Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study

Congregation leader and member discussions in a church-based family strengthening, mental health promotion and HIV prevention trial: Intervention

Collaboration with African religious congregations can promote psychosocial well-being with greater accessibility. Effective collaboration requires studying congregations as unique intervention contexts. This study explored how an intervention in western Kenya fit within and altered congregational discussion patterns. We conducted a cluster-randomized trial of a church-based intervention to improve family relationships, mental health and sexual health. For each intervention topic covered, we describe baseline and post-intervention changes in church leaders' beliefs and communication as well as discussion frequency between leaders and members and among members. Mixed-effects logistic regression assessed pre-post change in member-reported discussion frequency. At baseline, members and leaders reported already discussing family, parenting, and emotions frequently and sexuality and finances less frequently. Leaders generally felt they should discuss all topics but were less comfortable and knowledgeable about sexuality and finances than other topics. After the intervention, leader comfort and knowledge increased and discussion frequency increased for nearly all topics, especially those discussed less initially. Good fit between the desires and activities of church members and leaders suggests the potential for further collaboration, especially on mental health and family well-being. Increased discussion of sensitive topics underscores the potential of community-level interventions to affect social norms.

Intimate partner violence influences modern family planning use among married women in Tanzania: cross-sectional study

BACKGROUND

Married women who experience intimate partner violence (IPV) are less likely to negotiate with their partners on modern family planning (FP) use. This study aimed to determine the influence of intimate partner violence and sociodemographics on modern family planning use.

METHODS

A community-based cross-sectional study was conducted in the Mara region, Tanzania from April to July 2020. A total of 366 married women were interviewed. Data were collected using a structured interviewer-administered questionnaire. Analysis was done using SPSS version 25, and a binary logistic regression model was used to determine the predictors of modern FP use. The significance level was set at a p-value less than 0.05.

RESULTS

The overall prevalence of IPV was 73% with 54.1% physical, 36.3% psychological, and 25.4%, sexual violence. The prevalence of modern FP use was 62%, and the most (49.1%) common method practiced by married women was injection (Depo Provera). Physical violence (AOR = 0.32, p = 0.0056), and psychological violence (AOR = 0.22, p = 0.0022) had significantly reduced odds of modern FP use. Religion (AOR = 4.6, p = 0.0085), and availability of preferred modern FP methods (AOR = 9.27, p < 0.0001) had significantly increased odds of modern FP use.

CONCLUSION

In this study, there is a positive association between the use of modern FP methods and IPV. To prevent IPV and its negative health consequences, it is crucial to involve community leaders and primary healthcare workers. They can help in identifying the best strategies to prevent IPV and promote the use of modern FP methods. It is equally important to involve male partners in reproductive health decisions, including the use of modern FP methods. This approach will help reduce reproductive coercion.

"If I chose to listen to people, I possibly wouldn't be using family planning": Impact of external influences on women's contraceptive autonomy in rural Northwest Tanzania

BACKGROUND

There is an increasing emphasis on promoting women's autonomy in reproductive decision-making, particularly given global efforts to increase contraceptive access and uptake. Scales to quantify autonomy have inconsistently included the effect of external influences and focused primarily on influences of partners.

OBJECTIVES

This study aimed to gain greater depth in understanding how influences including and beyond a woman's partner affect her contraceptive decision-making, as well as how external influences can overlap and further complicate contraceptive decision-making.

DESIGN

A phenomenological, qualitative study in which in-depth interviews were conducted in three phases from May 2021 to February 2022 with women living in northwest Tanzania who had varying histories of contraceptive use or non-use.

METHODS

One-on-one, in-depth interviews were conducted in Swahili, the national language of Tanzania, by trained female interviewers. Interviews were digitally recorded, transcribed, translated into English, and independently coded by three investigators. Analysis was conducted using NVivo. The codes developed from the transcripts were grouped into overarching themes with supporting illustrative quotes.

RESULTS

A total of 72 women were interviewed. Partners were the most influential in women's family planning decision-making, followed by friends, relatives, community religious leaders, and healthcare providers. Out of the 52 women with a partner who had ever used family planning, 76.9% had discussed their desire to use family planning with their partner and nearly all reported strong pressures to use or not to use family planning from partners, family, and friends. Rarely, participants stated that they were devoid of any influence.

CONCLUSION

In rural Tanzania, women's decision-making about family planning was highly impacted by external influences, including not only partners but also family, friends, and community. Indicators of women's reproductive autonomy and measurements of interventions to promote contraceptive use should incorporate measures of these external influences.

Partnerships with religious leaders to promote family planning in rural Tanzania: an open-label, cluster randomised trial

BACKGROUND

Family planning benefits maternal-child health, education, and economic wellbeing. Despite global efforts, an unsatisfied demand for family planning persists in sub-Saharan Africa. Based on previous successful partnerships, the aim of this study was to determine whether an educational intervention for religious leaders would increase community knowledge, demand for, and ultimately uptake of family planning.

METHODS

In this open-label, cluster randomised trial in Tanzania, 24 communities were randomised (1:1) to intervention or control arm. Communities, defined as the catchment area of a single public health facility, were eligible if they were at least 15 km from Mwanza City and had not previously participated in a health intervention for religious leaders. Random allocations were determined by coin toss and were not revealed to clinicians at health facilities in intervention and control communities, nor to the data entry team; however, due to the nature of the intervention, masking of religious leaders in the intervention communities was not possible. All Christian religious institutions were invited to send four leaders to an educational intervention that incorporated cultural, theological, and medical teaching about family planning. The primary outcome was contraceptive uptake at the community health facility during the year post intervention versus the year before the intervention. This trial was registered at clinicaltrials.gov, NCT03594305.

FINDINGS

75 communities in three districts were assessed for eligibility. 19 communities were excluded and 56 were eligible for study inclusion and were placed in random order to be invited to participate. The first 24 communities that were invited agreed to participate and were randomly assigned to receive the educational intervention either during the trial or after trial completion. Between July 10, 2018 and Dec 11, 2021, we provided the intervention in 12 communities and compared contraceptive uptake with 12 control communities. All were followed up for 12 months. In intervention communities, contraceptive uptake increased by a factor of 1·47 (95% CI 1·41-1·53) in the post-intervention (prospective) versus pre-intervention (historical) year (geometric mean of contraceptive uptake, 466 in the prospective year vs 312 in the historical year), versus 1·24 (95% CI 1·20-1·29) in control communities (geometric mean, 521 in the prospective year vs 429 in the historical year). The rate of change in contraceptive uptake was greater in intervention communities (between-group ratio of geometric mean ratios over time, 1·19 [95% CI 1·12-1·25]; p<0·0001). The COVID-19 pandemic was associated with decreased contraceptive uptake (geometric mean, 365 during the pandemic in communities that had the majority of their prospective 12-month data collection periods occur after March 16, 2020, vs 494 before the pandemic; geometric mean ratio, 0·72 [95% CI 0·57-0·90]; p=0·0040).

INTERPRETATION

This intervention offers a scalable model, leveraging influence of trusted religious leaders to increase knowledge and uptake of family planning. New strategies such as this could help to overcome setbacks that occurred during the COVID-19 pandemic.

FUNDING

John Templeton Foundation and Weill Cornell Medicine Dean's Diversity and Healthcare Disparity Award.

TRANSLATION

For the Kiswahili translation of the abstract see Supplementary Materials section.

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Perspectives of Muslim Religious Leaders to Shape an Educational Intervention About Family Planning in Rural Tanzania: A Qualitative Study

INTRODUCTION

Uptake of effective contraceptive methods can be hindered by poor understanding and uncertainty about its compatibility with religious beliefs. We sought to understand the perspectives of Muslim religious leaders in rural Tanzania on family planning (FP) and acceptable strategies for providing FP education to leaders and their communities.

METHODS

We conducted in-depth interviews with Muslim leaders from 4 communities in northwest Tanzania. Open-ended questions explored leaders' views on FP in relation to their communities, Muslim texts and teaching, and their experience as leaders. We also investigated how FP education could be provided in their communities and asked practical questions regarding seminar implementation. Interviews were conducted in Kiswahili and transcribed and translated into English. Data were coded independently by 2 investigators using NVivo 1.5.1 and analyzed thematically.

RESULTS

We interviewed 17 male and 15 female Muslim leaders. All leaders supported FP as a concept in which births are spaced, interpreting this as espoused by the Qur'an and a basic right of children raised in Islam. Leaders uniformly endorsed the use of breastfeeding and the calendar method to space births but had divergent and sometimes opposing views on other methods, including condom use, oral contraceptives, and intrauterine devices. All leaders acknowledged the need for FP education among their congregants and were in favor of helping to teach an FP seminar in their communities.

CONCLUSION

Our data reveal insights into how education for Muslim leaders may equip them to promote birth spacing and enhance understanding of FP in their communities in ways that are concordant with Islamic teaching. Our findings will guide the design and pilot-testing of an educational intervention for Muslim religious leaders to promote knowledge and uptake of FP in rural Tanzania.

Exploring a faith-based approach to puberty education in Tanzania

Background

Many adolescents in Tanzania do not receive timely and comprehensive puberty education. This study explored faith-based organizations a site for puberty education. Two puberty books, each developed through participatory research with Tanzanian adolescents and stakeholders, were promoted to 177 Christian denomination churches in Dar es Salaam, Tanzania to understand the factors that faith leaders considered in their decision to purchase puberty books, or share information about the intervention to their peers and congregants.

Methods

Data collection included routine monitoring via weekly reports and ethnographic observation. Data were analyzed using the Ecological Framework for Health Promotion to capture how individual, interpersonal, and institutional factors influenced leaders' decisions to purchase or promote puberty books.

Results

At the individual level, leaders cited their personal experiences in their support for the intervention, but leaders' time and confidence in their ability to effectively promote books to others were barriers to participation. Interpersonally, the diffusion of information between church leaders, particularly when information came from well-known or respected leaders, emerged as an important factor in leaders' willingness to promote books. At the institutional level, leaders' decisions were impacted by resources, institutional culture, and institutional hierarchy. Importantly, twelve churches in the sample purchased books. Limited financial resources and the need to receive approval from denominational leaders were discussed by leaders as barriers to purchasing books.

Conclusions

Despite research showing high religiosity in Tanzania, the role of religious institutions in providing puberty education has remained unexplored. Our results inform future research and practice by providing an articulation of the socioecological factors that played a role in faith leaders' decisions related to puberty education interventions in Tanzania.

Faith Leaders Improve Healthy Timing and Spacing of Pregnancy: Results of Operations Research on the Channels of Hope Methodology in Kenya and Ghana

Background

Family planning averts unintended pregnancies, unsafe abortions, and maternal deaths, while improving child health and socio-economic progress, but an estimated 218 million women and girls in low- and middle-income countries, especially in sub-Saharan Africa, have an unmet need for modern family planning. Faith leaders can impact the demand and uptake of family planning. However, there is limited understanding of the mechanisms for effective family planning advocacy by faith leaders. Channels of Hope (CoH) is World Vision's process that engages faith leaders and faith communities to address health issues.

Objectives

To determine the impact of CoH on promoting healthy timing and spacing of pregnancies and family planning (HTSP/FP) by mothers of children under two years old in select parts of Kenya and Ghana. To also determine faith leaders' attitudes, perceptions, and potential roles in influencing HTSP/FP after exposure to CoH.

Methods

A mixed methods operations research comprising quantitative (quasi-experimental design with surveys of 4,372 mothers of children under two years old) and qualitative arms (in-depth interviews of 17 faith leaders and their seven spouses) was implemented.

Findings

Taking both countries together, male sterilization, female condom, and LAM were the only FP methods that did not show increases from baseline to endline. Methods with the highest knowledge increases between intervention areas and control areas were implants, injectables and pills, with 18.4, 12.1 and 11.2 percentage point increases, respectively. The faith leaders in both countries reported that their views on healthy timing and spacing of pregnancies changed due to the Channels of Hope workshops.

Conclusion

The HTSP/FP model has potential for positive health and social transformation that is built on the trust of faith leaders. Ghana and Kenya provide great examples of possible scenarios in order to help prepare implementers to scale the learnings of this operations research across sub-Saharan Africa.

Health providers' perspectives on contraceptive use in rural Northwest Tanzania: A qualitative study

Objectives

In Tanzania, contraceptive use is limited, particularly in rural communities and even among women who would like to delay childbearing. This paper aims to present health providers' perspectives on populations seeking contraception and barriers that could be addressed to increase access to and uptake of contraception, given their interface with large portions of their communities.

Study Design

We conducted 18 in-depth interviews with providers stationed at health dispensaries in six rural villages in northwest Tanzania. Two investigators independently coded interviews using a stepwise process to achieve consensus on prevalent topics.

Results

Three topics emerged from our analysis: (1) nature of clients seeking contraception; (2) barriers to uptake of contraception; and (3) the role of secrecy in obtaining and using contraception. Health providers reported that married women with children were the most frequent users of contraception, alongside some single women, men, sex workers, and students. Barriers to contraception included lack of supplies and trained staff, misconceptions and fears, stigma, and unsupportive partners. Providers observed that contraception was often used secretly. They reported surreptitious visits and described clients' preferential use of discreet methods. Providers respected and supported clients' desires to keep visits confidential.

Conclusion

Our data suggest maintaining high stocks of discreet contraceptive methods and deploying more trained staff to dispensaries could increase availability and access to contraceptives. At the community level, more education campaigns are warranted to address barriers, especially those related to stigma.

Implications

Our work highlights the need for additional contraceptive methods that are easy to administer and discreet for women who must maintain secrecy. Future studies of the effectiveness of interventions and new contraceptives should obtain healthcare providers' perspectives, as they can provide important insights to service provision.

"I let others speak about condoms:" Muslim religious leaders' selective engagement with an NGO-Led family planning project in rural Tanzania

In the past two decades, religious leaders have garnered increased interest from health ministries and NGOs as promoters, educators, and implementers of sensitive health programs such as family planning in several African countries. While religious leaders' role as public health actors has been well-documented, there are few ethnographic accounts of how religious leaders engage with public health programs, especially family planning. Informed by twelve months of ethnographic study in three rural and peri-urban locations in Kilombero district in 2014-2016, this article examines how Muslim religious leaders experienced and negotiated their role as implementers of family planning services. Governments and NGOs seek religious leaders' social capital to increase community's knowledge of and demand for family planning as well as to diffuse the community's moral anxieties surrounding its use. Participant observation and interviews, however, show that religious leaders selectively engage with family planning projects, balancing project demands, their own interests and the existing norms and perceptions in the community. Religious leaders stood beside other team members promoting condoms, but they remained silent themselves on condom promotion selecting instead to speak on the dangers of teenage pregnancy. Tensions, power differentials and a mélange of interests, existing and emergent, set the stage for religious leaders to selectively engage with the family planning project. Selective engagement was beneficial for both parties. Religious leaders received training on modern family planning, gained symbolic capital by associating with a powerful NGO, and expanded their social networks while government officials and NGOs received indirect support for family planning programs.

Global myth busting in family planning

PURPOSE OF REVIEW

Myths and misconceptions about family planning are pervasive around the world and can adversely affect both initiation and continuation of family planning services. Here, we review the current literature and identify major themes among them to better understand these myths and misconceptions.

RECENT FINDINGS

Myths and misconceptions regarding family planning are a global phenomenon with the most recent studies focused on sub-Saharan Africa and West Africa.The belief that family planning negatively impacts future fertility was mentioned in all studies reviewed.Other major themes include misconceptions about the adverse effects, complications, mechanisms of action, and reproductive health.

SUMMARY

Myths and misconceptions regarding family planning are widespread. Current literature suggests that there is a globally prevalent belief that family planning negatively impacts future fertility. Misconceptions related to adverse effects and mechanism of action were also identified. There is overall poor knowledge of sexual and reproductive health in the populations studied. Recent studies focus primarily on sub-Saharan Africa and West Africa. These findings and lessons learned may be helpful in customizing contraceptive counseling and increasing both global access to family planning and satisfied clients.

Nothing so practical as theory: a rapid review of the use of behaviour change theory in family planning interventions involving men and boys

BACKGROUND

There is growing recognition of the need for interventions that effectively involve men and boys to promote family planning behaviours. Evidence suggests that the most effective behavioural interventions in this field are founded on theoretical principles of behaviour change and gender equality. However, there are few evidence syntheses on how theoretical approaches are applied in this context that might guide best practice in intervention development. This review addresses this gap by examining the application and reporting of theories of behaviour change used by family planning interventions involving men and boys.

METHODS

We adopted a systematic rapid review approach, scoping findings of a previously reported evidence and gap map of intervention reviews (covering 2007-2018) and supplementing this with searches of academic databases and grey literature for reviews and additional studies published between 2007 and 2020. Studies were eligible for inclusion if their title, abstract or keywords referred to a psychosocial or behavioural intervention targeting family planning behaviours, involved males in delivery, and detailed their use of an intervention theory of change.

RESULTS

From 941 non-duplicate records identified, 63 were eligible for inclusion. Most records referenced interventions taking place in low- and middle-income countries (65%). There was a range of intervention theories of change reported, typically targeting individual-level behaviours and sometimes comprising several behaviour change theories and strategies. The most commonly identified theories were Social Cognitive Theory, Social Learning Theory, the Theory of Planned Behaviour, and the Information-Motivation-Behaviour Skills (IMB) Model. A minority of records explicitly detailed gender-informed elements within their theory of change.

CONCLUSION

Our findings highlight the range of prevailing theories of change used for family planning interventions involving men and boys, and the considerable variability in their reporting. Programmers and policy makers would be best served by unified reporting and testing of intervention theories of change. There remains a need for consistent reporting of these to better understand how complex interventions that seek to involve men and boys in family planning may lead to behaviour change.