University of Ghana http://ugspace.ug.edu.gh RG147.G3L83 bite C.l G368264 University of Ghana http://ugspace.ug.edu.gh TO USE OR NOT TO USE: FACTORS INFLUENCING UTILIZATION OF FAMILY PLANNING SERVICES IN BOMFA SUBDISTRICT, EJISU JUABEN BY ALBERTA Y. LOMOTEY A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE AUGUST 2002 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that this dissertation is an original work based on my own research except for the citations that has been duly acknowledged and that it has not been submitted towards the award of any other degree. ALBERTA Y. LOMO TEY ACADEMIC SUPERVISORS DR. GLORIA QUANSAH ASARE DR. CLEMENT AHIADEKE University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my husband, Vincent Ankamah Lomotey and my children, Adoiey and Adorkor for their patience, support and encouragement. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am very grateful to the Alm ighty God for giving me the necessary strength and w isdom to go through the MPH Course. I wish to express my sincere gratitude to my Academ ic Supervisors, Dr. G loria Quansah Asare and Dr. C lement Ahiadeke for guiding me through all the stages of the preparation o f this document. To my field supervisor, Dr. Felicia Owusu-Antwi, the staff o f the D istrict Health Administration and Bomfa Health Centre, I say thank you fo r your guidance and hospitality. I am also very grateful to the staff of the Regional Health Adm inistration, Ashanti fo r their support and encouragement. To Dr. (Mrs.) Matilda Pappoe, God bless you richly fo r your words o f encouragem ent. Finally I wish to say thank you to the entire staff of the School of Public Health fo r their role in making this research work a reality. University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS PAGE DECLARATION I DEDICATION II ACKNOW LEDGEM ENT III TABLES OF CONTENTS IV LIST OF ABBREVIATIONS VI LIST OF TABLES AND FIGURES VII ABSTRACT IX CHAPTER ONE INTRODUCTION 1.1 Background Information 1 1.2 Statement Of The Problem 8 1.3 Rationale For The Study 9 CHAPTER TWO LITERATURE REVIEW 10 2.1 Determinants of family planning utilization 11 2.2 Objectives 16 CHAPTER THREE METHODOLOGY 3.1 Study Type 1 7 3.2 Study Area 1 7 3.3 Sample Size 1 7 3.4 Sampling 1 8 3.5 Variables 1 9 iv University of Ghana http://ugspace.ug.edu.gh 3.6 Data Collection Tools And Techniques 20 3.7 Data Processing And Analysis 21 3.8 Ethical Considerations 22 3.9 Training and Pretesting 22 3.10 Lim itations to the study 22 CHAPTER FOUR FINDINGS 4.1 Socio-demographic characteristics 24 4.2 Socio-demographic characteristics and current use of fam ily planning 27 4.3 Practice of Family planning 31 4.4 Attitudes and Beliefs towards family planning 37 4.5 Perception about the quality o f Family Planning 43 CHAPTER FIVE DISCUSSION 5.1.1 Socio-dem ographic characteristics and current use of fam ily planning 45 5.1.2 Practice of Family planning 46 5.1.3 Attitudes and Beliefs towards fam ily planning 48 5.1.4 Perception about the quality of Family Planning 49 5.2 CONCLUSION 51 5.3 RECOMMENDATION 52 REFERENCES 54 APPENDICES APPENDIX 1 QUESTIONNAIRE ON FAMILY PLANNING 57 APPENDIX 2 FGD GUIDE 65 V University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATION AIDS Acquired Immune Deficiency Virus FGD Focus Group Discussion GDHS Ghana Demographic and Health Survey HIV Human Immunodeficiency Virus JSS Junior Secondary School IEC Information, Education and Communication IUD Intra Uterine Device LAM Lactational Am enorrhoea Method PPAG Planned Parenthood Association of Ghana SDA Seventh Day Adventist TFR Total Fertility Rate VFT Vaginal Foaming Tablet v i University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES AND FIGURES PAGE Table 1.1 Distribution of Health facilities 7 Table 1.1 Family planning Acceptor rate 9 Table 3.1 Description of Variables 19 Table 4.1 Distribution of respondents by Age, Education and Marital status 24 Table 4.2 Distribution of num ber of living children of respondents 27 Table 4.3 Current use of family planning methods by sex 27 Table 4.4 Age and current use of family planning methods 28 Table 4.5 Marital status and current use of family planning 29 methods Table 4.6 Educational level and current use of family planning 30 methods University of Ghana http://ugspace.ug.edu.gh Table 4.7 Past use of family planning methods 31 Table 4.8 Distribution of the types of methods currently being used 32 Table 4.9 Distribution of people with whom respondents discuss family planning 36 Table 4.10 Discussion of family planning and current use among females 36 Table 4.11 Partner attitude towards fam ily planning 38 Table 4.12 Partner approval and current use among fem ales 39 Table 4.13 Decision to use family planning 39 Table 4.14 Decision to use family planning and current use 41 Table 4.15 Distribution of the num ber of children desired by respondents 41 Figurel Occupation of respondents 26 Figure 2 Educational level and current use of fam ily planning 31 Among women University of Ghana http://ugspace.ug.edu.gh ABSTRACT Family planning is a cost effective health intervention that has imm ediate benefits for women, children and families. However, in the Bomfa subdistrict fo r the past five years, 1997-2001 the fam ily planning acceptor rate has never exceeded 5%. The objective of this study was therefore to determ ine the factors accounting for this low acceptor rate. A descriptive cross sectional study was carried out over a four-week period. A total number of 170 persons, 76% females and 24% males were interviewed using structured questionnaires and focus group discussions to assess their practices, beliefs and attitudes towards fam ily planning. Some aspects o f the results were analysed in relation to sex. The findings of the study revealed that 32.4% of the respondents were currently using a family planning method. Education was found to be positively related to contraceptive use among females. The m ajor reason for non-use o f contraceptives was the fear of side effects. Eighty percent of the respondents discussed the use of fam ily planning with their friends and neighbours. Child spacing is greatly valued but fertility regulation to some extent was seen as a w om an’s responsibility. It is therefore being recommended that Information, Education and Communication activities on fam ily planning should be intensified through community durbars and identified male and female groups to dispel m isconceptions and allay fears about side effects. Awareness on the importance of spousal communication and male involvement in reproductive health issues should also be promoted. University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background Information The w orld ’s population has reached six (6) billion and is growing rapidly by nearly 80 million each year. It is estimated that by 2050, the w orld ’s population will increase by 50% that is from 6.1 billion to 9.3 billion. Developing countries will account fo r 85% of this projected growth.1 The dem ographic transition from high fertility and high mortality to low fertility and low mortality has been substantially completed in the developed world and is underway in most of the developing world. Nevertheless in many countries of Sub-Saharan Africa, the Near East and South Asia the population continues to grow at 2% a year or more and the average woman bears four to seven children.2 In Ghana, between 1960 and 1984 the population doubled from about 6.7 million to 12.3 million with a growth rate of 3.1% per annum 3 Currently the population is about 18.4 m illion.4 Ghana’s population could be described as a young population with about 48.2% of the people being under age 15 years. This represents a high dependency ratio.5 Rapid population growth if not controlled, could outstrip the provision of infrastructure and social services. Slower population growth aids developm ent in that more of the population will be in their productive years and thus resources can be invested into l University of Ghana http://ugspace.ug.edu.gh education, job creation and better health care. As more people choose family planning fertility falls and population growth slows. Family planning services are therefore, designed to assist couples and individuals in their reproductive ages to space or lim it the number of births, prevent unwanted pregnancy, manage infertility and improve their reproductive health. Family Planning is a cost effective health intervention that has immediate benefits fo r women, children and families. Globally, about half a million women die every year from complications of pregnancy and childbirth.6 In developing countries, women are 30 times more likely to die from pregnancy related causes than those in the developed world. It is estimated that a third of all maternal mortality and infection could be avoided if all women had access to a range of modern, safe and effective fam ily planning services that would enable them to avoid unwanted pregnancy. Prevention of unwanted pregnancy would mean a reduction in more than 78,000 maternal deaths that result from unsafe abortions yearly in developing countries.1 Closely spaced pregnancies are more likely to result in low birth weight infants who are more vulnerable to illness and thus less likely to survive. In many countries birth spacing alone could prevent 20% of infant deaths. Babies born less than two years after a sibling are almost twice as likely to die as those born after an interval of at least two years.6 2 University of Ghana http://ugspace.ug.edu.gh Throughout the world governments are aware of both the need and benefits o f family planning. Thus Ghana was one of the first sub Saharan African countries to sign the w orld ’s leaders declaration on population in 1967. In 1969 the governm ent issued a general policy paper on population planning for national progress and prosperity and this included provisions for family planning services. The objective of the policy paper was to reduce the population growth from 3.1% to 1.7% by the year 2000. Mass publicity and educational campaign was therefore launched to create awareness on the need for Family P lanning.3 The 1988 Ghana Demographic and Health Survey showed that 79% of currently married women had knowledge about family planning but there had been almost no change in attitudes and practices from those of the 1960’s. The contraceptive prevalence for 1988 was 13%. Most Ghanaian women still preferred to have large fam ilies and probably saw their childbearing abilities as a form of social and econom ic security. Children are considered as property of the extended family. A woman who has no child surviving is branded as useless because she has nothing to pass on to her family and society. In certain societies such women are ostracized. Children are also valued for their contribution towards farm labour. The population of Ghana thus continued to grow rapidly. In 1994 there was renewed effort to control the effects of rapid population growth by the Government. This led to a revision of the 1969 population policy, which emphasized 3 University of Ghana http://ugspace.ug.edu.gh improving the quality of life rather than reduction in numbers. Some of the objectives of the revised policy include: • Integration of population issues in all aspects of planning and developm ent at all levels; • To provide Information Communication and Education (IEC) on the value of small family size and reproductive health; • To ensure accessibility and affordability of family planning services for all couples and individuals to enable them regulate their fertility; • To educate the youth on reproductive health in order to guide them towards responsible parenthood; • To integrate family planning services into maternal and child health care services so as to reduce infant, child and maternal mortality; • To educate the general population about the cause, consequences and prevention of HIV/ AIDS. Some of the strategies adopted to achieve these objectives revolved around improving the range of family planning methods, intensification of the activities o f fam ily planning clinics and commercial distribution outlets with special emphasis on provision of IEC Programmes to reach the male population at all levels. The M inistry o f Health provides family planning services through a network of Maternal and Child Health/Family planning clinics, health centres and hospitals. Complementing the efforts of the Ministry of health are Non-governmental Organizations such as, the Planned Parenthood Association of Ghana (PPAG) and the Ghana Social Marketing 4 University of Ghana http://ugspace.ug.edu.gh Foundation (GSMF), which are involved in Community Based Distribution of contraceptives and IEC activities. O ther private participating agencies include Ghana Registered M idwives Association, Private Clinics and Chemical Sellers. It is estimated that 46% of women get their methods from Ministry of Health outlets and about 39% from pharmacies and chemical sellers.7 The Ejisu-Juaben D istrict The Ejisu-Juaben district is one of the 18 districts in the Ashanti Region. It lies in the South-Eastern part of the region. It covers an area of about 1635 square kilometers with a population of 120,968.4 The district is divided into 5 sub-districts namely Kwaso, Ejisu, Bomfa, Juaben and Achiase. Ejisu is the district capital. Most of the inhabitants are subsistence farmers. Others engage in Kente weaving and petty trading as their sources of income. Few are employed as factory hands in the wood industry and the oil palm plantation at Juaben. With the exception of Juaben that enjoys pipe borne water, most o f the communities use either boreholes or wells as source of drinking water. Only a few towns are connected to the national electricity grid. Bomfa Subdistrict The study took place in the Bomfa Subdistrict that is located in the North-Eastern part of the District and shares boundaries with Juaben in the North, Achiase in the South, 5 University of Ghana http://ugspace.ug.edu.gh Asante Akim North District in the East and Kwaso Subdistrict in the West. The total land area of the sub district is 264 square kilometres, which is approximately 16% of the total land area of the district. For administrative purposes the subdistrict has 9 recognized comm unities namely Bomfa, Adumasa, Nobewam, Kubease, Duampompo, New Koforidua, Boamadumase, Hwereso and Sekyere. The projected population for the year 2001 is 19,200 with an annual growth rate of 2.7%. (Projected from 1984 census figures since that of the year 2000 has not been released). Ethnic and Religious Groups The inhabitants are predominantly Akans but there are other ethnic groups such as Ewes, and Kotokolis. Asante Twi is the most common language used. The principal religions are Christianity, Islam and Traditional. Educational Institutions The total number of schools in the subdistrict is 29. The breakdown is as follows: Seven Preschools Thirteen Primary schools Nine Junior Secondary Schools There are no Senior Secondary or Tertiary Institutions Electricity and Telecommunication services The Bomfa Subdistrict does not have electricity nor telecommunication services. 6 University of Ghana http://ugspace.ug.edu.gh Road Network and Transportation Most of the comm unities are located along the main A ccra -K um asi road. W ith the exception of Boamadumase, all the roads leading to the comm unities are tarred. Taxis and M inibuses serve as the major means of transportation. During the rainy season some parts o f the Boamadumase community become inaccessible. Occupation The inhabitants are predominantly farmers and petty traders. There are no factories or industries to provide em ploym ent opportunities. Health Services Table 1:1 below presents the distribution and ownership of health facilities in the Bomfa Subdistrict. TABLE 1.1 HEALTH FACILITIES Facility Location Ownership Bomfa Health Centre Bomfa Government Huttel Health Centre Boamadumase The Presbyterian Church SDA Clinic Nobewam Seventh Day Adventist Church Daasebre Health Services Adumasa Private The Bomfa Health Centre provides Clinical and Reproductive and child health services at the facility and on outreach basis. The family planning methods provided include; the Pill, Condoms, Vaginal Foaming Tablets, Intra Uterine Devices, Injectable and Implant. 7 University of Ghana http://ugspace.ug.edu.gh Clients who opt for Sterilization are referred to e ither Juaben or Komfo Anokye Teaching Hospital. Staff of the Bomfa health Centre also provides fam ily planning services on outreach basis at the Huttel Health centre. The SDA clinic and the Daasebre clinic do not provide family planning services (Table 1.1). The PPAG has two Community Based Distributors in Nobewam and New Koforidua respectively providing contraceptives such as the Pill, condoms and Vaginal Foaming Tablets. There are ten (10) Chemical shops in the Bomfa subdistrict providing the same range o f services. 1.2 Statem ent o f the Problem The fam ily planning acceptor rate for the past five years has generally been low in the Bomfa Subdistrict. The rates for the district and regional levels had also been fluctuating. From Table 1.2, in 1997, the acceptor rate for the region was 26% and that of the district was15% . Both figures dropped to as low as 5.7% and 10% respectively in the year 2000. In the Bomfa Subdistrict the acceptor rate has never exceeded 5% for the past five years despite the improvement in the range of fam ily planning methods and IE&C activities on the value of spacing and limiting births. There is lack of information as to why there is this very low Acceptor Rate. In a sub-district like Bomfa, which is not endowed with adequate infrastructure, there is a need to control fertility rates in order to ensure that social services are not over stretched. Moreover the lack of employment opportunities coupled with the fact that University of Ghana http://ugspace.ug.edu.gh most o f the inhabitants are subsistence farmers whose incomes generally tend to be unstable, makes it imperative for couples to plan their families. T a b le l. 2: Family planning Acceptor Rate (1997-2001) 1997 1998 1999 2000 2001 REGIONAL (Ashanti) 26 12 12 10 11 DISTRICT(Ejisu-Juaben) 15 13.5 14.5 5.7 10.7 SUBDISTRICT (Bomfa) 4.2 0.70 3.8 2.6 4.8 Sources: Annual Reports of Ashanti Region, 1997 - 2001 District Health Profile, Ejisu-Juaben, 2000 Reproductive and Child health Annual Reports, 1997-2001 1.3 Rationale for the study In family planning programs there can be gaps between services offered and the services clients need. A better understanding of the factors influencing client’s use of family planning services can help bridge the gap. Conducting a study to identify some of these factors is therefore necessary in order to design an intervention programme to improve the coverage of family planning services in the sub district. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW The Programme of Action, principle 8 of the International Conference o f Population and Development states, " all couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have information and means to do so' 1 The developm ent o f modern contraceptives has given people the freedom and ability to plan their families. The use of contraceptives by couples worldwide has increased from less than 10% to about 60% over the last 3 decades. Family planning programmes have contributed considerably to decline in average fertility rates fo r developing countries from about six to seven per woman in the 1960's to about three to four children at present.8 However, 350 million couples worldwide do not have access to the full range o f modern contraceptives. Surveys from developing countries indicate that more than 100 million women want to delay the birth of their next child or to stop having children but are not using a contraceptive method thus creating a situation of an unmet need.1 10 University of Ghana http://ugspace.ug.edu.gh In Ghana contraceptive prevalence increased from 13% in 1988 to 22% in 1998 for all methods. For modern methods the prevalence was 5% in 1988,10% in 1993 and 13% in 1998. The Total Fertility Rate (TFR) has declined from 6.4 to 4.6 in 1988 and 1998 respectively. The two child fertility declined observed within this period far exceeds the increase in contraceptive prevalence over the same period and is inconsistent with International experience in the relationship between fertility and contraceptive prevalence. TFR will fall to 3.7% births per woman if all the unwanted births were prevented. About 23% o f married women have an unmet need fo r Family Planning. It is estimated that 11 % have unmet need for spacing and 12% unmet need for lim iting .9 W estoff and Ochoa in 1991 defined unmet need as the percentage of married, fecund women not using contraception but wanting to space or limit their next birth as well as those who are not pregnant or amenorrheic and whose last birth was unwanted or m istim ed.10 2.1 DETERM INANTS O F FA M ILY PLANNING UTILIZATION According to the Herm alin’s model there are two main proximate determ inants of contraceptive use; these are motivation to control fertility and the cost of regulation, which operate through a set of Socioeconom ic and dem ographic variables. A t any given point, motivation is regarded as a function of the interaction between supply of children and demand for children. The cost of regulation includes econom ic costs (money and time), social cost (outcome of transgressing social norms favoring 11 University of Ghana http://ugspace.ug.edu.gh childbearing) health and Psychic costs which refers to the consequences of experimenting with something new that may be risky or unpleasant.11 Studies in Ghana, Indian, Pakistan, Philippines and Zambia as well as Guatemala consistently found that fear of side effects; lack of husband support and lack of knowledge are the m ajor factors contributing to the non-use of family planning methods. Other factors include poor access to or limited range of contraceptive choice.12 2.1.1 Fear O f Side Effects Many couples stop or refuse to use contraception because of real or perceived side effects. Some of the side effects commonly cited are headaches, amenorrhea, prolonged bleeding and weight gain. In a study conducted in the Philippines nearly 40% of non-Contraceptive users said they were concerned about side effects. In Pakistan a large portion of women who had heard o f modern methods o f contraception feared the harmful effects from using them. The range was 40% for female sterilization and 70% for Intra Uterine D ev ices .12 In Ghana fear o f side effects is the most frequently cited reason fo r non-use of contraceptives and this accounts for 16% of the reasons given. It was more likely to be mentioned by women with an unmet need for limiting than fo r spacing.10 I2 University of Ghana http://ugspace.ug.edu.gh 2.1.2 Consent o f Spouse and Significant Others The traditional African pattern of male involvement in fertility decision-m aking is clearly reflected in many studies. A study in Nigeria among married students revealed that, one out of every five women who were not using a contraceptive method gave husband’s objection as the reason for non-use. Another study reported that men fear their w ives use of contraceptive will undermine their own authority as head of the household or encourage their wives to be prom iscuous.13 The 1998 Ghana Demographic and Health Survey revealed that 21% o f women indicated that their partners or someone else is opposed to their use of contraception. Spousal influence is an exclusive right exercised only by the husband. Thus the limited impact o f family planning in Ghana could partly be attributed to neglect of men as equal targets in such program m es.14 W hilst husbands and male partners have tremendous impact on a w om an’s contraceptive use or non-use other family members play a significant role as well. In some countries parents and In-laws view grandchildren as necessary to extend the family line, to provide financial support for parents during old age or to provide labor on family farms. Studies conducted in Egypt and Zimbabwe showed that mothers in law influence w om en’s decision about family size and contraceptive use is encouraged only as a means of limiting births once a couple has the number of children they w anted.12 13 University of Ghana http://ugspace.ug.edu.gh 2.1.3 Discussion o f fam ily planning utilization A study in Ghana indicated that the two most important factors determ ining contraceptive use were communication between spouses (including w ives perception that husbands supported their contraceptive use) and people outside the family who offered encouragem ent and support for family planning use.15 In Addis Ababa the use of contraceptives was nearly doubled among women who received counseling with their husbands as compared to those who did not. The coverage was 33% and 17% respectively.16 2.1.4 Quality O f Fam ily Planning Services The quality of fam ily planning services is likely to be an important determ inant of contraceptive use by increasing adoption of methods and significantly increasing continuity of contraceptive use. A range of situational factors such as knowledge of location of clinics and other supply sources, their proximity, and reputation o f family planning personnel and suitability of clinic procedures are known to influence the decision to adopt fam ily planning methods. To explore the linkages between quality of care and continued contraceptive practice, a study in Indonesia revealed that 72% of women who had been denied their choice o f contraceptive method at the clinic they attended discontinued use within 12 m onths.17 14 University of Ghana http://ugspace.ug.edu.gh Separate studies in Gambia and Niger reported that in both countries contraceptive discontinuation was substantially higher among women who perceived that they had not received adequate counseling about side e ffe c ts .17 A study in Ghana showed that most providers especially nurses, imposed unnecessary restriction for family planning methods based on age, marital status, weight, parity and spousal consent. More than half of the providers enforced marriage requirem ents and spousal consent for at least one reversible method with the aim of upholding social mores or protecting the health of the client. The dangers of contraceptive use are often exaggerated thereby limiting access.18 2.1.5 Socio Econom ic Status o f women Other studies have shown that women who earn income, contribute to their fam ily ’s support are more likely to use contraception than women who do no t.19 Findings from a study conducted in Mali, Nigeria and Ghana indicate that a w om an’s level of education is positively related to the adoption of family planning methods.20 The literature reviewed indicates that several factors contribute to the utilization of family planning services. These factors may be socio-cultural, health or programme related. Most of the studies involved women with limited information regarding the attitude and behaviour of men. 15 University of Ghana http://ugspace.ug.edu.gh 2.2 OBJECTIVES G eneral Objective To identify the factors which influence utilization of fam ily planning services in the Bomfa sub district, Ejisu Juaben District. Specific Objectives 1. To describe socio-dem ographic characteristics such as age, marital status, education and contraceptive use. 2. To describe the attitude, beliefs and practices of both men and wom en towards family planning. 3. To describe the perception of both female and male users o f the Bomfa Health Centre about the quality of fam ily planning services in terms o f access to relevant information, privacy, waiting time, availability o f methods and provider attitude. 16 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 Study Type The study is a descriptive cross sectional study, which was carried out w ithin a four- week period June -J u ly 2002 to determ ine the factors that influence utilization o f Family planning services. 3.2 Study Area The study was carried out in 5 communities out o f a total of nine com m unities in the Bomfa subdistrict. The communities were Bomfa, Hwereso, Nobewam, Adum asa and Boamadumase. The study population was women in their reproductive age that is 15-49 years and men above 15 years. 3.3 Sam ple Size N = 7t (1-7i) z2 (Source Kirkwood, 1996) W here N = Sample Size 7i = Proportion of women using Family planning - 4.8% z = 1.96 at 5% Significance level e= Error margin of 3% 17 University of Ghana http://ugspace.ug.edu.gh Therefore N = 0.05 (0.95) 1.962 0.032 The required sample size = 202 With an assumption of 10% non-response the sample size will be 220. But a total number of 170 respondents were interviewed because of time constraint and resources. 3.4 Sam pling Procedure Five comm unities were selected by simple random sampling. All the names o f the nine (9) comm unities were written on a paper and put in a box. Five of them were then picked one after the other. Anytime a comm unity was picked the name was recorded until the five comm unities had been selected. After the comm unities have been selected, on the day of data collection the centre of the community was located. The central point differed from one com m unity to the other; in some cases it was a lorry station, a market or a park for social gathering. A sharpened pencil was then spanned on the ground. The direction of the pointed edge was chosen as the starting point. Moving in that direction every third house was selected. Upon entering the house the consent of eligible individuals was sought and interviewed. If there were no eligible persons the next third house was selected. The procedure was repeated until the required number of respondents was obtained. The number of people interviewed was evenly distributed for the five comm unities because the population of the communities was not readily available. Thus 34 respondents were interviewed in each community. 18 University of Ghana http://ugspace.ug.edu.gh 3.5Variab les The dependent variable is utilization of family planning services. Table 3.1 shows the independent variables. TABLE 3.1 Description of independent variables INDEPENDENT INDICATOR Age Age As At Last Birth Day Marital Status Married, W idowed, Divorce, Separated, Single Educational Level No education, Primary, JSS, Secondary, Tertiary Religion Christianity, Islam, Traditional Occupation Farming, salaried worker, Trading and others ATTITUDE AND BELIEFS • Preferred number of children and birth spacing • Reasons for being for or against family planning • W ho decides contraceptive use and family size 19 University of Ghana http://ugspace.ug.edu.gh INDEPENDENT INDICATOR PRACTICE • Past use of family planning methods • Current use of family planning methods • Intention to use a fam ily planning method • Sources of information about family planning • Discussion about the use of family planning • Reasons for non-use QUALITY OF FAMILY PLANNING • Use of the Bomfa health Centre for SERVICES family planning services • Access to relevant information • Privacy • Waiting time • Provider Attitude • Availability of methods 3.6 Data Collection Tools and Techniques A questionnaire was administered to assess the beliefs and attitudes of respondents towards contraceptive use, and perception about the quality of fam ily planning services. See Appendix 1. On the day of data collection the research assistant upon entering a house introduced herself, explained the purpose of the study to eligible persons, sought for verbal consent and then proceeded with the interview. 20 University of Ghana http://ugspace.ug.edu.gh Four (4) Focus group discussions were organized; two groups o f fem ales and two groups o f males in two selected communities, Hwereso and Bomfa respectively. A guide (Appendix 2) was used to get in-depth information about their beliefs and attitudes towards family planning to support the quantitative data obtained. The participants were recruited through the help of the Village Health Committee members. There were about 10 participants in a group with their ages ranging from 16 to 45 years. There was one m oderator (the researcher) who coordinated the discussion and a recorder to keep a record of the content of the discussion. A tape recorder was also used to assist in the capturing of information. A fter self-introduction, the participants were encouraged to feel free and express their opinions since there were no right or wrong answers. Each FGD lasted for about an hour. 3.7 Data Processing and Analysis During the data collection, the researcher monitored the process to ensure that research assistants adhered to the research procedures. Also at the end o f each day each questionnaire was cross-checked for completeness and internal consistency. Problems identified were discussed with research assistants. Each questionnaire was given a serial number. The information obtained was coded, keyed into the computer and analysed using the EPI INFO Statistical Package. A report of the FGD was prepared using the participants' own words. A list o f the key opinions expressed by both groups was categorized in relation to the objectives. The most useful quotations were used as a narrative text to support the quantitative data. 21 University of Ghana http://ugspace.ug.edu.gh 3.8 Ethical Consideration Permission to proceed with the study was obtained from the Regional Health Authorities, the District Assem bly and Community Leaders. The purpose and objectives of the study was clearly discussed with the respondents and a verbal consent was sought. Respondents were assured of confidentiality. 3.9 Training and Pretesting A one-day training was organised for two research assistants from the D istrict Health Adm inistration, Ejisu. The rationale and objectives o f the study were explained after which they were taken through basic interview techniques such as asking questions in a neutral manner, how to record answers to open ended questions w ithout sifting or interpreting them and also translation of the questions into the local language. Pretesting o f the questionnaires was carried out in the Ejisu Subdistrict. Some corrections were made. These included rephrasing of ambiguous questions, closing of open-ended questions and addition of other relevant questions. 3.10 Lim itations to the study Due to time and financial constraints the sample size was scaled down to 170 from 220 thereby limiting the extent to which the findings may be generalized. Also because of the low utilization of the Bomfa Health Centre, exit interviews and observations that could have provided firsthand information for the assessment of the quality of family planning services could not be carried out. The assessment was based on responses 22 University of Ghana http://ugspace.ug.edu.gh from a few people who had ever used the facility within the last two years there is therefore the tendency of recall bias by respondents. 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 FINDINGS A total number of 170 persons were interviewed. One Hundred and Thirty (76%) of them were women and 40(24% ) were men. Table 4.1: Distribution of respondents by Age, Education and Marital Status FEMALE MALE SOCIO - FREQUENCY PERCENTAGE FREQUENCY PERCENTAGE DEMOGRAPHIC (% ) (% ) CHARACTERISTIC N=130 N=40 AGE 1 5 - 19 10 7.7 2 5.0 2 0 -2 4 24 18.5 6 15.0 2 5 -2 9 29 22.3 7 17.5 3 0 -3 4 24 18.5 8 20.0 3 5 -3 9 23 17.7 5 12.5 4 0 -4 4 13 10.0 5 12.5 4 5 -4 9 7 5.4 3 7.5 5 0 -5 4 0 0 1 2.5 5 5 -5 9 0 0 3 7.5 EDUCATION No education 31 23.8 1 2.5 Primary 36 27.7 5 12.5 M iddle / JSS 61 46.9 27 67.5 Secondary 2 1.5 7 17.5 Tertiary 0 0.0 0 0.0 M ARITAL STATUS Single (Never Married) 20 15.4 10 25.0 Married / L iv ing 101 77.7 29 72.5 Together W idowed 1 0.8 0 0 Divorced/Separated 8 6.2 1 2.5 24 University of Ghana http://ugspace.ug.edu.gh 4.1 SOCIO - DEM OGRAPHIC CHARACTERISTICS Age The ages of the respondents ranged from 15-59 years. For the females, age group, 25­ 29 had the largest number of respondents 29(22.3%) and 45-49 years had the smallest 7(5.4%). For the males, age group, 30-34 had the largest number of respondents 8(20%) and 50-54 years formed the smallest 1(2.5%). The age distribution is shown in Table 4.1. Educational level Most o f the respondents had had education up to M iddle or JSS level, 61 (46.9% ) for females and 27 (67.5%) for males respectively. Thirty-six (27.7% ) fem ales and 5(12.5%) males had Primary education. Only 2(1.5% ) females and 7(17.5% ) males had Secondary education. Thirty-one (23.8%) females and one(2.5%) male had no education. None of the respondents had education up to Tertiary level as shown in Table 4.1 Marital Status Majority of the respondents, 130(76%) were married or living together. One hundred and one (77.7%) females were married, 20 (5.4%) were single and 9(6.9% ) were divorced, or w idowed. Twenty-nine males (72.5%) were married, 10(25.0%) single and 1(2.5%) divorced. It is worth noting that for the 30 persons who were single, 17 were in a sexual relationship. See Table 4.1. 25 University of Ghana http://ugspace.ug.edu.gh Religion One hundred and Forty (82.4% ) o f the respondents w ere C hristians belonging to various denom inations such as the Catholic, Presbyterian, Pentecost and Spiritual churches. Seventeen (10% ) were M oslem s while 13 (7.6% ) practiced Traditional religion. O ccupation M ajority o f the respondents were farm ers, 78 (45.9% ), and 55(32.4% ) w ere petty traders. N ineteen (11.2% ) were Artisans com prising o f carpenters, ta ilors, hairdressers and dressm akers. Fifteen (8.8% ) were unem ployed. The occupation o f respondents is shown in F igure 1. Figure 1: OCCUPATION OF RESPONDENTS Unemployed 9% Artisai 11% Farmer 46% Petty Trad 32% Salaried W orker 2% 26 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Distribution of number of living children of respondents NUMBER OF CHILDREN FREQUENCY PERCENTAGE (%) 0 29 17.1 1 26 15.3 2 26 15.3 3 29 17.1 4 22 12.9 5+ 38 22.4 TOTAL 170 100 N um ber o f Children (Living) Table 4.2 shows the distribution of number of living children, which ranged from none to 10. Twenty-nine (17.1) had no children, 103(60.6%) had 1 to 4 children and 38 (22.4 %) had more than 4 children. 4.2 SO CIO-DEMOGRAPHIC CHARACTERISTICS AND CURRENT USE OF FAMILY PLANNING METHODS. Table 4.3: Current use o f Fam ily Planning Methods by Sex SEX CURRENT USE OF FAMILY PLANNING METHODS YES NO TOTAL FEMALE 39 91 130 (30%) (70%) (100%) MALE 16 24 40 (40%) (60%) (100%) TOTAL 55 115 170 27 University of Ghana http://ugspace.ug.edu.gh 4.2.1 Current use of Family Planning Methods by Sex From Table 4.3, 30% of women and 40% of men were currently using a family planning method. Table 4.4: Age and Current Use of Family Planning Methods Age group CURRENT USE OF FAMILY PLANNING METHODS FEMALE MALE YES NO YES NO TOTAL 15-19 0 10 1 1 12 (11%) (6.3%) (4.2%) 20-24 8 16 3 3 30 (20.5%) (17.6%) (18.8%) (12.5%) 25-29 10 19 1 6 36 (25.6%) (20.9%) (6.3%) (25%) 30-34 8 16 4 4 32 (20.5%) (17.6%) (25%) (16.7%) 35-39 5 18 0 5 28 (12.8%) (19.8%) (20.8%) 40-44 5 8 2 3 18 (12.8%) (8.8%) (12.5% (12.5%)) 45-49 3 4 3 0 10 (7.7%) (4.4%) (18.8%) 50-54 0 0 1 0 1 (6.3%) 55-59 0 0 1 2 3 (6.3%) (8.3%) TOTAL 39(100%) 91(100%) 16 24 170 28 University of Ghana http://ugspace.ug.edu.gh 4.2.2 Age and Current Use of Family Planning Methods From Table 4.4, current use of family planning among women and men though not uniform showed a rise with age. For the women, a peak of 25.6% was observed at age 25-29 and dropped to 7.7% at age 45-49. With the men, it rose from 6.3% at age 15- 19,a peak of 25% was observed at age 30-34 and dropped to 6.3 % for age 55-59. 4.2.3 Marital Status and Current Use of Family Planning Methods Table 4.5 shows that the use of family planning was highest among married men and women 48.3% and 34.7% respectively. For those who were not married but were in a sexual relationship it was 20.0% for both women and men. The divorced, separated and widowed were currently not using any method. Table 4.5: Marital Status and Current Use of Family Planning Methods Marital Status CURRENT USE OF FAMILY PLANNING METHODS FEMALE MALE YES NO TOTAL YES NO TOTAL Single 4 16 20 2 8 10(100%) (20%) (80%) (100%) (20.0%) (80.0%) Married 35 66 101 14 15 29(100%) (34.7%) (65.3%) (100%) (48.3%) (51.7%) Separated/ 0 9 9 0 1 1 Divorced/ (100%) (100%) (100%) (100%) (100%) Widowed TOTAL 39 91 130 24 16 40 29 University of Ghana http://ugspace.ug.edu.gh 4.2.4 Educational level And Current Use of Family Planning Methods The percentage of current users for both men and women shows an increasing pattern from no education 25% to Middle school 37.5% and then a decrease at the Secondary level 22.2%. It is worth noting that the pattern observed is not statistically significant p value > 0.05. This was because the sample of respondents who had had secondary education was small. See table 4.6. 4.6: Educational level And Current Use Of Family Planning Methods CURRENT USE OF FAMILY PLANNING METHODS YES NO TOTAL No 8 (25%) 24 (75%) 32(100%) Education Primary 12 (29.3%) 29 (70.3%) 41(100%) Middle/JSS 33 (35.7%) 55 (62.5%) 88(100%) Secondary 2 (22.2%) 7 (77.8%) 9(100%) TOTAL 55 115 170 30 University of Ghana http://ugspace.ug.edu.gh 4.2.4. Educational level And Current Use among females. Current use of family planning among females showed an increasing pattern from no education 25.8 % to Secondary level, 50%. This is illustrated by Figure 2. Figure 2: Educational level and current use among females 4.3 PRACTICE OF FAMILY PLANNING 4.3.1 Past use o f family planning methods Out of the 170 persons interviewed 100 (58.82%) had ever used a family planning method while 70 (41.18%) had never used any method as shown in Table 4.7. Table 4.7: Past Use of Family Planning Methods USE OF FAMILY PLANNING FREQUENCY PERCENTAG E(%) METHODS Ever used 100 58.82 Never used 70 41.18 TOTAL 170 100 31 University of Ghana http://ugspace.ug.edu.gh 4.3.2 Current use of family planning methods One hundred and fifteen (67.6%) of the respondents were not using any method. Only 55 (32.4%) were currently using a family planning method (22.4% for modern methods and 10% for traditional methods such as periodic abstinence and withdrawal). For all women currently using a method the Pill was the most commonly used modern method 16(41.0 %) followed by the Injectable 3 (7.7%). None of the women reported condom use. With the men, the condom and the Injectable follow the Pill. None of the men reported the use of VFTs and withdrawal. See Table 4.8. Table 4. 8: The Distribution of the type of methods currently being used FEMALE MALE METHOD FREQUENCY PERCENTAGE FREQUENCY PERCENTAGE (%) (%) Condom 0 0 3 18.8 Injectable 3 7.7 2 12.5 Female Sterilization 2 5.1 1 6.3 Lactational 1 2.6 1 6.3 Amenorrhea Method Pill 16 41 0 6 37.5 Vaginal Foaming 2 5.1 0 0 Tablet (VFT) Withdrawal 1 2.6 0 0 Periodic Abstinence 13 33.3 2 12.5 Intra Uterine Device 1 2.6 1 6.3 TOTAL 39 100 16 100 4.3.2.1 Current use of methods among married women Among married women, 21(20.8%) were using modern methods and14 (13.9%) were using traditional methods. 32 University of Ghana http://ugspace.ug.edu.gh 4.3. 3 Other “ methods” of family planning currently being used Five (4.3%) of those who were not using any of the methods discussed above were using different kinds of substances to prevent unwanted pregnancies. The breakdown was as follows: • Taking of saccharin before sexual act 2 (1.7%) • Having an enema of herbs some few days before ones menses 2 (1.7) • Drinking of Nescafe 1 (0.9%) 4.3.4 Sources Of Acquisition of Family Planning Services by Current Users The most common source of acquisition of family planning services by current users was the Drug stores. The break down was as follows for the 55 current users: • Twenty- three (41.8%) Drug stores • Fourteen (25.5%) health centres and hospitals • The remaining 18 were using natural family planning methods such as periodic abstinence and withdrawal. Participants of the focus group discussion expressed the following opinions about why the drug store is most preferred in terms of procedures, proximity and time. They had this to say: “ In The drug store there is nothing like getting a card, no queue you get what you want immediately”. “Through conversation with friends some get to know certain drugs that can be used to prevent pregnancy. Such persons who want to use it go straight to the drug store to buy”. “ The drug store is just around us, no consultation fee, no interview 33 University of Ghana http://ugspace.ug.edu.gh 4.3.5 Intention to use family planning methods Out of the 70 who had never used any method 31(44.3%) intend to use a method in the future, while 34(48.6%) never intend to use. Five(7.1%) were not sure if they would ever use a method. 4.3.6 Reasons for non-use o f family planning methods The major reasons given for currently not using a method or not intending to use a method were side effects and the want for more children as indicated below. • Fear of side effects (34%) • Wanted more children (26%) • Sub fertility (10%) • Against Religious beliefs (7%) • Too expensive (3%) • Menopause (2%) • Others (18%) Some of these included infrequent sex, inconvenient to use and others did not give any reasons. Findings from the focus group discussion from both men and women also show side effects as a major reason why people do not practice family planning. This is what some of the participants had to say: “Sometimes the nurses do not tell us of the side effects and even if you have side effects and you go to them, they keep reassuring you that it will stop but it 34 University of Ghana http://ugspace.ug.edu.gh doesn’t. I know of a woman who was using IUD and was having problems but the nurse did not take heed till she collapsed. If it happens like that then no one will go for it” . Female (F) “ After using the method for a long time it makes the woman very weak and sick during pregnancy and child birth" Male (M) "It gives abdominal distention and it makes you bleed a lot” (F). “After using the pill I became so obese and had some fibroids so as for family planning my entire family has vowed never to use any". (F) “ Sometimes the methods can fail" (M) Another man had this to say about religious beliefs: “ There is no record of family planning in the bible that’s why people are not using it". 4.3.7 Discussion of Family Planning Utilization Out of the 170 persons interviewed 100 (58.8%) indicated that they discussed the utilization of family planning with others while 70(41.2%) did not. Majority of the respondents discussed family planning with their friends and neighbours (80%). Fifteen percent discussed it with their spouses or partners. Discussion was least with Health workers, 1%. Table 4.9 represents the distribution of the different people respondents discussed family planning with. 35 University of Ghana http://ugspace.ug.edu.gh Table 4.9: Distribution of people with whom respondents discuss the use of family planning PERSONS FREQUENCY PERCENTAGE (%) Spouse 15 15 Mother 1 1 Sister 3 3 Friends and Neighbours 80 80 Health Worker 1 1 TOTAL 100 100 4.10: Discussion of Family Planning and Current Use among females CURRENT USE OF FAMILY PLANNING METHODS YES NO TOTAL Spouse 5 2 7 (71.4%) (28.6%) (100%) Friends/ 21 35 56 Neighbours/ (37.5) (62.5%) (100%) Relatives Health Worker 0 1(100%) 1 (100%) Do not discuss 13 35 48 (27.1%) (72.9%) (100%) TOTAL 39 73 112 4.3.7.1 Discussion of Family Planning and Current Use among Females Table 4.10 indicates that current use was highest among women who discussed family planning with their spouses, 71.4%. For those who discussed with their friends and those who did not discuss with anyone it was 37.5% and 27.1% respectively. 36 University of Ghana http://ugspace.ug.edu.gh 4.3.8 Exposure to family planning messages The radio was the most common source of information on family planning. • Eighty two (48.2%) of the respondents had heard family planning messages on the radio • Forty Four (25.9%) from the health facility • Nineteen (11.2%) Friends and Relatives • Sixteen (9.4 %)from the television and • Nine (5.3%)did not indicate their source of information. These persons do not approve of family planning because of their religious belief and others because they were menopausal had no interest. 4.4 ATTITUDES AND BELIEFS TOWARDS FAMILY PLANNING UTILIZATION 4.4.1 Reasons for approving or disapproving the use of family planning One hundred and forty seven (86.5%) out of the 170 persons interviewed approve of the use family planning while 23 (23.5%) did not. The major reasons for approval and disapproval were as follows: Reasons for Approval • It helps to space birth thus eases financial burden (66%) • It makes the children grow healthily (17%) • The mother is free to work (2%) • The mother usually remains healthy (2%) 37 University of Ghana http://ugspace.ug.edu.gh A woman summarized the reasons for approving family planning in the focus group discussion as follows: “Family planning makes the woman strong all the time, if you are healthy then you will give birth to healthy children and you’ll also be able to work to take care o f them" Reasons fo r disapproval • Those who disapproved of family planning gave two reasons. Four (2%) indicated that it is against their religious belief and 19(11%) because of side effects. 4.4.2 P artner‘s Attitude towards Family Planning Sixty-five (58.0%) of the 112 women who were currently in a union (married or in a sexual relationship) indicated that their partners approve of family planning, 16(14.3%) had partners who disapprove of its use and 31(27.7%) did not know their partners attitude. Twenty-seven (77.1%) men reported of their partners’ approval, 4(11.4%) had partners who disapprove and the remaining 4(11.4%) did not know of their partners’ attitude as shown in Table 4.11. 4.11: P artner‘s Attitude towards Family Planning FEMALE MALE PERSONS FREQUENCY PERCENTAGE FREQUENCY PERCENTAGE (%) (%) Approves 65 58.0 27 77.1 Disapproves 16 14.3 4 11.4 Don’t Know 31 27.7 4 11.4 TOTAL 112 100 35 100 38 University of Ghana http://ugspace.ug.edu.gh Table 4.12: Partner Approval And Current Use Among Females Partner CURRENT USE OF FAMILY PLANNING METHODS Attitude YES NO TOTAL Approves 28 37 65 (43.1%) (56.9%) (100%) Disapproves 3 13 16 (18.7) (81.3%) (100%) Don’t Know 8 23 31 (25.8%) (74.2%) (100%) TOTAL 39 73 112 _ 4.4.3 Partner Approval And Current Use among Females Table 4.12, shows that women who indicated that their partners approved of family planning reported the highest use, 43.1%. For those whose partners disapproved and those who did not know of their partner's attitude it was 18.7% and 25.8% respectively. 4.4.4 Decision to use family planning methods Out of the 147 respondents who were in a union (the married and single in a relationship), 72 (49%) indicated that the decision to use family planning methods was made by themselves, 38(25.9%%) by their spouses and the rest 37(25.1%) by both (Table 4.13). Table 4.13: Decision to use family planning methods FREQUENCY PERCENTAGE Self 38 25.9 Spouse 72 49 Both 37 25.1 TOTAL 112 100% 39 University of Ghana http://ugspace.ug.edu.gh Participants of the focus group discussions expressed similar views on who decides on contraceptive use as the husband, the wife, or the couple. "The decision lies with you the woman, as for the man he gets up takes his cutlass and o ff he goes. The burden o f caring for the children rests on you. If you have to go and fetch water one will be at your back and the other on your shoulders". (F) “It depends on both (couple). If the woman does not agree you cannot use it". (M) "If the man does not give his consent and you do it, then it can even lead to break up o f the marriage" (F) "The responsibility lies with the man because if your children become wayward everybody will refer to the child using your name” (M) “The decision lies with the woman because she experiences the woes o f caring for children. (M) 4.4.5: Decision to use family planning and current use From Table 4.14, 39.1% of women who had their spouses or partners deciding on contraceptive use were current users. The percentages for those who decide together and those deciding by themselves were 30.4% and 28.0% respectively. With the men, 50.0% indicated that the decision to use family planning was taken with their partners, 46.2% took the decision by themselves and 37.5% by their partners. 40 University of Ghana http://ugspace.ug.edu.gh Table 4.14: Decision to use family planning and current use CURRENT USE OF FAMILY PLANNING METHODS FEMALE MALE YES NO TOTAL YES NO TOTAL Self 7 18 25 6 7 13 (28.0%) (72.0%) (100%) (46.2%) (53.8%) (100%) Spouse 25 39 64 3 5 8 (39.1%) (60.9%) (100%) (37.5%) (62.5%) (100%) Both 7 16 23 7 7 14 (30.4%) (69.5%) (100%) (50.0%) (50.0%) (100%) TOTAL 39 73 112 16 19 35 Table 4.15: Distribution of the number of children desired by respondents FEMALE MALE NUMBER OF FREQUENCY PERCENTAGE FREQUENCY PERCENTAGE CHILDREN (%) (%) 1 1 0.8 0 0 2 10 7.7 2 5.0 3 30 23.1 9 22.5 4 35 26.9 9 22.5 5 18 13.8 11 27.5 6 21 16.2 4 10.0 7+ 10 7.7 5 12.5 ** Non numeric 5 3.8 0 0 response TOTAL 130 100 100 41 University of Ghana http://ugspace.ug.edu.gh 4.4.6 Desired number o f children The number of children desired ranged from 1 to 15 children. Seventy-six (58.5%) of women and 50% of men desired one to four children. However, Five (3.8%) of women indicated that it is God who decides on the number of children to have. See Table 4.15 Findings from the focus group discussions show social, economic and religious reasons for an ideal family size as follows: “ As for giving birth is good, I think 6 is okay. Death can occur at anytime so if you give birth to three they can all die but with 6 some will die and some will remain”.(F) “ I think if you give birth to 4 children you’ll have less financial constraints in taking care of them” (M) “I think having 12 children is good because some can go to the farm with you and some can send the food stuffs to the market to sell” .(M) “It is nice to have both sexes, so six; 3 boys and 3 girls ”(F) “I feel giving birth is Gods gift. He can choose to give you the number He wants. Thus the issue is how to space them and not the number".(F) 4.4.7 Child spacing The figures presented show the views of respondents about the number of years a person should wait between the birth of one child and the other as indicated by respondents. The mean number of years is 3.7. The distribution is shown below: • One to three years 99(58.2%) 42 University of Ghana http://ugspace.ug.edu.gh Four to six years 57(33.5%) Seven to ten years 11(6.5%) Don’t Know 3 (1.8%). 4.5. QUALITY OF FAMILY PLANNING SERVICES Use of Bomfa health Centre for Family planning Service Out of the 170 persons interviewed only 8(4.7%) had ever sought for family planning services in the Bomfa Health Centre. Three of them were current users. The breakdown was as follows: • Two were using the Pill and • One was using IUD • The other five used the Pill and stopped because of side effects. When the facility was visited Out of the 8 persons who had visited the facility, only 1 had used it within the last six months and 7 of them more than two years ago. Availability of methods All the 8(100%) had their method of choice at the health centre. Privacy Seven (87.5%) described the privacy provided during their visit as very adequate and 1(12.5%) said it was adequate. 43 University of Ghana http://ugspace.ug.edu.gh Told Side Effects Four (50%) were told of the side effects whilst the other 4 (50%) were not told. Three (75%) of those who were not told were currently non-users because they experienced some side effects whilst 1(25%) was currently using. Two (50%) of those who were told of the side effects were current users and the other 2 (50%) were not using. Told When To Return Seven (87.5%) were told when to return and 1(12.5%) was not told. Attitude of the provider All the 8(100%) described the attitude of the provider as being friendly and respectful. Time Spent at the facility Seven (87.5%) spent below one hour and 1(12.5%) spent about an hour. The amount of time clients preferred to spend at a facility All 8(100%) indicated that they wanted to spend not more than an hour in a facility. What will make one continue to use a facility All 8(100%) indicated that the warm reception provided by staff would make them continue to use a facility. However one of them mentioned in addition the availability of the method of choice. 44 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION 5.1.1 Socio-demographic characteristics and Current use of Family planning In Ghana about one in four married women who want to avoid pregnancy are not using a method of contraception due to social and cultural factors that tend to influence sexual practices and reproductive health.9 Sex In this study, current use of family planning was higher among males than females (Table 4.3). Forty Percent of men were currently using as compared to 30% of women. .The higher use among males could be attributed to the fact that men with multiple partners are likely to report use with any partner. Age Current use of family planning showed a rise with age though not uniform. A peak of 25.6% was observed for age group 25-29 among females and this dropped to 7.7% at age 45-49 years (Table 4.4). The 1998 GDHS reported a peak of 24% at age 35 -3 9 and lowest use of 12% at age 45-49. The lowest use observed in age group 45-49 is consistent with the GDHS. Though the peak percentage observed compares favourably with the GDHS, the age group differed. 45 University of Ghana http://ugspace.ug.edu.gh Marital status Thirty-five (34.7%) of married women and 20% of unmarried women were current users. This confirms the fact the use of contraceptives is not restricted to only married persons (Table 4.5). Education Research findings suggest that education is positively related to contraceptive use.21 Current use of family planning showed an increasing pattern from no education, 25.8% to 50% at the Secondary level among females. The 1998 GDHS showed a similar pattern of 13 % for women with no education and 42% for those who had secondary education. The relationship between current use and educational level was found to be non significant the p value >0.05. This is because the sample of respondents who had had secondary education was small. 5.1.2 Practice of Family Planning The 1998 GDHS reported that the current use of modern methods of family planning is 13 % and 9% for traditional methods. Though a higher use of modern methods, 20.8% and 13.9% for traditional methods was observed in this study, the pattern is similar. Among all women, the Pill was found to be the most popular modern method 41.0 % followed by the Injectable 7.7% for the females. With the males the condom and Injectable followed the pill respectively (Table 4.8), which is consistent with the 1998 GDHS. The male-female difference observed was due to difference in condom use. 46 University of Ghana http://ugspace.ug.edu.gh Three men reported condom use but no woman reported of its use. The 1998 GDHS also showed that men were three times likely to report condom use than women. Forty two percent of current users reported using the drug stores as their source of supply of contraceptives and 26% used health facilities. A similar pattern is shown in the GDHS 32% and 29% respectively. This shows that drug stores serves as an important source of supply for modern methods (the pill and condom) within the private sector. The drug stores were the most preferred because of proximity and convenience. Studies in India, Zambia and Ghana consistently found that lack of knowledge, fear of side effects and lack of husbands support are some of the factors accounting for the non-use of family planning methods.12 The impact of contraceptives on a woman’s health, whether real or perceived, was found to be a major reason for the non-use of family planning in this study. Thirty four percent of the respondents, who were currently not using a method, cited the fear of side effects as the main reason for non-use. This is about twice that of what was observed in study by Govindasamy and Boadi (2000) and the 1998 GDHS. Their findings indicated that fear of side effects accounts for 16% and 18% respectively for the reasons for non-use of methods in Ghana. 10 The high percentage observed in this study may be due to misconceptions or false information that needs to be addressed. It is worth mentioning that a few 8 (7%) cited religious opposition as a reason for non­ use. Spousal consent however was not stated as a reason for non-use. 47 University of Ghana http://ugspace.ug.edu.gh A greater proportion of the respondents 80% discussed the use of family planning with their friends and neighbours and 15% with their spouses. This clearly reflects the difficulty that couples often have in talking to each other about issues that affect their sexual life. Females who discussed family planning with their spouses reported the highest use of 71.4%. This was approximately twice that of those who discussed it with their friends or neighbours (37.5%) and about thrice that of those who did not discuss with anybody, 27%, (Table 4.10). In diverse settings spousal communication has been consistently associated with greater contraceptive use. In Ghana women who had discussed contraceptive use with their husbands were twice as likely to be current users than those who had not which is consistent with this study.21 5.1.3 Beliefs and Attitudes towards Family Planning A positive attitude towards family planning facilitates its use. Majority of the respondents 86.5 % indicated that they approve of the use of family planning based on health and economic reasons.” Family planning makes the woman strong all the time, if you are healthy then you will give birth to healthy children and you'll also be able to work to take care o f them", said a woman during the FGD. The mean number of years for birth spacing preferred was 3.7 years, which is comparable to the actual birth intervals of more than 3 years reported in the 1998 48 University of Ghana http://ugspace.ug.edu.gh GDHS. Even those who indicated that children are gifts from God also emphasized the need for child spacing. This reflects to some extent the value placed on child spacing. Fifty-eight percent of women indicated that their partners approved of the use family planning, 14.7% disapproved and 27.7% did not know of their partners’ attitude. A highest use of 43.1% was reported among those whose partners approved of family planning as compared to those who partners disapproved, 18.7% (Table 4.12). This suggests that partner approval play a role in the use of family planning methods. The results of this study also show that about 50% of those in a relationship leave the decision to use family planning with their spouses or partners, only 25% make the decision together. The idea of shared commitment by couples to regulate their fertility was not clearly demonstrated. Family planning was portrayed as a woman’s concern as expressed by a man in the FGD, "The decision lies with the woman because she experiences the woes o f caring for children“ 5.1.4 Perception about the Quality of Family Planning Services The perception of clients regarding the quality of services is significantly related to the probability of subsequent adoption of a family planning method. A study by Koenig et al., 1997 demonstrated that what might be most critical is not the absolute number of methods offered but the degree of trust, rapport and confidence established between the provider and the client.17 All the 8 persons who had ever used the Bomfa Health Centre for family planning services indicated that the warm reception offered by the 49 University of Ghana http://ugspace.ug.edu.gh provider is what would cause them to continue the use of the facility with only 1(12.5%) mentioning in addition the availability of the method of choice. It is worth noting that those who were using other health facilities were doing so because of access. Most of the communities in the subdistrict are located on the main Accra-Kumasi road and therefore they preferred to get transport straight to Konongo, in the Asante Akim north District, than to take a vehicle, stop at a junction and then take another one to the Bomfa health centre. A study by Cotton et al. showed that providing women with adequate counseling on side effects can also improve the chances that women would continue using a method. 22 In this study it was observed that out of the four who were not told of side effects, 3(75%) had stopped using the method because they experienced some side effects as compared to 2(50%) of those who were told. This was consistent with findings from the FGD. "Sometimes the nurses do not tell us o f the side effects and even if you have side effects and you go to them, they keep reassuring you that it will stop but it doesn’t. I know of a woman who was using IUD and was having problems but the nurse did not take heed till she collapsed. If it happens like that then no one will go for it", said a woman. 50 University of Ghana http://ugspace.ug.edu.gh 5.2 CONCLUSION Current use of family planning among women was observed to increase with the level of education, from no education to secondary level. The current use of family planning was 32.4%, 22.4% for modern methods and 10% for traditional methods. A major reason for non-use of family planning methods was fear of side effects. Counseling women therefore about how the use of contraceptives can affect health is important. Majority of the respondents discussed family planning with their friends and neighbours, the importance of promoting spousal communication cannot be over emphasized. Though child spacing was greatly valued, the views expressed by both men and women during the FGD showed that the decision to use contraceptives was seen as a woman s responsibility. This was because; it is the woman who goes through the ordeal of childbirth and care. Finally, all the respondents who had ever used the Bomfa Health centre indicated that the friendly and respectful attitude of the staff would make them continue to use the facility. This underscores the fact that interpersonal relationship between service providers and clients may influence a client’s decision to continue the use of a family planning method or a facility. 51 University of Ghana http://ugspace.ug.edu.gh 5.3 RECOMMENDATION Based on the findings of this study the following recommendations are being made. To The District Health Management Team 1. Information Education and Communication on family planning should be intensified to: • Dispel misconceptions and allay fears about side effects through community durbars and identified male and female groups • Encourage satisfied clients in communities to share their experience during out reach programmes on family planning. • Increase awareness on the importance of communication between partners on reproductive health issues through religious, women and youth organizations. • Educate young men about sexual responsibility during school health programmes 2. Provision of family planning services on outreach basis should be intensified to improve access. 3. The District Health Management Team should liase through forum and meetings with the Drug stores so as to capture information on clients who obtain family planning methods from such sources. To the family planning service Provider • Clients should be provided with adequate counseling on the side effects of methods 52 University of Ghana http://ugspace.ug.edu.gh • Side effects reported by clients should be investigated for the necessary action to be taken. 53 University of Ghana http://ugspace.ug.edu.gh REFERENCES 1. UNFPA. Reproductive Health and Rights. Population Issues Briefing Kit, 2001:4­ 8 . 2. Johns Hopkins University. Population and the environment. Population Reports,2000, 2 8 :1 5 -2 8 . 3. Government of Ghana. National Population Policy revised edition, 1994; 24 - 30 4. Ghana Statistical Service. 2000 Population and Housing Census Provisional Results. 5. Ghana Statistical Service and Macro International Inc. Ghana Demographic and Health Survey 1993, 1994. 6 . The International Programs of the Population Reference Bureau. Infant and Child survival. Family Planning saves lives, 1991: 2 - 15. 7. Harold JM et. Al. Report on Baseline study o f knowledge Attitude and Practice Regarding Family Planning and Health in Ghana, 1993. 8 . United Nations. Report o f International Conference on Population and Development, 1994:43. 54 University of Ghana http://ugspace.ug.edu.gh 9. Ghana Statistical Service and Macro International Inc. Ghana Demographic and Health survey 1998, 1999. 10. Govindasamy P, Boadi E. A decade o f unmet needs for contraception in Ghana Programmatic and Policy Implication, 2000: 3 - 10. 11. National Population council and Macro International Inc. Perspectives on fertility and Family planning in Egypt: National Population Council Demographic Health Surveys, 1995:15. 12. Family Health International Unmet need affects millions. Network Family Health International, 1998,19:12- 18. 13. Greene PA. Male involvement in Family Planning an overview. Male participation in Family Planning; a review o f programme approaches in Africa, 1991.21. 14. Ezeh AC. The influence Of Spouses over Each Other Contraceptive Attitudes in Ghana. Studies In Family Planning, 1993, 24:163-79. 15. Family Health International. Strategies to involve men and other family members. Network Family Health International, 1998,18:13. 55 University of Ghana http://ugspace.ug.edu.gh 16. Family Health International. Men influence contraceptive use. Network Family Health International, 1998,18: 13. 17. Michael AK, Mian BH, Maxine W. The influence of quality of care upon contraceptive use in Rural Bangladesh. Studies in Family Planning, 1997,28: 278 -2 8 9 . 18. Family health International [http://www.fhi.org/en/fp1 26th February 2002. 19. Family Health International. Empowering women. Network Family Health International, 1994,15:15. 20. Uchudi JM. Spouses' Socioeconomic characteristics and fertility differences in Sub Saharan Africa, does spouse’s education matter? Journal o f Biosocial Science, 2001, 3:481-502. 21. Salway S. How attitudes towards family planning and discussion between wives and husbands affect contraceptive use in Ghana. International Family Planning Perspective, 1994,20:44-47. 22. Cotton N, Stanback J, Maidouka H, et al. Early discontinuation of contraceptive use in Niger and the Gambia. International Family Planning Perspective, 1992,18:144-149. 56 University of Ghana http://ugspace.ug.edu.gh APPENDIX 1 QUESTIONNAIRE ON FACTORS INFLUENCING UTILIZATION OF FAMILY PLANNING SERVICES INTRODUCTION Good morning, I am working with the Ministry of Health and undertaking a study in family planning. The aim of this study is to identify the factors that affect utilization of family planning services in order to obtain information, which would be used to improve the delivery of services. We count on your cooperation to answer the questions candidly. All responses will be treated as confidential. Date of interview .............................................................................................................. Community .......................................................................................................................... Serial Number......................................................................................................................... Name of Interviewer.............................................................................................................. SECTION ONE : BACKGROUND INFORMATION 1. Age 2. Sex [ ]F [ ]M 3. Occupation [ ] Farmer [ ] Salaried worker [ ] Petty Trader Other spec ify ............ 57 University of Ghana http://ugspace.ug.edu.gh 4. Educational level No Education Primary Middle/J.S.S Secondary Tertiary and above 5. Religion Roman Catholic /Anglican Protestant Spiritual Islam Traditional Other S pecify ....................... 6 . Marital status Single( In a relationship) Married Divorced/Separated Widowed Single(Not in a relationship) 7. How many children do you have?. SECTION TWO : ATTITUDE AND BELIEFS 8 . How many children would you prefer to have in your lifetime? 9. How long should one wait between the birth of one child and the other? 58 University of Ghana http://ugspace.ug.edu.gh 10. W ho dec ides on the num ber o f ch ild ren to have? Self Spouse/Partner Mother Father Mother in law Other specify. 11a. Do you approve of family planning? [ ]Yes [ ] No Give reasons for your answer 12. Does your partner/spouse approve of family planning? [ ]Yes [ ] No [ ] Don’t know [ ] Not Applicable 13. Who decides on the use of family planning methods? [ ] Self [ ] Spouse/Partner [ ] Mother [ ] Father [ ] Mother in law [ ] Not Applicable Other specify......................................... 59 University of Ghana http://ugspace.ug.edu.gh SECTION THREE: PRACTICE 14(a) Have you or your partner ever used any family planning method? [ ]Yes [ ] No IF NO SKIP TO QUESTION 16a 14(b) If yes which method? [ ] Condom [ ] Injectable [ ] Norplant [ ] Female Sterilization [ ] Male Sterilization [ ] L A M [ ] Pill [ ] Vaginal Foaming Tablet [ ] Withdrawal [ ] Natural Family planning [ ] Intra Uterine Device Other spec ify ............................. 14(c) How long did you use the m ethod?....................................................... 15(a) Are you currently using any method? [ ]Yes [ ]No 60 University of Ghana http://ugspace.ug.edu.gh 15 (b) If yes which method? Condom Injectable Norplant Female Sterilization Male Sterilization L A M Pill Vaginal foaming tablet Withdrawal Natural Family planning Intra Uterine Device Other spec ify ................ 15 (c) If no why? 16(a) If you have never used any method do you intend to use one in the future? Y e s [ ] [ ] No 16(b) If no why? [ ] fear of Side effects [ ] Religions beliefs [ ] Wants more children [ ] Spouse opposed [ ] Too expensive [ ] Menopause Other specify.................................... 61 University of Ghana http://ugspace.ug.edu.gh 17(a) Do you discuss Family Planning utilization with others ? [ ] Yes ] No 17(b) If yes with whom? Spouse/Partner Mother Father Sister Brother Mother in law [ ] Friends/Neighbours. 18. Do the people you discuss family planning with approve of its use? Yes [ ] [ ] No [ ] Don’t Know SECTION FOUR: QUALITY OF FAMILY PLANNING SERVICES 19(a). Have you ever sought for Family Planning Services in the Bomfa Health Centre? [ ] Yes [ ] No 19(b)lf no why? If Answer is NO Skip to Question 28 62 University of Ghana http://ugspace.ug.edu.gh 20. If yes, how long ago did you seek for family planning services in the Bomfa Health Centre? [ ] less than 6 months [ ] 6 months - 12 months [ ] 13m onths-18 [ ] 2 years and above 21. Did you get the method of your choice? [ ] Yes [ ] No 22. Were you told of the side effects? [ ] Yes [ ] No 23. How would you rate the privacy provided during your visit? [ ]Very Adequate [ ]Adequate [ ] Not Adequate 24. Were you told when to return? [ ] Yes [ ] No 25. How will you describe the attitude of the provider? [ ]Friendly [ ] Respectful [ ] Disrespectful [ ]Hostile [ ]lndifferent University of Ghana http://ugspace.ug.edu.gh 26. (a) How long did you spend? [ JBelow one hour [ ] Above one hour (b) How long will you like to spend in a facility? 27. What will make you continue to use a facility for family planning services? 28. Where do you usually get information on family planning? [ ] TV [ JRadio [ ] Newspaper [ ]Health facility [ ] Relatives Other Specify 64 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 FOCUS GROUP DISCUSSION GUIDE Good morning, I am Alberta Lomotey working with the Ministry of Health but currently a student of the School of Public Health. I am undertaking a study in Family Planning in your community. The findings would be used to improve the delivery of Family Planning services. I would therefore like to discuss a few issues with you. With me is ....................................to help me with the recording. There are no right or wrong answers. So please feel free to express your views. Could you please introduce yourselves. 1. What have you heard about family planning? 2. Where do you get information on family planning? 3. Is family planning important? 4. Who decides on the number of children one should have in a union? 5. How many children should one have in a lifetime and why? 6. Who decides contraceptive use and why? 7. What are the reasons why people do not use family planning methods? 8 . Where do people prefer to have their family planning methods? 9. Why do people prefer such outlets? 65 University of Ghana http://ugspace.ug.edu.gh