A total of 1,410 participated in the study, majority (1143; 81%) of whom were from Kigungu (Table 1). The mean age was higher in Nsazi than in Kigungu and in both sites males were older. Majority of the men in Kigungu (338; 58%) and in Nsazi (97; 82%) were engaging in fishing or a fishing related activity. A small number (62; 4%) of the participants were students residing in Kigungu, the majority (39; 63%) of whom were males. Half (706; 50%) of them had attained only up to primary level of education with very few (106; 7%) in both villages reaching the tertiary education level, and more males attaining that level in both villages. Most (1,043; 74%) of the participants stayed over twelve months in the community. Majority (1,157; 82%) of the participants reported being in a sexual relationship even though just over a half (810; 58%) of the participants were married. In both villages, more than half of the male participants, Kigungu (297; 51%) and Nsazi (81; 68%), reported having multiple sexual partners in the past 12 months. Nearly all the participants indicated the ideal number of children for a couple as four or fewer children (1134; 80%) and the ideal spacing interval as 2 or more years (136; 97%).
Almost all (1,333; 95%) the participants were able to list without prompting at least one method of family planning (Table 2). Nineteen (1%) and 292 (22%) of the participants who knew at least one family planning method had correct or satisfactory family planning knowledge respectively. The short acting reversible methods (pills, injectable methods, condoms) were the most commonly known family planning methods (98%). 75% of the participants knowledgeable about family planning were aware of long acting reversible methods (implants and IUD/coil) while 10% were aware of permanent methods (vasectomy and bilateral tubal ligation) and 21% were aware of natural or traditional methods (periodic abstinence, calendar, breast-feeding rhythm/withdrawal, moon beads)
Factors associated with satisfactory family planning knowledge were age, employment status, level of education, area of residence, marital status, having multiple sexual partners in past 12 months and currently being in a relationship (Table 3). After adjustment, participants aged 30-39 were more likely to have satisfactory family planning knowledge compared to those aged 16-29 years (aOR: 1.59; 95% CI: 1.14-2.22). An occupation in trade/business (aOR: 3.14; 95% CI: 1.21-8.17), or as a house wife (aOR: 3.69; 95%CI: 1.35-10.1) were better correlates of satisfactory knowledge as being a farmer. Participants who resided in Nsazi (the island site) were more likely to have satisfactory family planning knowledge (aOR: 1.58; 95%CI: 1.09-2.30) compared to those in Kigungu. Participants were also more likely to have satisfactory family planning knowledge if they were married (aOR: 6.96; 95% CI: 3.42-14.13) or if they were divorced, separated or widowed (aOR: 17.67; 95% CI: 8.54-36.54) compared to those who were single.
Findings from the qualitative aspect of the study
Four FGDs (One of female and one of male minors aged 16-17 years, one of female and one of male adults aged 25-49 years) each comprised of 8-11 members and ten one-on-one IDIs from significant members of the community including a community advisory board member, religious leader, political/ local council leader, Commercial Sex Worker, Traditional Birth Attendant, Village Health Team member and some study participants were conducted in a total of 47 individuals. Each discussion or interview lasted approximately one hour. We identified four themes relevant to knowledge of family planning: 1) General community understanding and awareness of family planning, 2) Beliefs and Attitudes towards family planning, 3) Known sources of information on family planning with their related challenges and 4) perceived reasons for or choices of preferred methods.
General community understanding and awareness of family planning
The first theme which emerged revealed that the community members generally understood the concept of family planning and that they were all aware of at least one family planning method. The Methods that were mentioned included pills, injectable methods such as Depo-Provera® or injectaplan®, condoms, implants, intra-uterine device, vasectomy, bilateral tubal ligation, withdrawal, calendar method, breast feeding and abstinence. Although the awareness of family planning methods was high, participants didn’t seem to know much about how and for how long most methods work. While some appreciated that family planning was for both limiting the number of births and allowing a good spacing interval between births, there were others who thought family planning may affect future fertility or even induce permanent sterility. A male respondent in an in-depth interview said, “The understanding of family planning in this community is that it is used to completely stop one from getting children and yet it should really be for spacing births. Majority think that when you use family planning you stop giving birth because your eggs get damaged.”
Like what was observed in the survey, most of the community members were mostly aware of modern family planning methods like pills, injectable hormonal methods, implants, intra-uterine devices and condoms. There were participants who knew about both modern and natural or traditional methods of family planning. They however mentioned the complexity of using the natural or traditional methods which they said were not reliable. Many of the participants knew that condoms can prevent both pregnancy and sexually transmitted diseases and commented that condoms were popular. They however said that using condoms consistently was difficult especially for the men who think that condoms interfere with sexual satisfaction. A few know that condoms are the only family planning method for men. There are others who said condoms were difficult to use in a married setting resulting in mistrust and misunderstandings in the home. Some expressed concerns about limited knowledge on condom use among the youth saying that the youth may be stigmatised and shy away from getting the required family planning knowledge before engaging in sexual activities.
Some participants didn’t know about the female condom and the few who knew about it neither knew how it works nor where it can be accessed if one wanted to use it.
Some of the knowledge community members had about family planning was inaccurate. Although many have heard about injectable methods for females, there are those who said that they heard that men too have injectable hormonal methods of family planning. Some said that vasectomy can make a man fail to get an erection or release sexual fluids.
Like the female condom, some modern family planning methods were either not known or not mentioned at all by the focus group or interview participants such as the diaphragm, spermicides, dermal patch and others. Some participants mentioned ineffective methods such as use of herbs and remains of an umbilical cord to prevent conception. One in-depth interview participant who is a Traditional birth attendant and a Community health worker or Village health team member said, “….I also know some herbs that one can use if they don’t want to use those other family planning methods I have listed”. The use of herbs was attributed to low levels of education by some participants who doubted their effectiveness. The use of remains of an umbilical cord was cited by some as a medically unproven family planning method.
Beliefs and Attitudes towards family planning
It was noted that people had divergent beliefs and attitudes towards family planning. Although some were supportive of FP, negative and incorrect beliefs still exist concerning effects of family planning on women’s reproductive health and health in general. We observed that some participants believed that family planning can lead to sterility, cancer of the uterus, abnormal uterine masses and foetal abnormalities or disability. A participant from a focus group of males aged 16-17 years said,” people fear to use a coil [IUD] because they think it can cause cancer or lead to barreness”. Because the menstrual cycle changes in some women who are using family planning, some participants believe that women who miss their periods, a side effect to some methods of FP, end up getting uterine masses.
Side effects of some family planning methods were pointed out such as weight gain or loss, menstrual irregularities or excessive prolonged bleeding, loss of sexual desire and reduced vaginal secretions. Some said that prolonged bleeding, loss of sexual desire and reduced vaginal secretions interfere with sexual activities which later result into family disputes. A participant in a focus group of male minors said,” Family planning is a long term issue which requires one to decide on what to do during the long periods of ‘no sex’ depending on the methods of choice used; some family planning methods make women lose their sexual desire. Some men cannot do without sex for a long time and that creates problems in the family.”
There are still some who report that family planning causes congenital abnormalities or abnormal features in those children born to mothers using family planning. Some do not trust information on family planning because they think health workers promote family planning for monetary gains.
Most of the participants think that family planning should be used by women and youth. They attribute this to the shift in gender roles where women in fishing communities bear the burden of fending for the homes and children. The youth are thought to have very little information on FP and yet they are reported to be mobile and promiscuous. A female participant in an in-depth interview said,” The men here tend to have many women. So if you get many children, you as the woman will suffer because you will bear the burden of feeding them, treating them and taking them to school. Our husbands these days neglect their roles of being heads of families. The women do everything. Because women are left to do everything, they end up engaging in other sexual relationships to get money.” Another female participant who is also a community health worker said,” Women are the ones who should use family planning because women these days have responsibilities like looking for food to feed the children, taking the children for treatment when they fall sick, buying clothes and paying school fees”.
Others say that because of their vulnerability, family planning should be a woman’s responsibility.
There are some community members who believed that family planning was for educated people and yet they were concerned about the few educated people in fishing communities.
Men’s awareness of family planning was thought to be low compared to that of the women and some report shame in attending FP sessions. One participant in an in-depth interview said,” It is only a small number of men who have attended family planning sensitisation meetings. ”The men feel ashamed to go with their wives to family planning sessions, they know it is a ‘woman’s thing’. Because of this, most of the men do not know much about family planning issues.”
It was observed that both men’s attitudes and their work schedules may hinder them from attending sensitization meetings.
Known sources of information on family planning and related challenges
Community members get information on family planning from various sources, some of which are formal and trusted while others are informal and doubted. The formal sources of information on family planning include; health facilities (both governmental and non-governmental), private clinics and media (print, audio and visual). Some of the informal sources include places of worship (churches and mosques), peers, schools, health outreach sessions and village meetings. Regarding sensitization by health workers, the issue of language barrier was one that was mentioned as a challenge to awareness. Because fishing communities attract job-seekers from across Uganda, there are those who are disadvantaged when they go to health centres where the staff only know English and the village’s local language.
A new trend of using social media as a source of family planning knowledge was cited although it was thought to be limited to those with smart phones and computers with internet. One participant from a focus group of male minors said,”…only updated youth get information about family planning from social media. The reason is not many people are educated enough to use social media or afford it but a few are there”.
Traditional “Aunties” were also known to provide information on family planning even though they were thought to lack formal training. In the Ugandan context, a traditional “Auntie” is a woman (usually advanced in age) who counsels other women on family issues and is entrusted by community members to do so based on her past experience.
Village Health Team members (VHTs) were noted to be another source of information, especially to those who are unable to access health centres due to long distances or stigma. These VHTs, however, were often reported as insufficient sources of family planning information. They refer those who require information on long term or permanent methods to big health centres.
Perceived reasons for preferred methods.
In these communities, different factors were reported to inform FP method choice. Some members said that some health facilities or clinics sell specific family planning methods and attendees get these methods if they can afford them. A participant from a focus group of female minors said, “If you go to the government health centres, it’s assumed that the medicines or services are free, but at times the health workers demand for some money before the services are provided. So if you have no money, you are denied the service”.
Others attributed choice of methods to their availability, known side effects of the methods, health worker skills and behaviour, invasiveness of the methods and preference of spouse. A participant from a focus group of female minors said, “Some preferred family planning methods are not readily available at the health centres, and usually the health centres stock methods known to be demanded by most clients, who use the services. A client may want a tubal ligation but health centres cannot do it. They end up referring the client who may not even go where they are referred because they don’t have money for transport.”