Family Planning Campaign Strategy

Uganda

2006/2007

Prepared by

And

The Uganda Family Planning Revitalization Group

For

The Uganda Ministry of Health


Background

According to the2002Uganda census, Uganda’s population is growing at a rate of 3.2% per annum. At this rate of growth, the population is increasing by approximately 1,200,000 new people each year[1]. The Population Secretariat indicatesthat by 2050, the total population of Uganda will have nearly quadrupled to more than 100 million people. This fact, and the fact that the current population growth rate in Uganda is surpassing the rate of economic growth and the country’s ability to provide essential services for the population has prompted the Population Secretariat to state that the current and projected population growth in Uganda is of ‘crisis’ proportion.

Uganda’s rapidly growing population is the result of continuing high fertility rates.and declining mortality levels. In fact, Uganda has one of the highest fertility rates in the world. Since 1989, the total fertility rate (TFR) in Uganda has hovered at approximately 7 children per woman. According to the 2006 UDHS Report, the TFR is now 6.7.Additionally, there is a considerable disparity in TFR between urban and rural women with TFR at 7.7 and 4.4 respectively.

Fertility in Ugandahas remained high in large part because men and women continue to desire large families. According to the 2001 UDHS, men would like an average of 5.6 children and women would like an average of 4.8children. In the 2006 UDHS report, these preferences have slightly increased with women desiring an average of 5 children and men desiring 5.7. Additionally, the desired family size is higher for both married men and married women at 5.3 and 6.4 respectively. The less educated a woman is, the more children she is likely to have. Both women and men in the lowest wealth quintile are more likely to desirelarger families than people who are wealthier[2].

Despite this continued desire to have large families, there is a growing unmet need for family planning among women. There are more women todaythan in the past who would prefer not to become pregnant butwho are not using modern family planning methods. According to the 2001 UDHS, thetotal unmet need for family planning was 35%. According to the 2006 UDHS this has slightly increased to 41%.

In response to this situation, the Family Planning Revitalization Working Group of the Division of Reproductive Health, Ministry of Health convened a workshop to design a national communication campaign to revitalize family planning.

In preparation for the workshop, the Health Communication Partnership conducted formative research to understand the most prevailing barriers to and promoters of family planning uptake. Additionally, the research sought to understand the perceptions rural and urban Ugandans have about family planning and their understanding of its impact on population and development. The research consisted of focus group discussions conducted with 98 men and women between 18-55 years in 4 districts; the addition of discussion questions on the Afford Project’s Wellness Survey and quantitative questions about family planning added as part of an impact assessment for the African Transformation project.

The strategy design workshop took place on November 28th -30th, 2006in Kampala. During the workshop, participants drawn from public and private sectors, including family planning clients, reviewed the research findings and prior communication strategies and subsequently identified the over all goal, intended audiences, and communication objectives for a 6-month communication campaign to revitalize family planning. This document describes the resulting campaign strategy.

Campaign Strategy Overview

The National Communication Strategy to Accelerate Implementation of Reproductive Health in Uganda, 2005 summarizes the MoH primary behaviour change communication objectives for family planning as the following:

  1. Improve attitudes and communication skills of service providers to offer quality FP services and increase the proportion of FP providers who do this accurately
  2. To dispel myths, rumors and misconceptions about modern FP methods and increase the proportion of men and women with accurate knowledge to make informed choices
  3. To increase the proportion of women and men who act on their expressed desire for spacing and limiting and their stated intention to use a contraceptive
  4. To increase the proportion of men and women who understand the link between family size and poverty and who approve of having smaller, manageable sized families.

This campaign strategy will prioritize numbers 2, 3 and 4 of the above while directing audiences to seek services from quality FP providers. Objective 4 is being addressed through training and performance improvement efforts of the Ministry of Health and other service delivery partners on the Family Planning Revitalization Working Group.

Communication goal:

Smaller, healthier, more prosperous families in Uganda.

Audiences:

The campaign will focus on one primary and one secondary audience:

  • Primary Audience: Sexually active men 18 – 35 years old, living in rural areas, who are not currently using modern family planning methods with their partners, regardless of educational level.
  • Secondary Audience: Women who are the sexual partners of the primary audience.

Communication strategies for each of these audiences are described below.

Message Brief by Audience

Primary audience: Sexually active men 18-35 years old, rural, regardless of education level, who are not currently using family planning with their partners.

Audience Analysis:

The desired behaviour among this audience:

  • To choose to have smaller families as a means of improving their family’s and their community’s development; and
  • To actively support and involve themselves in family planning decision making with their partners.

Unfortunately, most men neither choose to have smaller families nor do they support or discuss family planning with their partners. Often, men have more than one wife, and have children by all of them, setting up a situation where their wives compete with one another to have more children.

There are a number of factors that contribute to men’s continued desire for larger families. These include:

  • Culture and tradition: traditionally, Ugandan cultures have encouraged men to produce many children, as a sign of virility, and as a means of ensuring the continuation of theclan and tribe. Even today, many cultural and political leaders encourage men to produce many children.
  • Prestige and ego: men often consider large families a sign of prestige. In many communities and families, men who have many children are revered for their strength and ‘manliness’.
  • Sex mix and sex preference: most couples prefer to have a mixture of both sons and daughters. If they continue to have children of one sex, particularly girls,they will continue to produce until they have a child of the other sex. Most men particularly, want sons, and will continue to produce and encourage their partners to produce in order to have sons.
  • Belief that large families will increase productivity and wealth: many men think that if they have many children, these children will help the family to be more productive. For these men, children are seen as a financial asset rather than a financial liability.
  • Religion: some men believe that it is wrong to interfere in reproduction, as it is God-given. These men believe that God should determine the number of children a man produces.

There are also a number of factors that contribute to men’s lack of support and involvement in family planning decisions. These include:

  • Lack of mutual understanding and communication between couples: most men see their wives as their property, and neither seek nor value their wives’ opinions or ideas. As a result, husbands and wives do not openly communicate with one another. Since family planning is considered to be woman’s issue, the man sees no need to bring the topic up with his wife; and because his wife feels that it is not her place to bring up the issue of family planning with her husband, the topic is never discussed. Most Ugandan men do not think that they need to discuss family planning with their wives; they assume that their wives are “taking care” of that. In fact, because many women have never discussed family planning with their husbands, and they need their husband’s approval and money to use family planning, they either do not “take care” of it or they secretly obtain a family planning method, usually injectables, that they do not discuss with their partners.
  • Lack of access to family planning information: most family planning information is available through family planning service providers. However, these providers usually work at maternal and child health clinics, which are generally not welcoming to men. Most information about family planning is usually designed for women, not for men. Thus, men often have very little accurate information about family planning.
  • The belief that it is manly to have many children and the ego associated with large families: many men do not want to practice family planning because they want to have many children. They feel more important and more ‘manly’ if they have more children. Thus, there is no desire for family planning and no reason to discuss family planning with their wives.

Men feel they benefit from having large families and by not discussing family planning or family size with their partners. As described above, men gain respect and recognition from other men and their parents when they have large families. By not discussing family planning or the number of children they desire with their wives, they avoid arguments and disharmony in their homes.

Men often do not want to have open discussions with their wives, because they fear that they will lose control over them. In order to have open discussions, men need to see their wives as having a voice in family decisions, and this could undermine their authority in the home. Thus, their current behaviour helps them to maintain control over their wives and authority in the home.

This audience is likely to be semi-literate to literate with access to radio. They also receive a good deal of information in community meetings and newspapers. Most media accessed is in local language.

Communication goal: Smaller, healthier, more prosperous families in Uganda.

Behaviour outcomes:Men actively supporting or involving themselves in Family Planning decision making.

Men and women choosing to have smaller families as a means of improving their family and community development.

Communication objective: By the end of the campaign, there will be an increase in the proportion of our audience who discuss family planning with their partners because they believe it is the best way to a healthier and more prosperous life.

Key promises (Benefits):

If you actively support or involve yourself in family planning decision making:

  • you will be seen as a role model
  • you will be considered to be more sophisticated and modern
  • you will have a peaceful home
  • you will raise healthier children with a bright future
  • you will have higher productivity and save more money
  • You will have a happier and stronger relationship.

Support points:

  • Having a smaller family does not make you less of a man, it makes you more of a man because you can provide adequately for your family
  • Your quality of life is reduced by larger families e.g. there is less clean water, firewood, fewer jobs;
  • The exponential growth of the population will have drastic impact on the quality of life in every Ugandan home no matter how wealthy your family is;
  • Make decisions about family planning with basic and accurate family planning information—methods available, safety, effectiveness;
  • Responsible, ‘real’ men discuss family size and family planning with their wives;
  • “Plan a small, manageable family for a better life”

Communication channels and approaches:radio talkshows, mini radio serial drama, radio spots, men-only seminars, Every Day Health Matters with basic family planning facts,posters, road stars (street pole signs), rainbow over the yellow flower labels for private sector clinics and drug shops carrying FP products, services, and Every Day Health Matters;Local leader endorsements of smaller families and family planning

Secondary audience: Women who are partners of the sexually active men

Audience Analysis: The desired behaviour among this audience:

  • Initiate family planning discussion with their partners
  • Use modern family planning methods.

Social and cultural norms and values in Uganda still expect and encourage young women to marry and start child bearing at a young age; as young as 15 years especially in rural areas. According to the Ministry of HealthDivision of Reproductive Health, nearly one-third (31%) of girls age 15-19 have already begun child bearing, and by 18 years of age, 54% of the girls are mothers.

These norms and values also influence contraceptive prevalence among women which slows down the national development potential. According to the the 2006 UDHS, only 19.6% of women use any contraceptive method and only 15.4% use a modern contraceptive method.

There are a number of factors which influence women’s likelihood to initiate discussions about family planning with their partners and discourage them from using modern family planning methods:

  • Women are not empowered to initiate discussions with their partners and spouses: Cultural and traditional values dictate that women must be ‘obedient’ and should not to speak openly to men. While women are expected to manage many aspects of family planning, to initiate a discussion about family planning and issues related to sexual relations with their husbands is often taboo.The few women who use modern family planning methods often hide their methods from their partners because they assume that their husbands do not approve of family planning.
  • Low status of women influences access to accurate information: Women’s lack of access and control over household resources and their traditional roles influences many women’s access to family planning information and services, especially among rural women. In many homes women do not control the finances necessary to allow them to physically get to a provider that could give them accurate information about reproductive heath and family planning. Access to mass media at a household level is also often controlled by the male head of household which limits women’s access to reproductive health information that may be disseminated through the radio or newspaper
  • Belief that modern family planning is harmful or ineffective: Many women continue to harbor a number of misperceptions about family planning and are therefore uninterested and unwilling to seek services or discuss family planning with their partners.
  • Social pressure for women to have many children: Women are usually pressured to have many children by their partners who want to be viewed as “manly” in society, and by their extended families who want to “protect” their clans. Women in polygamous marriages often ‘compete’ with co-wives to have more children as a means to maintain their husband’s favor and continued support.

Women are most likely to access health serviceswhen they are pregnant and for their children. They get much of their information about health issues from friends and relatives and from the radio. Many women are only semi-literate. Many have access to radio and prefer listening in local languages. This audience is largely rural but admires what are considered to be urban trends and norms.

Communication goal: Smaller, healthier, more prosperous families in Uganda.

Behaviour outcomes:Women initiate family planning discussion with their husbands and partners and use modern family planning methods

Communication objective:By the end of the campaign, there will be an increase in the proportion of our audience who discuss modern family planning with their husbands/partners because they believe it is the best way to a healthier and more prosperous life.

Key promises (Benefits):

If you and your partner choose to use modern family planning methods:

  • You will be seen as a role model
  • You will be protecting the health of your family.
  • You will be seen as a sophisticated woman who is more modern and up

to date with current trends

Support points:

  • open communication between a woman and her husband/partner about family planning is important for the health and prosperity of the family
  • There is a direct relationship between family size and family well-being
  • Modern family planning methods are safe and effective
  • There are many satisfied family planning users

Communication channels and approaches:Every Day Health Matters on the basic facts of family planning, flipcharts for clinical and community based family planning providers, radio call-in program detailing the benefits and safety of family planning, satisfied FP customer endorsements, radio spots and mini-dramas demonstrating open communication about family planning among husband and wife, rainbow over the yellow flower logo signboards for private and public sector providers offering family planning services.