An exploratory qualitative study, National Family Planning Behavioral Study (FPBS), is conducted to identify factors that influence the use of modern birth spacing methods and to identify ways to mitigate or alter those influencers at the individual, couple/family, service accessibility, socio-cultural and policy environment for improvement of CPR in Afghanistan. Constructs from the socioecological model, health belief model and theory of planned behavior were used to develop the conceptual framework for the study. The constructs were arranged in four different levels: (1) individual level, (2) couple & family level, (3) service accessibility level, and (4) socio-cultural and policy environment level. FGDs, IDIs and KIIs were used to collect data from nine distinct target groups residing in the ten purposely-selected provinces: Kabul, Herat, Kandahar, Bamyan, Khost, Jawzjan, Kunar, Badghis, Badakhshan, and Samangan.

1. National Family Planning Behavioral Study on the Use
and Non-use of Contraceptives in Afghanistan

2. Outline
Study Objectives
Methodology
Field Work
Data Processing
Findings
◦ Individual level
◦ Couple level
◦ Service accessibility level
◦ Socio cultural and policy level
Recommendations
Q&A Session

3. Study Objectives
Overall study objective:
To identify factors that influence use of modern contraceptives and to identify ways to mitigate or alter
those influencers at the individual, couple/family, service accessibility, socio-cultural and policy
environment
Specific study objectives:
To determine the factors influencing modern contraceptive use at the individual, couple & family level and
explore the reasons for unmet need
To determine the factors at service delivery level (public & private) influencing modern contraceptive use
by married couples
To determine the socio-cultural, religious & policy environment factors influencing modern contraceptive
use by married couples

4. Methodology
Exploratory Qualitative Study
◦ Focus Group Discussions (FGDs)
◦ In-depth Interview (IDIs)
◦ Key Informant Interviews (KIIs)

5. Methodology
This study was conducted in ten purposely-selected provinces;
First Group
(CPR >23% )
Second Group
( CPR 23% -16%)
Third Group
(CPR 15%-10%)
Fourth Group
(CPR <10%)
Herat Bamyan Badghis Badakhshan
Kabul Khost Jawzjan Kunar
Kandahar Samangan

6. Methodology
The target study population included:
1. User/non-user women aged 15-49 yrs.
2. Husbands and user/non-users
3. Mother in law
4. Community Health workers (CHWs) both male and female
5. Family Health Action Groups (FHAGs)
6. Religious Scholars
7. Midwives and pharmacists at public health facilities
8. Female doctors/gynecologists and pharmacists in private sector
9. Program and Policy level people including MoPH, PPHD (RH, CBHC), Implementing
Partners (RH, CBHC)

7. Sampling and Sample
Sizes

8. Study Conceptual Framework

9. Management of Study
Study Steering Committee
Members: MoPH-EHIS, RH, CBHC,
USAID, UNFPA
Chair: EHIS
UNFPA Core Study Team
YHDO

10. Field Work
◦ Data Collectors were trained in Kabul at YHDO office
◦ Training monitored by EHIS directorate and APHI-IRB
◦ Pilot data collection in Kabul and feedback provided to the data collectors
◦ Data collected October –December 2016
◦ Robust monitoring of the data collection
◦ Online system for daily feedback on the recorded interviews

11. Data Processing
◦ All data transcribed in local languages
◦ Translated into English
◦ Back translation to check the quality of translation
◦ Atlas.ti used for analysis
◦ Stata used for analysis of quantative data

12. Study Implementation Process
Draft
Protocol &
Tools
Presentation to
Steering
Committee and
Approval
IRB
Approval
Data
Collection
Data
Analysis
Draft
Report
Presented
to and
reviewed
by the
Steering
Committee
Presented
to and
Reviewed
by the EHIS
Board
Meeting
Present to
the
Workshop
Final
Report

13. Findings
Findings are presented as four different sections;
◦ Individual level
◦ Couple level
◦ Service accessibility level
◦ Socio cultural and policy level

14. Findings: Individual Level
The following factors were reported to affecting the use of family planning
methods;
◦ Self Efficacy (strong Vs. weak, locus of control)
◦ Perceived Fertility Norms (personal desired family size, desired family size of
in laws, number of children = social power/influence)
◦ Perceived Religious Norm (appropriate Vs. inappropriate)
◦ Health Concerns (side effects )
◦ Cues for Actions (packaging material, user card, users networks)
◦ Attitude towards methods (shaped by rumors, side effects)

15. Individual Level: Self Efficacy
◦ Among the users a strong sense of confidence in their ability to manage their
families was reported:
“In my opinion (each individual) has his own opinion, and they have a
program for their life, if a person has 4 or 5 children, and not more
than 8 children, that will be great, 6 children are must, and everyone
should have at least 6 children. As there are problems in the country,
so if we have more boys instead of girls, that is good. Boys give
strength to family. When people have many sons they get happy
because sons stay with parents.” – a man currently using
contraceptives from Kabul province IDI635

16. Individual Level: Self Efficacy
While among the non-users a weak sense of confidence in their ability to
manage their families was reported :
“We do not have any family plan. That is Allah’s wish
whether he blesses us with more children or not. But if Allah
blesses us with a child, then the sex does not matter; son or
daughters, both are the same for us.” – a man not currently
using contraceptives from Bamyan province IDI846

17. Individual Level: Perceived Religious Beliefs
Inappropriate religious beliefs contributes to non use :
“I am illiterate, but my husband says that anyone who eat pills to stop
pregnancy she will go through monthly menstrual cycle. Each month
the blood would equal to killing a human being. I am also afraid of
God that how would I justify to Him. I have so many other sins. And I
don’t want to be a killer by using the method.” – a woman not
currently using contraceptives from Kabul province IDI624

18. Individual Level: Perceived Religious Beliefs
Appropriate religious beliefs contributes to use :
“It has been stated in Quran that a child should be
breastfeed up to 2 years therefore. It is allowed in Islam to
use family planning methods to achieve this.” – a man
currently using contraceptives from Kandahar province
IDI735

19. Individual Level: Cues for Action
Users have developed their networks which is source of knowledge,
motivation, sustained use
◦ Discussion within network happens
◦ Users networks promotes the use
◦ Men consult men network
◦ Women consult women network

20. Individual Level: Cues for Action
The network factor:
“We are 10 families in the village, from which 4 families are using these methods.
We don’t go to the clinic, because the CHW is near so we go there and get the
methods.” – a man currently using contraceptives from Bamyan province IDI831
“Most of my married friends use methods, and all of them are happy from usage.
We encourage each other and go to health facility together.” – a man currently
using contraceptives from Khost province IDI932

21. Findings: Couple Level
Use is affected by couple communication:
◦ Mainly between husband and Wife, lesser role played by the mother in law
◦ Decision making is through Consensus
◦ Submissive Consent by wife to the husband view
◦ Open communication resulting in a consensus between husband and wife
contributed towards use
◦ Rigid communication resulting in disagreement between husband and wife
contributed towards nonuse
◦ Disagreement between husband and wife leads to involvement of other family
member in the decision making process
◦ Communication does not happen early in the early years of marriage as the goal
is to reach the desired family size
◦ Early communication leads to early use

22. Couple Level: Communication
◦ Communication is submissive consent by wife to the husband view :
“I consult with my husband as he is my life’s partner. If he says that I
should use the methods I will use them if he says that I shouldn’t use
them I will not use them.” – a woman currently using contraceptives
from Samangan province IDI413

23. Couple Level: Communication
• Disagreement between husband and wife leads to involvement of other
family member in the decision making process :
“I decided myself to use the methods. My husband did not want me to
use the injection; but no one can prevent me. I consult with my
mother and mother-in-law; and I got permission to use the method.”
– a woman currently using contraceptives from Jawazjan province
IDI016

24. Couple Level: Communication
Communication does not happen early in the early years of marriage as the
goal is to reach the desired family size:
“We still want more children and have not discussed much on birth spacing
methods. I know the methods are good I have a plan for one or two more
children then we shall use them. In fact I have directed many people to go to the
provincial hospital or to Keshem clinic and get information about family
planning.” – a man not currently using contraceptives from Badakhshan province
IDI342

25. Findings: Service Accessibility
The following factors were reported to affecting the use of family planning
methods;
◦ Gender specific interaction (mostly females with females, males with male
CHWs, males with private pharmacists)
◦ Involvement of male facility care providers in FP services is minimum
◦ In adequate provider skills (midwife-IUD & implant skills; CHWs-DMPA skills)
◦ Behavior of the providers (mostly satisfactory )
◦ Private sector used as secondary source of methods but in not case of
condoms (methods are free in public sector)
◦ Stock outs (more in public than private)
◦ IEC materials not supplied to private health providers

26. Service Accessibility : Provider involvement
• Less involvement of male facility care providers in FP services contributes
towards non use:
“Once I went to the health facility for my next injection and
the midwife was not there. The [male] doctor gave me the
injection to get it administered at home; he did not even tell
me how to use it. I took it and my brother’s sister injected
me.” – a woman not currently using contraceptives from
Herat province IDI526

27. Service Accessibility : Provider Skills
Some CHWs do not have the adequate skills to administer the FP methods:
“I cannot give the injection correctly I do not have enough skill in
administering it.” – a female CHW from Khost provinceKII914.

28. Service Accessibility : Provider Skills
Some midwives do not have the adequate skills to administer the FP methods:
“First, I did not participate in any kind of training and second I do not
have enough experience in the inserting IUD. All the misconceptions
that exist at the village, people are not ready to use this device. That
is the reason the client of this device is getting decreased.” – a
midwife working in a public health facility from Herat province KII533.

29. Findings: Socio Cultural and Policy Environment
The following factors were reported to affecting the use of family planning
methods;
◦ An approved national population policy not present
◦ RMNCAH strategy includes FP, however no comprehensive and costed
implementation plan for the country
◦ Strong multi sectorial approach for population management and family
planning not present (family planning is the agenda of health sector)
◦ FP unit within MoPH (narrow scope, limited resources)
◦ Limited use of mass media for demand generation
◦ In adequate emphasis of FP methods in medical schools curricula
◦ High school curricula does have content about family planning
◦ Conducive religious beliefs environment for use of FP methods

30. Recommendations
Strengthen the Policy Environment
◦ Contribute towards the development of a national population policy
◦ Develop a costed implementation plan for the national RMNCAH strategy
◦ Strengthen the family planning unit within the MoPH by expanding its scope and
provision of needed resources so that it can become a fully functional entity within
the MoPH
◦ Improve the involvement of male care provider in the family planning services at
health facility level by revising the job descriptions

31. Recommendations
Strengthen Coordination and Collaboration
◦ Work with MoHE on improving the curricula in health training institutions for
doctors, midwives, nurses, etc., so that all new graduates have the required
skills and knowledge about all relevant family planning methods
◦ Advocate for inclusion of family planning in the high school curricula
◦ Enhance partnership with MoHRA for greater involvement of religious
leaders for promoting family planning among masses

32. Recommendations
Improve capacity of the FP service providers
◦ Improve the involvement of male care provider in the family planning services at
health facility by provision of needed trainings and proper monitoring of male
providers’ involvement in the provision of the family planning services to the clients
◦ Enhance the skills of midwives and CHWs for proper administration of the family
planning methods including long-acting reversible methods
◦ Enhance skills of the private FP service providers and provide job aids especially in
large urban centers (trainings and monitoring & recognition system)

33. Recommendations
Strengthen Effective Use of the Communication
◦ Promote the use of mass media for FP demand generation (radio, TV, social media)
◦ Create mass media messages based on the adequate theoretical framework
◦ Design communication strategies to promote couple communication based on mutual
respect and equality, and to promote early couple communication on child bearing and birth
spacing as an element in pre-marriage counselling
◦ Design capacity building strategies to improve counseling skills of the health care providers
so that clients are properly counseled on method choice and effective use, and on
management of problems associated with method use

34. Recommendations
Strengthen Effective Use of the Communication
◦ Design social network interventions to promote the use of family planning methods
and enhance participation of women and men with experience using contraceptives
as FP communicators.
◦ Design communication strategies to manage the rumors about family planning
methods and to promote the use of long acting family planning methods

35. Recommendations
Strengthen FP commodity supply system
◦ Improve family planning commodity stock outs in public sector by
establishing a mobile technology based stock management system and
timely provision of the family planning supplies.

36. Thank You
Question/Comments?