Overview
This study was implemented by the United States Agency for International Development (USAID)-funded Social and Behavior Change Activity (SBCA) in Uganda, a 2020–2025 program managed by the Johns Hopkins University Center for Communication Programs that envisions a Uganda where individuals and communities are healthy, resilient, and supported by strong and adaptable systems and institutions to lead productive lives(29). The program provides social and behavior change (SBC)-related technical assistance to the Ministry of Health and other stakeholders to design and implement SBC initiatives that contribute towards a healthy nation. Specific outcomes include a reduction in maternal and child mortality, malaria prevalence, total fertility rate, new HIV infections, and tuberculosis prevalence, and improved nutrition outcomes. This study was part of formative research to identify individual and social cultural determinants affecting the uptake of key desired health behaviors and practices, including family planning. Results of this study and other formative research have since been used to inform the design and implementation of contextually relevant SBC interventions.
Study Design and Participants
Study data were drawn from a cross-sectional nationally representative telephone survey of adults aged 18–49 years in Uganda in December 2020. The telephone survey was conducted due to limitations in face-to-face data collection during the COVID-19 pandemic in the context of high telephone ownership (about 77%) in Uganda(30). Study inclusion criteria included the following: i) Resides in one of the four selected regions of Uganda: Central, Northern, Western, and Eastern; ii) Communicates effectively in the local language or English; iii) Provides informed consent; and iv) Has access to a mobile phone either personally or through someone in the household.
Sampling and Sample Size
The sampling procedure included a probability proportional to size (PPS) sampling of enumeration areas (primary sampling units), stratified by region, and based on projected data from the most recent 2014 national census. Next, study enumerators visited the enumeration areas and worked with community leaders to acquire a list of representative phone numbers for all households in the area. Specifically, study team members visited each household, briefly introduced the study, and requested the contact number of the head of the household or responsible adult. The target number of telephone numbers was then randomly selected from the list of representative phone numbers within the enumeration area. After this, study data collectors systematically contacted, recruited, and interviewed sampled respondents. An adult man or woman was selected from each household. If a potential participant was not reachable, a replacement telephone number was then randomly selected from the list of representative phone numbers.
The telephone survey recruited a total of eight households from all 175 enumeration areas for an overall sample of 1400 based on the following parameters: an outcome prevalence of 0.50 (for maximum variability); power = 0.80; alpha = 0.05; delta = 0.075; and a design effect of 1.5. This study explores family planning outcomes and thus excludes ineligible participants who are not in sexual partnerships (n = 233) for an analytical sample size of 1177 adults.
Data Collection
The telephone survey was administered in December 2020. Trained data collectors called participants, explained the purpose and benefits of the study, conducted eligibility screening, and obtained informed consent before proceeding with the survey questions. The survey interview lasted about 20–30 minutes and included questions on sociodemographic characteristics and behavioral outcomes related to family planning, malaria, maternal and child health, HIV, and COVID-19.
Ethical considerations
The ethical review and approval of the study were conducted by the Institutional Review Boards (IRB) from the Johns Hopkins Bloomberg School of Public Health (IRB No. 00013837) and the Makerere University Institute of Public Health Higher Degrees, Research and Ethics Committee (No. 864). Before participating in the telephone survey, all respondents provided verbal consent.
Measures
Key variables included the following:
Current family planning use (yes versus no) was based on the survey question: Are you or your partner currently doing anything to prevent or delay becoming pregnant?
Family planning decision-making considerations were assessed using the survey question: In your experience, which of the following are the three most important considerations as you make family planning decisions? Response options included discussing with my partner; choosing the right method; knowing a place where I can get family planning services; getting money to pay for family planning services; my partner or I do not approve of family planning; and other responses.
Preferred partner support was explored using two constructs: preferred level of partner support and specific partner support activities. The preferred level of partner support was assessed using the survey question: What level of involvement would you like to see from your partner in your family planning decisions? Response options included no, some, or high involvement.
Specific partner support activities were explored with the survey question: What specific involvement would you like to see from your partner in your family planning decisions? Response options included giving permission to go to the health center to get more information about family planning; accompanying me to the health center; discussing with me family planning options to consider; giving me permission to use family planning; paying for the family planning service.
Other variables included reasons for non-use of family planning (Why are you or your partner NOT doing anything to prevent or delay becoming pregnant?); sociodemographic characteristics by region (Central, Northern, Western, and Eastern); age in years (18–24, 25–39, and 40–49); location (urban versus rural); education (< primary, primary, ≥ secondary); and parity (0, 1–4, ≥ 5).
Analysis
Cross-tabulations and tests of associations explored male and female differences in sociodemographic characteristics and family planning outcomes, decision-making priorities, and preferred partner support. Multivariable logistic regressions explored factors associated with decision-making priorities and preferred partner support. Covariates included current use of family planning, age, sex, region, rural versus urban residence, education, and parity.