Abstract
SUMMARY
Community reproductive health workers play a valuable role in family planning counselling and the distribution of contraceptive methods in rural communities. However, they face stigma, misconceptions and a lack of support. Regular supervision by health workers and support from community leaders can help address these issues.
Introduction
Reproductive health implies the ability to have a responsible, satisfying and safe sex life and the capability to reproduce, with the freedom to decide if, when and how often to do so. 1 Implicit in this is the right to safe, effective, affordable and acceptable family planning methods. This is a health priority area in Uganda. 2,3 Masindi District has a total fertility rate of seven, a maternal mortality rate of 614 per 100,000 live births and a contraceptive prevalence rate of 3%. According to the District Health Management Information System Database, utilization of reproductive health services is poor.
Community reproductive health workers (CRHWs) play an important role in family planning counselling and the distribution of contraceptive methods in developing countries. 4,5 About 100 CRHWs received training in Masindi District between 1996 and 2002. However, due to the low reporting rates, it is difficult to estimate the actual levels of their activity, but is believed to be low. This study aims to discover the current practices, barriers and training needs of CRHWs.
Methods
A one-day training course in English and Runyoro was organized for CRHWs (including traditional birth attendants), health workers and community leaders of a convenient sample of one parish from each of the four health subdistricts. A purposely designed 10-item semi-structured questionnaire was used to gather information from the CRHWs. Five of the items in the questionnaire related to language use in training materials, two were about use of these materials and three sought suggestions for their training (free-text items). In addition, participants were asked to role-play four scenarios (Box 1) after which a focused discussion was generated around issues of their current practice. The discussion and role-plays were transcribed and analysed by two researchers, a themed analysis was used.
Scenarios used for role-play and focused discussion
Role-play scenarios:
Sue is a 30-year-old woman with eight children, and she does not want anymore. She comes to you to ask for advice. What can you do? Margaret is a 19-year-old schoolgirl who has a boyfriend and is afraid that she might become pregnant. How would you counsel her? Jenny is a 25-year-old with four children – the youngest is four months old. She has come to you because she wants some help with child spacing. How would you go about helping her? You are in a home visit and Lucy tells you that she has missed her period for the last two months and she feels sick in the mornings. What advice would you give her?
Results
In total, 45 CRHWs, nine health workers and six community leaders attended the training. All the 45 participating CRHWs completed the questionnaire. Table 1 shows a summary of the data collected. The use of educational materials tended to vary greatly. Less than half used the Runyoro version of a family planning book supplied during the original training. In our sample, 37 (82%) CRHWs spoke English and preferred English (53.3%) for their training materials and job aides; the remainder preferred their mother tongue. Suggestions were given to improve the materials. When such materials are intended to be used by clients, they should be written in one of the local language and include pictures, as many women in the community cannot read or write. The preferred format was a flipchart-type with pictures. The CRHWs wanted aides who could help them to discuss the myths and misconceptions which abound in the community.
Background information from a questionnaire completed by 45 community reproductive health workers
aExcludes three free-text questions
Role-play analysis and group discussions
The CRHWs demonstrated a good knowledge of family planning methods and showed an understanding of the wider issues, such as male involvement and client confidentiality. The main themes were: barriers to the CRHWs' work; reasons for under-utilization; myths and misconceptions; training needs.
Barriers to the CRHWs' work
CRHWs found it difficult to approach clients because of the stigma attached to family planning – instead they would wait for clients to approach them. They wanted to be supported by community leaders as they felt this would mitigate some of the stigma. Meetings with health workers to discuss problems or to refer cases would be useful, but the lack of resources meant this did not happen. Reporting was an issue as there was a shortage of stationary and the CRHWs had to travel some distance to health units in order to deliver their reports and to collect the contraceptives.
Reasons for under-utilization
Cultural and religious beliefs played a role in the uptake of family planning services. Communication among couples about these issues was difficult and, generally, the final decisions were taken by the men. Women would sometimes use a concealed method and keeping it secret from their husbands. The unreliability of the delivery of supplies of contraceptives made it difficult to retain clients. This led to poor service utilization and fuelled rumours about the reasons for shortages. There appeared to be stigma attached to the term ‘family planning’ and ‘child spacing’ and therefore the CRHWs preferred to discuss the subject in terms of the health gains to the family.
Myths and misconceptions
Misconceptions about contraception were seen as one of the major factors hindering their work. Popular beliefs in the study area included the belief that family planning methods lead to infertility or fetal malformation and, among men, that contraceptives decreased their libido. These misconceptions had been made worse by advertising on the local radio of a herbal remedy which was said to increase libido in people taking contraceptives. The CRHWs felt there was a need for more information and support in dealing with these misconceptions.
Training needs
The CRHWs felt that they needed more training and factual information in order to deal with the rumours and misconception in their communities. Health educational materials which deal with these myths and misconceptions would be helpful. CRHWs felt that it was important to include the community leaders in the training as they could influence opinion in the community.
Discussion
CRHWs play an important role in the reproductive health services of rural areas. Low levels of activity can be attributed to a number of factors, of which stigma, misconceptions and lack of support are the most important. CRHWs have to face misconceptions among their communities as has previously been reported. 6 Supervision and links with a health unit is important as they give the CRHW recognition and make them feel part of a team and may also impact on the monitoring of activities, assessment of the use and demand for their services.
The main limitation of this study was that it used a representative sample of the district's reproductive health system and community leadership. Hence some of the issues raised are merely of local relevance. However, a number of the factors discussed are common to the practice of family planning in rural areas in other developing countries.
The misconceptions faced by CRHWs in their communities have also been reported elsewhere. 6 Other studies have highlighted the importance of the male partner in the acceptance and use of contraceptive methods and the involvement of men in family planning. 7,8 In addition, we explored the involvement of community leaders as a way increasing the acceptance and perception of the men in the community. Local leaders can help the community workers to dispel the myths and misconceptions surrounding the issues of family planning.
A regular and reliable supply of contraceptive methods is essential, as stock shortages can fuel rumours and undermine the CRHWs' morale. Educational materials can be tailored to the needs of CRHWs. Factual information would enable them to challenge such misconceptions and rumours.
Supervisors of CRHWs and community leaders are in a good position to address these issues. A continued approach to learning through support and supervision by health workers should be encouraged and links between both the health units and the community leaders must be improved.
Footnotes
Acknowledgements
We thank all the community reproductive health workers who participated in this study and Dr Isaiah Musinguzi, District Director of Health Services, for his support.