We conducted a household cluster survey in Hoima district, Western Uganda, between March and May, 2013. Hoima District is located 230km West of Kampala, the Capital City of Uganda. Hoima had a total population of 549,000 people, 106,000 of whom were aged under-five and 22,000 were infants. The annual population growth rate is 4.7% 12, with an infant mortality rate of 85/1000 and under-five mortality of 88/1000 live births 7. Hoima has 54 functional health facilities (45 public, 7 Private Not for Profit (PNFP) and 2 Private for Profit (PFP) facilities) and all provide routine child immunization (RCI) services 12.

Fathers who were at least 18 years old with children aged 10 to 23 months, and had lived in Hoima for at least a year prior to the survey were included in the study. The required sample size was 460 men using the formula by Bennett for sampling in cluster surveys, with the following assumptions; a two-sided test with a precision of 0.03, 80% power, 10 households per cluster, intra-cluster correlation of 0.1, and a design effect of 1.9 and 50% level of male involvement in routine child immunization 13.

Multistage cluster sampling method was used to select study participants. In the first stage, five of 13 sub-counties in Hoima district were randomly selected using computer generated random numbers. In the second stage, two parishes from each of the five selected sub-counties were randomly selected (ten parishes in total). In the third stage, a list of all villages from each of the ten parishes was generated. A total of 46 out of 116 villages were then selected proportionate to the number of villages in each parish. Villages (lowest administrative units) were considered as clusters in this study. At the last stage, households were consecutively searched for eligible fathers. Ten fathers were interviewed in each village, selecting one respondent per household.

In each of the selected villages, a random starting point preferably a main junction in the village was identified. Then beginning with the house on the eastern side, data collectors moved from house to house looking for eligible respondents until the desired sample for the village was obtained.

In case a household did not have an eligible respondent, the respondent declined to participate, or was not at home at the time the house was approached for study inclusion, the next household was considered. In a household with an eligible man with more than one child aged 10-23 months or a polygamous man with partners each having a child in the 10-23 months age group; the male partner would be interviewed in reference to the youngest child in the age group. This last criterion was chosen to reduce recall bias for the study outcome.

The ASE model was originally developed for smoking cessation by de Vries et al 14, and has been widely applied in explaining health behavior 3, 15, 16. We used the ASE model in this study because it not only considers social influence and self-efficacy as predictors of behavior but it is also better suited to explaining current behavior; unlike the health belief and the trans-theoretical models that do not consider social influence as a predictor of behavior, and trans-theoretical model that is much more focused on promoting change in behavior 17.

As shown in figure 1, behavior related to male involvement in RCI is a result of behavior intention. This is in turn is influenced by three main factors; attitude, social influence and self-efficacy. Attitude is an individual’s evaluation of merits and demerits of involvement in routine child immunization services. Social influence results from social norms in regard to male involvement in routine child immunization. It’s influenced by gender roles, and support, or discouragement from significant others such as one’s parents and spouse 18, 19. Self-efficacy is the perceived ability to perform a behavior, and to cope with barriers to perform a behavior. It influences both behavior intention and behavior itself. Self-efficacy may be influenced by a man's perceived benefits of their involvement in routine child immunization. Barriers and abilities could influence male partner involvement in RCI. Previous behavior or trying to perform the behavior has a feedback mechanism that in turn influences the attitude, social influence and self-efficacy. Demographic characteristics on the other hand are unchangeable but useful in identifying men less supportive of their partners in routinely immunizing their children so they can be targeted 3.

The measurements used in this study were based on the ASE model described above. Data were collected through face-to-face interviews using a pre-tested structured questionnaire that was translated into Runyoro (local dialect) and back translated into English for consistence in meaning. We describe below the measurements used for this study; male involvement in routine child immunization, attitude, social influence and self-efficacy.

This was estimated based on an involvement index developed from five indicators: 1) if the male partner had taken their child for routine immunization, 2) had accompanied the partner for routine child immunization, 3) provided financial support for a child’s routine immunization visits, 4) discussed with the partner about the child’s immunization schedule, and 5) had participated in making a decision with partner to have a child immunized. Each indicator had an equal weight score of one. The involvement score of each respondent ranged from 0=no involvement to 5=involved in all five areas at least once. A total score of at least 4 was considered as high male involvement and ≤3 as low male involvement 20.

A male partners' attitude was defined as his evaluation of merits and demerits of his involvement in routine child immunization (RCI) 3, 15. The man’s attitude towards involvement in RCI was measured on an ordinal scale using a four- point likert item (3=Strongly agree, 2=Agree 1=Disagree, 0=Strongly disagree) using the following four statements: 1) routine child immunization care is equally a man’s role, 2) male involvement in routine child immunization is beneficial, 3) I am willing to be involved in routine child immunization, and 4) I can encourage another man to be involved in a child’s routine immunization. A binary variable (agree/disagree) was then created from the likert scale for each statement and a score of one was assigned to each statement agreed to. If a respondent scored a maximum of ≥3 points then they would be categorized as having a positive attitude and those who scored ≤2 points were regarded as having a negative attitude towards male involvement in RCI.

Social influence was described as resulting from social norms in regard to male involvement in routine child immunization 3, 15. In this study, social influence was assessed using three key questions: 1) who is mainly responsible for ensuring that a child is immunized in this community? 2) have you ever been encouraged by significant others like your spouse or parent to be involved in RCI? 3) Have you ever been discouraged by significant others like your spouse or parents from being involved in RCI? 21

Self-efficacy was defined as a father’s perceived ability to cope with barriers to their involvement in RCI 2, 3, 15. Fathers were asked if they felt they were able to cope with or overcome the following major barriers to participate in routine child immunization: competing work demands, gender role rigidities, peer disapproval, financial constraints; long distance to, and long waiting time at the health facility. Again, a 4-point likert scale was used here (4=most likely, 3=likely, 2=less likely, 1=not likely). Respondents who responded “most likely” or “likely” to overcome to four of the challenges were categorized as having high self-efficacy and those who responded similarly to ≤3 of the challenges were classified as having low self-efficacy.

Data were coded, entered, cleaned and analyzed using STATA version 12.0. We computed prevalence risk ratios (PRR) as a measure of association between the outcome and independent factors (attitudinal, social influence and self-efficacy factors) using generalized linear model (GLM) with Poisson family and a log link with robust standard errors 22. Univariable then multivariable analysis were conducted. All factors with p <0.15 at univariable analysis and factors plausibly associated with the primary outcome were entered in multivariable GLM models to obtain adjusted prevalence risk ratios (adj.PRR). Two multivariable models were used in this study; in the first multivariable GLM, background characteristics and the specific variables that were used to create overall attitude, social influence and overall self-efficacy were run. In the second GLM model, the background characteristics, overall attitude, overall social influence and overall self-efficacy were run. A stepwise backward elimination approach in each of the two models was used to ascertain the best fitting model with a log likelihood tending towards zero.

Ethics approval was obtained from Makerere University School of Public Health Higher Degrees Research and Ethics Committee. Interviews were conducted only when written informed consent had been obtained from the study participants.

Overall, 29% (132/460) of all respondents were highly involved in routine child immunization (RCI). The level of involvement varied by activity; for instance, most (76.1%, 350/460) respondents reported provision of financial support for the child’s routine immunization session(s), followed by accompanying the partner (61.5%, 283/460), discussing a child’s routine vaccination schedule with partner (57.8%, 266/460), and least involvement (18%, 84/460) was in taking their children for routine immunization, table 2.

Overall, 87% (399/460) of respondents had a positive attitude towards involvement in RCI (Cronbach’s alpha correlation coefficient (α) = 0.8). The majority (87%, 401/460) agreed that male involvement in RCI was beneficial in terms of: sharing parental responsibility (60%, 275/460), showing love to partner (40%, 186/460), opportunity to receive child care education as a couple at immunization clinic (15%, 69/460), and help both parents plan and be better prepared for the next visit (9%, 42/460), and improve timely completion of routine child immunization schedule (12%, 55/460). Nearly all (90%, 415/460) respondents were willing to be involved in RCI and to encourage other men to be involved in RCI (88%, 405/460).

Most (73%, 334/460) respondents reported that it is mainly a woman’s responsibility to have a child immunized and only 3% (14/460) said it was mainly a man’s role. In terms of the key roles fathers thought other community members expected of them in RCI, 21% (95/460) reported taking the child for immunization, 34% (155/460) reminding partner of next visit and 45% (209/460) reported providing financial support.

Most men (68%, 313/460) reported encouragement for involvement in RCI mainly from their spouses (28%, 129/460). Respondents reported that other community members considered the act of male involvement in RCI as an expression of love for the wife and child (23%, 107/406), and as a way of a father showing a sense of responsibility for his family (50%, 230/460).

On the other hand; 23% (106/460) of respondents reported discouragement from involvement in RCI mainly from their peers (22%, 101/460). Their involvement was viewed by other community members as a sign of “weakness” for a man (34%, 157/460) and as having time to waste (4%, 19/460).

Overall, most (72%, 333/460) respondents had a high self-efficacy towards involvement in RCI (Cronbach’s alpha correlation coefficient (α) = 0.83).Key barriers to male involvement in routine child immunization (RCI) were: competing work demands (88.7%, 408/460), long waiting time at immunization clinics (43.3%, 199/460), considering routine child immunization as a woman’s responsibility (38.9%, 179/460), financial constraints (24.4%, 112/460), long distance to immunization facility (17.6%, 81/460), and perceived ridicule from peers (5.7%, 26/460). Nearly all fathers (90%, 395/460) expressed ability to cope with or overcome financial constraints; 79% (362/460) with long distance to immunization clinic; 76% (348/460) with ridicule from peers; 70% (321/460) with traditional gender roles, 67% (306/460) with competing work demands; and 56% (258/460) with long waiting time at immunization clinic.

Both univariable and multivariable level analyses are shown in table 3. At multivariable analysis high male involvement in RCI was significantly associated with; men who were 45 years or older (adj. PRR 2.0, 95% CI 1.15 - 3.76), and men who had a positive attitude towards involvement in RCI (adj. PRR 2.3, 95% CI 1.18 – 4.98). Low Male involvement in RCI was observed among men whose main occupation was trading (adj. PRR 0.55, 95% CI 0.37 - 0.82). Male education level, perceived self-efficacy, and social influence towards involvement in RCI were not significantly associated with male involvement in RCI, table 3.