Abstract
Background:
Lack of credible sexual partner dialog and support regarding family planning (FP) and other sexual reproductive health issues is a major impediment to contraception service uptake and utilization. This study examined the feasibility and acceptability of attitudes toward using telehealth for remote education of couples through behavioral, motivational, and informational messaging on FP methods and its eventual impact on partner conversations around FP.
Methods:
The study was conducted in Kampala, Uganda, and involved recruiting 450 men from diverse settings. These men received regular SMS content on FP and sexual and reproductive health for a duration of 6 months. The content aimed to provide information and motivation while serving as a resource for discussions with their spouses. Following the main quantitative study, a qualitative follow-up study was conducted with a subset of 15 randomly selected men. In-depth interviews were conducted with these men to gain deeper insights into their experiences and perspectives.
Results:
The study revealed positive outcomes where men reported improved knowledge of FP methods such as child spacing, and types of contraception. The messaging prompted discussions with spouses on family size and spousal support. Couples reported a shift toward viewing FP as a joint responsibility, with some couples even taking concrete actions. The findings suggested that telehealth interventions can promote social and behavioral change and can improve couple communication and male involvement in FP decisions in Uganda.
Conclusion:
The study found that using telehealth messaging to educate men about FP in Uganda successfully improved communication between couples on the topic.
Introduction
Uganda’s national modern contraceptive prevalence rate is approximately 35% among married women 15–49 years of age, which highlights a significant concern regarding the country’s modern contraception use and the rates among adolescents are notably lower at around 9.4%, indicating a substantial gap in contraceptive uptake. 1 Moreover, there are considerable regional disparities, with prevalence ranging from 6.5% in the Karamoja region to 43% in the Bugisu and Kigezi regions. 2 Despite the government’s target to increase the modern contraceptive prevalence rate to 39.6% by 2025, there remains a substantial unmet need for family planning (FP), estimated at 28%. 3 This challenge is particularly pronounced in rural and semi-urban areas, where women have a high fertility rate of 5.4 children per woman, emphasizing the urgency to address these disparities and improve access to FP services. 4
The low uptake of FP in Uganda can be attributed to various factors. People are hindered from obtaining FP services by barriers based on gender, persistent cultural views, 1 and an incomplete understanding of contraceptive techniques and their adverse effects. 5 Husbands’ opposition can severely limit women’s access to contraceptives, therefore, male partner resistance is a key challenge. 6 Additionally, the presence of unmet needs among married women underscores the gap between reproductive intentions and actual contraceptive behavior, highlighting the risks associated with unintended pregnancies and maternal health. 7 A comprehensive strategy that addresses information gaps, empowers women, encourages male engagement, improves service availability and quality, and guarantees an affordable and steady supply of contraceptives is needed to address this complex situation.
Couple communication is a major factor in the low rate of FP utilization. Studies show that FP decision making and uptake are significantly influenced by the level of partner conversations. Additionally, couples who never talk about contraception have a higher unmet need for FP, particularly among rural women, low-income individuals, and those with little educational attainment. Additionally, involving men as active partners in maternal health is highlighted as essential for their engagement in reproductive health matters, emphasizing the need for comprehensive programs that address the role of both partners in FP decision making and uptake. 7 The lack of communication between couples regarding FP has a significant impact on the usage of contraceptives and the state of reproductive health in Uganda. Poor communication between spouses has been linked to gender-based abuse, a lack of support, and difficulty making decisions about contraception, all of which can hurt women’s autonomy and choices, according to research. 3
The lack of couple communication or low male involvement in FP can be attributed to the current modalities of information dissemination not being well contextualized to suit men. Men often perceive FP as a woman’s domain due to social norms and health system factors that assign the role of childbearing and child-rearing to women. This perception leads to men being less engaged in discussions about FP as they prioritize earning income for their families and may view such discussions as burdensome. This lack of tailored information and campaigns for men can hinder their constructive engagement in FP discussions and decision-making processes. 8
The use of digital technologies offers a great chance to increase male involvement in FP and education. The Demographic and Health Surveys indicate that 84% of men in Uganda own mobile phones, indicating a high rate of mobile phone ownership in the country. This broad accessibility creates opportunities for creative FP strategies. Digital tools such as video chats, SMS messaging, and mobile apps can provide men with important information, counseling, and support in making decisions about contraceptive options. 9
This article aims to share the findings of a qualitative analysis of a pilot project that leveraged a telehealth model for informational behavioral messaging targeting men in Uganda. The project aimed to influence couples’ communication on FP by providing men with information about FP methods and their benefits through mobile phone messaging.
Methods
STUDY SETTING AND PARTICIPANT RECRUITMENT
This cross-sectional study was conducted in Kampala district, Uganda, targeting men 18–55 years of age who consented to participate. A total of 450 men were recruited in the main study from various settings, including academic institutions, workplaces, and social gatherings, among others. The study team set up a tent at each site to achieve an informed consent process with appropriate levels of privacy and confidentiality. The participants’ socioeconomic profile, education, and employment status were collected through a baseline survey conducted at the time of recruitment.
SELECTION OF PARTICIPANTS FOR QUALITATIVE STUDY
From the initial pool of 450 participants, a random sample of 15 men from the main study was selected for in-depth phone interviews to gain deeper insights. To conduct this random selection, a random number generator to randomly select 15 men from the pool of 450 participants was used. This random selection process was employed to avoid any potential bias in the sample. The selection of participants for the qualitative study was based on this simple random sampling approach to ensure representation from the larger study population. The demographic characteristics of the selected men, including age, marital status, level of education, employment status, and number of children, are summarized and presented in Table 1.
Summary of Participants
Sample SMS Messages for Family Planning Information, Behavior Change, and Motivation
FP, family planning.
MOBILE MESSAGE DESIGN AND DISSEMINATION
The study team developed messages on sexual and reproductive health, with a focus on modern contraception, for the intervention. These messages were designed to cover informational, behavioral, and motivational aspects of contraception communication as shown in Table 2. The messages were reviewed for appropriateness, relevancy, and local context by a community advisory board and a sexual and reproductive health specialist. They were then delivered to the study participants on a weekly schedule, with an average of two messages received per week over 60 days. The messages were delivered in both English and the local language known as Luganda.
FOLLOW-UP AND DATA COLLECTION
All study participants had access to a toll-free number and SMS platform manned by qualified health professionals. This platform was available 24/7 and provided remote resolutions of inquiries, referrals, and linkages to sexual and reproductive health and other health services. Proactive follow-up by the study team was conducted at 1, 4, and 6 months from the date of study enrollment to complete specific study procedures and gather information related to knowledge gained on modern contraceptive methods, couple communication on FP, and partner uptake on FP.
QUALITATIVE DATA COLLECTION
After a 6-month follow-up period, 15 men from the main study were randomly chosen for the qualitative study to gather deeper insights. The selected men were contacted and invited to participate in in-depth phone interviews. Additionally, the men were asked to provide their spouses’ phone numbers to include their perspectives in the study. Ten out of the fifteen men agreed to provide their spouses’ phone numbers. The women were then contacted and invited to participate in in-depth phone interviews as well. The interviews were conducted using an in-depth interview guide, which covered various topics such as the participants’ experiences with the intervention, their perceptions of the benefits and challenges, and their suggestions for improvement.
INTERVIEW PROCESS AND DATA TRANSCRIPTION
The in-depth phone interviews were conducted by trained interviewers who followed the interview guide. The interviews were chosen to be conducted over the phone to facilitate remote data collection due to logistical considerations and to ensure participant convenience. The interviews were recorded with the participant’s consent and later transcribed for analysis.
DATA ANALYSIS
The recorded discussions and interviews were transcribed and analyzed using a qualitative approach. The analysis began with open coding to identify data codes without preconceived categories. Themes were then generated from the coded data to answer the research questions and provide a comprehensive understanding of the participants’ experiences and perceptions.
ETHICAL CONSIDERATIONS
The study received ethics approval from the Institutional Review Board of the Joint Clinical Research Center before data collection. Informed consent was obtained from all study participants, ensuring their understanding of the study’s purpose, procedures, and potential risks or benefits. Confidentiality of participant information was strictly maintained, and participants were informed that their data would be anonymized and used only for research purposes. Participants were also assured that their participation was voluntary and that they had the right to withdraw from the study at any time without facing any consequences.
Results
A total of 25 participants were enrolled in the qualitative aspect of the study, comprising 15 men and 10 women. Participants were between 20 and 59 years with the majority being married (23 out of 25). Most had attained tertiary education (12 out of 25), were formally employed (12 out of 25), and had between 1 and 4 children (17 out of 25). The study population’s demographic characteristics are summarized in Table 1.
In-depth interviews were conducted with 15 men who participated in the telehealth intervention. The interviews aimed to explore the impact of the intervention on their knowledge of FP methods and their communication with their partners about FP. The findings of the interviews revealed significant outcomes related to couple communication and male involvement in FP decisions.
KNOWLEDGE AND ATTITUDES TOWARD FP
The majority of the respondents exhibited existing knowledge regarding FP, with a particular emphasis on child numbers and spacing. A male, 32 years, described FP as “just producing a few children.” Similarly, a male, 30 years old, provided a concise definition, stating, “It is the use of birth control methods to plan when to have a child… it entails child spacing.” In contrast, the women’s perceptions of FP encompassed both family size and spacing, influenced by the available resources for parents. A female, 25 years, elaborated on the concept of FP, stating, “It helps us to space our births… planning well for them.” She further criticized parents who rely on government support, parents who compromise their children’s lives by neglecting proper planning, and those who defend large family size by attributing blessings to each child.
COUPLE COMMUNICATION
The intervention in the study facilitated discussions between couples regarding FP, covering various topics such as family size, spacing between children, financial considerations, and the choice of FP methods.
Both male and female participants recognized the significance of open and meaningful discussions about their plans and the well-being of their families. As a male, 33 years old, expressed, “Our discussion has been about the number of children we should have… how long we should take to have the next one.”
The study uncovered a positive shift in spousal communication about FP, with participants emphasizing the importance of collective decision making. Discussions evolved from being solely the responsibility of women to a joint effort involving both partners. A male participant of 34 years highlighted the need for FP, stating, “I have always discussed with my spouse about the methods of family planning and the need for family planning.”
Spousal support emerged as a crucial factor in FP use. Emotional support and a genuine interest in each other’s well-being were identified as essential aspects of maintaining adherence to the chosen FP method. A female, 26 years, highlighted the significance of emotional support, stating, “When we have discussions, it’s a meaningful discussion, and he takes the time to ask how I’m feeling, what my current condition is… he is genuinely supportive,” while a female, 25 years, described the encouragement received from her spouse, who emphasized the importance of giving themselves some space between children.
Decision making regarding FP was portrayed as a joint effort between couples, with participants acknowledging the value of discussing and reaching a consensus. A male, 36 years, emphasized the shared responsibility, stating, “Family planning is not entirely the responsibility of women. We should all be part of it, as we plan for our families. It shouldn’t be one-sided.”
Experiencing the benefits of FP led participants to emphasize the importance of discussing and agreeing upon the timing of future pregnancies based on individual circumstances. A male, 35 years, noted, “We discuss and agree on family planning decisions. It used to be different before, but now we understand that it’s a joint responsibility.” Participants recognized the potential risks to their quality of life if FP was not practiced, further reinforcing the shared responsibility between spouses in ensuring the well-being of both partners.
Overall, the intervention successfully promoted discussions between couples, resulting in improved communication, shared decision making, and increased support for FP within the study participants’ relationships.
FP-focused discussions between spouses and the subsequent decisions arrived at have brought comfort in families as a male, 34 years, testifies, “it has helped me in a way, that I talked to my spouse and we agreed, now we have a kid of four years but we are comfortable using our family planning method, she is on an injection.”
Couples have opened up to each other in ways that had not been possible before. The wife of a 32-year-old man, opened up about using FP, which she had never told her husband about, for fear that it would hurt his feelings. As a male, 38 years, explained, “she used to hide it from me…then when this study came in, she came in telling me about Depo, then I said it would be better if you go in for that, and she told me, I have been using it. And I said aah, without my knowledge? But because I had already started sharing this information, I said, that is good, but you could have told me. She said, but I thought it could be painful on your side.”
Harmony in the home is another benefit that some male participants attributed to this intervention, which encouraged couples to discuss FP. In proving this, a male, 27 years, explained that his wife discussed FP with him, as opposed to secretly seeking FP services: “This study has helped…it has brought unity between me and madam, because some time back these ladies used to sneak and go for family planning without our knowledge, but when this study came, we came together and discussed the best method to use.”
Discussion
This study effectively illustrated the viability and acceptability of a telehealth platform for promoting improved partner conversations about FP. The platform’s focus on social and behavioral change communication significantly improved participants’ knowledge and the interviews revealed significant outcomes related to couple communication and male involvement in FP decisions. The study found that FP couple communication had a significant impact on the comfort and decision making within families. Participants reported positive outcomes from discussing FP with their spouses, such as agreeing on specific FP methods, improved understanding and support, and increased emotional support among others. The intervention empowered men to become more supportive of their wives’ FP choices, leading to consistent support and involvement in FP services. The discussions between couples fostered harmony in the home and improved relationship harmony. These findings align with a study conducted in Uganda, 10 which aimed to assess the impact of a couple-based FP intervention on men’s involvement in FP decisions and women’s use of modern contraceptives. The intervention involved providing information and counseling to couples on FP methods, including male involvement in decision making and support.
Similarly, a study by Mohammed et al., 11 Ethiopia 12 and the Netherlands, 13 revealed that couple communication and male involvement were associated with higher FP use and continuation rates in various low- and middle-income countries. These results highlight the importance of partner discussions and collaborative decision-making interventions in FP.
Furthermore, the intervention demonstrably sparked engagement and discourse between partners, with many actively involving their spouses in discussions about contraceptive options. This highlights the promise of telehealth in supporting social and behavioral interventions for FP. Notably, a similar study found that nonvideo-based telehealth for FP is well received by patients and providers, particularly during the COVID-19 pandemic. 14 Similarly, a national survey 15 demonstrated telehealth’s acceptability for contraceptive care and emphasized the importance of patient perspectives in evaluating such interventions.
However, the study by Kumar et al. 16 evaluated a telehealth intervention for FP in a rural Indian setting and indicated that the program did not lead to substantial increases in partner communication or male involvement in FP decisions. This suggests that the effectiveness of such interventions may be influenced by sociocultural factors and gender dynamics within specific communities, as highlighted by a study by Kabagenyi et al. 17 Therefore, careful consideration is needed when evaluating the impact of telehealth interventions on FP dynamics in different contexts.
LIMITATIONS
Geographic Limitation: The study was conducted in Kampala district, Uganda, which may limit the generalizability of the findings to other regions or settings within the country with different sociocultural contexts.
Conclusions
In conclusion, this qualitative study explored the feasibility and acceptability of using a telehealth-based intervention to facilitate social and behavioral change communication and enhance partner conversations on FP among men in Uganda. The researchers employed a rigorous random sampling approach, conducting in-depth interviews with 15 men selected from the pool of 450 participants in the main quantitative study. This ensured the qualitative findings were representative of the larger target population. The results indicated that the telehealth platform and messaging content were well received and perceived as highly useful by the participants. The educational and informative nature of the messages increased the men’s knowledge and understanding of FP methods, and importantly, promoted open discussions between partners. This research contributes valuable insights to the growing body of evidence on the efficacy of leveraging digital health interventions to enhance couple communication and male engagement in FP initiatives.
Building on the positive user reception and impact observed in this pilot, the program holds significant potential for wider implementation and scale-up in other parts of Uganda. We have a plan to pursue funding for a larger-scale study to further assess the intervention’s effectiveness in improving FP knowledge, attitudes, and couple communication outcomes. Additionally, the research team will explore strategies to optimize the program’s cost-effectiveness, training requirements, and potential integration with existing health care systems in Uganda. By addressing these elements of sustainability and scalability, the telehealth-based approach could be transformative in driving meaningful progress toward enhanced male involvement and couple collaboration in FP in the country.
Footnotes
Acknowledgments
The authors appreciate the support provided by the doctors at The Medical Concierge Group call center, who handled the participants’ inquiries.
Authors’ Contributions
Author 1: Writing, review, editing, and article review (lead). Author 2: Review, writing, and data collection (equal). Author 3: Writing and data collection (equal). Author 4: Writing, review, and editing and article review (lead). Author 5: Data analysis, writing (lead). Author 6,7,8,9,10,11: Review and editing (equal). Author 12: Study design and article review (equal). Author 13: Writing, review, study design article review and editing (lead).
Data Availability
The data that support the findings of this study are available from the corresponding author (J.A.) upon request. The data are not publicly available due to the containing information that could compromise the privacy of research participants.
Disclosure Statement
The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Funding Information
This study was funded by The National Academies of Sciences, Engineering, and Medicine under the Partnership for Enhanced Engagement in Research funding mechanism.