Data are presented based on community members’, healthcare providers’ and key stakeholders’ perspectives. Through the data analysing process, four core thematic categories emerged as critical to facilitating community participation in FP/C services. These include accountability, community engagement, building trust and facilitative strategies. Though this study explored perspectives from a varied group of participants, no major differences in perspectives according to participant category were reported with regards to community participation in FP/C services.
Table 3: Data code-list
Accountability in FP/C services provision
- Defining the context of participation
- Defining who participates in FP/C services
- Incorporation of community feedback in FP/C services programming
Engagement of community structures/resources in FP/C services provision
- Involvement of family planning champions
- Leveraging established community structures
- Motivation of community members
- Capacity building of FP/C services counselling among volunteers
Building trust in FP/C methods/Services
- Promotion of appropriate FP/C methods/services
- Community and health provider meetings/dialogue
- Ensuring credibility of community-based distributors
- Defeminisation of FP/C services
- Health facilities responsive towards the delivery of adolescent FP/C services
- Accountability in recruitment of community participants and incorporation of community feedback in family planning and contraceptive services provision
Accountability was thought to be an important factor in facilitating community participation in FP/C services provision. Both the community members and HCPs indicated that to facilitate community participation, FP/C services programmes had to be accountable in the way they defined participation, recruited community participants, as well as embraced community feedback. Community participation was defined as the willingness to be 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 programmes of mutual benefit. Community members expressed that participatory programmes were beneficial if they facilitated knowledge, skills and resource sharing. Additionally, they expressed that meaningful community participation in FP/C services could only be attained if community members were adequately sensitized about the programme before 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]
The community members narrated that people were more likely to be encouraged to participate in FP/C services when they felt the right beneficiaries are engaged. They suggested some possible participants in FP/C services activities. They indicated that both adults and adolescents should be involved because FP/C is a cross-cutting issue.
“I think it’s everyone who should participate. Both adults and young people because these family planning issues 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 the community members and HCPs felt that since men are key decision-makers in FP/C methods choices, they need to participate in FP/C activities so that they could better understand the benefits and therefore provide support to their female partners. They indicated that it was important for FP/C programmes to find innovative ways to involve men. Further, 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.
“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 childbearing 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]
The study participants narrated that incorporating community feedback in FP/C services programming, using existing mechanisms, would facilitate participation. The HCPs reported that appropriate use of complaint/suggestion boxes in healthcare facilities by community members could be one such mechanism of providing feedback on FP/C services. Complaint /suggestion boxes provide a platform to get community member’s views on their experiences with the quality of FP/C services. However, the HCPs indicated that there was limited information in most communities on the role of complaint/suggestion boxes. They stated that in most instances, community members complained directly to government officials or the media rather than engaging with the health facilities.
“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 suggestionbox, they can even suggest on how best the FP/C 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. Sometimes you only hear of these complaints in the media or from the politicians” [Healthcare Provider FGD, Managerial, UZHG_H004]
Although suggestion/complaint boxes were widely available in all facilities, the HCPs indicated that they were not being used by community members. Community members believed that by using the suggestion/complaint boxes they would be risking their access to healthcare including FP/C services if identified by the HCPs. The HCPs suggested that community health workers (CHWs) be used to educate community members on the importance of these suggestion/complaint boxes. They also recommended that the boxes should be located in convenient places where potential FP/C services clients could drop their complaints/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]
- Engagement of existing community resources and structures
The second thematic category underscores the significance of utilising local resources such as community leaders and community-based health structures and providers. These local actors include influential persons, while the structures include community level health committees. Involving influential community persons, such as councillors, ward committee chairmen, religious leaders, headmen and chiefs, in community FP/C services provision efforts would facilitate community participation as these are gatekeepers who commanded respect in society. Some of these leaders had already been selected as FP champions to lead community mobilisation efforts in previous programmes. It was indicated that champions could use their political, traditional and religious influence to increase awareness 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]
Both the HCPs and community members, particularly those from rural areas, indicated that community participation could also be facilitated through exploring and strengthening existing community health governance systems such as Neighbourhood Health Committees and community based health workers such as Traditional Birth Attendants, Safe Motherhood Action Groups and Community-Based Distributors. These community-based health structures and providers act as a link between the community and healthcare system, providing a wide variety of healthcare services. They conduct health education as well as provide FP/C methods such as oral contraceptive pills and condoms to communities. The HCPs stated that it was easier to work with the CHWs because of the already established relationships with the community members.
“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]
To further promote participation of local healthcare providers, community members suggested that volunteers ought to be capacitated in providing contraceptive injections as well as FP/C counselling services to supplement the HCPs. It was reported that some volunteers had challenges approaching households that did not subscribe to the idea of FP/C methods in rural areas. Such households would benefit from capacitated volunteers who do not only possess counselling skills but also the right approach technics to engage all households. Further, it was recommended that these counselling and outreach activities needed to build the capacity of households to freely discuss FP/C.
“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 that they are sexually active... I think community volunteers should encourage this practice in their outreach activities.” [Male FGD, Young Adult, UZFG_UZMG_Y003]
The community members on the other hand, reported that discontinuation of most partner funded participatory health programmes was a challenge to participation. Some community members were said to be demotivated to get involved in new programmes as they had concerns that they may eventually close down. They reported that this often occurred at the end of a project life after the termination of funding supporting participatory activities such as sport, drama and community groups. It was expressed that some people participated in these activities with the hope of acquiring benefits, and when there was none, they left. The community members recommended there was a need to motivate community members for them to continuously participate in FP/C services activities.
“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]
- Building trust in family planning and contraceptive methods and services
The third thematic category emphasises the role of building trust in FP/C methods/services to enhance community participation. One of the key challenges with regards to sustaining community use of contraceptives methods/services was addressing the associated myths and side effects. Community members thought such challenges could be addressed through building trust in FP/C methods and services by developing and disseminating appropriate information, community dialogues, as well as, community participation in selecting community-based distributors. Community members reported that the promotion of specific FP/C methods to suit different user needs was cardinal in facilitating participation, as well as building trust in FP/C services. They emphasized the importance of providing appropriate information on FP/C methods’ side effects, to counter myths as well as address discontinuity. They suggested that diffusion of information among community groupings such as local support and women groups was vital in building trust in FP/C services among social networks. It was also indicated that there was need to ensure that appropriate information was developed through joint planning and information dissemination with the church.
“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]
The key stakeholders futher indicated that participation and trust in FP/C services could be enhanced if the HCPs engaged community members in service provision using platforms such as community dialogues/meetings. The community members narrated that dialogue between the community and HCPs regarding adolescent use of FP/C methods would encourage parents to begin opening up to adolescent use. Further, these dialogues were also said to allow community members and HCPs to jointly develop solutions and address issues affecting FP/C services, hence foment participation and trust.
“Continuous dialogue, training and meetings and other interactions between health workers and the community will make people 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]
Engagement of the community leaders in selecting community based distributors (CBDs) was another strategy for building trust as it promotes credibility of the CBDs. The HCPs expressed that the CBDs tend to face rejection if community members suspect that they are inappropriate to provide FP/C methods/services. This affected demand and trust in FP/C methods/ services as community members would question the credibility of CBDs. It was suggested that the selection of CBDs be done with the approval of the local leadership and general community membership to legitimise their work and enhance trust in the FP/C services. This locally-driven process assured community buy-in and support for FC/C services.
“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]
- Facilitative strategies in family planning and contraceptive services
The fourth thematic category underscores community experiences with the status-quo and how it affects participation in FP/C services programmes. It highlights critical challenges to participation inherent within the design of health system structures for FP/C services and the possible role of facilitative strategies. The participants discussed various strategies including defeminisation of FP/C services and making the health facilities responsive to the delivery of adolescent FP/C services. The key health sector stakeholders narrated that FP/C services were predominantly designed for women, which consequently excluded men from participating. This was visible in the terminologies used to refer to certain FP/C services which seemed to imply that they only concerned with women. For example, the terms “Maternal Child Health” or “Prenatal Services” were said to be designed without men in mind. According to the key stakeholders, embracing inclusivity would require revisiting the naming of certain FP/C services as well as creating the infrastructure that is welcoming to both males and females within the health system.
“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]
Supporting youth friendly corners was cited as another key facilitative mechanism. Most of the HCPs reported that the youth-friendly corners at their health facilities were not fully functional. Not many youth were utilising FP/C services due to logistical and local challenges such as stigma, lack of privacy and confidentiality. It was suggested that enhancing youth-friendly corners’ capacity to respond to adolescent-specific FP/C service needs and challenges would facilitate youth participation. Strengthened youth-friendly corners would provide a platform for HCP and adolescent engagement, as well as peer to peer learning mechanisms in FP/C services programming. Further, it was reported that providing adequate logistical support to youth-friendly corners would also encourage youth 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 in the whole province and some of them are not fully functional. There is [a] need to increase the number of and improve support to youth-friendly corners in all the facilities if we are to improve adolescent use of contraceptives” [Key stakeholder, Health sector, UZI006]