounced for 'it is your life it's your choice' (OR=4.0,p<0.001) and 'choose the best for you' (OR=4.10,p<0.05).Other significant negative relationships exist on regional basis.For instance, as indicated in Models one to four, residents of Upper West region were less likely to have heard about 'it is your life it's your choice' (0.19, p<0.001), 'make the choice best for you' (0.24, p<0.001), 'contraceptives are safe effective' (0.31, p<0.05) and 'Obra ne wora bo' (0.03, p<0.001).
Respondents from Ashanti region were more likely (OR=1.44) to be familiar with 'Obra ne wora bo' message.Obviously, that could be expected since Akan is the most pervasive language in the region.The relationship between exposure to 'Obra ne wora bo' and ethnic affiliation besides being an Akan were negatively strong and this is unusual.However, unexpected indirect associations occurred in adolescents' exposure 'contraceptives are safe and effective' though such effects were insignificant.

Discussion and conclusion
The evolution of family planning communication was highly praised as an unprecedented breakthrough.Their appeal later began to fade apparently due to over-aggregation of message audiences.Later studies threw the spot light on the need to disaggregate information on family planning adoption.
Similarly, the exclusion of men from initial discourses on family planning became a major setback to the targeted objectives.
Generally, levels of exposure were observed to be high among the respondents.Nonetheless, some obvious varied levels are noted in exposure to the different contents by background characteristics.For instance, older adolescents (20-24 years) had a higher propensity to have heard all the four messages.In matters of family planning and contraceptive use, ethnicity and spatial factors play important roles.In many parts of Africa and for that, Ghana, large families are highly cherished and encouraged (Awusabo-Asare, 1988) revealed by Ajzen (1985), the quantity and quality of information to a greater extent can guarantee adoption and application of new ideas.Contrary to this conscious fact, the quantity of information available to the region lagging behind in the fertility transition unfolding in Ghana did not seem impressive.
The messages with the highest levels of exposure among the respondents were those which positioned family planning as a benefit to the individual.For instance, the message titled 'Obra ne wora bo' translated to mean 'life is what you make of it' was quite attractive to both the younger and older adolescents.Self efficacy is observed to be instrumental in individual's health decision-making.Similarly, this phenomenon suffices in family planning decision.
Fear of effects of methods still present a considerable obstacle to acceptance and use of contraceptives.Agha (2010) suggests that fear of contraceptives side effect poses one of the greatest challenges to intentions to use contraceptives.Consequently, one of the messages during the intervention years was a message that presented to the audience the availability of several options of contraceptive thereby given people alternatives to choose from.This message was captured in 'make the choice best for you'.By far, respondents with tertiary education seemed more likely to have been exposed to this message.Kabir and Islam (2000) have reported similar results from Bangladesh on the positive synergy between education, exposure to mass media messages on family planning and subsequent intended and actual use of contraceptives.Other significant positive factors on exposure to this message were age, economic status at and beyond average quintiles and residence in Brong-Ahafo and Upper Eastern regions.Besides the need to providing targets with available alternatives, it is also important to reassure people the safety of methods they use (contraceptives are safe and effective).Education again remained the most robust determinant of exposure.'Contraceptives are safe and effective' exposure significantly related with economic status, status and place of residence (Brong-Ahafo and Upper East regions).
Given the status of men in the Ghanaian context in relation to decision making, it will be prudent that young males are targeted with messages on family planning and other reproductive health issues.Ignoring their future gatekeeping roles can thwart efforts at increasing adoption and use of contraceptives and subsequent family planning.Evidence so far gathered also makes it far-sighted to encourage audience segmentation of young people along the lines of socio-demographic characteristics such as age, rural-urban residence and level of education.Any assumption of one-size-fit-all approach will be inconsequential to achieve results among people with such diverse orientations.Disproportionate exposure to all messages relative to region of residence is evidential from the analysis.Amidst these results, the wider socioeconomic circumstances of these regions become relevant.The most common means of advertising the messages were radio and television.However, exposure to messages in these media sources was limited in these regions (GSS et al., 2004).To accelerate saturation of messages on family planhttp://aps.journals.ac.za ning, there is a need to engage in more interpersonal means of putting across messages in places where media channel use are bounded in socioeconomic backgrounds.Assumptions of universalism in health communication will continue to perpetuate the several obstacles to change, particularly, towards family planning.
Evidence-based understanding of factors that make people accessible to critical mass of social information and services is one-step away from designing timely and reliable information needed by young people towards behavioural change.The complexities associated with the unstable trends in contraceptive use in Ghana for the past 22 years (observed in the GDHSs) require that a number of factors are taken on board in reaching out with information on contraceptive use.Behaviour change takes time; however, taking into account the multivariate nature of change will be needed to make messages on family planning and contraceptives appealing and acceptable with potentials of inducing change.

Table 2
Determinants of exposure to messages among unmarried adolescents http://aps.journals.ac.za