Though the UPTAKE Project explored perspectives from a varied group of participants, no major differences in perspectives were reported amongst them with regards to community participation in FP/Cs services. Data are presented based on community members’, healthcare providers’ and key stakeholders’ perspectives. Through the process of analysing the data, four core thematic categories emerged from the data as critical to facilitating community participation in FP/Cs services. These include accountability, community engagement and learning approaches, trust building and facilitative strategies.
Accountability in FP/C services
• Appropriate community representation
• Incorporation of community feedback in programming
• Effective suggestion boxes usage
Engagement of community structures
• Involvement of family planning champions
• Youth engagement through youth friendly corners
• Leveraging established community structures
• Appropriate and timely information on FP/C methods
• Community and provider regular meetings and information exchange
• Credibility in selected community facility representatives
• Defeminization of contraceptive services
• Motivation of community members
1. Accountability in FP/C services provision
Accountability was generally thought to be an important component of FP/C services programs. Both the community members and HCPs indicated that to facilitate community participation, FP/C services had to be accountable in various aspects. This thematic category underscores the importance of FP/Cs programs’ responsibility to ensure that appropriate people are involved in FP/Cs, they strengthen community FP/Cs services feedback mechanisms, as well as ensuring that participation occurs within the local context of a given community to facilitate participation.
a. Defining participation and who participates in family planning and contraceptive services programmes
According to both community members and HCPs, community participation was defined as the willingness or process of being involved in activities that improved the lives and health of communities. It was a combination of community member efforts in activities and programs of mutual benefit. Community members thought participatory programs were beneficial as they facilitated knowledge, skills and resource sharing. Additionally, they expressed that meaningful community participation could only be attained if community members were well sensitized about a given programme or activity prior to implementation.
“I think community participation this is the willingness of the community to participate in all the activities that are taking place in our centres. Since we are talking about family planning, it means they should involve themselves in sensitizing people especially to those who have knowledge about it. They should take part in sensitizing those people who don’t have knowledge about family planning, that’s what I think.” [Female FGD, Unmarried, UZFG_C008]
“I think I can define it, I can define it… as how an individual or the attitude and maybe the effort in which you put in doing things [for] the community.” [Male FGD, Adolescent, UZMG_T007]
Community members suggested a number of possible participants in FP/C services activities. They recommended that both adults and adolescents should be involved because FP/C is a cross cutting issue. Bringing them together would help foster understanding and create the much-needed community support for adolescent use of SRH services. It would also help deal with the judgement and stigma causing possible discomfort that either of them may experience when accessing FP/C services at health facilities. The adolescents indicated that such participatory programmes could offer an opportunity for them to learn from adult experiences in using FP/C methods and services.
“I think it’s everyone who should participate. Both adults and young people because this affects all of us.” [Female FGD, Urban Adolescent, UZFG_UT002]
“Also, the parents, they have to be involved in the programmes so that they support their children, so that they don’t feel shy about it” [Male FGD, Young Adult, UZMG_Y006]
Both community members and HCPs felt that since men are key decision makers in FP/C methods choices, it is imperative that they participate in FP/C services so that they can better understand the benefits of these services and therefore provide support to their wives/female partners. They indicated that it was important for FP/C programmes to find innovative ways to involve men. It was felt that both married and unmarried, as well as the sexually active and non-active community members should participate in FP/C programmes to get empowered with information for them to make informed reproductive health choices.
“Both men and women should play an active part because if part of the community say ‘no this is for females alone’, then we will not win. But if everybody in the child bearing age plays an active part such that when they are given information, they share with a neighbour, then this information will go to the whole community and everyone will access family planning.” [Key stakeholder, Health sector, UZI003]
b. Enhancing established feedback mechanisms –suggestion boxes
The HCPs reported that regular and consistent use of suggestion boxes in healthcare facilities, by community members, is essential to providing feedback on FP/C services. Suggestion boxes provide a platform to get community member’s voices on their experiences with FP/C services– the lapses and how to improve quality. However, there was no clarity on how these suggestion boxes were introduced and what role the community played. HCPs also stated that there was limited information in most communities on how to appropriately use suggestion boxes.
“You can get information from the community’s responses to the services that are provided through the suggestion box as one of the ways. Through the suggestion box they can even suggest on how best the services can be rebuilt in a health facility where they seeing some lapses. However, community members don’t know how to use these facilities well” [Healthcare Provider FGD, Managerial, UZHG_H004]
Although suggestion boxes were widely available in all facilities, HCPs further indicated that they were not being used by community members. Community members believed that by using suggestion boxes they would be risking their access to healthcare if identified by the HCPs. HCPs suggested that community health workers (CHWs) could be used to educate community members on the importance of these suggestion boxes, and that they should also be located in convenient and private places where clients/potential clients could drop their suggestions without fear of possible discrimination or stigmatization.
“Currently, suggestion boxes are not being utilized as they are supposed to be, because community members usually fear to be seen. They think maybe they might be stigmatized once they are seen going near that box to put in whatever suggestion they may have.” [Healthcare Provider FGD, Managerial, UZHG_H009]
2. Engagement of community structures
The second thematic category brought to the fore the importance of engagement in facilitating community participation in FP/C services. Participants identified some of the structures already doing FP/C work within their communities and how they could best be leveraged. Further, participants identified particular categories of people with influence that could play a role in FP/C service provision, including information dissemination and demand creation. For example, they described the critical role of FP/C champions and community groups, churches, and support of youth friendly corners as ways to reach out to adolescents.
a. Working with family planning champions
HCPs suggested that involving influential community persons, like councillors, ward committee chairmen, religious leaders, headmen and chiefs, in community FP/C services sensitisation efforts would facilitate community participation. Leaders were stated to command huge respect and were viewed as gatekeepers in society. Some leaders had already been selected as FP champions in previous programmes in order to lead community mobilisation efforts. It was reported that champions could use their political, traditional and religious powers to influence others on the importance and benefits of participating in FP/C services programmes.
“I think if we can involve the leaders, we bring them on board and teach them the importance [of] family planning, it will help us a lot. You can imagine how many people are staying in [name of area], but there is headman there, there is a leader there, who can influence those men and make them understand the importance of family planning.” [Healthcare Provider FGD, Frontline, UZHG_L004]
b. Support and strengthen youth friendly corners
Whilst most HCPs reported that their facilities had youth friendly corners –spaces where adolescents can access SRH services at health facilities– they also indicated that many were not fully functional. Not many youths were utilising these services due to logistical and local challenges, particularly due to stigma/judgment around adolescent use of FP/C methods/services. It was suggested that youth friendly corners be strengthened to deal with adolescent SRH needs– through providing incentives and enhanced youth participation. Strengthened youth friendly corners can provide a platform for dialogue between HCPs and adolescents, as well as sensitization on FP/C methods and services use, hence facilitating participation.
“I think in the past we have somehow overlooked the teenagers, but there is now more emphasis on teenagers. The last time we had a planning meeting, we only had 12 youth friendly corners the whole province and some of them are not fully functional. There is need to increase the number of and improve support to youth friendly corners in all the facilities, if we to improve adolescent use of contraceptives”. [Key stakeholder, Health sector, UZI006]
c. Leveraging local community and sexual reproductive health non-governmental organisation structures
Both HCPs and community members, especially those from rural areas, pointed out that community participation could be achieved by exploring and strengthening existing structures of community healthcare cadres such as traditional birth attendants, neighbourhood health committees, safe motherhood action groups and community-based distributors. These act as a link between the community and healthcare system, providing a wide variety of healthcare services to people who cannot be reached, due to factors such as long distances from facilities. For example, they conduct health education as well as provide actual FP/C methods such as Oral Contraceptive Pills and condoms to communities in hard-to-reach areas, together with information on other methods available at the facilities. The HCPs stated that it was easy to work with the CHWs because they can be motivated with non-financial incentives. They also stated that CHW, if trained, could as well learn to provide contraceptive injections in the community.
“In this community, we have what we call the Safe Motherhood Action Groups, these usually disseminate information within our community, but for Kabwe I think the only people that are used to provide that information are the Community Based Distributors. Those are the ones that disseminate part of the information on family planning and also distribute basic family planning commodities.” [IDI, Key stakeholder, Health Sector, UZ1006]
“The community health workers are motivated when they are called for a meeting, and then they are given books, ball pen or maybe a bag with an ID. It is a lot of motivation to them. Others feel like bicycles are more motivation to them so that they are able to reach other families that are far away and provide health education [to] them or maybe even give contraceptives.” [Key stakeholder IDI, Health sector, UZI006]
Local non-governmental organisations such as Society for Family Health, Marie Stopes and Zambia Prevention, Care and Treatment Partnership, were reported to be actively providing SRH services in most communities. The HCPs however thought that some NGOs were more focused on reporting improved quantitative indicators of service provision –that is the number of people accessing a given FP/C service, rather than the participatory processes that allow people to be more informed and involved in FP/C services provision. The emphasis on increased numbers of clients was reported to negatively affect the quality of FP/C services according to the HCPs. They suggested that the NGOs and health centres should work in harmony with the community members by providing accurate information as well as FP/C services.
“The biggest challenge we find as healthcare providers is that NGOs demand a lot of numbers [high level of commodity utilisation]. This tends to have repercussions on how we provide these services. Let’s say maybe in a day I have been assigned to insert twenty Intra Uterine Contraceptive Devices, I won’t have much time to give all the information for each and every other method which we may have, in a rush to reach that set target”. [FGD, Frontline HCPUZHG_L003]
3. Trust Building
This thematic category highlights the importance of building trust in FP/C programmes to enhance community participation. One of the key challenges with regards to sustaining community use of contraceptives methods/services was addressing the myths and side effects associated with use of these. Community members thought it was important that HCP provided adequate information explaining method side effects, in order for them to trust and participate in FP/C programmes. They underscored the importance of providing information on what specific methods are suitable for different users, for more awareness and informed participation. Further, the participants narrated that community representatives such community-based FP/C distributors needed to be credible, that people with respected local opinion for them to win the trust of the community members.
a. Promotion of appropriate family planning and contraceptive methods and information
Community members indicated that promotion of specific FP/C methods to suit different users’ needs, was cardinal to facilitating participation in FP/C services. If this was implemented, users would not need to try various methods and experience side effects, before choosing an appropriate FP/C method. Further, community members emphasized the importance of providing appropriate information to counter misinformation around FP/C methods in the community. They suggested that information dissemination targeting community groupings such as women’s group was cost effective for any successful participatory effort. Some of the grouping referred to included youth groups, women’s groups, local supports groups and the churches. They thought capacity building of various groupings in FP/C methods information dissemination would facilitate reaching a large number of people. It was also reported that FP/C promotion activities need to involve various stakeholders, at both community and health system levels, to not only facilitate co-planning, but also building of mutual trust and support for services.
“I think maybe they should be people from the church and people from the health sector and again from the community so that when these people [sit] together, they can plan well, if there is a person who has to talk about natural family planning, they should talk within the same fora.” [IDI, Key stakeholder, Community leader, UZI009]
b. Community and healthcare provider meetings/dialogues
Key stakeholders reported that participation in FP/C programmes could be enhanced if HCPs were more willing to engage and work with community members in all aspects of service provision. Community members suggested this could be done via community dialogues, trainings or meetings. They indicated that attending community meetings on FP/C methods/services was motivating in particular to community-based distributors (CBDs), because it allowed them to gain more knowledge. Community dialogues were also highlighted to be an important platform for engagement of HCPs with community members on FP/C services. For example, community members stated that that ongoing dialogue and meetings between the community and HCPs regarding adolescent use of FP would be important to encourage parents to open up towards adolescent use of FP/C services. Further, the dialogues could allow for community members to share their concerns about FP/C services. The community members narrated that with proper training on use and increase knowledge about methods and side effects, CBDs could properly explain FP/C methods to the community member and hence foment trust and awareness.
“Continuous dialogue, training and meetings and other interactions between health workers and the community will make people become aware of the benefits of family planning and participate in these programmes. It [is] also a nice platform for people to talk about some of the issues they have with family planning [Male FGD, Urban Male Adolescent UZMG_A003]
c. Credibility of community representatives
Healthcare providers expressed that CHWs may face rejection if the community members think that they are not knowledgeable enough to talk about FP/C methods and services. In such instances, their credibility would be questioned, hence affecting community members’ demand for FP/C services. It was also suggested that selection of CHWs should be done with support from local leadership and general community membership, otherwise they could face challenges in executing their duties. This locally driven process assures community buy-in and support, and ensures that community members with credible reputation are selected.
“Concerns are there sometimes because of their status especially where we don’t call the leader to explain to them that these are the people who we will be working with and will be in the community. The leaders will reject them because they have never been chosen by the leaders,” [Healthcare Provider FGD, Frontline, UZHG_L002]
4. Facilitative strategies
This thematic category underlines community experiences with the current set-up of FP/C services programs, and how this affects participation. It highlights critical challenges to participation inherent within health systems structures and the possible role of facilitative strategies. The participants discussed the feminization of family planning, demotivation of community members due to short project life and the valuable role of facilitating male involvement in addressing some of the issues.
a. Defeminisation of family planning and contraceptive services
Key health sector stakeholders narrated that FP/C services were predominantly designed for women, which deliberately excludes men from participating. The terminologies used to refer to particular FP/C services seemed to exclusively imply that only women are to be involved, while this is in the contrary. For example, the terms “Maternal Child Health” or “Prenatal Services” were felt to be discriminatory to men. According to the key stakeholders, making services inclusive would require revisiting the departmental names as well as creating infrastructure that is welcoming to both males and females within the health systems.
“When you say parental, even I as a man I will feel welcome at this place. But if you are telling me this is a clinic for mothers and children you have excluded the men. You even go to the extent of creating a Ministry of Gender where you are excluding them [male].” [IDI, Key stakeholder, Health sector, UZI007]
Outreach activities that encourage parents to talk about contraception with their children were suggested, as critical to supporting adolescent FP/Cs services within communities. Community members suggested that community volunteers, like the NHCs and SMAGs could be further trained in counselling services. Counselling skills and approach technics were said to be vital especially in rural areas, where some male community members were thought to be against the idea of FP/C methods.
“Even before we access the Family planning from the clinic, even in our very homes we are coming from, we should try to talk to our children about the benefits of family planning since we know it already as parents. I think health providers should encourage this practice in their outreach activities.” [Male FGD, Young Adult, UZFG_UZMG_Y003]
b. Motivation of community members
Community members reported that discontinuation of most funded participatory health programmes was a challenge to participation, whereby community members may be demotivated to participate in new programmes as they have concerns that they may eventually close down. They reported that this often occurs at the end of a project life when there is termination of funding supporting participatory activities within community groups, such as sport, drama and other local groupings. Although clubs/groups were viewed as more organized platforms for sharing and transmission of information among community members, it was described that recently, some of groups like the drama clubs and the football clubs had not been working due to lack of motivation, disinterest, lack of time and support. It was described that the challenge sometimes was that people participated in these groups with the hope of acquiring monetary or material benefits, and that when there was none, they simply left. Key stakeholders suggested that it was important for programs to embed some activities within routine community practice as opposed to having all activities program fund dependent to allow for sustainability as well as continuity.
“What I can say is that all the clubs, community groupings, the drama clubs and even sport, they can work and again they can’t work. What makes them work is the motivation. Wherever you go, when there is no motivation, nothing works, and where there is motivation things [go] well.” [Male FGD, Urban Young Adult, UZMG_Y001]