This section highlights the community dialogue implementation process. Thereafter, results according to the participant observations and from the FGDs are presented under the following headings: recruitment and identification (attendance), orientation and ground rules, participation in the community dialogue, the dialogue of FP/C, and QoC, technical, schedule and cultural feasibility.
The Community Dialogue Process
The community dialogue was conducted at a location in a suburban district of the Lusaka, outside the project intervention district. The entire dialogue took 125 minutes, with a 20-minute break. The dialogue sessions were divided among three facilitators who were project staff members, according to 3 sections: 1) Orientation, 2) Establishing ground rules, 3) refining the ToC approach (annexe 2: Agendas for Community Dialogue meeting)
The first presenter gave a detailed background to the project, its’ goals, and the aims of the community dialogue. This activity lasted 20 minutes. The participants were then asked to suggest some ground rules that they felt would guide community dialogue. The ground rules session took 15 minutes. The ground rules for the dialogue included: having respect for other people’s opinions, speaking loudly, setting mobile phones to vibrate or be silent, raising hands if they wanted a chance to speak, not having any side meetings, participating actively, staying on topic during the discussions, acknowledging that all the participants in the room were equal, confidentiality- no one’s opinion would be revealed after the meeting ended or any time thereafter. Reference was made to the ground rules throughout the dialogue. This was then followed by FGD with the dialogue participants to get their views on the entire dialogue process, and how it could be improved.
After setting the ground rules, the first facilitator presented the simplified ToC to the participants. This part aimed to show the participants how the discussions would lead to the overall outcome, which was to reduce the unmet need for family planning. To explain further how the ToC was going to be used, a simple dry-run was done. A discussion, led by the second facilitator, was introduced to identify the assumptions and causal pathways to improved QoC in family planning and contraception provision. The intermediate outcomes were then discussed, with activities and assumptions for each outcome. Some of the intermediate outcomes included: having qualified health workers, the availability of preferred methods at the health facilities, having more respect for clients and having more equipped family planning areas. This activity took 60 minutes.
Once the causal pathways, activities and assumptions had been identified, the third facilitator led a discussion on identifying the most feasible and acceptable pathways with regards to acceptability, demand, implementation, practicality, adaptation and integration of the pathways. This criterion was based entirely on each participants’ opinion and participants were encouraged to speak freely on the ‘best’ pathways that could achieve more than one intermediate outcome. This activity took 90 minutes. After the discussions using the ToC participatory-tool had been concluded, the first facilitator wound down the discussion with a summary of the community dialogue activity, concluded and thanked the participants for their active contributions throughout the discussions
Observations and Focus-Group results
Recruitment and Identification of dialogue participants
During the FGDs, while some health care providers felt that there was adequate representation in the community dialogue, the community members mentioned that the dialogues required more representative to produce even more relevant results. For example, there was a need for political leaders to also be represented. An adolescent said:
“We were not represented properly because were outnumbered, others were more, but we were just a few of us (…)”
[Community focus group discussion, Adolescent]
The community members also mentioned a need for representation from the churches and other faith-based organizations since it was recognized that they played an important role in shaping reproductive health behaviours. The community members also stated that the Community Health Workers were well represented, but that the pharmacists were needed to bring out more information on the vastly experienced stock-outs of family planning and contraception supplies.
“(...) I think to be specific, we should have some representatives from churches, yes, and from the political wing, the stakeholders they should have called them because they are part of it (the discussion on family planning and contracdeotion) as well.”
[Healthcare provider focus group discussion, Healthcare Provider]
From the observations, it was noted that the adolescents' turn-out was less than the intended number (2 out of 3). Most of the people who did not attend the meeting were from the community, while almost all the health care providers invited attended the meeting.
Orientation and Ground Rules
The participants felt that ground rules were appropriate since they all took part in creating them. Participants reported that they were able to remind themselves and each other to follow the rules because they were displayed throughout the discussion. Participants appreciated the importance of the rules in maintaining organization and order throughout the dialogue. A participant had this to say:
They (ground rules) came from the participants, it was not imposed on the participants, but it’s the participants that came up with those rules.”
[Mixed focus group discussion, Healthcare Provider]
One of the young people, among the community members, on the other hand, felt that the rules should have been explained in more detail for him to understand what they meant. It was assumed that all the rules were understood because they came from the participants. An adolescent said:
“I did not understand the first one, the one that says speak through the chair, and do you speak alone or…?”
[Community focus group discussion, Adolescent]
Participation in the Community Dialogue
During the dialogue, there was a consensus among the participants that English was suitable for the articulation of ideas by participants, whether they were from the health sector or not. However, some community members during the FGDs mentioned they could have expressed themselves better in the local language despite agreeing to use English during the dialogue session. Other members of the community felt as if the discussion was specialized or technical, especially when the health care providers spoke. The use of technical language and abbreviations during the dialogue was discussed during the FGDs. With regards to the presentations during the dialogue, community members indicated that where some acronyms they did not understand, hence on some occasions, they could not answer appropriately.
”.. the language; it is not everyone that has been to school or up to grade12, at least there was supposed to be a mix up of language with English because some of us work in the community and we use local languages. So somehow to some of us, some words were big (complicated or unfamiliar jargon).”
[Community focus group discussion, Community Member]
During the FGDs, young people also mentioned that they felt English was the most appropriate language to use. However, some of the terminologies and acronyms were too complicated for them to understand and they felt too shy to ask what these meant.
“Like the term ‘integration’, that term yes was not clear.”
[Community focus group discussion, Adolescent]
A community member, who sat next to a young person during the dialogue also felt that the youth were unable to ask what the terms meant in the larger group. It was much easier for them to inquire from their neighbours in the meeting and not through the moderator.
“Oh yeah, okay they (terminologies) were coming from us participants and some community health workers because those are normal terminologies, but it might have been different from teachers, those are not like, this man (name mentioned) am sure he is very aware of them, but there are community workers who are from teaching maybe like my son here, the adolescent, he is not familiar with those terminologies.”
[Healthcare provider focus group discussion, Healthcare provider]
From the observations and interviews, community members participated well in the community dialogues despite being outnumbered by the health care providers in the meeting. Overall, both the community members and the health care providers, as well as other stakeholders, reported during the FGDs that they felt free to speak their minds and participate as this was reinforced by one of their ground rules (having to no wrong answers). One health care provider had this to say:
“I feel there were no barriers because people were able to express whatever they wanted to say and no one was opposing even when the answer that one gives or opinion that one gives was not opposed…”
[Mixed focus group discussion, Healthcare provider]
A community member also said:
“Actually, it (the dialogue) was something that was good, it is important once in a while to meet together with the community and the health providers because, for health providers, there is nothing that we can do without the community, cause or anything sensitization and other things we depend on the community so the community should be given information on everything that is there in the health facility. So we are represented, it’s a link actually between the community and the health Centre, and so these representatives are important to us and the health providers because they are the ones who speak to us and whatever we want from the community we ask these people to speak for us.”
[Community focus group discussion, Community Members]
It was observed that the adolescents also expressed themselves by bringing out issues that affected their access to family planning and contraception information and services. However, they were not entirely free to speak and required active encouragement from the facilitators. This was attributed to their discomfort of speaking out in such a forum and they felt there were too many adults in the meeting compared to adolescents.
Dialogue on family planning and contraception and QoC
Despite the feeling that the health care providers were more familiar with the topics being discussed, the community members felt able to express their views on the subject of QoC in family planning and contraception. A healthcare provider said:
“I think it was okay, we have interacted freely, openly and we have understood each other’s views, and from this, I think we are picking a leaf for forward (to move forward) in life”
[Healthcare provider focus group discussion, Healthcare providers]
FGD participants agreed that access to family planning and contraception information and services was vital. They agreed that this was an area that needed to be deliberated so that overall unmet need could be reduced. The Participants also mentioned the benefits of family planning and contraception and that there was more work to do regarding sensitizing the community about the different options they had. They made specific reference to the need for more ‘appropriate’ information and services among the youth.
“I would concur with her (fellow participants) because of the unwanted pregnancies mostly, and they end up to have unsafe abortions, so if the services are given to these adolescents, I think it will prevent the abortions and unwanted pregnancies among the youth.”
[Healthcare provider focus group discussion, Healthcare provider]
Conversely, an education sector representative expressed reservations, especially regarding the dissemination of all family planning and contraception information with the youth. The representative felt adolescents were too young and that this information needed to be altered to make it more age-appropriate. Without such censoring, the information was seen to increase the rates of promiscuity among the youth.
Despite such dissent, all the participants agreed that the dialogue allowed them to learn from each other, and they agreed that they had different viewpoints- concerning QoC (health care providers and the community members: supply and demand-side views). For example, the lack of certain services such as the Intra-Uterine Device was attributed to staff shortages and not negligence on the health care providers’ part. This was discussed during the dialogue.
“I would say it was good because there were some divergent views before we could come to agree because we were also given opportunity to argue, and try to raise some concerns, challenges that we need, and also what the community is complaining, but at last we agreed to say we have to work together, we need to prioritize our systems and working so that both of us benefit.”
[Community focus group discussion, Community Member]
From the observations, some strong differences in opinion about QoC were noted between the community members and the health care providers. During the FGD discussion, participants concluded that they were looking at QoC, but from different perspectives—the supply side and the demand side.
“(...) yes I think this was a very good discussion, this one has helped since we have people from the district office: education, it will help them plan, how can we get out there to the children, how can we reach them with this information and we also heard their blocks/obstacles and all this. So we didn’t know as health providers that we also have a limit. We thought it was easy for us to go and talk about sexuality openly in their schools. So I think it was a very good thing that at least even as health workers will know how we are going to take it when we meet a child who is ours and will not behave like a parent but as a health service provider(...)”
[Mixed focus group, Healthcare provider]
When asked about their view on the importance of the discussion on QoC, all the participants reported that they agreed on both the definition and the key constitutes of QoC. They could explain what they thought should constitute QoC even though a single definition was still a challenge to achieve among the various stakeholders invited. A young person felt he expressed his fellow young peoples’ views- that healthcare providers needed to be more welcoming at health care centres.
“It was useful such that it kind opened up on how the people in the health centres talk to the adolescent when they come to ask for help from them like if you want to ask for a condom, they shouldn’t go like ”as young as you are” and all.”
[Community focus group discussion, Adolescent]
A health care provider said;
“I think we did agree on what Quality of Care is as a community and the health care providers and that’s the more reason why we came up with those terms, yes we were very free to express ourselves and even after expressing ourselves although seemingly we were putting the health provider in a squeeze position but no it was so nice that at least both parties were able to understand, where each one of us is coming from and then at the end of the day we fully realized how important and the stressful conditions that this other person is in.”
[Mixed focus group discussion, Healthcare providers]
Schedule Feasibility
It was observed that most of the participants found it difficult to get acquainted with the topics being discussed. As the participants got more familiar with the dialogue topics, and what was needed of them, the meeting became more interactive. Some community members in the FGDs noted the need for more time to be allocated to the discussions. A need for more time was requested, to provide the participants with more room to express all their opinions and ideas. It was reported that since participants were from different locations, each one of them needed to be actively given a chance to take part in the dialogue. The time limitation was attributed to the pace of the richness of the discussion. Participants felt that the activity was much clearer towards the end of the allocated time for the discussion. This is when they felt even more encouraged to express their opinions.
“The duration of the meeting was …we needed to be here for two days or so.”
[Community focus group discussion, Community Member]
On the other hand, a few community members felt the time allocated to the dialogue was sufficient. However, certain participants (healthcare providers) had too much time to speak compared to the others and that there needed to have been some control in the time allowed to speak.
“Yes, I think it was ok except that other people dominated the floor, and I feel other people would have also benefited to make their views known but some people took most of the time.”
[Community focus group discussion, Community Member]
Interestingly, the health breaks between sessions were appreciated, as it was noted that they allowed participants to refresh themselves.
Cultural Feasibility
Though mentioned briefly, all the participants felt the community dialogue approach was culturally sound. This is because it allowed them to address a common problem; reducing problems associated with unmet need for family planning and contraception. A community member further added that there was a need for more representation from the community to further determine the cultural acceptability of the Approach. In other words, if more representatives from different sectors were invited to share their views, then the cultural acceptability would be clearer. They said:
“The approach was quite okay like we are saying, we know society is dynamic and we move with time and trends that we have previewed at that particular time, but am sure like we heard from the young man, he said he could not come so easily because he was amongst the elders, because our tradition says that they are certain things that we can easily mention in the public, others we cannot. Although in this forum, it wasn’t coming out like hinting so much on our tradition.’
[Community focus group discussion, Community Member]
However, others still felt that the approach dealt with an issue that was seen to potentially be problematic to discuss if certain members of the dialogue were present or more had more representation.
“I feel it [the approach] cannot be applied especially in the religious context, for instance, if the girls are introduced to using family planning, it is like you are telling them to start engaging in sex. Whereas religious in the bible the bible says children not to start engaging [in sex] until they get married. So if you give them contraceptives, it is like you are telling them to go ahead and have sex.” [Community and Healthcare Provider HCP]
Technical Feasibility: the use of visual aids during the community dialogue
In the FGDs, participants mentioned the usefulness of the aids used during the dialogue: the flip chart, the one-pager documents with information of QoC and the unmet need for family planning and contraception, and the PowerPoint presentations, especially during the discussion on the different pathways, activities and assumptions.
(...) because we were able to get everything they were teaching there (able to use the visual aids).
[Community Member focus group discussion, community member]
The participants also felt that the aids used were able to open up their minds to the broader project context, and give them even better ideas about what would or would not work in the Zambian context. Community members and health care providers were able to understand more about what the aim of the dialogue session was.
“I am talking in terms of how the program started because we were using PowerPoint we were able to see the definition, we would start by introducing the background of the project itself, we learnt that the project is running in three countries so we were able to understand (...).”
[Healthcare provider focus group discussion, Healthcare providers]