Our study results are presented in themes; influences to contraceptive uptake, key sources of information on modern contraceptive patterns and media consumption habits. The major subthemes that emerged from the theme of influences of contraceptive use were individual, interpersonal, organisational and community as indicated in figure 2. These subthemes were developed from codes that included knowledge, personal experiences, friends and peers, Mothers- in law and grandparents, religious leaders, health workers, housing and cultural values. Key sources of information included radios, television and mobilisation vans whereas media consumption pattern themes comprised of language to be used, conform to cultural practices and male involvement.
Influences to contraceptive uptake
Individual influences
Knowledge about contraceptive method
As seen from the first level of SEM, knowledge of contraceptive methods among people of reproductive age was reported to influence the uptake. This came majorly from Kibaale and Moroto districts which are rural or have scarcity or services respectively. A participant from Kibaale district reported to have switched to short term method due to the knowledge she had received about contraceptive methods. People involved in contraceptive service delivery also mentioned that knowledge gap about contraceptive methods influence people not to seek these services.
“I was using capsules, I heard on the radio that capsules are equivalent to injectaplan, so it helped me to know that if I want to use short term methods, I should use injectaplan, rather than using a long term method. That’s why am using it.” IDI-contraceptive Switcher, Kibaale district
Personal experience
Across all age categories, the personal experiences and environments in which participants lived influenced their use of contraceptive methods. In Kibaale male participants reported that women who had faced domestic violence from their spouses were forced to use contraceptive methods whereas those who had experienced side effects did not want to use the methods again. Side effects was raised by male participants from almost all study districts as a reason for none use of modern contraceptive methods. It was mentioned that men whose spouses had faced this challenge from previous use feared to use contraceptive methods again. Expert clients who had used contraceptive methods for long acted as role models and cleared the negative perceptions about contraceptive methods.
“Friends, my wife has a group of friends that told her that men beat women a lot and if they give birth to many children then it is worse. They encouraged her to go for family planning to avoid fighting with me.” FGD_Male_20-24years, Kibaale district
“If you have earlier used a method and it treated you badly [meaning experienced side effects] then stopped. After giving birth, even though you want to use it, you fear. So, you decide to leave it and give birth again.” FGD_ Female_20-24year, Mbale district
Interpersonal influencers
Friends and Peers
As indicated from the model, the way friends and peers relate with an individual influenced the decision on contraceptive methods uptake as unanimously reported by 20 FGDs, 6 IDI and 6 KII participants. Of the FGDs, six were adolescents and the rest for other ages. Discussions held with youth from all the four districts proposed peers and friends having a big contribution on the decisions and knowledge they had about contraceptive methods. Adolescent males stated that female of their age group were the category that were majorly influenced by peers and friends to use contraceptive methods. Besides those that had experienced side effects, adolescent from Kibaale who had used contraceptive methods encouraged their colleagues to use the same methods. In contrast, peers in Moroto district advised each other that contraception was not good and that the young people should give birth to many children like it is in their tradition. In Mubende which is relatively a rural district, adolescents shared information related to sexual issues while at school or in their places of residence. They acknowledged that people of their age lacked information on sexual health and got recommendation from their friends who had used the methods and not had side effects.
“At school we hear from each other, also in the village, we do talk to each other about health issues.” FGD_Male_15-19years, Mubende district
“Our peers in schools and where we reside who have had seminars on the methods and had positive effects also encourage us to use them too.” FGD_ Female _15-19years, Mubende district
Focus Group Discussions with older participants (20 years and above) emphasised that peers and friends particularly influenced contraceptive non-use when they had experienced side effects. Across all districts, it was reported that friends of these age groups shared a lot about the side effects faced from contraceptive use which information created fear among intended users.
“Depending on what those that have used it say about how bad contraceptives make them feel, they have unending periods whereby every week they are in their periods. This is the reason I fear it” FGD_Female_20-24years, Kibaale district
Despite all this discouraging information from friends and peers, people in Moroto and Mubende who had friends that successfully used modern contraceptive methods, and had healthier well-spaced and educated children positively influenced colleagues to also utilize these methods. The friends acted as role models who would encourage families that have many children to go for contraceptive services as well as switching to alternative methods in case of side effects. People who were interested in adopting a method went further to seek clarity from health workers who gave them correct information.
“We also get advice from our friends. For example, I have a friend whom I used to admire how she brings up her children, with good plan and nice education. When I approached her, she told me that it’s due to family planning. Honestly I had to join and am now happy too when I space my kids.” FGD_Female_25-50years, Moroto district
From the IDIs, friends being influencers among users was only reported in Kibaale where the advice was a result of families’ financial state being not too good. On the other hand, switchers and non-users reported that the friends mainly told them about side effects which made then switch methods or total abandonment of contraceptive methods. This was further emphasized by KII respondents that friends were mainly sharing information about negative effects of the modern contraceptives which caused their colleagues to shun its use.
Mothers- in law and grandparents
Our data from FGDs and KIs show that parents, mothers-in-law and grandparents are influencers of contraceptive use. From all the districts across all FGD categories, parents especially mothers mainly encouraged their children to use contraceptives. The parent gave this advice in circumstances where their children had husbands who were seen as uncaring, had no land to raise children (grandchildren) and or with economic difficulties especially in Mbale which was an urban study district. In Moroto, it was reported that some mothers even take their married children to receive contraceptives method after the latter have had many children. At best, grandparents advised the women to use traditional family planning methods like safe days. In contrast, reports from participants of rural study districts showed that some mothers discouraged their married or sexually active children from using contraceptives stating side effects, causes future fertility challenges and advising that they instead produce like how their parents gave birth to them. Also, parents from small families discouraged their children to have few offspring as a way to widen the family.
Mothers-in-law and grandparents specifically advised and forced their daughters-in-law not use modern contraceptive methods. Mothers-in-law are highly respected and feared by their daughters-in-law and have power over their sons. Hence, they majorly wanted the daughters-in-law to have many children for their sons which led some women to use contraceptives stealthily. In Kibaale, a discussion with women aged 20-24years echoed strongly about the threat they got from mothers-in-law some threating to chase them away from the marriage if they did not want to give birth. Some in-laws even related modern contraceptives use to being promiscuous. Only a few FGD respondents reported positive influence on contraceptive use from their in-laws due to the high cost of living.
From Mbale, a nonuser mentioned that grandparents advised their granddaughters to quit contraceptives use due to side effects whereas users from Mubende were advised by their mothers not to stop using family planning as a way to avoid suffering.
“Mostly, family planning methods are used by the educated people. When you talk to our mothers about family planning, they tell us not to associate ourselves with it as they were able to give birth to us without using the methods. And in case you share with her any side effects of the methods, they say we are to blame for taking up the white man’s methods” FGD_Male_20-24years, Mubende district
Organisational influences
Religious leaders
As different sectors reach individuals, they take upon themselves to either encourage or discourage contraceptive use. From the sector or religion, both Christian and Muslim religious leaders were reported to negatively influence use of modern contraceptives methods especially in rural study districts among all age categories for both male and female. Majority of participants from FGDs mentioned that religious leaders advise people to produce and fill the world since that’s what God wants as it is written in the bible. It was further emphasized that faith-based beliefs related contraceptives use to murdering of the unborn babies and regarded it a sin. They preached to their congregation that those who used contraceptives will be punished by God. This message was preached majorly by Catholic, Moslems, some Pentecostals, some Anglicans and other sects. There was a sect that operated in Kibaale and Mubende district that had many followers and barred people from using contraceptives. Most preachers emphasise the myths and side effects of contraceptives as dangers faced by people who use these methods.
“In my religion you are not allowed to kill. So if you use family planning, they regard you to have killed.” FGD_Female_20-24years, Mubende district
Natural methods were the only recommended options and lessons on how to use natural methods were given during marriage counselling for those soon to wed. However, male and female FGD participants from Mubende mentioned that a few Pentecostal leaders advised people to use modern contraception and give birth to children they could afford to care for. Similarly, in Kibaale a discussion with female of 20-24years stated that places of worship hosted people who sensitized the congregation about contraceptives use. In addition, a quarter of respondents from FGDs mostly in urban study areas acknowledged that people appreciate the value of using contraceptives compared to the expense of having so many children.
“According to religious beliefs, one is not allowed to use these methods because they are sin in the Catholic faith but they only encourage natural methods like abstinence, use calendar, so some people end up not using these methods” FGD_ Female _20-24years, Moroto district.
Across the IDIs and KIIs, participants equally held this view of religious leaders against modern contraceptives with the one exception of a contraceptive user who mentioned that a catholic priest had at one time encouraged them to uptake family planning methods.
“On Easter, a priest told us that you’re over producing, use family planning and educate your children.” IDI contraceptives user, Kibaale district
Health workers
Health workers were reportedly positive influences to people’s uptake of contraceptives by participants from all interviews and study areas. However, there was a difference in how health workers influenced different age groups towards modern contraceptives uptake. Age groups of 20-34years for men and women reported health workers as positive influences through offering counselling and advice at health facilities and communities. The counselling was often given to women who came for antenatal, postnatal and immunization services especially those with many children. Health workers also moved in communities to sensitise on contraceptives, provide outreach services, and participated in radio talk shows to health education as a means to sensitize the public on the available contraceptive methods and encourage people to use contraceptive methods. Same reports were given by teenage mothers in Moroto district, with teenage and young fathers reporting to have been counselled and asked to go home and talk to their spouses to use contraceptives and space their children.
“We get advice from nurses mostly when we come for antenatal services. They tell us that we have to use have family planning methods available in hospital after giving birth.” FGD_ Female _25-50years, Moroto district
In contrast, health workers discouraged adolescents not in marriage or union and those who had never given birth from using contraceptives. Adolescents from Mbale and Mubende districts reported being denied contraceptives by health workers on account of being young. Other providers asked for money of which the young people did not have since the majority are not in employment. In Mbale, adolescents’ further revealed feeling stigmatized when they were asked why at a young age they were already engaged in sexual relations and being asked to be escorted by their parents before receiving contraceptives.
“Yes. Some health workers are kind however others are money minded and charge for every material provided by the facility. So, we know these workers by face and shun away when we find them at the facility” FGD_Female_15-19years, Mubende distict
Participants from IDIs emphasized the role of health workers in contraceptive method uptake. It was mentioned that persons who sought information from health workers after being discouraged by their friends were able to take up contraception after receiving counselling and options of different methods including their side effects. Health workers also reportedly routinely urged male spouses to encourage their wives to turn up for family planning services. However, an individual who wasn’t using contraceptives in Kibaale, reported that health workers who were not well trained in FP were not able to give comprehensive guidance and biased clients on the contraceptive methods to be used.
Village health team members influenced the community members to take up contraceptive methods as they provide information on the contraceptive methods and even supplied some like condoms. They were reported to be highly influential because they move door-to-door and respondents felt gave a personal touch and encouraged communities to ask openly about contraceptives. However, VHTs were reported to have limited knowledge of some contraceptive methods and thus could only offer narrow information.
“The VHTs also help us, they do this on a one-on-one when you visit them. They will give you a range of options that you can use. Condoms, injector plan and others but on individual basis.” FGD_ Male_15-19, Mubende district
Housing
The sector of housing influenced people’s decision on contraceptive use. In Mbale district which was more urban, challenges with housing influenced women’s use of family planning to reduce family size. Focus group participants reported that many property owners were not willing to rent their houses for accommodation to people with many children. Hence the people not owning houses were forced to use contraceptives so that they don’t get chased away from the properties they rented.
Community influences
Cultural values
Culture as indicated in SEM, was an influence reported within the Karimojong community. The importance of many children to this community surpasses the decision to use contraceptive methods as reported by male FGD participants across all age groups from Moroto district. It was mentioned that cultural leaders have a strong voice within the community where they impose norms and values by forcing people not to use contraceptives. In addition, grandparents encouraged their grandchildren to give birth to many children as children are equated to wealth, pride and support to parents as they grow older. The young people were asked to give birth and replace old generation. The cultural practice of paying dowry for women encourages them to disregard contraceptives as the women aim to produce many children as a way of showing appreciation to the husband and to pay back the dowry. Further, parents wanted their families to follow their lineage hence fathers ask their son to have 3-4 wives and produce many children.
“Long ago, in the years of our grandfathers and grandmothers …the order of the day was to produce children, the more children you produce, the more wealth, the more support and pride you get, so that is what we say the cultural aspect. …it is the elders”. FGD_ Male _35-49years, Moroto district
Sources of contraceptive information and radio consumption patterns
Sources of contraceptive information
The main sources of information regarding contraception for the communities in all the study sites were radios followed by health workers, televisions and mobile vans mounted with speakers.
Radio
From all the study districts, FGDs from 28 categories said radio was their source of contraceptive information. Though both sexes reported radio, in Moroto district this came from mostly male discussions. Contraceptive information was passed mainly in adverts and health programs where health workers were hosted to sensitise listeners. Also IDI and KII participants supported radio as a major source of contraceptive messages in both rural and urban communities. A key informant remarked:
“It is mostly the radio that can help greatly since that is the most reliable one in our community”. KII, Moroto district
Television
Of all the 32 FGDs, 11 mentioned television as a source of contraceptive information and of these seven were female FGDs mainly from Mubende and Mbale which were more urban compared to the other two districts. Though a good source of information, participants noted that few people actually had televisions hence limited access to contraceptive information through this media. Key informant participants including VHTs, DHT and community leaders reported television as a media they have used to disseminate contraceptive information to communities.
“We have been receiving it through television and at times over the radio but these days. We are no longer on radio because we are mainly on TV though not all people have TVs. Few people have them so it’s better that they broadcast it on TV and also radios”. FGD_ Females _15-19years, Mbale district
Mobile vans
Community mobilisation by use of mobile vans was another source of information for contraceptives. Male and female FGD participants from all study districts reported to have received information from mobile vans. Fifteen of the 32 FGDs where the mobilisations were often organised by non-government organisations. These vans had megaphones which are used to pass on this information. Similar reports were given by community leaders from Kibaale and Moroto as well as users and nonusers from Mbale districts.
Media Consumption habits
Language to be used
Participants reported that language used in the media would impact how much communities listened or watched. Emphasis was put on avoiding language and words that communities considered vulgar or obscene while airing of contraceptive information. This would enable adults to listen and watch even the programs in the presence of children or young people. This was majorly reported in Moroto a remote district where 6 out of 8 FGDs asked for shows not contain language and word that their community considered vulgar. Whereas for other districts only two discussions per study area generated information on language to be used while acting. The younger people however preferred that media messages speaks directly about contraceptives and sexual related issues without hiding information, but still not be obscene
Other respondents mentioned that the language used shouldn’t be abusive to the community since people will feel offended. This was also emphasised by community leaders from Kibaale and VHTs from Mbale and Mubende.
“Okay the things I see that can be avoided are obscene words. Because accidentally, that drama might be airing, when there is a young child. In that way she/he will also hear an obscene word. So, they should not be there” KII_ Community leader, Kibaale district
Conform to cultural practices
Study found that community would welcome information and drama that are not contrary to the cultural practices of people where they will be aired. This was echoed in 5FGDs across all study districts. Respondents discouraged indecent dressing of actors and speaking openly about sexual parts which would ago against the traditional practices of most Ugandan communities. Similar submission was given by community leaders and VHTs in all study areas except Mubende.
“Avoid practising open acting like use of condoms as some people do it practically in shows which is bad. It makes the youth practice it too. You better get a stick and use as a practical object” FGD_ Female_25-50years, Moroto district
Content was another media consumption habit. Respondents felt that appropriate media shows should focus on positive testimonies from known people/figures and ignore people who call in and talk about myths. The information provided should include the real sources of contraceptive methods and ensure that those service delivery points indeed have the methods when people are referred there. In Moroto, they noted that they needed a show that talks about the side effects of contraceptive methods and how to manage them. This should be comprehensive to allay people’s fears. The shows need to be detailed and focus on managing side effects for users. Male FGDs participants from Mbale and Mubende districts of all age categories discouraged the inclusion of political discussions since it did not influence uptake of contraceptive methods.
Male involvement
Focus group discussants showed that people would consume media that attract men to listen or watch so that they can learn the available modern methods of contraception and to support their spouses. This was submitted by mainly women from Mbale and Kibaale districts. These women discussed that many men have limited knowledge about contraceptive methods and that they are not supportive to the women to use modern methods hence content focusing on the former would interest the men to listen to. They should involve them in the characters, especially encouraging older men to plan for families because they reportedly marry younger wives.
“……… should address men too on the importance of family planning so that they are aware of how good family planning is. They will also stop blaming women on issue concerning family planning when loss appetite of sex, grow fat, over bleeding” FGD_Female_25-50years, sMoroto district