CHAPTER TWO

LITERATURE REVIEW

In this chapter, related literature is reviewed by the researcher under the following headings; Conceptual review, Theoretical review,
Empirical review and summary.

CONCEPTUAL REVIEW

According to the World Health Organization (WHO), family planning is defined as “the ability of individuals and couples to anticipate
and attain their desired number of children and the spacing and timing of their births which is achieved through use of contraceptive
methods and the treatment of involuntary infertility” (WHO, 2008). It refers to the planning of when to have children, and the use of
birth control. It allows individuals and couples to anticipate and have their desired number of children, and to achieve healthy spacing
and timing of their births. Family planning may involve consideration of the number of children a woman wishes to have, including
the choice to have no children, as well as the age at which she wishes to have them. These matters are influenced by external factors
such as marital situation, career considerations, financial position, and any disabilities that may affect their ability to have children and
raise them. If sexually active, family planning may involve the use of contraception and other techniques to control the timing
of reproduction (WHO, 2019). Other aspects of family planning include sex education,  prevention and management of sexually
transmitted infections,  pre-conception counseling  and management, and infertility management. Abortion is not considered a
component of family planning, although access to contraception and family planning reduces the need for abortion, although access to
contraception and family planning reduces the need for abortion (Bajos et al, 2014).

Most of the countries with lowest rates of contraceptive use, highest maternal, infant, and child mortality rates, and highest fertility
rates are in Africa. (World Bank, 2017). Only about 30% of all women use birth control, although over half of all African women
would like to use birth control if it was available to them. The main problems that preventing access to and use of birth control are
unavailability, poor health care services, spousal disapproval, religious concerns, and misinformation about the effects of birth control
(WHO, 2018). The most available type of birth control is condoms.

OBJECTIVES FOR FAMILY PLANNING

Approximately 222 million women in developing countries would prefer to delay or stop childbearing but are not using any method of
contraception (WHO, 2012). A national survey in Nigeria in 2005 found almost a third of women believed that certain methods of
contraception could lead to female infertility.

Family Planning’s objective is to encourage individuals and couples to take responsible decision about pregnancy and enable them to
achieve their wishes with regard to: preventing unwanted pregnancy, securing desired pregnancies, spacing of pregnancies, limiting
the size of the family (Lucas & Gilles, 2003).

Family planning is however wider than this, as it may further include: sexuality education, prevention and management of sexually
transmitted infections (STIs), pre-conception counseling and management, Infertility management (Austin, 2015).

Benefits of Family Planning

Family planning has several benefits, some of which are specific to the health of mothers and their children. Others include
socioeconomic benefits; for example, women are able to advance their education and careers by delaying or limiting childbearing and
this can bring better economic prospects to their household (Smith, Ashford & Clifton, 2009). Family planning serves to reduce child
and maternal morbidity and mortality by preventing unintended pregnancies and unsafe abortions (Scott & Sandra, 2006). The number
of maternal deaths that could be averted during childbirth as a result of a reduction in the number of pregnancies and induced
abortions would be significant (Adogu & Obionu, 2007). Family planning also enables birth spacing, ultimately reducing child
mortality while enhancing the nutritional status of both mother and child (Smith, Ashford & Clifton, 2009).
Sexuality education, prevention and management of sexually transmitted infections (STIs), pre-conception counseling and
management, and infertility management are some of the major benefits associated with family planning.

METHODS OF FAMILY PLANNING

There are several methods of family planning. These methods, also called contraceptives, are devices or medications used for reducing
the likelihood of the fertilization of an ovum by a spermatozoon (Lucas & Gilles, 2003).

Broadly, these methods can be divided into temporary methods and permanent methods. These can further be divided into Natural
family planning methods and artificial or modern family planning methods (Clerk & Ladipo, 2006).

NATURAL FAMILY PLANNING (NFP) METHOD

Natural family planning (NFP) is the method that uses the body’s natural physiological changes and symptoms to identify the fertile
and infertile phases of the menstrual cycle. Such methods are also known as fertility-based awareness methods. Natural family
planning comprises of various methods which makes use of the physiological changes occurring in a woman’s body. There are
basically three (3) methods, which include:

1. Periodic abstinence (fertility awareness) method

2. Use of breastfeeding or Lactational Amenorrhea Method (LAM)

3. Coitus interruptus (withdrawal or pulling out) method.

  Periodic abstinence (fertility awareness) method

During the menstrual cycle, the female hormones estrogen and progesterone cause some observable effects and symptoms. Estrogen
produces alterations in the cervical mucus, which changes from thick, opaque and sticky to thin, clear and slippery as ovulation
approaches and progesterone produces a slight rise in basal body temperature (temperature at rest) after ovulation. Otherwise, the
function of progesterone on the cervical mucus is just the opposite effect of estrogen — it makes the cervical mucus thick, opaque and
sticky.

  Lactational Amenorrhea Method (LAM)

The Lactational Amenorrhea Method (LAM) is the use of breastfeeding as a contraceptive method. Lactational means breastfeeding
and amenorrhea means not absence of menstruation. In this case, there is a delay in ovulation caused by the action of prolactin
hormone from the effect of lactation or breastfeeding. An infant’s suckling of the nipple sends neural signals to the mother’s
hypothalamus (part of the brain), which influences the anterior pituitary gland to secrete prolactin to stimulate the breast for milk
production. This, in turn, inhibits the secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH), and as a result
ovulation does not occur. While women are exclusively breastfeeding, prolactin continues to be secreted and pregnancy is unlikely.
When prolactin levels decrease, the woman’s monthly bleeding may return, and if she continues to have unprotected sexual
intercourse she may get pregnant.

Lactational Amenorrhea Method (LAM) has a success rate of 98-99% (WHO, 2007) however; any factor that causes a decrease in
suckling can result in the return of ovulation and decreased milk production. These factors include supplemental feeding of the infant,
reduction in the number of breastfeeds or long intervals between breastfeeds, maternal stress and maternal/child illness. In these cases,
the client should not rely on LAM. When using LAM, Women should use both breasts to breastfeed their babies on demand, with no
more than a four hour interval between breastfeeds during the daytime, and no more than a six hour interval between breastfeeds
during the night-time. If they are unable to fulfill these conditions, you should advise and provide them with a complementary family
planning method. If a woman has any risk of STI/HIV infection, you should advise her to use condoms.

Coitus Interruptus (Withdrawal or Pulling Out) Method

Coitus interruptus or withdrawal is a traditional family planning method in which the man withdraws or pulls out his penis from his
partner’s vagina and ejaculates outside, keeping his semen away from her genitalia. Coitus interruptus method prevents fertilization by
stopping contact between spermatozoa in the sperm and the ovum or egg. It is important for you to teach this method as part of natural
family planning methods. It costs nothing and requires no devices or chemicals. It is available in any situation and can be used as a
back-up method of contraception. This method however, has several disadvantages. Interruption of the excitement of sexual
intercourse may result in the incorrect or inconsistent use of this method, as well as decreasing sexual pleasure for both partners. A
high failure rate is common due to a lack of self-control, and semen containing sperm may leak into the vagina before the person
ejaculates. There is a further possibility of premature ejaculation by the man. In addition, the couple is not protected from STIs,
including HIV.

This is the least effective method of natural family planning because it depends on the man’s ability to withdraw before he ejaculates.
However, it is about 73% effective if used correctly (Family Planning: A Global Handbook for Providers, WHO, 2007).

MODERN FAMILY PLANNING METHOD

Modern family planning methods are also referred to as modern contraceptive methods or artificial method, and they were invented so
couples could act on their natural impulses and desires with diminished risks of pregnancy. Modern contraceptive methods are
technological advances designed to overcome biology. In this regard, modern methods must enable couples to have sexual intercourse
at any mutually-desired time. Researchers who measure levels of modern contraceptive prevalence often differ in how they categorize
particular methods.

Modern family planning methods are further categorized into three subgroups:

 Short-term methods (the pill, condoms,), diaphragms, foaming tablets, jelly, and the emergency contraceptive pill),
 Long term methods (injectables, implants and IUDs) and
 Permanent methods (female and male sterilization).

TEMPORARY AND PERMANENT METHODS OF FAMILY PLANNING

Temporary methods are methods whose effects can be reversed after termination of its use. They include: periodic abstinence during
the fertile period; withdrawal (coitus interruptus); the naturally occurring periods of infertility (i.e. lactational amenorrhea method);
use of reproductive hormones (e.g., oral pills and long-acting injections and implants); placement of a device in the uterus (e.g.,
copper-bearing and hormone-releasing intrauterine devices); interposing a barrier that prevents the ascension of the sperm into the
upper female genital tract (e.g., condoms, diaphragms, and spermicides) (Clerk & Ladipo, 2006).

Permanent methods, on the other hand, offer terminal contraception. This means that their effects cannot be reversed. These are
basically male and female sterilization namely vasectomy and tubectomy respectively (Clerk & Ladipo, 2006).

Family Planning Efforts in Nigeria

During the period of 1992-1993, a massive mass media campaign was launched to change Nigerians' attitudes toward family planning,
and to thereby increase their contraceptive use. This was based on studies which showed that mass media is a major way of promoting
awareness and utilization of family planning among the populace (Clifford, 1999). For example, the use of mass media in the
Philippines promoting sexual responsibility substantially increased requests for contraceptive information among adolescents, and one
study which showed one-quarter of new clients attending a family planning clinic in Nigeria identified a television campaign as their
source of referral (Clifford, 1999). Since then, there have been reports of a general increase in the awareness and knowledge of family
planning among Nigerians.

The 2017 National Family Planning Communication Plan by the Nigerian Federal Ministry of health aims to increase the Contraceptives
Prevalent Rate (CPR) from the current 15% to 36% by December 2018. It hopes to achieve this through an improvement of family planning
strategies and introduction of new strategies, notably the Integrated Strategic Communication Actions Model (ISCAM).

MALE ATTITUDES AND PERCEPTION TOWARDS CONTRACEPTIVE

A meta- analysis of men’s attitudes found a very wide range of beliefs that were heavily influenced by culture and background (Hoga,
Rodolpho & Sato, 2014). Religion, large family size, culture, fear of side effect, access and exposure to information, attitudes, norms
and self-efficacy and interaction with a health care provider are determinants of male involvement in family planning use (Faeda &
Lubna, 2019).
Men’s perception of contraception as a woman’s business from previous researches showed no associations with use of a modern
method over no method. Also, men’s view that contraception makes women promiscuous was negatively associated with women’s use
of modern contraceptives versus no method (Sarah & Juliet, 2017).

Despite the lack of significant effects of male partner attitudes on folkloric/traditional method use, the negative effect of men’s
perception of promiscuity among contraceptive users has implications for practice and policy. Working to decrease male partner
stigma toward using modern contraceptive methods can be incorporated into future reproductive health initiatives, among other
methods of targeting male partner knowledge, attitudes, and unmet need for contraception (Duze & Mohammed, 2006).

CONTRACEPTIVE PRACTICE AMONG MALES

In many countries, men play a principal role in reproductive decision-making, as they are expected to take the initiative in family
matters (Petro-Nustas, 1999). The involvement of men in family planning processes can either be through directly taking up male
family planning methods themselves, or indirectly by influencing the choices of their wives or female partners on utilization of family
planning services. Previous work has found that among men aged 35 to 39 years in need of family planning, the majorities are not
using condoms and have a partner who is not using hormonal contraception (Casey et al, 2016).
Despite the death of research in this area, previous work indicates that men who are concerned about preventing pregnancy, talk with
their partners about fertility intentions, and are involved in pregnancy prevention (Heinemann, Wiesemes & White, 2015). Also, less
than 25% of men have ever initiated FP discussion with their wives, 35% have never discussed FP with their wives while 49% have
discussed FP with their wives at least twice in the year preceding the study (Ijadunola, Abiona, Esimai & Olaolorun, 2010). All
previous research indicates that few men have discussed contraception with a health care provider but almost all are willing to have
the conversation in the clinical setting (Same, Bell, Rosenthal & Marcell, 2014).
From all literature reviewed, the participation of men in their partners’ use of family planning seems to be even more vital to the
increase of contraceptive prevalence than the use of FP methods by men themselves. This involvement includes having discussions
about FP with their partners, granting their partners permission to take up FP methods, following their partners to FP clinic, providing
funding for FP services, among others.

INDICATIONS FOR MALE CONTRACEPTIVES

i In all cases were family planning is desired for child spacing.
ii When family size is completed.

iii The presence of conditions that limits the woman’s use/access to contraceptive. (Palamuleni & Adebowale, 2014)

iv To avoid the side effect associated with female contraceptives.

v High rate of unintended pregnancies. (Palamuleni & Adebowale, 2014)

vi The high rate of non-compliance among women. (Austin, 2015)

vii Unmet contraceptive needs among women. (Austin, 2015)

viii. Break the chain of sexually transmitted infections by the use of barrier methods.

BARRIERES TO USE OF CONTRACEPTIVES AMONG MALES

The participation of men in family planning is largely influenced by an array of factors. This includes having knowledge about FP, the
cost of FP methods, the desire to have more children, the desire to space children, attainment of desired family size, desire for a male
or female child, religious beliefs and cultural practices, fear of partner’s promiscuity, fear of resultant barrenness, availability and
accessibility of the services (Dreweke, 2019).
Some of the factors encouraged men to participate in family planning while others discouraged their participation. While women were
said to be reluctant in discussing family planning with their husbands unless their husbands introduce the subject, an Enugu study
found desire for more children (61%), fear of side effects (11%), religious beliefs (9%), and lack of FP knowledge (1%) as the major
cause of the non-acceptance of FP among men (Austin, 2015). This is similar to the findings in Uganda (Kabagenyi et al, 2014)
In another study in South-western Nigeria, 71% of the men participated in FP because of desire to space their children, 20% did so
because they have attained their desired family size, while 44% disapproved use of FP because of religious dictates (Ijadunola,
Abiona, Esimai & Olaolorun, 2010). Similar reasons were found in an Ethiopian study where desire to have more child (28.9%),
source of contraceptive not known (10.28%), wife opposed (9.34%), fear of side effect (8.41%), health concern (8.41%), religious
prohibition (5.6%) were the factors elicited (Abraham, Adamu & Deresse, 2010). Cultural practices were found to be generally very
influential in Nigerian men participation in FP, especially in relation to visiting health facility for FP services and discussion of FP
with their partners (Ijadunola, Abiona, Esimai & Olaolorun, 2010).

THEORETICAL REVIEW
In this aspect, the literature is reviewed under the following theories:

 Social Cognitive Theory (SCT)

 Health Belief Model

SOCIAL COGNITIVE THEORY

Fig 2.1: diagrammatic representation of social cognitive theory

Social cognitive theory is a learning theory based on the idea that people learn by observing others. These learned behaviors can be
central to one's personality. The social cognitive theory was developed by Bandura from the mid1970s onwards (Bandura, 1977; 1986;
1988; 1989; 1998; 2000; 2001; 2004; 2009). Social Cognitive Theory’s (SCT) roots can be traced to the 1940s and articulations of
Social Learning and Imitation Theory (Pálsdóttir, 2013). The main principle of Social Learning and Imitation Theory is that
individuals are prompted to learn in response to various drives, cues, responses, and rewards, one of which is social motivation. A
more recent, and direct antecedent of SCT is Social Learning Theory (Bandura, 1997). Social Learning Theory explains that people
learn through the social processes of observing, imitating, and modeling the behaviors of others. Bandura in 1986 further developed
Social Learning Theory to Social Cognitive Theory to encompass determinants of learning that are neglected in its predecessor;
cognitive elements important to the learning process, such as thought (for example, anticipated outcome expectations) and feelings
(for example, anxiety).

While social psychologists agree that the environment one grows up in contributes to behavior, the individual person (and therefore
cognition) is just as important. People learn by observing others, with the environment, behavior, and cognition acting as primary
factors that influence development in a reciprocal triadic relationship (Bandura, 2009). In general terms, SCT is a psychologically
derived theory that explains how individuals within social systems enact multiple human processes, including the acquisition and
adoption of information and knowledge. Its main focus is the processes of learning, and the interplay between multiple factors therein.
SCT suggests that acquisition of knowledge and skills comes through ‘enactive mastery experience’, i.e. direct experience of skills or
tasks, and ‘mastery modeling’, i.e. observational learning from role models (Gong, Huang and Farh, 2009). Thus, interactions between
social and cognitive factors of learning as determinants of behavior are thus a distinctive feature of SCT (Pálsdóttir, 2013). The
behavior witnessed by an individual can change the person's way of cognition. In the same way, the environment one is raised in may
influence later behaviors. For example, if a man grows up in a family with a multitude of children, that environment and behavior to
which he has been exposed to, affects his perception and attitude toward family planning.

The social cognitive theory when it was evolved from the social learning theory was developed under six (6) constructs. These are:
1. Reciprocal Determinism - This is the central concept of SCT. This refers to the dynamic and reciprocal interaction of person
(individual with a set of learned experiences, whether the individual has high or low self-efficacy toward the behavior),
environment (Aspects of the environment or setting that influence the individual's ability to successfully complete a behavior,
i.e. the external social context), and behavior (responses to stimuli to achieve goals). It is important to note that learning can
occur without a change in behavior. According to J.E. Ormond’s general principles of social learning, while a visible change in
behavior is the most common proof of learning, it is not absolutely necessary. Social learning theorists believe that because
people can learn through observation alone, their learning may not necessarily be evident in their performance. It is critically
important to recognize that the relative influences exerted by one, two, or three interacting factors on motivated behavior will
vary depending on different activities, different individuals and different circumstances (Stajkovic & Luthans, 2003).

2. Behavioral Capability - This refers to a person's actual ability to perform a behavior through essential knowledge and skills. In
order to successfully perform a behavior, a person must know what to do and how to do it. People learn from the consequences
of their behavior, which also affects the environment in which they live. Four primary capabilities are addressed as important
foundations of social cognitive theory: symbolizing capability, self-regulation capability, self-reflective capability, and
vicarious capability (Bandura, 2008).

 Symbolizing Capability: People are affected not only by direct experience but also indirect events. Instead of merely learning
through laborious trial-and-error process, human beings are able to symbolically perceive events conveyed in messages,
construct possible solutions, and evaluate the anticipated outcomes.
 Self-regulation Capability: Individuals can regulate their own intentions and behaviors by themselves. Self-regulation lies on
both negative and positive feedback systems, in which discrepancy reduction and discrepancy production are involved. That is,
individuals proactively motivate and guide their actions by setting challenging goals and then making effort to fulfill them. In
doing so, individuals gain skills, resources, self-efficacy and beyond.
 Self-reflective Capability: Human beings can evaluate their thoughts and actions by themselves, which is identified as another
distinct feature of human beings. By verifying the adequacy and soundness of their thoughts through enactive, various, social,
or logical manner, individuals can generate new ideas, adjust their thoughts, and take actions accordingly.
 Vicarious Capability: One critical ability human beings feature is the ability to adopt skills and knowledge from information
communicated through a wide array of mediums. By vicariously observing others’ actions and their consequences, individuals
can gain insights into their own activities. 

3. Observational Learning - This asserts that people can witness and observe a behavior conducted by others, and then reproduce
those actions. This is often exhibited through "modeling" of behaviors.   If individuals see successful demonstration of a
behavior, they can also complete the behavior successfully. To illustrate that people learn from watching others, Albert
Bandura and his colleagues constructed a series of experiments using a Bobo doll. In the first experiment, children were
exposed to either an aggressive or non-aggressive model of either the same sex or opposite sex as the child. There was also a
control group. The aggressive models played with the Bobo doll in an aggressive manner, while the non-aggressive models
played with other toys. They found that children who were exposed to the aggressive models performed more aggressive
actions toward the Bobo doll afterward, and that boys were more likely to do so than girls. Observations should include:

 Attention: Observers selectively give attention to specific social behavior depending on accessibility, relevance,
complexity, functional value of the behavior or some observer's personal attributes such as cognitive capability, value
preference, preconceptions.
 Retention: This involves observing a behavior and it’s subsequent consequences, then converting that observation to a
symbol that can be accessed for future redisplay of the behavior.
  Production: This refers to the symbolic representation of the original behavior being translated into action through
reproduction of the observed behavior in seemingly appropriate contexts. During reproduction of the behavior, a person
receives feedback from others and can adjust their representation of that same behavior for future references.
 Motivational process: This deals with reenacting a behavior depending on responses and consequences the observer
receives when reenacting that behavior.

4. Reinforcements - This refers to the internal or external responses to a person's behavior that affect the likelihood of continuing
or discontinuing the behavior. Reinforcements can be self-initiated or in the environment, and reinforcements can be positive
or negative. This is the construct of SCT that most closely ties to the reciprocal relationship between behavior and
environment.
5. Expectations - This refers to the anticipated consequences of a person's behavior. Outcome expectations can be health-related
or not health-related. People anticipate the consequences of their actions before engaging in the behavior, and these anticipated
consequences can influence successful completion of the behavior. Expectations derive largely from previous experience.  
While expectancies also derive from previous experience, expectancies focus on the value that is placed on the outcome and
are subjective to the individual.
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to successfully perform a behavior. Self-
efficacy is unique to SCT although other theories have added this construct at later dates, such as the Theory of Planned
Behavior. Self-efficacy is influenced by a person's specific capabilities and other individual factors, as well as by
environmental factors (barriers and facilitators).
Limitation of Social Cognitive Theory

There are several limitations of SCT which should be considered when using this theory, and they include the following (Bandura,
2018):

 The theory assumes that changes in the environment will automatically lead to changes in the person, when this may not
always be true.
 The theory is loosely organized, based solely on the dynamic interplay between person, behavior, and environment. It is
unclear the extent to which each of these factors into actual behavior and if one is more influential than another.
 The theory heavily focuses on processes of learning and in doing so disregards biological and hormonal predispositions that
may influence behaviors, regardless of past experience and expectations.
 The theory does not focus on emotion or motivation, other than through reference to past experience. There is minimal
attention on these factors.
 The theory can be wide-ranging and extensive, so it can be difficult to carry out in entirety.
HEALTH BELIEF MODEL

Figure 2.3 diagrammatic representation of Health Belief Model (HBM)

The Health Belief Model (HBM) is one of the most widely used conceptual frameworks for understanding health behavior.
The Health Belief Model (HBM) is a social psychological health behavior change model developed to explain and predict health-
related behaviors, particularly in regard to the uptake of health services (Janz & Marshall, 1984). The Health Belief Model is a
framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the
prime motivation. The Health Belief Model (HBM) was developed in the 1950's by social psychologists Hochbaum, Rosenstock and
others, who were working in the U.S. Public Health Service to explain the failure of people participating in programs to prevent and
detect disease. Later uses of HBM were for patients' responses to symptoms and compliance with medical treatments. The HBM
suggests that a person's belief in a personal threat of an illness or disease together with a person's belief in the effectiveness of the
recommended health behavior or action will predict the likelihood the person will adopt the behavior (Siddiqui, Ghazal, Bibi, Ahmed
& Sajjad, 2016). Ultimately, an individual's course of action often depends on the person's perceptions of the benefits and barriers
related to health behavior. The HBM is derived from psychological and behavioral theory with the foundation that the two
components of health-related behavior which are;

i. The desire to avoid illness

ii. The belief that a specific health action will prevent, or cure an illness.

There are six constructs of the HBM. The first four constructs were developed as the original tenets of the HBM. The last two were
added as research about the HBM evolved.

1. Perceived susceptibility - This refers to a person's subjective perception of the risk of acquiring an illness or disease. There is
wide variation in a person's feelings of personal vulnerability to an illness or disease. The HBM predicts that individuals who
perceive that they are susceptible to a particular health problem will engage in behaviors to reduce their risk of developing the
health problem.  Individuals with low perceived susceptibility may deny that they are at risk for contracting a particular
illness. Others may acknowledge the possibility that they could develop the illness, but believe it is unlikely. Individuals who
believe they are at low risk of developing an illness are more likely to engage in unhealthy, or risky, behaviors. Individuals
 who perceive a high risk that they will be personally affected by a particular health problem are more likely to engage in
behaviors to decrease their risk of developing the condition (Rosenstock, 1974).
2. Perceived severity - This refers to a person's awareness and feelings on the seriousness of contracting an illness or disease, or
leaving the illness or disease untreated. The HBM proposes that individuals who perceive a given health problem as serious are
more likely to engage in behaviors to prevent the health problem from occurring (or reduce its severity). Perceived seriousness
encompasses beliefs about the disease itself (e.g., whether it is life-threatening or may cause disability or pain) as well as
broader impacts of the disease on functioning in work and social roles. (Glanz, Barbara & Viswanath, 2008).There is wide
variation in a person's feelings of severity, and often a person considers the medical consequences (e.g., death, disability) and
social consequences (e.g., family life, social relationships) when evaluating the severity.
3. Perceived benefits - Perceived benefits refer to an individual's assessment of the value or efficacy of engaging in a health-
promoting behavior to decrease risk of disease. It concerns a person's perception of the effectiveness of various actions which
can reduce the threat of illness or disease, or to cure illness or disease (Janz & Marshall, 1984). The course of action a person
takes in preventing or curing the illness or disease relies on consideration and evaluation of both perceived susceptibility and
perceived benefit (Rosenstock, 1974).
4. Perceived barriers - This refers to a person's awareness of the obstacles to be encountered when performing a recommended
health action (Janz & Marshall, 1984). Even if an individual perceives a health condition as threatening and believes that a
particular action will effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior. In other
words, the perceived benefits must outweigh the perceived barriers in order for behavior change to occur (Glanz, Barbara &
Viswanath, 2008). Perceived barriers to taking action include the perceived inconvenience, time consuming, expense, danger
(e.g., side effects of a medical procedure) and discomfort (e.g., pain, emotional upset).
5. Cue to action - This is the stimulus needed to trigger the decision-making process to accept a recommended health action. The
HBM posits that a cue, or trigger, is necessary for prompting engagement in health-promoting behaviors. These cues can be
 internal, for example; chest pains, wheezing, etc., or external such as; advice from others, illness of family member, newspaper
article, etc. (Carpenter, 2010).
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to successfully perform a behavior. This
construct was added to the model most recently in mid-1980. Self-efficacy was added to the HBM in an attempt to better
explain individual differences in health behaviors (Rosenstock, Strecher & Becker, 1988). The model was originally developed
in order to explain engagement in one-time health-related behaviors such as being screened for cancer or receiving an
immunization. Self-efficacy is a construct in many behavioral theories as it directly relates to whether a person performs the
desired behavior.

Limitations of Health Belief Model

There are several limitations of the HBM which limit its utility in public health. Limitations of the model include the following (Janz
& Marshall, 1984):

 It does not account for a person's attitudes, beliefs, or other individual determinants that dictate a person's acceptance of a
health behavior.
 It does not take into account behaviors that are habitual and thus may inform the decision-making process to accept a
recommended action (e.g., smoking).
 It does not take into account behaviors that are performed for non-health related reasons such as social acceptability.
 It does not account for environmental or economic factors that may prohibit or promote the recommended action.
 It assumes that everyone has access to equal amounts of information on the illness or disease.
 It assumes that cues to action are widely prevalent in encouraging people to act and that "health" actions are the main goal in
the decision-making process.
EMPIRICAL REVIEW

Based on the study carried out in the south western part of Nigeria by Ademola Adelekan, Philomena Omoregie and Elizabeth Edoni
in 2014, Public health officials have advocated the involvement of men as a strategy for addressing the dismal performance of family
planning (FP) programmes. This study was therefore designed to explore the challenges and determine way forward to male
involvement in FP in Olorunda Local Government Area, Osogbo, Nigeria. This cross-sectional study involved the use of a four-stage
sampling technique to select 500 married men and interviewed them using semistructured questionnaire. In addition, four focus group
discussions (FGDs) were also conducted. Mean age of respondents was 28.5 ± 10.3 years. Some (37.9%) of the respondents’ spouse
had ever used FP and out of which 19.0% were currently using FP. Only 4.8% of the respondents had ever been involved in FP.
Identified barriers to male involvement included the perception that FP is woman’s activity and was not their custom to participate in
FP programme. More than half of the FGD discussants were of the view that men should provide their wives with transport fare and
other resources they may need for FP. The majority of the respondents had never been involved in family planning with their wives.
Community sensitization programmes aimed at improving male involvement in FP should be provided by government and
nongovernmental agencies.

Based on the study carried out in Ganmo, Ilorin, by Olusola Olugbenga, Kayode Ijadunola, Johnson Komolafe and Wasiu Olalekan
Adebimpe on the knowledge and attitude of men towards family planning, Men's Knowledge of and attitudes to family planning (FP)
in suburban and rural Nigeria is still poor despite a global move to increase the involvement of men in reproductive health matters. A
cross-sectional survey was conducted to determine men's knowledge of and attitude to family planning at Ganmo, a sub-urban
community on the outskirts of Ilorin, Nigeria. The study employed an interviewer administered semi-structured questionnaire to elicit
information from 360 men in the households. Only males above the age of 15 years resident in the community were selected for
interview. A proportionate sampling procedure was employed in selecting the required number of men from each of the 32 compounds
that make up the community. Nearly all men (96.5%) were aware of family planning and a majority of them were aware of some
common methods of family planning e.g. Oral Contraceptive Pills (OCPs) (72.5%), Injectables (69.2%), Condoms (86.6%) and
Traditional methods (70.6%). Knowledge of other alternative female methods was low e.g. Norplant (17.5%), IUCD (26.3%),
Diaphragm (39.8%), vaginal cream (30.2%), vaginal tablet (37.8%) and vaginal sponge (16.8%), and Tubal Ligation (51.3%).
Knowledge of male controlled FP methods like Withdrawal (49.6%), Rhythm or periodic abstinence (54.6%) and Vasectomy (28.6%)
was also poor. The Respondents had low knowledge of common side effects of FP methods e.g. nausea (9.8%), vomiting (13.1%),
abnormal menstruation (34.4%), pain (23.2%) and unwanted weight gain (17.0%); some 25.3%% of respondents had no knowledge of
any side effects. The attitude of respondents to family planning was also relatively poor as only a moderate proportion of men
supported the FP concept (52.7%) and the Nigerian Population Policy (54.8%) of "four children to a woman". Some 54.8% of
respondents were in support of men discussing about FP with their spouses. The major reasons for non-approval of FP by men were
the fear of side-effects (70.4%) and perception of FP as being against religion (52.1%). The predictors of poor FP attitude were not
having formal education, practice of polygyny and to a lesser extent being a Muslim. The study concluded that, men at Ganmo have
limited knowledge of, and poor attitude to FP An intensive drive at a community based adult reproductive health education was
advocated among other recommendations.

Based on the study carried out 2019, in Cross River State by Nnette Okon Ekpenyong, Ogban Ezukwa, Iwasam Elemi and Nwoha
Doris Charles, on the knowledge, perception and attitude of men towards family planning in rural communities of Cross River State ,
unmet need for family planning remains very high regardless, especially in rural areas. Multistage sampling method was used to
recruit 220 men in rural communities of Cross River State aged 15- 59 years who were in a union. Although the level of awareness of
family planning among respondents was high(96.2%), adequate knowledge of family planning methods was poor(89.9%);  the
practice of family planning was poor—condom use as a method of family planning practiced by 37.2%, withdrawal by 1.4%, while no
respondent had undergone male vasectomy.

Bivariate analysis revealed that religion was statistically significantly associated with knowledge of pills as a family planning method
(p=0.008): Catholics were less likely to be knowledgeable about pills: occupation was significantly associated with family planning
practice among respondents (p=0.015). Respondents who were students, recent school leavers or unemployed (66.7% in all) practiced
family planning more than those who were government- (34.4%) or self- employed (36.4%) (p = 0.015). Despite recognition and
recommendation of male involvement during the International Conference on Population and Development (ICPD), male participation
in this service is still very poor in the rural area.

Based on a study carried out 2016, in Abuja by Godwin Akaba, Nathaniel Ketare and Wilfred Tile, on the attitudes and behaviors of
men towards modern family planning, in order to investigate the knowledge, attitudes, and extent of involvement of men in family
planning in Nigeria, and to evaluate spousal communication regarding family planning. A community-based, mixed-methods study
enrolled participants in Gwagwalada, Abuja, Nigeria between January 11 and June 30, 2012. Quantitative surveys including semi-
structured interviews were used to collect information from married men regarding their knowledge and attitudes to modern family
planning. The qualitative components constituted focus group discussion sessions and in-depth interviews that included married men,
married women, religious leaders, community leaders, and family-planning providers. Results: Quantitative surveys were completed
by 152 men; 99 (65.1%) reported that they would accompany their wives to family-planning clinics in the future, 116 (76.3%)
reported approving of the use of modern contraception by their wives, and 132 (86.8%) reported wanting to know more about family
planning. Both quantitative and qualitative aspects of the study indicated that husbands were the major decision makers regarding
family size, choice of contraceptive, and pregnancy timing. Conclusively, in terms of fertility goals and family planning, men were the
primary decision makers; consequently, obtaining their support and commitment to family planning is of crucial importance in
Nigeria.

SUMMARY

A better understanding of theories applied to this research study, as well as an understanding of the previous studies carried out in
relation to this research, may help bring about the prevalence of family planning amongst married men in Nnewi.
Social cognitive theory focuses on understanding the risks and benefits and benefits of changing ones behavior, developing self
efficacy and assessing outcome expectations of a change in behavior. According to social cognitive theory, individuals learn by
observation of people’s behaviors and the environment they grow in, which plays a major role in their learning experience. Individuals
are able to put into practice, what they have experienced firsthand. Hence, to create an awareness of family planning among the men
of Nnewi, and to further improve their attitude towards the practice of family planning, exemplary families, who have already begun
the practice of family planning should be used as a reference point to prove that the pros of family planning outweighs the cons, i.e.
observational learning from role models (Gong, Huang and Farh, 2009). This can help to change the way of thinking of majority of the
married men in Nnewi.

Furthermore, the Health Belief Model makes us understand that a person's belief in a personal threat of an illness or disease together
with a person's belief in the effectiveness of the recommended health behavior or action will predict the likelihood the person will
adopt the behavior (Siddiqui, Ghazal, Bibi, Ahmed & Sajjad, 2016). Thus, if through the use of the media and other channels of
information distribution, the benefits of family planning practice can be communicated, as well as the disadvantages of the lack of
family planning, the attitude and perception of men toward this practice would definitely improve for the better.

In summary, for people to progress they need a growing awareness that the advantages (the "pros") of changing outweigh the
disadvantages (the "cons"), the confidence that they can make and maintain changes in situations that tempt them to return to their old,
unhealthy behavior and strategies that can help them make and maintain change.