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Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia

Community and health systems barriers and enablers to family planning and contraceptive services... Background: Unmet need for contraception results in several health challenges such as unintended pregnancies, unwanted births and unsafe abortions. Most interventions have been unable to successfully address this unmet need due to various community and health system level factors. Identifying these inhibiting and enabling factors prior to implementation of interventions forms the basis for planning efforts to increase met needs. This qualitative study was part of the formative phase of a larger research project that aimed to develop an intervention to increase met needs for contraception through community and health system participation. The specific study component reported here explores barriers and enablers to family planning and contraceptive services provision and utilisation at community and health systems levels. Methods: Twelve focus group discussions were conducted with community members (n = 114) and two with healthcare providers (n = 19). Ten in-depth interviews were held with key stakeholders. The study was conducted in Kabwe district, Zambia. Interviews/discussions were translated and transcribed verbatim. Data were coded and organised using NVivo 10 (QSR international), and were analysed using thematic analysis. Results: Health systems barriers include long distances to healthcare facilities, stock-outs of preferred methods, lack of policies facilitating contraceptive provision in schools, and undesirable provider attitudes. Community level barriers comprise women’s experience with contraceptive side effects, myths, rumours and misconceptions, societal stigma, and negative traditional and religious beliefs. On the other hand, health systems enablers consist of political will from government to expand contraceptive services access, integration of contraceptive services, provision of couples counselling, and availability of personnel to offer basic methods mix. Functional community health system structures, community desire to delay pregnancy, and knowledge of contraceptive services are enablers at a community level. Conclusions: These study findings highlight key community and health systems factors that should be considered by policy, program planners and implementers in the design and implementation of family planning and contraceptive services programmes, to ensure sustained uptake and increased met needs for contraceptive methods and services. Keywords: Barriers, Community, Contraception, Enablers, Family planning, Health system * Correspondence: [email protected] Department of Health Policy and Management, School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 2 of 11 Background regarding the underlying community and health system fac- Family planning and contraceptive programmes (FP/C) tors that shape provision and utilisation of FP/C services/ play a critical role in national and human development. methods. They facilitate regulated population growth that results in The health system consists of various elements involved social-economic benefits such as decreased poverty levels, in healthcare delivery, including human resources for enhanced education opportunities and reduced gender in- health, service delivery, and supply chain and governance equality [1]. Furthermore, they provide an opportunity for systems [14]. At community level, the health system can improved maternal and child health, through prevention be said to comprise “a set of local actors, relationships, of sexually transmitted diseases (STIs), unwanted and and processes engaged in producing, advocating for, and early pregnancies, and unsafe abortions [2]. Cates et al., supporting health in communities, but existing in relation- state that FP/C programmes are among the most cost- ship to established health structures” [15]. The interaction effective development investments because of their direct of community and health systems factors has a critical role influence on improving lives through national security to play in as far as the success or failure of a given health and enhanced financial resources for communities [3]. programme. This paper, therefore, seeks to document The United Nations has prioritised increasing and sus- community and health systems barriers and enablers to taining utilisation of FP/C services as one of its eminent provision and utilisation of FP/C services/methods. strategic investment focus areas in attaining sustainable development goals (SDGs) [4]. The target is to achieve Methods universal access to sexual and reproductive health (SRH) Study design services, including family planning, information and This studywas part of theformativephaseofamulti- education by 2030 through investment in various FP/C country (Kenya, South Africa and Zambia), complex services programmes at national and community levels designed intervention, to increase contraceptive met needs, [5]. FP/C services programmes have and continue to through community and healthcare provider (HCP) partici- play a major role in raising the prevalence of contracep- pation in the provision and use of FP/Cs, within a human tive use globally. Cleland et al., [6] state that these rights framework (the UPTAKE Project). The proposed programmes are responsible for raising contraceptive intervention consisted of a facilitated community and HCP prevalence from less than 10% to 60%, and reducing dialogue using a theory of change framework to identify, fertility in developing countries from six to about three implement and evaluate activities (within the human rights births per woman on average over the past six decades. domains), to increase contraceptive met needs. The project Despite these recorded improvements, FP/C services/ was commissioned by the World Health Organisation method uptake still remains low in various parts of the (WHO), and formative work was conducted between 2015 world including Asia and Latin America but continues and 2016. It was designed to be executed in two phases, to be lowest in sub-Saharan Africa [7]. Approximately, formative (intervention development) and intervention (im- 14 million unintended pregnancies occur in sub-Saharan plementation), respectively. Africa annually, and a large proportion are due to lack During the formative phase, we conducted a mapping of of access to FP/C services/methods [2]. As of 2015, an national family planning legislation and policies, facilities estimated 225 million women in developing countries and services and exploratory qualitative research, which would have preferred to delay or stop child bearing, but contributed to identifying key human rights domains, were not using any method of contraception [8]. Various within which to contextualise the intervention focus areas reasons have been advanced for low uptake of these and activities to increase met needs in each country. This services such as limited method choices, limited access study focuses on the qualitative research activities con- to contraception, poor quality services, users and ducted in Zambia, which explored; (i) Knowledge, atti- provider bias and also gender-based barriers, particularly tudes, and practices in FP/C services and utilisation; (ii) for marginalised groups like adolescents and the poorer barriers and enablers to FP/C services; (iii) understanding sections of society [9]. of quality care and; (iv) community participation practices In Zambia, the overall unmet need for contraceptives and activities (please see Additional files 1, 2, 3 and 4). For among married women stands at 21%, of which 14% are this manuscript, we report on the second objective (bar- spacers and 7% are limiters [10]. The contraceptive preva- riers and enablers to FP/C services). lence rate (CPR) is at 47%, with a noticeable difference between rural and urban communities [10]. Many studies Data collection have focused on identifying and highlighting the complex A total of 14 focus group discussions (FGDs) were under- social and economic factors at play during the supply of taken, each lasting between 60 to 90 min. Of these, 12 con- FP/C services [11–13]. However, less has been documented sisted of community members (users and non-users) and about community and healthcare providers’ perspectives two were conducted with HCPs (stratified as managerial Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 3 of 11 and frontline providers) (Table 1). Ten in-depth interviews Table 2 IDI participants (IDIs) lasting between 30 and 60 min were conducted with Participants (categories) Number of interviews key stakeholders (Table 2). Both IDIs and FGDs were Political leadership 1 conducted by experienced facilitators who were super- vised by the research team on best practices in quali- Neighbourhood health committee 1 tative research. The facilitators were selected from Sexual and reproductive health non-governmental 1 various backgrounds with relevant experience, includ- organisation ing FP/C services providers, an expert on community Traditional leadership 1 participation approaches and an adolescent experi- District health office 1 enced in youth mobilisation. All had the essential un- Provincial medical office 2 derstanding of local context and language. Teacher 1 Religious leadership 2 Study setting The study was conducted in Kabwe district, the provincial Total IDI participants 10 capital of the Central Province of Zambia, which has a population of 217,843 people, of which 58,381 (26.8%) are women in the reproductive age group of 15–49 years [10]. The district was chosen by both WHO and Zambian team These were stratified into three male and nine female of investigators due to its high unmet need for contracep- groups. All the FGD participants were selected and cate- tion [10]. After mapping of all health facilities in the district, gorised into groups according to age - adolescents (15– a single health facility with a large catchment area catering 19 years), young adults (20–34 years) and adults (35– for both rural and urban communities (peri-urban) was 49 years). Female groups were further categorised accord- chosen as the study site for the qualitative research. ing to location (n = 6) -either rural or urban, marital status (n = 2) - either married or unmarried, and according to par- Study participants and recruitment ity (n = 1) - those without children (Table 1). The community members recruited for the FGDs were Though purposive, the recruitment process of commu- those within the reproductive age range (15–49 years). nity members ensured a participatory approach by en- gaging a local district coordinator who was recommended by the District Health Office (DHO). The coordinator Table 1 FGD participants worked with the nursing sister-in-charge at the study site Focus group discussions (categories) Age in Number of (selected health facility) together with some community years participants health representative groupings, in recruiting participants Community members for FGDs. Females, urban, adolescents 15–19 10 Recruitment of key informants for IDIs was also done Females, rural, adolescents 15–19 09 through purposive sampling. This sampling technique ensured representation of key groups, and was based on Females, urban young adults 20–34 08 knowledge of FP/C services experts, as well as key Females, rural young adults 20–34 10 community persons who were influential in the health Females, urban adults 35–49 08 sector. Some of the key informant participant categories Females, rural adults 35–49 09 included: political, traditional and religious leadership, Females, unmarried young adults 20–34 10 sexual and reproductive health non-governmental organ- Females, married young adults 20–34 10 isation representative, district and provincial medical of- ficers, and a teacher from the education sector (Table 2). Females, no-children 18–49 10 Males, adolescents 15–19 10 Males, young adults 20–34 10 Data analysis Males, adults 35–49 10 Data were analysed using thematic analysis, which is a Total 114 method for identifying, analysing and reporting patterns Healthcare providers (themes) within data [16]. Thematic analysis organises and describes the data set in (rich) detail and goes fur- Healthcare providers-managerial – 10 ther to interpret various aspects of the research topic. Healthcare providers-frontline – 09 The data analysis process started with the collection of Total 19 information gathered through field notes. Interviews and Total FGD participants 133 FGDs were audio recorded in local language-Bemba, Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 4 of 11 with participant permission, and transcribed and trans- Barriers to family planning and contraceptive lated verbatim into English. services provision and utilisation A qualitative data analysis software, NVivo (version 10, Health systems barriers QSR International) was used to organise and manage the Long distances to health facilities data. A single master code-list with thematic definitions Community participants from rural areas recounted that was iteratively developed by researchers from the three walking long distances to healthcare facilities in order to countries. The researchers then double coded the tran- access FP/C services hindered utilisation. They narrated scripts to determine the validity of the cross-country that long distances were demotivating to women who coding, and to guide discussions around emergent themes, wanted to consistently use FP/C services/methods, and which arose from the study data. Any differences in cod- were a major contributor to discontinuation and inter- ing were discussed within the qualitative research team. mittent use. The long distances also put clients at risk of The master code-list was updated based on these discus- being denied access to FP/C services if they got to the sions, and the codes were grouped into major and emer- health facility outside the established schedule of service gent themes. A consolidated NVivo database containing provision. transcripts from the three countries was created. After every coding activity was completed, country NVivo data- “The problem I have seen is that some women live very bases were shared and merged to create a single database far away and the time is fixed for provision of family with comparable country data [17], which enabled planning and contraceptive methods such that when country-specific data analysis. they want to use, they cannot access the services. They are told they are late and they should come next time. So this is another problem.” [Female FGD, Rural Ethical considerations Young Adult, UZFG_RY003] This study received WHO Ethics Review Committee (ERC) and Research Project Review Panel (RP2) approval. In addition, for the Zambian component of the study, eth- Undesirable healthcare provider attitudes ical approval was obtained from the University of Zambia Undesirable HCP attitudes were stated as a barrier to Biomedical Research Ethics Committee (UNZABREC) to FP/C services utilisation, especially for marginalised user conduct the research, and all prerequisite authorisations groups, like the unmarried and adolescent users. The were obtained from the Ministry of Health. All partici- healthcare providers and key community stakeholders pants (> 18 years) provided written, informed consent to reported that negative attitudes such as shouting, scold- participate in the study. Participants who were under the ing, not allowing clients to explain their side effect expe- age of 18 years provided written assent, and their parents/ riences, and giving preference to socially accepted FP/C guardians provided written consent for their participation. services user groups like the married women, existed in In the event that participants were not literate, a witness some of the health facilities. was required to be present during the consenting process and sign consent on their behalf. The participants gave “To be frank some healthcare providers are rude, very separate consent to being audio recorded. rude. That is the major complaint. That is why even most women shun away, they prefer buying from drug stores in town instead of going to clinics.” [Laughs] Results [Key stakeholder IDI, traditional leader, UZI008] Every FGD was distinctively composed to allow for attri- bution of themes to specific groups as well as maximise “Youths in most cases when they go to the health participation within the discussions. Similarly, the IDIs in- facility to access family planning, the attitudes of cluded a variety of categories representing both commu- caregivers send them away, especially when they are nity and health sector key stakeholders. No major scolded to say, 'you’re still in school, you’re supposed to differences were noted in the discussions by the different concentrate on books and not coming for family participant groups. However, where the views were spe- planning.'” [Healthcare provider FGD, Managerial, cific to certain groups, these are noted in the manuscript. UZHG_L004] Below we present community members, HCPs and key stakeholders' perspectives regarding the factors hindering and enabling family planning and contraceptive services Stock-outs and lack of long acting reversible contraceptives provision and utilisation, at health systems and commu- Stock-outs of preferred contraceptive methods and unavail- nity levels. Relevant quotes are provided to support each ability of long acting reversible contraceptives (LARCs) in of the identified themes. some facilities, negatively affected contraceptive utilisation, Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 5 of 11 as it meant that communities could not use nor access such Myths, rumours and misconceptions about contraceptive services when they wanted to. Furthermore, it was reported methods that some healthcare facilities where unable to offer LARCs Both community members and HCPs reported that a because some of the health personnel had not undergone number of myths associated with various FP/C methods training to provide these methods. negatively affected community use of methods/services. The myths included concerns that FP/C methods could “The pills should always be available at the clinic, not cause general body harm, impact on future births, cause whereby whenever you go there, they tell you that they are infertility, and result in reduced sexual pleasure. Some not available every now and then. In the end, they even respondents reported that taking the contraceptive oral become rude to you and you also lose interest in going pill (CoC) could result in giving birth to a lame child, there” [Female FGD, Rural Young Adult, UZFG_RY002] for example, a baby with an abnormal head. “I think the challenge like for the Intra-Uterine Device “They say if you are taking the pill, your children will is that some facilities are unable to offer because some be lame, your children will grow up with big heads, members of staff are not trained to offer that service.” and so on and whatever, trying to discourage people [Key stakeholder IDI, Health Sector, UZI006] from taking the pills.” [Female FGD, Young Adult, UZFG_Y006] Lack of policies facilitating contraceptive provision in Others narrated that FP/C methods, such as CoCs like schools Mycrogynon 30 and Safe plan, could accumulate in the The lack of policies aimed at facilitating contraceptive stomach, resulting in the development of fibroids and methods provision in schools was cited by some key stake- cancer of the stomach. holders as a barrier to adolescent access to these services. The key stakeholders reported that adolescents were being “When you are taking pills like Mycrogynon and Safe denied an opportunity to receive the much-needed plan, you are likely to develop cancer in the near future. contraceptive services, despite the reported high levels of So, you have to be going for cancer check-ups every now early marriages and teenage pregnancies in the district. and then.” [Female FGD, Married Young Adult, UZFG_ MY001]. “There should be a policy by the Ministry of Education that allows sexually active girls to access contraceptives Injectable contraceptives like Depo-Provera were thought in schools. We cannot stop these girls from using to result in delayed or difficulty in having future pregnan- contraceptives because they are in school. cies. Furthermore, adolescents stated that myths were If we do that, we will end up losing our teenage girls widely used by the elderly to discourage FP/C service use, through unwanted pregnancies and criminal abortions.” for example, they were told that using FP/C methods at a [Key stakeholder IDI, Health Sector, UZI006] young age could result in failure to conceive in future. “Some say if you are taking family planning you will Community level barriers be barren. You will not have a child in your life.” Women’s experiences with contraceptive side effects [Female FGD, Urban Adolescent, UZFG_UT007] All community members reported that the side effects of hormonal methods were a major barrier to using con- traceptives. They cited prolonged and irregular menses, Stigma towards certain user categories (adolescents and dizziness, headaches, stomach-aches, weight gain and unmarried) weight loss as some of the most common side effects of Societal stigma was cited by both community members contraceptive methods. These side effects were said to and HCPs as one of the major hindrances to adolescent be the main reason as to why people discontinued, chan- access and utilisation of FP/C services. Adolescents re- ged or stopped using particular contraceptive methods. portedly would rather not utilise FP/C methods/services, due to negative HCP attitudes and the risk of commu- “Like for me I used to take the pill safe plan [name nity members knowing that they were sexually active. of contraceptive pill], it used to give me prolonged periods then I tried the injection for three months, “In this community it’s actually known that family I never used to see my periods, so I stopped. I prefer planning services can only be accessed by married condoms.” [Female FGD, Married Young Adult, couples. The community does not expect a young UZFG_MY001] person to access family planning. So the greatest Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 6 of 11 barrier has been stigma and discrimination.” “We are promoting couples counselling in most of the [Key stakeholder IDI, Health Sector, UZI004] health centres in Kabwe district. Not only are we targeting women alone, but also men as well. We Both adolescents and unmarried users reported being encourage women to come together as couples with stigmatised when they accessed FP/C services, as FP was the men, so that when they want to access family generally thought to be only for adults and married planning, they understand what type of services we people. offer at facility level.” [Healthcare provider FGD, Frontline, UZHG_L007] “The other experience I have gone through is that us who [are] unmarried, we are not usually free to be helped because at times they [healthcare providers] Availability of personnel trained to offer the basic look down upon us when we come to collect the contraceptive method mix (barriers, short and medium acting) methods. They perceive us to be prostitutes or very Healthcare providers reported that personnel, in both promiscuous individuals.” [Female FGD, Unmarried urban and rural facilities, were trained to provide most young adult, UZFG_SY007] of the basic contraceptive methods and services, like condoms, CoC pills (Safe plan and Mycrogynon 30) and “When you go to the clinic, the first question the nurse injectables (Depo-Provera and Nuristerat). This was or doctor will ask is “are you married?” Then you if you perceived to be an enabler, as it provided a basis for say no, the next question will be, “but why do you want provision of the minimum method mix to the commu- to use FP?” Yet you yourself know that you are sexually nity members. active.” [Female FGD, No children, UZFG_C008] “We are privileged as Kabwe, they trained most healthcare providers to provide at least most of the Religious beliefs common and basic contraceptive methods. Three Community members and HCPs narrated that certain quarters of the health workers have been trained, religious beliefs were barriers to provision and use of FP/C though some do not practice. We also have mentors services, because they discouraged people from using any at the district level who mentor the providers at the method. Some religions believed that the use of contra- facilities.” [Healthcare provider FGD, Frontline, ception was synonymous to committing abortion, which is UZHG_L002] considered sinful. Additionally, provision of FP/C services to unmarried users was generally considered to be in- appropriate as it was thought to be promoting promiscuity Integration of FP/C services with other healthcare services and sex before marriage in society. Healthcare providers reported that integration of services in the health facilities provided an enabling environment “We were discussing about family planning at our to reach as many clients as possible and provide them ministry and the issue that came out strong was that, with FP/C services. The integrated model of service when the egg is released and you use family planning provision mentioned by most HCPs facilitated service medicine, it will make you abort. They said that the provision, as it enabled clients who may have come for function of a pill is to abort the pregnancy each time other healthcare services to be provided with FP/C ser- you get pregnant. So, it is not right for us to abort vices/methods. because abortion is murder.” [Female FGD, Urban adult, UZFG_UA008] “In every clinic there is this integration of services. For example, if the client comes for antenatal we include services like family planning, if she needs to go for ART, Enablers to contraceptive services provision and the same day she will even go for ART to collect her ARVs. utilisation We don’t have to let the clients make trips to our clinics. Health systems enablers When they come, it’slike a supermarket. They move from Couples counselling services point B to point C, from point C to D, just like that.” Provision of counselling services before and after admin- [Healthcare provider FGD, Managerial, UZHG_H005] istering of FP/C methods in most heath facilities was reported by HCPs as an enabler. Couples counselling services in some facilities were also cited by HCPs as be- Government commitment to extending FP/C services ing particularly helpful in facilitating male involvement Key stakeholders from the health sector explained that in FP/C services uptake and support. there was renewed government commitment towards FP/C Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 7 of 11 services provision in Kabwe district. They reported that the Community desire to delay pregnancy increased number of new health facilities and healthcare Community members from both urban and rural areas personnel being deployed to rural areas would improve reported that they desired to delay pregnancy until they access to contraceptive services. Additionally, it was stated were financially and psychologically ready to support their that the provincial medical office had deliberately taken it babies. To this effect, they indicated that using FP/C upon themselves to strengthen FP/C services provision and methods and services allowed them to concentrate on use within the district, due to poor indicators, such as the work, complete their schooling, avoid unwanted pregnan- low contraceptive prevalence rate (CPR) and high unmet cies, and raise healthy and planned families. need for contraception. “We use family planning because most of us “One of them is what the government is doing in [girls], we don’t want to get pregnant at an opening up more health facilities, especially the early age, so we propose to our partner to use health posts. This is contributing to reducing the a condom when we are having sex.” physical distance that most women have to travel [Female FGD, Adolescent, UZMG_T005] to access FP/Cs. Though there is still much more to be done, such efforts are contributing FP/C services being taken close to the people.” “It gives [us a] chance to work. Usually you stop [Key stakeholder IDI, Health Sector, UZI007] work temporarily if you have a child. family planning allows you to plan so that you are not disturbed by work stoppages due frequent child Community level enablers bearing. You can plan that at least three years Community-based health structures passes before having another child.” Community participants from rural areas reported that [Female FGD, Married Young Adult, UZFG_MY006] the existing network of community-based health workers, like community based distributors (CBDs), traditional birth attendants (TBAs), neighbourhood health commit- Community knowledge of FP/C services tees (NHCs) and safe motherhood action groups Community members had knowledge of most of the (SMAGs), facilitates FP/C services/method provision and common and basic FP/C methods, but had less utilisation. This network reportedly acts as a link between knowledge of emergency contraceptives and other more the community and the healthcare systems, providing a advanced methods like LARCs. Some participants were variety of healthcare services including FP/C methods/ser- able to define FP, others could explain how particular vices to people, who otherwise may not be reached by the contraceptive methods worked, as well as their healthcare system. advantages and disadvantages. Community members also had knowledge of natural FP methods, which they “We have what are called community-based distributors. used, including withdrawal, thigh sex and breastfeeding These are basedinthe communityand they are able methods. to explain and also provide, especially the oral contraceptives.” [Female FGD, Rural Young Adult, “FP is a way a way of taking care of oneself where UZFG_RY006] child bearing is concerned. A woman's body needs time to rest after delivery, say 2 to 3 years after Other community structures included cooperatives, delivery, after which one can be able to get pregnant churches, community drama groups, football clubs, youth again. The other thing I know is that it helps us and women’s groups, and the savings groups which could to bring up our children well in terms of feeding, also be explored to empower community members with clothing and taking them to school.” FP/C services/methods information. [Female FGD, Urban Adult, UZFG_UA002] “There are gatherings where community members meet. For example, saving groups, interdenominational “The methods of family planning we use in our prayers, and sometimes we have women meetings to rural areas, if one fails to go to the clinic and your share information, like for family planning. There are husband comes, you let him ejaculate between your also some cooperatives where we share things for farming. thighs or he withdraws and ejaculates from outside. So, there are a lot of situations which require us to meet It helps us until the day we go to get an injection as a community.” [Key stakeholder IDI, Community, for family planning.” Religious Leader, UZI009] [Female FGD, Rural Adult, UZFG_RA005]. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 8 of 11 Discussion that aim at neutralising myths and rumours, and provide Since the UPTAKE Project sought to bring together com- detailed information about side effects, may help address munity and health systems efforts in increasing met needs this barrier. for contraception, these findings were of major importance in situating and understanding the context in which the Enablers to family and contraceptive services provision proposed intervention would be implemented. Further- and utilisation more, these findings facilitated identification of bottlenecks The study findings demonstrate that couples counselling and facilitators to contraceptive provision and use at both services targeting male involvement in contraceptive community and health systems levels to inform interven- choices are important enablers to contraceptive services tion activities to increase met needs. Below, we discuss the provision and use. Such counselling services allow for in- findings around the two core thematic areas of community creased male participation and support for family planning and health systems barriers and enablers to family planning and contraceptive choices. Various studies have under- and contraceptive services provision and use. lined that male partners are key decision makers [36, 37]. Hence couples counselling services help to educate and Barriers to family planning and contraceptive services encourage male partners to support their spouses in using provision and utilisation FP/C services [27]. While these findings underline government commitment Availability of personnel to offer a minimum method to extend health services to remote areas, long distances mix (barrier, short and medium acting) is an enabler, as to some health facilities still remain a challenge to access it provides for choice among clients. However, the and use of contraceptive services in many rural areas. results also show limited LARC options in some health Community efforts to leverage this includes using local facilities due to non-training of their staff in this particu- structures to distribute and generate demand for contra- lar method. Strengthening of District level training and ceptives. However, many of these local structures still face mentorship of personnel in LARC services at all health numerous challenges, such as lack of incentives (for facilities will help improve access to this method. example bicycles) to function optimally [18]. Appropriate Though found to be an enabler, integration of SRH incentives, as well as effective management strategies that interventions into community health systems remains enhance local structures’ capacity to deliver FP/C services complex [38], due to diverse norms, values, as well as the can help increase met needs for contraception [19]. less formal mechanisms which shape coordination, ac- Though most Zambian policies on SRH do recommend countability, health practice and health-seeking behaviour provision of adolescent-friendly services, contraceptive [39]. Key factors to consider at the community level may provision in schools is still not allowed [20–22], suggesting include the community’s capacity to engage and partici- the need for a policy framework that builds community pate in the implementation process, commit and sustain support for adolescent contraceptive provision and use in health actions and ensure the development of effective all settings, including schools [23]. These findings highlight partnerships between a complex array of actors involved the need for further discussions and possible readjustment in the intervention [22]. of policy on FP/C provision in schools as adolescents are The findings also reveal high levels of knowledge about unable to freely access these services at health facilities due FP/C methods/services, which is consistent with the to stigma and negative provider attitudes. Zambia Demographic Health Survey (ZDHS) findings Stock-out of preferred methods affects demand and [10]. The desire to delay pregnancy is another community sustained use of contraceptives. Gaps in commodity sup- level enabler. Though high knowledge levels and desire to ply have also been reported elsewhere [23–25], and are delay pregnancy provide an enabling environment for FP/ said to be as a result of the mismatch between supply C methods/services provision, they do not necessarily and demand projections on most occasions [26]. Redu- translate into utilisation, as evidenced by the low national cing incidences of contraceptive stock-outs will require CPR of 47% and high TFR of 5.3 births per woman [10]. strengthened commodity supply chain management, and The need to address some of the barriers suggested balancing of demand projections and real-time availing above cannot be overemphasised if we are to improve FP/ of commodities [26, 27]. C services practices among community members. Indeed, Experiences with contraceptive side effects shape involving key community stakeholders (parents, teachers, choices and sustained use of methods [28–33]. Side effects churches and HCPs) in identifying, planning, implementa- have also been reported to perpetuate myths and miscon- tion, monitoring and evaluation of FP/C services interven- ceptions [34, 35]. For instance, inability to experience tions, as proposed by the UPTAKE project, will contribute periods is associated with blood accumulation in the to improved service delivery and community support for womb, leading to cancer or fibroids. Adopting innovative contraceptives use. Furthermore, Interventions targeting and context-specific community engagement strategies provision of contraceptives in settings other than family Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 9 of 11 planning clinics, strengthened integration of FP/C ser- provision and use, but also, goes further to explore ap- vices, and training that addresses communication, coun- proaches to maximise implementation success of com- selling skills and cultural values clarification will be crucial munity and health system participatory interventions to enhancing contraceptive use [23, 27, 40]. seeking to increase met needs for contraception. Strengths and limitations Additional files The collection of data from various categories of com- Additional file 1: Appendix D, FGD guide_females. (DOCX 44 kb) munity members, HCPs and key stakeholders enabled Additional file 2: Appendix D, FGD guide_healthcare providers. gathering of a wide range of views, which allowed for (DOCX 45 kb) strengthened data triangulation on key thematic areas. Additional file 3: Appendix D, FGD guide_males. (DOCX 43 kb) Community perspectives on barriers/enablers to FP/C Additional file 4: Appendix D, In-depth interview guide_key stake- methods/services uptake are not well explored, so this holders. (DOCX 51 kb) study adds to this perspective. Additionally, the qualitative team comprised professionals from various academic Abbreviations backgrounds, which further strengthened critical analysis CBDs: Community based distributors; CPR: Contraceptive prevalence rate; and interpretation of the data. DHO: District health office; FGDs: Focus group discussions; FP/C: Family planning/contraceptives; HCPs: Healthcare providers; IDIs: In-depth However, there were also limitations to this research. interviews; NGO: Non-governmental organisation; NHC: Neighbourhood Conducting the study in one setting/district per country, health committee; OPD: Outpatient department; PTMCT: Prevention of the use of a small sample of respondents, as well as, using mother to child transmission; SDGs: Sustainable development goals; SMAGs: Safe motherhood action groups; SRH: Sexual and reproductive only qualitative approaches, limits the generalisability of health; STIs: Sexually transmitted infections; TBAs: Traditional birth attendants; study findings. Though generalisability was not the TFR: Total fertility rate; WHO: World Health Organisation intention, the rich description of the phenomena (commu- Acknowledgements nity and health systems barriers and enablers to contra- The authors would like to acknowledge the contribution from the Kabwe ceptive provision and use), led to an in-depth account of community members who were actively involved in all phases of the barriers/facilitators to FP/C services in Kabwe district of project. In particular, we thank the Kabwe District Health Office for the immense support provided to the project. We would also like to thank Zambia. We believe this provides a valuable contribution members from the UPTAKE project multi-country qualitative team (Zambia, to the body of knowledge on FP/C services provision and Kenya and South Africa). use in Low and Middle-Income settings. Funding The UPTAKE Project was conducted with support of the UNDP/UNFPA/ Conclusion UNICEF/WHO/World Bank Special Programme of Research, Development and Our findings highlight community and health systems Research Training Human Reproduction, which is the main instrument and leading research agency within the United Nations system concerned with factors that ought to be considered by policy, planners sexual and reproductive health and rights. and implementers in the design of FP/Cs programmes, to ensure sustained uptake and increased met needs. Availability of data and materials Tackling health systems inhibiting factors such as nega- The data are not publicly available as it contains information that could compromise research participant privacy/consent. However, some tive provider attitudes, gaps in sustained commodity and anonymised aspects of the datasets may be available upon request and with services supply, together with enforcing adolescent permission of the Department of Reproductive Health and Research, World friendly policies will be vital in improving contraceptive Health Organisation. Note that data sharing is subject to WHO data sharing policies and data use agreements with the participating research centres. uptake. Addressing community-level factors such as stigma, myths and negative beliefs will require full en- Declarations gagement of community members in service provision, The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the which will also enhance community participation and institutions with which they are affiliated. support for FP/C services programmes. Additionally, FP/ C services programmes should seek to build on the Authors’ contributions The study was part of the formative phase of a bigger multi-country UPTAKE reported enabling factors both at community and health project, conceived and designed by the WHO (PS, JC), country Principal system levels for successful implementation. Investigators (TN) and the qualitative research leads (CM, YK). AS, TN, MM, Identifying the factors that shape delivery and adop- JMZ, CM, YK: conducted the data collection, analysis and reporting of findings. AS: drafted the manuscript. All authors critically reviewed, revised tion of FP/C interventions at various levels, and the role and edited the draft manuscript. All authors read and approved the final they play, both as facilitators and barriers, is important if manuscript. we are to increase met needs for contraception. Under- standing these factors forms the basis for future FP/C Authors’ information The first author: Adam Silumbwe ([email protected]) is a Staff services programme planning and implementation Development Fellow in the Unit of Health Systems and Implementation efforts. We therefore recommend that future research Research, Department of Health Policy and Management, School of Public not only identifies barriers and enablers to contraceptive Health, University of Zambia. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 10 of 11 Ethics approval and consent to participate 14. Zulu JM, et al. Innovation in health service delivery: integrating community This study received WHO Ethics Review Committee (ERC) and Research health assistants into the health system at district level in Zambia. BMC Project Review Panel (RP2) approval. In addition, for the Zambian Health Serv Res. 2015;15(1):1. component of the study, ethical approval was obtained from the University 15. Schneider H, Lehmann U. From Community Health Workers to of Zambia Biomedical Research Ethics Committee (UNZABREC) to conduct Community Health Systems: Time to Widen the Horizon? Health Syst the research, and all prerequisite authorisations were obtained from the Reform. 2016;2(2):112–8. Ministry of Health. All participants (> 18 years) provided written, informed 16. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. consent to participate in the study. Participants who were under the age 2006;3(2):77–101. of 18 years provided written assent, and their parents/guardians provided 17. Milford C, et al. Teamwork in Qualitative Research: Descriptions of a written consent for their participation. In the event that participants were Multicountry Team Approach. Int J Qual Methods. 2017;16(1): not literate, a witness was required to be present during the consenting process and sign consent on their behalf. The participants gave separate 18. Kok MC, et al. 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Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia

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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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Abstract

Background: Unmet need for contraception results in several health challenges such as unintended pregnancies, unwanted births and unsafe abortions. Most interventions have been unable to successfully address this unmet need due to various community and health system level factors. Identifying these inhibiting and enabling factors prior to implementation of interventions forms the basis for planning efforts to increase met needs. This qualitative study was part of the formative phase of a larger research project that aimed to develop an intervention to increase met needs for contraception through community and health system participation. The specific study component reported here explores barriers and enablers to family planning and contraceptive services provision and utilisation at community and health systems levels. Methods: Twelve focus group discussions were conducted with community members (n = 114) and two with healthcare providers (n = 19). Ten in-depth interviews were held with key stakeholders. The study was conducted in Kabwe district, Zambia. Interviews/discussions were translated and transcribed verbatim. Data were coded and organised using NVivo 10 (QSR international), and were analysed using thematic analysis. Results: Health systems barriers include long distances to healthcare facilities, stock-outs of preferred methods, lack of policies facilitating contraceptive provision in schools, and undesirable provider attitudes. Community level barriers comprise women’s experience with contraceptive side effects, myths, rumours and misconceptions, societal stigma, and negative traditional and religious beliefs. On the other hand, health systems enablers consist of political will from government to expand contraceptive services access, integration of contraceptive services, provision of couples counselling, and availability of personnel to offer basic methods mix. Functional community health system structures, community desire to delay pregnancy, and knowledge of contraceptive services are enablers at a community level. Conclusions: These study findings highlight key community and health systems factors that should be considered by policy, program planners and implementers in the design and implementation of family planning and contraceptive services programmes, to ensure sustained uptake and increased met needs for contraceptive methods and services. Keywords: Barriers, Community, Contraception, Enablers, Family planning, Health system * Correspondence: [email protected] Department of Health Policy and Management, School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 2 of 11 Background regarding the underlying community and health system fac- Family planning and contraceptive programmes (FP/C) tors that shape provision and utilisation of FP/C services/ play a critical role in national and human development. methods. They facilitate regulated population growth that results in The health system consists of various elements involved social-economic benefits such as decreased poverty levels, in healthcare delivery, including human resources for enhanced education opportunities and reduced gender in- health, service delivery, and supply chain and governance equality [1]. Furthermore, they provide an opportunity for systems [14]. At community level, the health system can improved maternal and child health, through prevention be said to comprise “a set of local actors, relationships, of sexually transmitted diseases (STIs), unwanted and and processes engaged in producing, advocating for, and early pregnancies, and unsafe abortions [2]. Cates et al., supporting health in communities, but existing in relation- state that FP/C programmes are among the most cost- ship to established health structures” [15]. The interaction effective development investments because of their direct of community and health systems factors has a critical role influence on improving lives through national security to play in as far as the success or failure of a given health and enhanced financial resources for communities [3]. programme. This paper, therefore, seeks to document The United Nations has prioritised increasing and sus- community and health systems barriers and enablers to taining utilisation of FP/C services as one of its eminent provision and utilisation of FP/C services/methods. strategic investment focus areas in attaining sustainable development goals (SDGs) [4]. The target is to achieve Methods universal access to sexual and reproductive health (SRH) Study design services, including family planning, information and This studywas part of theformativephaseofamulti- education by 2030 through investment in various FP/C country (Kenya, South Africa and Zambia), complex services programmes at national and community levels designed intervention, to increase contraceptive met needs, [5]. FP/C services programmes have and continue to through community and healthcare provider (HCP) partici- play a major role in raising the prevalence of contracep- pation in the provision and use of FP/Cs, within a human tive use globally. Cleland et al., [6] state that these rights framework (the UPTAKE Project). The proposed programmes are responsible for raising contraceptive intervention consisted of a facilitated community and HCP prevalence from less than 10% to 60%, and reducing dialogue using a theory of change framework to identify, fertility in developing countries from six to about three implement and evaluate activities (within the human rights births per woman on average over the past six decades. domains), to increase contraceptive met needs. The project Despite these recorded improvements, FP/C services/ was commissioned by the World Health Organisation method uptake still remains low in various parts of the (WHO), and formative work was conducted between 2015 world including Asia and Latin America but continues and 2016. It was designed to be executed in two phases, to be lowest in sub-Saharan Africa [7]. Approximately, formative (intervention development) and intervention (im- 14 million unintended pregnancies occur in sub-Saharan plementation), respectively. Africa annually, and a large proportion are due to lack During the formative phase, we conducted a mapping of of access to FP/C services/methods [2]. As of 2015, an national family planning legislation and policies, facilities estimated 225 million women in developing countries and services and exploratory qualitative research, which would have preferred to delay or stop child bearing, but contributed to identifying key human rights domains, were not using any method of contraception [8]. Various within which to contextualise the intervention focus areas reasons have been advanced for low uptake of these and activities to increase met needs in each country. This services such as limited method choices, limited access study focuses on the qualitative research activities con- to contraception, poor quality services, users and ducted in Zambia, which explored; (i) Knowledge, atti- provider bias and also gender-based barriers, particularly tudes, and practices in FP/C services and utilisation; (ii) for marginalised groups like adolescents and the poorer barriers and enablers to FP/C services; (iii) understanding sections of society [9]. of quality care and; (iv) community participation practices In Zambia, the overall unmet need for contraceptives and activities (please see Additional files 1, 2, 3 and 4). For among married women stands at 21%, of which 14% are this manuscript, we report on the second objective (bar- spacers and 7% are limiters [10]. The contraceptive preva- riers and enablers to FP/C services). lence rate (CPR) is at 47%, with a noticeable difference between rural and urban communities [10]. Many studies Data collection have focused on identifying and highlighting the complex A total of 14 focus group discussions (FGDs) were under- social and economic factors at play during the supply of taken, each lasting between 60 to 90 min. Of these, 12 con- FP/C services [11–13]. However, less has been documented sisted of community members (users and non-users) and about community and healthcare providers’ perspectives two were conducted with HCPs (stratified as managerial Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 3 of 11 and frontline providers) (Table 1). Ten in-depth interviews Table 2 IDI participants (IDIs) lasting between 30 and 60 min were conducted with Participants (categories) Number of interviews key stakeholders (Table 2). Both IDIs and FGDs were Political leadership 1 conducted by experienced facilitators who were super- vised by the research team on best practices in quali- Neighbourhood health committee 1 tative research. The facilitators were selected from Sexual and reproductive health non-governmental 1 various backgrounds with relevant experience, includ- organisation ing FP/C services providers, an expert on community Traditional leadership 1 participation approaches and an adolescent experi- District health office 1 enced in youth mobilisation. All had the essential un- Provincial medical office 2 derstanding of local context and language. Teacher 1 Religious leadership 2 Study setting The study was conducted in Kabwe district, the provincial Total IDI participants 10 capital of the Central Province of Zambia, which has a population of 217,843 people, of which 58,381 (26.8%) are women in the reproductive age group of 15–49 years [10]. The district was chosen by both WHO and Zambian team These were stratified into three male and nine female of investigators due to its high unmet need for contracep- groups. All the FGD participants were selected and cate- tion [10]. After mapping of all health facilities in the district, gorised into groups according to age - adolescents (15– a single health facility with a large catchment area catering 19 years), young adults (20–34 years) and adults (35– for both rural and urban communities (peri-urban) was 49 years). Female groups were further categorised accord- chosen as the study site for the qualitative research. ing to location (n = 6) -either rural or urban, marital status (n = 2) - either married or unmarried, and according to par- Study participants and recruitment ity (n = 1) - those without children (Table 1). The community members recruited for the FGDs were Though purposive, the recruitment process of commu- those within the reproductive age range (15–49 years). nity members ensured a participatory approach by en- gaging a local district coordinator who was recommended by the District Health Office (DHO). The coordinator Table 1 FGD participants worked with the nursing sister-in-charge at the study site Focus group discussions (categories) Age in Number of (selected health facility) together with some community years participants health representative groupings, in recruiting participants Community members for FGDs. Females, urban, adolescents 15–19 10 Recruitment of key informants for IDIs was also done Females, rural, adolescents 15–19 09 through purposive sampling. This sampling technique ensured representation of key groups, and was based on Females, urban young adults 20–34 08 knowledge of FP/C services experts, as well as key Females, rural young adults 20–34 10 community persons who were influential in the health Females, urban adults 35–49 08 sector. Some of the key informant participant categories Females, rural adults 35–49 09 included: political, traditional and religious leadership, Females, unmarried young adults 20–34 10 sexual and reproductive health non-governmental organ- Females, married young adults 20–34 10 isation representative, district and provincial medical of- ficers, and a teacher from the education sector (Table 2). Females, no-children 18–49 10 Males, adolescents 15–19 10 Males, young adults 20–34 10 Data analysis Males, adults 35–49 10 Data were analysed using thematic analysis, which is a Total 114 method for identifying, analysing and reporting patterns Healthcare providers (themes) within data [16]. Thematic analysis organises and describes the data set in (rich) detail and goes fur- Healthcare providers-managerial – 10 ther to interpret various aspects of the research topic. Healthcare providers-frontline – 09 The data analysis process started with the collection of Total 19 information gathered through field notes. Interviews and Total FGD participants 133 FGDs were audio recorded in local language-Bemba, Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 4 of 11 with participant permission, and transcribed and trans- Barriers to family planning and contraceptive lated verbatim into English. services provision and utilisation A qualitative data analysis software, NVivo (version 10, Health systems barriers QSR International) was used to organise and manage the Long distances to health facilities data. A single master code-list with thematic definitions Community participants from rural areas recounted that was iteratively developed by researchers from the three walking long distances to healthcare facilities in order to countries. The researchers then double coded the tran- access FP/C services hindered utilisation. They narrated scripts to determine the validity of the cross-country that long distances were demotivating to women who coding, and to guide discussions around emergent themes, wanted to consistently use FP/C services/methods, and which arose from the study data. Any differences in cod- were a major contributor to discontinuation and inter- ing were discussed within the qualitative research team. mittent use. The long distances also put clients at risk of The master code-list was updated based on these discus- being denied access to FP/C services if they got to the sions, and the codes were grouped into major and emer- health facility outside the established schedule of service gent themes. A consolidated NVivo database containing provision. transcripts from the three countries was created. After every coding activity was completed, country NVivo data- “The problem I have seen is that some women live very bases were shared and merged to create a single database far away and the time is fixed for provision of family with comparable country data [17], which enabled planning and contraceptive methods such that when country-specific data analysis. they want to use, they cannot access the services. They are told they are late and they should come next time. So this is another problem.” [Female FGD, Rural Ethical considerations Young Adult, UZFG_RY003] This study received WHO Ethics Review Committee (ERC) and Research Project Review Panel (RP2) approval. In addition, for the Zambian component of the study, eth- Undesirable healthcare provider attitudes ical approval was obtained from the University of Zambia Undesirable HCP attitudes were stated as a barrier to Biomedical Research Ethics Committee (UNZABREC) to FP/C services utilisation, especially for marginalised user conduct the research, and all prerequisite authorisations groups, like the unmarried and adolescent users. The were obtained from the Ministry of Health. All partici- healthcare providers and key community stakeholders pants (> 18 years) provided written, informed consent to reported that negative attitudes such as shouting, scold- participate in the study. Participants who were under the ing, not allowing clients to explain their side effect expe- age of 18 years provided written assent, and their parents/ riences, and giving preference to socially accepted FP/C guardians provided written consent for their participation. services user groups like the married women, existed in In the event that participants were not literate, a witness some of the health facilities. was required to be present during the consenting process and sign consent on their behalf. The participants gave “To be frank some healthcare providers are rude, very separate consent to being audio recorded. rude. That is the major complaint. That is why even most women shun away, they prefer buying from drug stores in town instead of going to clinics.” [Laughs] Results [Key stakeholder IDI, traditional leader, UZI008] Every FGD was distinctively composed to allow for attri- bution of themes to specific groups as well as maximise “Youths in most cases when they go to the health participation within the discussions. Similarly, the IDIs in- facility to access family planning, the attitudes of cluded a variety of categories representing both commu- caregivers send them away, especially when they are nity and health sector key stakeholders. No major scolded to say, 'you’re still in school, you’re supposed to differences were noted in the discussions by the different concentrate on books and not coming for family participant groups. However, where the views were spe- planning.'” [Healthcare provider FGD, Managerial, cific to certain groups, these are noted in the manuscript. UZHG_L004] Below we present community members, HCPs and key stakeholders' perspectives regarding the factors hindering and enabling family planning and contraceptive services Stock-outs and lack of long acting reversible contraceptives provision and utilisation, at health systems and commu- Stock-outs of preferred contraceptive methods and unavail- nity levels. Relevant quotes are provided to support each ability of long acting reversible contraceptives (LARCs) in of the identified themes. some facilities, negatively affected contraceptive utilisation, Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 5 of 11 as it meant that communities could not use nor access such Myths, rumours and misconceptions about contraceptive services when they wanted to. Furthermore, it was reported methods that some healthcare facilities where unable to offer LARCs Both community members and HCPs reported that a because some of the health personnel had not undergone number of myths associated with various FP/C methods training to provide these methods. negatively affected community use of methods/services. The myths included concerns that FP/C methods could “The pills should always be available at the clinic, not cause general body harm, impact on future births, cause whereby whenever you go there, they tell you that they are infertility, and result in reduced sexual pleasure. Some not available every now and then. In the end, they even respondents reported that taking the contraceptive oral become rude to you and you also lose interest in going pill (CoC) could result in giving birth to a lame child, there” [Female FGD, Rural Young Adult, UZFG_RY002] for example, a baby with an abnormal head. “I think the challenge like for the Intra-Uterine Device “They say if you are taking the pill, your children will is that some facilities are unable to offer because some be lame, your children will grow up with big heads, members of staff are not trained to offer that service.” and so on and whatever, trying to discourage people [Key stakeholder IDI, Health Sector, UZI006] from taking the pills.” [Female FGD, Young Adult, UZFG_Y006] Lack of policies facilitating contraceptive provision in Others narrated that FP/C methods, such as CoCs like schools Mycrogynon 30 and Safe plan, could accumulate in the The lack of policies aimed at facilitating contraceptive stomach, resulting in the development of fibroids and methods provision in schools was cited by some key stake- cancer of the stomach. holders as a barrier to adolescent access to these services. The key stakeholders reported that adolescents were being “When you are taking pills like Mycrogynon and Safe denied an opportunity to receive the much-needed plan, you are likely to develop cancer in the near future. contraceptive services, despite the reported high levels of So, you have to be going for cancer check-ups every now early marriages and teenage pregnancies in the district. and then.” [Female FGD, Married Young Adult, UZFG_ MY001]. “There should be a policy by the Ministry of Education that allows sexually active girls to access contraceptives Injectable contraceptives like Depo-Provera were thought in schools. We cannot stop these girls from using to result in delayed or difficulty in having future pregnan- contraceptives because they are in school. cies. Furthermore, adolescents stated that myths were If we do that, we will end up losing our teenage girls widely used by the elderly to discourage FP/C service use, through unwanted pregnancies and criminal abortions.” for example, they were told that using FP/C methods at a [Key stakeholder IDI, Health Sector, UZI006] young age could result in failure to conceive in future. “Some say if you are taking family planning you will Community level barriers be barren. You will not have a child in your life.” Women’s experiences with contraceptive side effects [Female FGD, Urban Adolescent, UZFG_UT007] All community members reported that the side effects of hormonal methods were a major barrier to using con- traceptives. They cited prolonged and irregular menses, Stigma towards certain user categories (adolescents and dizziness, headaches, stomach-aches, weight gain and unmarried) weight loss as some of the most common side effects of Societal stigma was cited by both community members contraceptive methods. These side effects were said to and HCPs as one of the major hindrances to adolescent be the main reason as to why people discontinued, chan- access and utilisation of FP/C services. Adolescents re- ged or stopped using particular contraceptive methods. portedly would rather not utilise FP/C methods/services, due to negative HCP attitudes and the risk of commu- “Like for me I used to take the pill safe plan [name nity members knowing that they were sexually active. of contraceptive pill], it used to give me prolonged periods then I tried the injection for three months, “In this community it’s actually known that family I never used to see my periods, so I stopped. I prefer planning services can only be accessed by married condoms.” [Female FGD, Married Young Adult, couples. The community does not expect a young UZFG_MY001] person to access family planning. So the greatest Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 6 of 11 barrier has been stigma and discrimination.” “We are promoting couples counselling in most of the [Key stakeholder IDI, Health Sector, UZI004] health centres in Kabwe district. Not only are we targeting women alone, but also men as well. We Both adolescents and unmarried users reported being encourage women to come together as couples with stigmatised when they accessed FP/C services, as FP was the men, so that when they want to access family generally thought to be only for adults and married planning, they understand what type of services we people. offer at facility level.” [Healthcare provider FGD, Frontline, UZHG_L007] “The other experience I have gone through is that us who [are] unmarried, we are not usually free to be helped because at times they [healthcare providers] Availability of personnel trained to offer the basic look down upon us when we come to collect the contraceptive method mix (barriers, short and medium acting) methods. They perceive us to be prostitutes or very Healthcare providers reported that personnel, in both promiscuous individuals.” [Female FGD, Unmarried urban and rural facilities, were trained to provide most young adult, UZFG_SY007] of the basic contraceptive methods and services, like condoms, CoC pills (Safe plan and Mycrogynon 30) and “When you go to the clinic, the first question the nurse injectables (Depo-Provera and Nuristerat). This was or doctor will ask is “are you married?” Then you if you perceived to be an enabler, as it provided a basis for say no, the next question will be, “but why do you want provision of the minimum method mix to the commu- to use FP?” Yet you yourself know that you are sexually nity members. active.” [Female FGD, No children, UZFG_C008] “We are privileged as Kabwe, they trained most healthcare providers to provide at least most of the Religious beliefs common and basic contraceptive methods. Three Community members and HCPs narrated that certain quarters of the health workers have been trained, religious beliefs were barriers to provision and use of FP/C though some do not practice. We also have mentors services, because they discouraged people from using any at the district level who mentor the providers at the method. Some religions believed that the use of contra- facilities.” [Healthcare provider FGD, Frontline, ception was synonymous to committing abortion, which is UZHG_L002] considered sinful. Additionally, provision of FP/C services to unmarried users was generally considered to be in- appropriate as it was thought to be promoting promiscuity Integration of FP/C services with other healthcare services and sex before marriage in society. Healthcare providers reported that integration of services in the health facilities provided an enabling environment “We were discussing about family planning at our to reach as many clients as possible and provide them ministry and the issue that came out strong was that, with FP/C services. The integrated model of service when the egg is released and you use family planning provision mentioned by most HCPs facilitated service medicine, it will make you abort. They said that the provision, as it enabled clients who may have come for function of a pill is to abort the pregnancy each time other healthcare services to be provided with FP/C ser- you get pregnant. So, it is not right for us to abort vices/methods. because abortion is murder.” [Female FGD, Urban adult, UZFG_UA008] “In every clinic there is this integration of services. For example, if the client comes for antenatal we include services like family planning, if she needs to go for ART, Enablers to contraceptive services provision and the same day she will even go for ART to collect her ARVs. utilisation We don’t have to let the clients make trips to our clinics. Health systems enablers When they come, it’slike a supermarket. They move from Couples counselling services point B to point C, from point C to D, just like that.” Provision of counselling services before and after admin- [Healthcare provider FGD, Managerial, UZHG_H005] istering of FP/C methods in most heath facilities was reported by HCPs as an enabler. Couples counselling services in some facilities were also cited by HCPs as be- Government commitment to extending FP/C services ing particularly helpful in facilitating male involvement Key stakeholders from the health sector explained that in FP/C services uptake and support. there was renewed government commitment towards FP/C Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 7 of 11 services provision in Kabwe district. They reported that the Community desire to delay pregnancy increased number of new health facilities and healthcare Community members from both urban and rural areas personnel being deployed to rural areas would improve reported that they desired to delay pregnancy until they access to contraceptive services. Additionally, it was stated were financially and psychologically ready to support their that the provincial medical office had deliberately taken it babies. To this effect, they indicated that using FP/C upon themselves to strengthen FP/C services provision and methods and services allowed them to concentrate on use within the district, due to poor indicators, such as the work, complete their schooling, avoid unwanted pregnan- low contraceptive prevalence rate (CPR) and high unmet cies, and raise healthy and planned families. need for contraception. “We use family planning because most of us “One of them is what the government is doing in [girls], we don’t want to get pregnant at an opening up more health facilities, especially the early age, so we propose to our partner to use health posts. This is contributing to reducing the a condom when we are having sex.” physical distance that most women have to travel [Female FGD, Adolescent, UZMG_T005] to access FP/Cs. Though there is still much more to be done, such efforts are contributing FP/C services being taken close to the people.” “It gives [us a] chance to work. Usually you stop [Key stakeholder IDI, Health Sector, UZI007] work temporarily if you have a child. family planning allows you to plan so that you are not disturbed by work stoppages due frequent child Community level enablers bearing. You can plan that at least three years Community-based health structures passes before having another child.” Community participants from rural areas reported that [Female FGD, Married Young Adult, UZFG_MY006] the existing network of community-based health workers, like community based distributors (CBDs), traditional birth attendants (TBAs), neighbourhood health commit- Community knowledge of FP/C services tees (NHCs) and safe motherhood action groups Community members had knowledge of most of the (SMAGs), facilitates FP/C services/method provision and common and basic FP/C methods, but had less utilisation. This network reportedly acts as a link between knowledge of emergency contraceptives and other more the community and the healthcare systems, providing a advanced methods like LARCs. Some participants were variety of healthcare services including FP/C methods/ser- able to define FP, others could explain how particular vices to people, who otherwise may not be reached by the contraceptive methods worked, as well as their healthcare system. advantages and disadvantages. Community members also had knowledge of natural FP methods, which they “We have what are called community-based distributors. used, including withdrawal, thigh sex and breastfeeding These are basedinthe communityand they are able methods. to explain and also provide, especially the oral contraceptives.” [Female FGD, Rural Young Adult, “FP is a way a way of taking care of oneself where UZFG_RY006] child bearing is concerned. A woman's body needs time to rest after delivery, say 2 to 3 years after Other community structures included cooperatives, delivery, after which one can be able to get pregnant churches, community drama groups, football clubs, youth again. The other thing I know is that it helps us and women’s groups, and the savings groups which could to bring up our children well in terms of feeding, also be explored to empower community members with clothing and taking them to school.” FP/C services/methods information. [Female FGD, Urban Adult, UZFG_UA002] “There are gatherings where community members meet. For example, saving groups, interdenominational “The methods of family planning we use in our prayers, and sometimes we have women meetings to rural areas, if one fails to go to the clinic and your share information, like for family planning. There are husband comes, you let him ejaculate between your also some cooperatives where we share things for farming. thighs or he withdraws and ejaculates from outside. So, there are a lot of situations which require us to meet It helps us until the day we go to get an injection as a community.” [Key stakeholder IDI, Community, for family planning.” Religious Leader, UZI009] [Female FGD, Rural Adult, UZFG_RA005]. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 8 of 11 Discussion that aim at neutralising myths and rumours, and provide Since the UPTAKE Project sought to bring together com- detailed information about side effects, may help address munity and health systems efforts in increasing met needs this barrier. for contraception, these findings were of major importance in situating and understanding the context in which the Enablers to family and contraceptive services provision proposed intervention would be implemented. Further- and utilisation more, these findings facilitated identification of bottlenecks The study findings demonstrate that couples counselling and facilitators to contraceptive provision and use at both services targeting male involvement in contraceptive community and health systems levels to inform interven- choices are important enablers to contraceptive services tion activities to increase met needs. Below, we discuss the provision and use. Such counselling services allow for in- findings around the two core thematic areas of community creased male participation and support for family planning and health systems barriers and enablers to family planning and contraceptive choices. Various studies have under- and contraceptive services provision and use. lined that male partners are key decision makers [36, 37]. Hence couples counselling services help to educate and Barriers to family planning and contraceptive services encourage male partners to support their spouses in using provision and utilisation FP/C services [27]. While these findings underline government commitment Availability of personnel to offer a minimum method to extend health services to remote areas, long distances mix (barrier, short and medium acting) is an enabler, as to some health facilities still remain a challenge to access it provides for choice among clients. However, the and use of contraceptive services in many rural areas. results also show limited LARC options in some health Community efforts to leverage this includes using local facilities due to non-training of their staff in this particu- structures to distribute and generate demand for contra- lar method. Strengthening of District level training and ceptives. However, many of these local structures still face mentorship of personnel in LARC services at all health numerous challenges, such as lack of incentives (for facilities will help improve access to this method. example bicycles) to function optimally [18]. Appropriate Though found to be an enabler, integration of SRH incentives, as well as effective management strategies that interventions into community health systems remains enhance local structures’ capacity to deliver FP/C services complex [38], due to diverse norms, values, as well as the can help increase met needs for contraception [19]. less formal mechanisms which shape coordination, ac- Though most Zambian policies on SRH do recommend countability, health practice and health-seeking behaviour provision of adolescent-friendly services, contraceptive [39]. Key factors to consider at the community level may provision in schools is still not allowed [20–22], suggesting include the community’s capacity to engage and partici- the need for a policy framework that builds community pate in the implementation process, commit and sustain support for adolescent contraceptive provision and use in health actions and ensure the development of effective all settings, including schools [23]. These findings highlight partnerships between a complex array of actors involved the need for further discussions and possible readjustment in the intervention [22]. of policy on FP/C provision in schools as adolescents are The findings also reveal high levels of knowledge about unable to freely access these services at health facilities due FP/C methods/services, which is consistent with the to stigma and negative provider attitudes. Zambia Demographic Health Survey (ZDHS) findings Stock-out of preferred methods affects demand and [10]. The desire to delay pregnancy is another community sustained use of contraceptives. Gaps in commodity sup- level enabler. Though high knowledge levels and desire to ply have also been reported elsewhere [23–25], and are delay pregnancy provide an enabling environment for FP/ said to be as a result of the mismatch between supply C methods/services provision, they do not necessarily and demand projections on most occasions [26]. Redu- translate into utilisation, as evidenced by the low national cing incidences of contraceptive stock-outs will require CPR of 47% and high TFR of 5.3 births per woman [10]. strengthened commodity supply chain management, and The need to address some of the barriers suggested balancing of demand projections and real-time availing above cannot be overemphasised if we are to improve FP/ of commodities [26, 27]. C services practices among community members. Indeed, Experiences with contraceptive side effects shape involving key community stakeholders (parents, teachers, choices and sustained use of methods [28–33]. Side effects churches and HCPs) in identifying, planning, implementa- have also been reported to perpetuate myths and miscon- tion, monitoring and evaluation of FP/C services interven- ceptions [34, 35]. For instance, inability to experience tions, as proposed by the UPTAKE project, will contribute periods is associated with blood accumulation in the to improved service delivery and community support for womb, leading to cancer or fibroids. Adopting innovative contraceptives use. Furthermore, Interventions targeting and context-specific community engagement strategies provision of contraceptives in settings other than family Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 9 of 11 planning clinics, strengthened integration of FP/C ser- provision and use, but also, goes further to explore ap- vices, and training that addresses communication, coun- proaches to maximise implementation success of com- selling skills and cultural values clarification will be crucial munity and health system participatory interventions to enhancing contraceptive use [23, 27, 40]. seeking to increase met needs for contraception. Strengths and limitations Additional files The collection of data from various categories of com- Additional file 1: Appendix D, FGD guide_females. (DOCX 44 kb) munity members, HCPs and key stakeholders enabled Additional file 2: Appendix D, FGD guide_healthcare providers. gathering of a wide range of views, which allowed for (DOCX 45 kb) strengthened data triangulation on key thematic areas. Additional file 3: Appendix D, FGD guide_males. (DOCX 43 kb) Community perspectives on barriers/enablers to FP/C Additional file 4: Appendix D, In-depth interview guide_key stake- methods/services uptake are not well explored, so this holders. (DOCX 51 kb) study adds to this perspective. Additionally, the qualitative team comprised professionals from various academic Abbreviations backgrounds, which further strengthened critical analysis CBDs: Community based distributors; CPR: Contraceptive prevalence rate; and interpretation of the data. DHO: District health office; FGDs: Focus group discussions; FP/C: Family planning/contraceptives; HCPs: Healthcare providers; IDIs: In-depth However, there were also limitations to this research. interviews; NGO: Non-governmental organisation; NHC: Neighbourhood Conducting the study in one setting/district per country, health committee; OPD: Outpatient department; PTMCT: Prevention of the use of a small sample of respondents, as well as, using mother to child transmission; SDGs: Sustainable development goals; SMAGs: Safe motherhood action groups; SRH: Sexual and reproductive only qualitative approaches, limits the generalisability of health; STIs: Sexually transmitted infections; TBAs: Traditional birth attendants; study findings. Though generalisability was not the TFR: Total fertility rate; WHO: World Health Organisation intention, the rich description of the phenomena (commu- Acknowledgements nity and health systems barriers and enablers to contra- The authors would like to acknowledge the contribution from the Kabwe ceptive provision and use), led to an in-depth account of community members who were actively involved in all phases of the barriers/facilitators to FP/C services in Kabwe district of project. In particular, we thank the Kabwe District Health Office for the immense support provided to the project. We would also like to thank Zambia. We believe this provides a valuable contribution members from the UPTAKE project multi-country qualitative team (Zambia, to the body of knowledge on FP/C services provision and Kenya and South Africa). use in Low and Middle-Income settings. Funding The UPTAKE Project was conducted with support of the UNDP/UNFPA/ Conclusion UNICEF/WHO/World Bank Special Programme of Research, Development and Our findings highlight community and health systems Research Training Human Reproduction, which is the main instrument and leading research agency within the United Nations system concerned with factors that ought to be considered by policy, planners sexual and reproductive health and rights. and implementers in the design of FP/Cs programmes, to ensure sustained uptake and increased met needs. Availability of data and materials Tackling health systems inhibiting factors such as nega- The data are not publicly available as it contains information that could compromise research participant privacy/consent. However, some tive provider attitudes, gaps in sustained commodity and anonymised aspects of the datasets may be available upon request and with services supply, together with enforcing adolescent permission of the Department of Reproductive Health and Research, World friendly policies will be vital in improving contraceptive Health Organisation. Note that data sharing is subject to WHO data sharing policies and data use agreements with the participating research centres. uptake. Addressing community-level factors such as stigma, myths and negative beliefs will require full en- Declarations gagement of community members in service provision, The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the which will also enhance community participation and institutions with which they are affiliated. support for FP/C services programmes. Additionally, FP/ C services programmes should seek to build on the Authors’ contributions The study was part of the formative phase of a bigger multi-country UPTAKE reported enabling factors both at community and health project, conceived and designed by the WHO (PS, JC), country Principal system levels for successful implementation. Investigators (TN) and the qualitative research leads (CM, YK). AS, TN, MM, Identifying the factors that shape delivery and adop- JMZ, CM, YK: conducted the data collection, analysis and reporting of findings. AS: drafted the manuscript. All authors critically reviewed, revised tion of FP/C interventions at various levels, and the role and edited the draft manuscript. All authors read and approved the final they play, both as facilitators and barriers, is important if manuscript. we are to increase met needs for contraception. Under- standing these factors forms the basis for future FP/C Authors’ information The first author: Adam Silumbwe ([email protected]) is a Staff services programme planning and implementation Development Fellow in the Unit of Health Systems and Implementation efforts. We therefore recommend that future research Research, Department of Health Policy and Management, School of Public not only identifies barriers and enablers to contraceptive Health, University of Zambia. Silumbwe et al. BMC Health Services Research (2018) 18:390 Page 10 of 11 Ethics approval and consent to participate 14. Zulu JM, et al. Innovation in health service delivery: integrating community This study received WHO Ethics Review Committee (ERC) and Research health assistants into the health system at district level in Zambia. BMC Project Review Panel (RP2) approval. In addition, for the Zambian Health Serv Res. 2015;15(1):1. component of the study, ethical approval was obtained from the University 15. 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Published: May 31, 2018

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