Characteristics of participants
Sixteen focus groups with 150 participants were carried out, in four different areas (Bwindi, Jinja, Kampala, and Mbarara). There was an average of 10 participants per focus group, with a range of six to 13 participants. Table 1 gives an overview of the demographics of the participants involved in the focus groups. In some focus groups, data for participants were not collected, leading to some gaps in the statistics. Averages were therefore made based on the information available. Participants in the focus groups on average had 2.2 children, range 0-8 (data for 24 participants missing).
Table 1
Demographic data of participants
| | Total | M | F | Average age (years) | Educational level |
| None | Primary | Secondary | Tertiary |
| Women below 23 | 31 | 0 | 31 | 20.2 | 1 | 14 | 15 | 1 |
| Women aged 23-49 | 40 | 0 | 40 | 27.8 range 23-37) | 2 | 13 | 22 | 3 |
| Men* | 38 | 38 | 0 | 36.6 (range 21-53) | 1 | 17 | 16 | 4 |
| Health workers* | 41 | 9 | 32 | 37.4 (range 21-56) | | - | - | - |
| *Age of 24 health workers and eight men was missing. |
Main themes identified
The main themes identified are the acceptability/credibility of the information provided in the films; changes in knowledge/beliefs about family planning; changes in attitudes towards family planning; changes in intention to discuss family planning with their partner or with others; changes in intention to use the implant; and overall preferences for the drama or documentary.
Acceptability/ credibility of information provided in films
Participants felt both films provided useful information about avoiding unwanted/ unplanned pregnancies. The use of local people, language and settings meant the films were more relatable than other health promotion films participants had seen, which used non-locals (and often were not in the local language), and this gave further credibility and trustworthiness. People in the documentary addressing the advantages of the implant, but also discussing the side effects they had experienced and how this had impacted them, made viewers feel that they got a more rounded view of people's experience of the implant. They also felt that people within the documentary were giving a truthful view.
"I have liked it so much because my fellow women were explaining to us, they looked healthy, had no problems, and they showed us the implant in their arms and I am sure they haven't lied to us." (24-year-old postnatal woman, Rukiga documentary).
Participants felt that the drama depicted events that happen in the community, so they could relate to the story:
"That lady from the village, what happened to her is what takes place in the village. People from the village come with similar problems." (Female nursing assistant, Luganda drama).
"While acting those films, they represented people from different economic status. It's not that they should only represent people who are well off because everyone has her way of surviving." (29-year-old pregnant woman, Luganda drama).
Change in knowledge/beliefs about family planning
After watching the films, participants expressed views about how they caused a positive change in their knowledge and beliefs, about family planning especially concerning side-effects such as bleeding, and myths.
Side effects
Participants discussed being reassured by information in the films that the side effect of bleeding is likely to be temporary.
"It has taught about what I was most worried about. I didn't know about the headache but that bleeding - they have said that it can stop, so I think I have learned and understood that. It was the only thing which was worrying me." (38-year-old man, Luganda documentary).
"I have realized that bleeding after inserting the implant is not an issue because it can be managed." (19-year-old pregnant woman, Rukiga documentary).
"I heard that when a woman uses that implant, she experiences irregular bleeding, but what I have learned is that for the first time, she can bleed for like one week and it stops." (26-year-old man, Luganda drama).
However, some participants' concerns about bleeding were not alleviated after watching the films. They also wondered where the blood goes after using the implant, and one does not bleed.
"Yes, they are answering me but, that blood that is supposed to come out every month but does not by use of the implant for those years, I keep wondering where it goes and where is it kept? That is what I did not understand. I need to understand and, I keep thinking, won't it at one point come like a "river"?" (25-year-old man, Rukiga drama).
Participants said that both the documentary and drama improved their knowledge and had a positive change in their belief about the headache as a side-effect of an implant. They learned that if headaches occurred, they could be managed by consulting a health worker or taking pain killers.
"Even if she complains of the headache, I know that paracetamol can help, and when she experiences bleeding, I can advise her to consult a health worker." (40-year-old man, Luganda drama).
However, some participants were still worried about headaches after watching the films and wanted more information.
"I heard one of the actors saying that she feels headache which portrays a bad picture." (39-year-old man, Luganda documentary).
"Another thing, they have said that you may experience headache for one or two weeks. I think you feel bad because two weeks are very many while feeling headache. I am a bit worried." (29-year-old pregnant woman, Luganda drama).
"They said when they get a headache and then swallow Paracetamol, they become healed, but me when I get a headache and use Paracetamol, I don't get healed." (20-year-old pregnant woman, Rukiga drama).
Some of the participants were not convinced by information given in the drama about the loss of libido.
"In the film, we have seen that implant doesn't reduce on the libido but, some of our spouses have experienced a loss of libido and increased blood pressure which they haven't shown us there. Say something about that issue." (33-year-old man, Luganda drama).
The participants had a positive view that the documentary reduced their fear of the consequences of using implants such as being unable to work. Participants appreciated that after insertion of the implant, they could continue to do their work with no problem.
"What I knew was that when they insert it, you do not perform tasks that require a lot of energy but, I heard those who inserted it saying that after at least two weeks, you can perform your duties without any problem." (19-year-old pregnant woman, Luganda documentary).
Myths and misconceptions
Participants were happy that both films were equally informative about common myths and misconceptions around family planning. Participants appreciated that after insertion of the implant, it does not move around or disappear to other body parts, which had been a common myth.
"The film was good. I have learned that instead of listening to rumours, it is better to consult a health worker." (34-year-old pregnant woman, Luganda drama).
"I have learned about consulting health workers for advice on side effects management instead of listening to people's rumours." (30-year-old pregnant woman, Luganda documentary).
"I was worried because I heard that when you have the implant, it can move in the body and disappear. When I saw the nurse removing it, I saw her removing it from exactly where she put it." (27-year-old woman, Rukiga documentary).
"I was scared that this implant can move from one part of the body and it moves in all your body. I have learned that it does not move." (18-year-old pregnant woman, Rukiga drama).
Implant insertion and removal procedure
Many potential users of implants shy away from using it since they had heard exaggerated tales of its insertion and removal. To address this concern, the documentary film included clips of the implant being inserted and removed. It was however not possible to include this in the drama. The vast majority of participants were surprised by the simplicity of the procedure, which alleviated their fears.
"It was good because I thought that they make a big incision… but I have seen that it is ok." (21-year-old pregnant woman, Luganda documentary).
"It was practical. Some mothers think that during implant insertion, they cut the whole arm. They even think that removing it is difficult. So, when they watch this film, they will understand how it is done." (21-year-old midwife, Rukiga documentary).
"I have realized that my friend lied to me that during insertion, they just inject a drug. I have seen how it is, inserted and removed." (24-year-old woman, Luganda documentary).
On the other hand, a small minority of participants were concerned about the pain the woman goes through during the procedure or were scared seeing the procedure, which might deter them from using the implant.
"I did not like the part of inserting and removing of the implant because it seemed painful." (19-year-old pregnant woman, Rukiga documentary).
"The way they insert the implant is disgusting. It is so catchy but irritating." (33-year-old man, Luganda documentary).
Although the drama did not show how the implant was inserted or removed, some participants also felt that the drama helped to address their fears and concerns about implant insertion and removal.
"I was worried about cutting to insert it. I noticed that other women are using it so, I think that I can also use it." (19-year-old pregnant woman, Luganda drama).
Changes in attitudes towards family planning after watching films
Many viewers reported a positive change in their attitudes towards family planning after watching the films. The films passed several subliminal images, including that family planning helped people to be healthy and to become wealthier. Women were particularly influenced by the idea that family planning could improve their appearance and that of their home and children.
"It has shown us that when you give birth several times, you look unhealthy, and your home can't look good. Even if one met you, they can't think you have those children. So when you use family planning, your home will look good, and you and your children will look good." (28-year-old pregnant woman, Rukiga drama).
"The advice was good because if you don't give birth every day, you look good and healthy, and your husband also understands that you are beautiful. When you give birth frequently, your husband goes to look for the ones who are beautiful. But family planning helps you to keep young and beautiful, and your husband will keep with you." (24-year-old postnatal woman, Rukiga drama).
Men liked the concept of planning when and how many children to have, as they felt this would make it easier for them to support their family and organize their finances.
"This family planning method enables one to develop himself. When you agree with your wife, you can use this method, and it works for you well - even poverty will be fought against when using this method." (Man (unknown age), Rukiga Documentary).
The character of the drunkard in the drama appears to have been a particularly powerful force for change, in that many men did not want to be irresponsible like him.
"A responsible man should let his wife use the implant so that he doesn't get in the state of failing to get resources to take care of the children because such children won't get a chance to go to school. They won't even eat well. Even the woman looks unhealthy." (38-year-old man, Rukiga drama).
"What I have learned from the film is that it helps you to stop having stupid thoughts like the one the drunkard had that "the Bible says, produce and multiply." (21-year-old man, Luganda drama).
The drama also specifically improved attitudes towards the implant as opposed to other forms of contraception.
"I have understood that the women who use pills are not safe. Sometimes you can go back home drunk, and maybe she hasn't gone to the health unit to pick her pills, you end up impregnating her. Yet for an implant, it can even spend five years which is a good method." (Man (unknown age), Rukiga drama).
Information provided was about specific side effects of the implant, how they can be managed, and how they impacted users, improved participants' confidence in the uptake of family planning. Addressing side-effects also helped to allay these fears and led to a more positive attitude towards the implant.
“I was also afraid of using it because of the side effects I heard about it, but I have learned that they happen for a short period of time.” (29-year-old pregnant woman, Luganda drama) "I preferred the drama because I came with a bad attitude towards the implant because it can cause bleeding but, after watching the drama, I learned that it can be managed." (25-year-old man, Rukiga drama).
"It has encouraged me because if I experience some side effects, he can easily understand the cause so that we go the health centre, and then they see what they can do for us." (24-year-old pregnant woman, Luganda drama).
Change in intention to discuss family planning after watching the films
Indeed, the drama was likely to encourage discussion about family planning among spouses since women need support from their spouses especially when they get side effects.
"For me, I have seen in this film that when you do not tell your husband before using a method of family planning, it is bad. When you face challenges, he will assist you because he will be knowing the cause, and he will be patient with you." (37-year-old woman, Rukiga drama).
"I have realized that discussing family planning with the husband is good. It will help keep peace in the home." (20-year-old woman, Rukiga drama).
Men also changed their attitudes about agreeing with their wives to use family planning after watching the drama. This is important because so many women do not have agency to choose family planning without their husbands’ consent. The question remains if men will be able to see films in health centres.
"In the past, we as men have not been supporting family planning. Women somehow are educated, and they know something about family planning. Since the men do not understand much about it, they continue discouraging it. You find that since the woman knows about it, she goes ahead and uses it without the husband’s knowledge. Through this film, I have learned that sometimes we have to agree." (39-year-old man, Luganda drama).
The documentary also encouraged viewers to discuss family planning with their partner, especially the part showing a couple doing exactly this. Both men and women felt this was a convincing delivery of a message which applied to both husband and wife. The unity of the couples involved gave participants, especially women, the confidence to involve their partners and to begin using family planning.
"Like that part where a man, a woman, and their child were seated together, I think that when you watch this film with your husband, he can allow you to use family planning method and use the implant." (21-year-old postnatal woman, Rukiga documentary).
"In the documentary, we saw husband and wife seated together. The man was supporting the use of the implant." (16-year-old pregnant girl, Rukiga documentary).
However, a few of the viewers were sceptical about the documentary influencing them to initiate a discussion about family planning with their partners. They thought it was the role of health workers to talk about family planning.
"If I went now and tried to give this advice to my wife, she would not like it more than if the nurse teaches her herself. Women tend to believe more in the health workers." (Man (unknown age), Rukiga documentary).
Participants also said that both films encouraged them to discuss family planning with others:
"Those testifying about this implant, we have seen their faces, and we know them. They have the truth. This has made me like it, and I will even teach it to someone else in my family." (Man, unknown age, Rukiga documentary).
"The film is good; I have learned something in that I can even educate like my sisters and my friends. I can also educate others." (43-year-old man, Luganda drama).
"I have learned that family planning is good. I will tell my friends about it. I will tell them that they need to talk to their husbands and agree before using a method." (19-year-old pregnant woman, Rukiga drama).
Change in intention to use the implant
After watching the films, all participants were asked whether they would use the implant; all replied that they would. After seeing the documentary, women deemed it important and necessary to use the implant after delivery before being discharged home.
"Like we are here as women, some of us are pregnant, others have just given birth. Women should reach agreement with their husbands, and they start using family planning methods immediately after birth. You can go home without it and think you will come back to the health unit after six weeks, and before you know it, you conceive before then, thus not spacing your children. I suggest that women should go home with methods of family planning, so that they can have healthy children." (24-year-old postnatal woman, Rukiga documentary).
The film part of the insertion and removal of the implant particularly encouraged some participants to tell others to use the implant, since they had learned how simple the procedure was.
"What I have liked about this implant is that it was inserted in a woman while I watched, and then removed while I watched still. That means that it can be put and removed at any time, and the woman conceives. When I am in the village, I can tell them that when you use the implant, it can be removed when you want a child." (Man, unknown age, Rukiga documentary).
The drama also encouraged participants to use the implant, although the strongest message was the need to first discuss it as a couple.
"I should encourage my wife to use it to have a family that we can manage." (38-year-old man, Rukiga drama).
"The film was good because it has taught me that I need to first reach agreement with my husband before going for family planning to prevent chaos." (24-year-old pregnant woman, Luganda drama)
Overall preferences of documentary versus drama
Participants were asked which of the two films they liked most. The participants' preference was almost equally split between the drama and the documentary. People preferred the drama felt this was due to better communication, being persuasive, both sides of the story being shown, and being more relatable. They particularly liked to see the drunkard eventually being convinced by his friend to accept family planning:
"It was educative to the extent that even those who were not willing to join family planning can finally accept after being counselled by the health worker, just like the drunkard who had refused." (22-year-old pregnant woman, Luganda drama).
"I liked the drama because it shows what is going on in the community. It shows that use of the implant is good." (19-year-old pregnant woman, Rukiga drama).
On the other hand, participants who preferred the documentary cited that it was more educational, explained side effects and myths more clearly, and showed how it was inserted and removed.
"The documentary explained it very well, and it showed us what to do." (45-year-old man, Luganda documentary).
"I like the documentary because it exhausted everything about the implant like even the person who was addressing the film explained everything and yet in the drama, they just addressed the myth that one had said, and they never went deep to explore everything." (22-year-old nurse, Rukiga documentary).
"In the drama, they were just talking, but in the documentary, they have shown us where the implant is inserted. Some people told us how old their children are so you can see that they are spacing." (23-year-old pregnant woman, Luganda focus group).
Some participants liked both films equally; they felt that they were complementary to each other and could be used together. Some of them even suggested that the films could be merged. They also suggested that the drama should be screened first before the documentary.
"Both films are good because both are educative. The documentary - there were things for us to learn; even the drama - we have seen how one can start using this method." (35-year-old pregnant woman, Rukiga focus group).
"Between the two nurses, the nurse in the drama and her bit was just informing us about what we should do, but the documentary was real, so you should merge the two films; start with the drama and end with the documentary." (48-year-old man, Luganda focus group).
"Ah...now you see our people in the community; you first have to entertain them (drama) and then you give them the information (documentary)." (Male medical officer, Luganda focus group).
Participants said that health education films had advantages in promoting family planning use. They said the films will help in creating awareness about family planning, they are entertaining, persuasive and attractive so people will pay attention, they are educative to both young and old people, they will attract more people to health facilities, and they can be watched as clients wait to be served by the health service provider. Health workers were keen to show the films, which can be screened repeatedly, and this would save them time in giving health education talks.
"Films are acted once, and people keep learning from them for a very long time." (42-year-old midwife, Rukiga focus group).
"Films provide health messages to a larger group of people, compared to if someone had to educate those big groups." (38-year-old midwife, Rukiga focus group).
"Actions speak louder than words, and pictures explain messages better." (33-year-old female laboratory technician, Rukiga focus group).