A research brief outlining motivations and tipping points for SBCC to promote the uptake of contraception in a rural community with high TFR in Uganda.

1. Prepared by Alaii Jane, PhD and Anna Natukunda. USAID/Uganda Communication for Healthy Communities
Figure 1: Analytical Framework
Figure 2: What participants understand
about contraception
Contextual Barriers and Coping Strategies with the Uptake of Modern
Contraceptive Services and Commodities in a Selected Community in Uganda:
Highlights from a Rapid Qualitative Assessment
Between March and April 2014, USAID/Uganda Communication for Healthy Communities (CHC)
project conducted a rapid assessment – using Luwero district in central Uganda as a case study – to
document specific barriers and examine the role they play in the process of contraceptive decision-
making and uptake among men and women. The assessment aimed to support the development of
targeted social and behavior change communication (SBCC) on Family Planning to increase the
adoption of healthy behaviors and uptake of critical health
services.
Conceptual Framework
The Socio-ecological model (Figure 1) (McKee et al. 2000)
guided the question domains, interview and focus group
discussion guides, and analysis. Analytical review and
interpretation of the data focused on identifying underlying
drivers of barriers to contraceptive services uptake as well as
distinguishing the characteristics of current successful users
from non-users (discontinued and never-users).
Methods
The findings draw from eight focus group discussions and 29 in-depth interviews conducted with men
and women 18-49 years old in Luweero District. The study site was purposively selected based on
indication of rather low contraceptive uptake in the LQAS 2013 Report, and insight from discussions
with UNFPA-Uganda. Data was collected from purposively selected urban/peri-urban and rural
catchment populations living within a 5km radius of two public health service delivery points
supported by US government implementing partners and offering contraceptive services
.
Participant Knowledge of Contraception
Contraception was understood as a means to space or limit births. While participants discussed
limiting births to 3-4 children – especially due to perceived benefits highlighted in green and yellow
boxes in figure 2, they universally pointed out that the majority of people wanted 6-8 children.
Birth spacing was perceived to benefit babies i.e., adequate
time to breastfeed and/or wean. Benefits for the mother
included adequate time to recover and regain her beauty as
well as balance child care duties. Perceived all-family
benefits included reduced financial strain hence increased
potential to attain life goals, e.g., pursuit of further education
and securing financial stability. Also, birth spacing may
contribute to better spousal relations linked to restoration of
female beauty and less frequent financial demands
associated with new births, particularly when closely-
spaced.

While there may be real barriers to modern contraceptive uptake, successful adopters reside in the same communities and may experience the same social issues as non-
adopters. In-depth interviews with current users aimed to identify facilitating factors for adopters within existing constraints/barriers.

Choice of a site with contraceptive services within a radius of 5km rules out barriers such as non-availability of commodities and distance, respectively – hence enabling
focus of explorations on interpersonal and community factors affecting uptake of available contraceptive services.

2. Prepared by Alaii Jane, PhD and Anna Natukunda. USAID/Uganda Communication for Healthy Communities
Figure 3: Successful users –
Environmental and Community Factors
Fears, Misconceptions, and Sources of Information
Overall, mistrust for FP was attributed to how the concept was initially introduced: as a mechanism to
stop births [kizaala gumba], something that does not fit with the cultural norms and understanding of
the family as a unit of reproduction and accumulation.
“…then also the way family planning was introduced…as „Kizaala Gumba‟. The thing called Kizaala Gumba means
something very bad…for someone to say so and so is barren…it is very bad in this community” Male, FGD
The leading fear was inability to fulfill this reproductive role either because of 1) a failure to return to
fertility, 2) bearing unhealthy/deformed children in older age due to birth spacing, and 3) disruptions
in sexual functions of marriage due to contraceptive side effects such as decreased libido or extended
menstrual bleeding. These could result in serious social consequences including emotional burden due
to social ridicule, and ultimately abandonment of the female partner. Interestingly, participants were
quick to confirm that their perceptions of modern contraception were based on unverified information
within their networks i.e. their peers.
“…on side effects, the most important channel is our friends. They may tell you: I used this method and had this
problem…but we do not really seek advice from a health worker to verify the cause of this problem” Female, FGD
The assessement suggests that overcoming fears and
misconceptions at both the environmental, community
and individual levels would provide the window of
opportunity for SBCC to begin to shift long-standing
norms regarding family size (Figure 3). This is because
successful users of contraception do recognize the
existence of side effects but have developed health
seeking practices and appropriate coping strategies to
minimize the negative effects of contraception, indicating
the critical roles of partner dialogue and engagement with
health providers to inform contraceptive method choices.
Opportunities for SBCC
Information: Informal and often inaccurate information networks such as peers continue to intensify
misconceptions and fears about modern contraceptives. It is therefore critical to improve knowledge
with accurate information and strategically address fears and concerns as an important step towards
eliminating barriers. In parallel, it is important to spearhead actions to promote sustainable
relationships with the health service, for example, by enhancing provider IPC skills.
Motivation: The intrinsic motivation for birth planning set successful contraceptive users apart from
non-users. This motivation was driven by a mix of perceived benefits ranging from economic and
personal relief to improved spousal relations and ability to pursue other life goals. These benefits are
increasingly becoming important issues to exploit in a well-crafted communication initiative.
Ability to act: A key barrier or enabling factor for both non-users and users respectively was the
potential reaction of their spouse. This underscores the need to program inclusion of men both in
uptake and in advocacy, especially to foster shifting of gender norms regarding sexual and
reproductive health, and engender partner dialogue and decision making regarding contraception.
Norms: The perception that family planning was socially unacceptable is an underlying barrier to
contraception. The changing economic times offer a unique opportunity to target SBCC not only at
individuals but also their networks, to stimulate social reflection/debate on the balance between the
benefits of smaller families or spaced births and fear of social stigma associated with contraception.