Socio-demographic characteristics of the study participants
A total of 18 participants were interviewed; 6 HCPs (2 male and 4 female midwives) and 12 PAs. One HCP had a bachelor’s level of education while the rest had a master’s level. All HCPs had FP service experience of a minimum of three years (3-12 years of experience). The majority (83%) of the PAs had a primary level of education, more than 58.3% had no employment, and half of them were still single. More than half (66.7%) of the PAs reported the index pregnancy to be their first pregnancy.
The present study looked at the practicality, usefulness, and acceptability of the postpartum Green Star family planning decision aid in the choice for postpartum family planning among PAs in Tanzania from both adolescents and HCPs. From the data analysis, we will present three major categories with sub-categories as derived from the questionnaire: 1) practicality, 2) usefulness, and 3) acceptability.
The study participants were asked to discuss their views about the information presented in the decision aid (length i.e., too long, or too short or just right, and quality of the presented information in terms of flow, clarity, and comprehensibility of the information and language used) in relation to the level of education of PAs with a mainly primary level of education. The findings are as follows:
a) Right length of the information presented
The PAs and the HCPs said the length of the presentation was okay i.e., just right. However, the HCPs reported the amount of time required to reading the DA varied from 20-50 minutes, and the concern was the reading speed and understanding ability of the participants that are perceived to be different.
“By looking, the details are not too long or too short. I found that she can spend 50 minutes if she is a slow reader and if she is a fast reader then 20 minutes will be enough” [HCP]
The minimum time reported by the PAs to finish reading the DA was 25 minutes, while the maximum time was 60 minutes.
“It took me 20-30 minutes to read the whole DA” [adolescent]
“I used an hour to read all the information” [adolescent]
b) Good quality of the information
The study participants were asked to give their views about the flow of information, clarity, comprehensibility, and changes they think should be done to improve the decision aid.
Flow of the contents
Both the HCPs and PAs said that the flow of the contents was good and was organized systematically and more simply.
“Generally the DA is good and the information in it covers the areas that we aspire to be covered in a FP counseling to be understood by every woman. The flow is good and I like the DA most because it involves pictures with interesting colors that will improve the clarity of the presented information” [HCP]
“To me, I see the information presented as normal as I cannot say it is too long or too short, the explanation is clear and easy to understand” [adolescent]
However, one HCP participant suggested a small significant change to be made in order to improve the logical flow of the contents. This participant said:
“I have a small correction. In the second step where the client is told to choose the reasons for selecting that option and then below that she is asked to choose the method (option). In my opinion, I thought that after the explanation of how each option works, the benefits and side effects, she should choose the option first then start to give the reasons why she thought maybe she chose that method (option)” [HCP]
The HCPs further said the contents included most of the critical information needed when providing counseling and key information/components important to aid decision-making. This provider said:
“Looking at the experience of counseling, there are lots of important aspects presented and often are the things clients ask especially [about] the effectiveness and fertility return. It [DA] has also described each option, where it is inserted, and how it works to prevent pregnancy” [HCP]
Clarity of the information
Language and medical terms used in the presentation were reported to be appropriate by both the HCPs and pregnant adolescents. The adolescents said the language used (Kiswahili) was clear, and everyone who gives it time to read will understand because the information was elaborated.
“I would say that the information presented in the tool [DA] was easy to understand because the Kiswahili words used are simple and well elaborated” [adolescent]
The HCPs said Kiswahili is a National language and that almost everyone in the country speaks it therefore the terminology used in this DA will be understood. Nevertheless, the HCPs gave some suggestions so as to reduce ambiguity like the use of Kitanzi instead of Lupu or use both, use of kichocheo instead of the “hormone”, “slows down sperm motility” instead of “killing sperms”, etc.
“There are some words that I thought if used would enhance clarity. For example, FP clients are [more] familiar with the word “kitanzi” than “LUPU”. Use Kichocheo and not hormone as that is an English word. Similarly, killing sperm will be strange to women instead, rephrase it to “slow down the sperm motility” [HCP]
When the participants were further asked to give their opinion if the PAs could be given the DA to read by themselves, the HCPs said that the PAs would need support from providers to facilitate understanding of the information presented in pictures with colored and uncolored pictures as they believe that the PAs would not understand. In addition, Tanzanians do not have a culture of self-reading, especially with adolescents. So if the HCPs give them the DA to read by themselves it will be a challenge as they are not sure if the PAs will really read the tool. The HCPs advised that the information be read to all study participants who will be involved in the study.
“Mhhhh! It will be a challenge to read by themselves as we do not have a culture of self-reading. They might fail to appreciate the difference between the colored and the uncolored images. I recommend the HCPs to brief the participants about the information in every step and the meaning before they take the document home for further self-reading due to differences in the level of understanding” [HCP]
The PAs did not differ from what the HCPs suggested about self-reading of the DA. Almost all of the PAs said that it would be hard for them to read the DA by themselves. They requested someone to take them through the information presented before they are told to read by themselves.
“It will be difficult for me to read and understand all the information. When I finish reading the first page and go to the next page I do not remember what I read on the previous page” I need someone to explain to me as when I hear someone talking it sticks in my head more than if I read myself ”[adolescent]
The study participants were asked to say if the DA: would improve knowledge, would address the existing myths and misconceptions in the community about LARFP methods that hinder its utilization, and if the benefits and side effects of each option are well clarified.
a) Improves knowledge
The PAs reported that the DA changed/improved their knowledge after reading. They said they did not know the existence of IUCDs and implants as well as the immediate postpartum FP methods. They did not even know if someone could use FP methods just after the birth of the placenta or before one month after childbirth. They further said that they did not know how the methods were put in place but now they could imagine it from the pictures shown in the DA.
“I did not have prior information about IUCDs and implants apart from pills and injectables but after reading, I realized there are other FP methods that even last longer than a year” [adolescent]
The HCPs affirmed that the decision aid would be useful for PAs. They further said the flow of the information is so clear and it explains the types of women, including adolescents, who can use any of the options, which is missing in most of the FP counseling sessions and guides.
“The tool [DA] is a narrative that can be read within a short period of time and be understood than reading the entire FP book. The tool pointed out people who can use LARFP methods that also included women of any age as long as they are sexually active. Most teenagers think that contraceptives are for adults above their twenties. So this information opens up their mind and helps them realize FP is for any woman regardless of age as long as she is sexually active. This part has been overlooked in our FP counseling even in FP clinical guides” [HCP]
b) Adequately addresses the most common existing myths and misconceptions
The HCPs reported having seen some myths and misconceptions addressed in the DA. However, they pointed out they are too few while in the community there are a lot of existing misbeliefs about FP methods, especially about LARFP methods. They pointed out misbeliefs such as, if women happened to conceive while the IUCD was in the uterus, when the baby is born, it would be holding the IUCD, or that IUCD and implants at times escape from where they are and go to the heart or brain. The HCPs further reported that there was no specific section that talks about myths and misconceptions. By just reading the DA alone, it would not be enough to dispel existing misbeliefs about FP methods for PAs. When the PAs were probed about this part they all kept quiet despite clarifying the question for them several times.
“The tool has addressed some of the existing myths and misconceptions indirectly though they are very few despite the fact that there are a lot of misbeliefs existing in our communities. If you address more of them this tool [DA] will be useful in addressing the existing misbeliefs” [HCP]
“The information provided in this tool focused on the use of LARFP methods. But there is no specific section that addressed myths and misconceptions specifically. However, I see some of the misbeliefs in the tool like they do not cause uterine cancer, cannot interfere with the sexual act” [HCP]
One of the HCPs noted that the last part of the DA that requires the PA to note down some questions that need more clarification in the next antenatal clinic. That would help to explain more about the concerns and might also include myths and misconceptions she had about FP methods that were not explained in the DA. This HCP further said that it was not easy to address all of the myths and misconceptions existing in the community about IUCDs and implants as the DA would be too long.
“Self-reading of the tool [DA], may not be so easy to correct the existing myths and misconceptions known by the participant. The part that might help to cover the question about myths and misconceptions is at the comments section. If she has any ideas or any misconceptions about the things she read and needs clarifications, I think this part might help. If she will have any question, if she has something she understood differently, writing here for more clarification in the next antenatal clinic visits will help to address the concerns the woman has about FP” [HCP]
c) Adequately clarifies the benefits and side effects of each option
The HCPs reported that the DA clarifies the benefits and side effects of each option. The safety of artificial FP was a concern and was one of the barriers to using FP methods. Since the DA addresses such concerns it would provide realistic expectations of side effects and later would improve voluntary decision making to utilize FP immediately after delivery.
“Yeah! The area where society is stuck is in understanding how contraceptives work, how they prevent pregnancy, and if real they or do not cause all the complications (myths and misconceptions) they hear in the communities. The tool described the benefits and side effects that can be caused by each option. I think this tool will be useful in improving the utilization of FP” [HCP]
“The tool has explained well by comparing the benefits and side effects of each option, for example, I have read that the loop does not add on body weight and neither can my partner feel it during intercourse because they reduce the length of the string and this was my biggest fear as I heard it from my sister” [Adolescent]
We asked the study participants if they would recommend the DA to encourage women including adolescents to use LARFP methods. Two reasons for accepting the DA came out from the analysis; a) decision aid improves knowledge, and b) decision aid is a standardized guide with evidence-based information
a) Decision aid improves knowledge
The PAs said the DA should be used as it helps them get information that they were ignorant of before about the existence of FP offered immediately after giving birth.
“Let it [tool] be there in the clinic so that we can use it as it helped me to understand the available postpartum FP methods offered immediately after birth. I am sure even my fellow women will find the same benefit” [adolescent]
b) Decision aid a standardized guide with evidence-based information
Generally, the HCPs supported the use of the DA to complement their FP counseling education. They commended the DA that it is simplified and included all-important evidence-based information mothers need to learn the importance of child-spacing especially PPFP. It will also be good for use as a standardized guide for FP specifically for LARFP methods offered immediately after childbirth.
“Yes! The tool is so simplified and it included only the important information that a mother needs to be aware of in order to make an informed choice of the LARFP options. Generally, the tool is good to be used for both mother and caregiver” [HCP]
Another HCP further said that she would recommend the use of the DA because their health facilities do not have a standardized guide to be used for FP counseling. As a result, she finds the FP counseling being offered to be too subjective as they do not have a well-structured tool apart from the WHO FP handbook for HCPS . So, variations of the information are given to mothers simply because of the differences in knowledge, time, and attitude among HCPs. But the use of the postpartum Green Star family planning decision aid is formal and will enhance the objectivity of the information offered to everyone.
“I will support the use of the tool because the current FP health education being offered is too subjective as there is no a standardized guide for FP counseling. Since this is formal it will ensure the objectivity of counseling to everyone as mothers will receive the same information from different HCPs than when there is no a standardized guide” [HCP]