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Introduction: Male involvement in maternal and child health is a practice wherein fathers and male community members actively participate in caring for women and supporting their family to access better health services. There is positive association between male involvement and better maternal and child health outcomes. However, the practice is not always practiced optimally, especially in low- and middle-income countries, where women may not have access to economic resources and decision-making power. Aim: This study investigates how key stakeholders within the health system in Uganda engage with the ‘male involvement’ agenda and implement related policies. We also analyzed men’s perceptions of male involvement initiatives, and how these are influenced by different political, economic, and organizational factors. Methodology: This is a qualitative study utilizing data from 17 in-depth interviews and two focus group discussions conducted in Kasese and Kampala, Uganda. Study participants included men involved in a maternal health project, their wives, and individuals and organizations working to improve male involvement; all purposively selected. Result: Through thematic analysis, four major themes were identified: ‘gaps between policy and practice’, ‘resources and skills’, ‘inadequate participation by key actors’, and ‘types of dissemination’. These themes represent the barriers to effective implementation of male involvement policies. Most health workers interviewed have not been adequately trained to provide male-friendly services or to mobilize men. Interventions are highly dependent on external aid and support, which in turn renders them unsustainable. Furthermore, community and religious leaders, and men themselves, are often left out of the design and management of male involvement interventions. Finally, communication and feedback mechanisms were found to be inadequate. Conclusion: To enable sustainable behavior change, we suggest a ‘bottom-up’ approach to male involvement that emphasizes solutions developed by or in tandem with community members, specifically, fathers and community leaders who are privy to the social norms, structures, and challenges of the community.
We employed a case study approach, following Yin’s definition of a ‘case study as “an empirical inquiry that investigates a contemporary phenomenon in depth and within its ‘real-life’ context especially when the boundaries between phenomenon and context are not clearly evident” [50]. We conducted a case study of a male involvement project, namely, the Emanzi project, which was designed and implemented by Family Health International 360 (FHI360) as one of the few male involvement programs in Uganda. The Emanzi intervention evolved from another pre-existing, multi-country intervention called ‘Men as Partners’, developed and implemented by Engender Health International. The Emanzi project (‘emanzi’ means ‘champions’ in the local language) was then modified for the Ugandan context and implemented in three south-western Uganda districts – Kasese, Kamwenge, and Kanungu, in 2014. The project mainly involved working in tandem with the local governmental authorities to conduct learning-and-knowledge sessions for fathers who had or were about to have children. These sessions were conducted over 9 months and involved a wide range of topics from family planning to HIV. We followed a purposive, maximum variation sampling method to ensure the inclusion of different types of stakeholders and viewpoints [32]. We conducted 17 interviews with policymakers, academics, healthcare workers, and representatives from multilateral organizations, and two focus group discussions (FGD) with participants of the Emanzi project and their spouses. We recruited policymakers (academics, multilateral organizations, and NGO representatives) through email invitations. The fathers and women groups were recruited through announcements by, and referrals from the Emanzi project. Religious leaders and healthcare workers in Kasese and Kampala were identified via snowballing during interviews and through contacts established in and around the Emanzi project. The breakdown of the type of participants is provided in Table 1 below. Breakdown of participants by position and organisation Kasese was more accessible to the project team given the limited time for fieldwork. Multiple category design, which involves multiple homogenous groups of participants, was adopted to allow data collection and comparison across two groups, one with fathers and the other with their spouses. This approach allowed for rapid data collection and was well suited to understand deeply contextual topics [15]. Each interview took up to 1 hour and was conducted at the participant’s office, while the FGDs were conducted in a community center in Kasese. The interviews with national-level policymakers were all conducted in English. For the FGDs with the fathers and their spouses, we used translators, as well as translating copies of key documents such as the project information sheets and consent forms. The translations were checked by a member of the research team who is bilingual. All participants were fully informed about the objectives and expected outcomes of the research project. Ethical clearance was obtained from The AIDS Support Organization Research Ethics Committee in Uganda and the Research Ethics Committee at Imperial College London. All interviews were promptly transcribed to allow continuous review of emerging themes and subsequent interviews. This was followed by a thematic analysis that drew upon the apriori framework as well as incorporating new emergent themes from the data. The data were manually coded by the primary author. Primary themes were identified and grouped into broader themes based on their likeness or conceptual homogeneity [17]. This process was repeated until 4–5 major themes emerged. This study draws on the feminist philosophical perspective. The questions asked, and the subsequent analysis were guided by our strong stance regarding the enhancement of male involvement as a means for more egalitarian conditions around maternal health and newborn and childcare. All four authors come from varied backgrounds and countries – yet they strongly disapprove of hegemonic masculinity and its repercussions on society. The primary author comes from a deeply patriarchal society that subjects women to many forms of oppression and discrimination. However, the author’s liberal upbringing within her family and egalitarian values fostered a strong belief that men want to be active partners and involved-parents. Beyond this, we uphold a ‘non-deficit’ perspective, which situates the challenges of male involvement beyond men, within wider social structures and health systems [10]. We are aligned with the notion that men’s participation is limited by social and economic constraints and archaic gender norms [21].
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