Access to public sector family planning services and modern contraceptive methods in South Africa: A qualitative evaluation from community and health care provider perspectives.

Progress has been made to improve access to family planning services and contraceptive methods, yet many women still struggle to access contraception, increasing their risk for unintended pregnancy. This is also true for South Africa, where over fifty per cent of pregnancies are reported as unintended, even though contraception is freely available. There is also stagnation in the fertility rate indicators and contraceptive use data, indicating that there may be challenges to accessing contraception. This paper explores the evaluation of access to contraception from community and health care provider perspectives. This qualitative study explored factors affecting the uptake and use of contraception through focus group discussions (n = 14), in-depth interviews (n = 8), and drawings. Participants included male and female community members (n = 103) between 15 and 49 years of age, health care providers (n = 16), and key stakeholder informants (n = 8), with a total number of 127 participants. Thematic content analysis was used to explore the data using NVivo 10. Emergent themes were elucidated and thematically categorised. The results were categorised according to a priori access components. Overall, the results showed that the greatest obstacle to accessing contraception was the accommodation component. This included the effects of integrated care, long waiting times, and limited operational hours-all of which contributed to the discontinuation of contraception. Community members reported being satisfied with the accessibility and affordability components but less satisfied with the availability of trained providers and a variety of contraceptive methods. The accessibility and affordability themes also revealed the important role that individual agency and choice in service provider plays in accessing contraception. Data from the illustrations showed that adolescent males experienced the most geographic barriers. This study illustrated the importance of examining access as a holistic concept and to assess each component's influence on contraceptive uptake and use.

Feasibility testing of a community dialogue approach for promoting the uptake of family planning and contraceptive services in Zambia.

BACKGROUND: Community dialogues have been used in participatory approaches in various health prevention and awareness programs, including family planning interventions, to increase understanding and alignment of particular issues from different peoples' perspectives. The main objective of this paper is to document the feasibility of a community dialogue approach, which aimed to promote dialogue between healthcare providers and community members. The feasibility testing was part of formative-phase research needed to design an intervention, with the ultimate goal of increasing the uptake of family planning and contraception. The community dialogue intervention generated discussions on key approaches to improve family planning and contraception provision and uptake. METHODS: Key stages of the community dialogue were undertaken, with representation from healthcare providers and community members. Participants included frontline and managerial health care providers, community health workers, family planning and contraception users, the youth, other stakeholders from the education sector, and civil society. How the dialogue was implemented (operational feasibility) as well as the cultural feasibility of the community dialogue content was evaluated through participant observations during the dialogue, using a standardised feasibility testing tick-list, and through focus group discussions with the stakeholders who participated in the community dialogue. RESULTS: Overall, 21 of the 30 invited participants attended the meeting- 70% attendance. The approach facilitated discussions on how quality care could be achieved in family planning and contraception provision, guided by the ground rules that were agreed upon by the different stakeholders. A need for more time for the discussion was noted. Participants also noted the need for more balanced representation from adolescents as well as other family planning stakeholders, such as community members, especially in comparison to healthcare providers. Some participants were not comfortable with the language used. Young people felt older participants used complicated terminologies while community members felt the health care providers outnumbered them, in terms of representation. CONCLUSION: Generally, the community dialogue was well received by the community members and the healthcare providers, as was observed from the sentiments expressed by both categories. Some key considerations for refining the approach included soliciting maximum participation from otherwise marginalized groups like the youth would provide stronger representation.

Facilitating community participation in family planning and contraceptive services provision and uptake: community and health provider perspectives.

BACKGROUND: Although community participation has been identified as being important for improved and sustained health outcomes, designing and successfully implementing it in large scale public health programmes, including family planning and contraceptive (FP/C) service provision, remains challenging. Zambian participants in a multi-country project (the UPTAKE project) took part in the development of an intervention involving community and healthcare provider participation in FP/C services provision and uptake. This study reports key thematic areas identified by the study participants as critical to facilitating community participation in this intervention. METHODS: This was an exploratory qualitative research study, conducted in Kabwe District, Central Province, in 2017. Twelve focus group discussions were conducted with community members (n = 114), two with healthcare providers (n = 19), and ten in-depth interviews with key community and health sector stakeholders. Data were analyzed using a thematic analysis approach. RESULTS: Four thematic categories were identified by the participants as critical to facilitating community participation in FP/C services. Firstly, accountability in the recruitment of community participants and incorporation of community feedback in FP/C. programming. Secondly, engagement of existing community resources and structures in FP/C services provision. Thirdly, building trust in FP/C methods/services through credible community-based distributors and promotion of appropriate FP/C methods/services. Fourthly, promoting strategies that address structural failures, such as the feminisation of FP/C services and the lack FP/C services that are responsive to adolescent needs. CONCLUSIONS: Understanding and considering community members' and healthcare providers' views regarding contextualized and locally relevant participatory approaches, facilitators and challenges to participation, could improve the design, implementation and success of participatory public health programmes, including FP/C.

Community and Provider Perspectives on Addressing Unmet Need for Contraception: Key Findings from a Formative Phase Research in Kenya, South Africa and Zambia (2015-2016).

Unmet need for contraception remains a challenge especially in low and middle-income countries. Community participation or the -active involvement of affected populations in all stages of decision-making and implementation of policies, programs, and services‖ is a precondition for attaining the highest standard of health. Participation as a key component of rights and quality of care frameworks could increase met needs. However, it has been inadequately addressed in contraceptive programs. A qualitative, exploratory methodology that included focus group discussions and in-depth interviews with community members, healthcare providers, and other stakeholders were conducted to identify domains or key thematic areas of action through which stakeholders could be engaged. The study conducted in Kenya, South Africa, and Zambia explored knowledge and use of contraceptives, barriers and enablers to access, quality of care, and participatory practices. Thematic analysis was used, facilitated by NVivo (version 10 QSR International) with a single master codebook. Comparing the thematic areas that emerged from the county data, four domains were selected: quality of care, informed decision-making, acceptability, and accountability. These domains informed the theory of change of a participatory programme aiming to meet unmet needs. Identifying possible generalizable domains establishes measurable and comparable intermediate outcomes for participatory programs despite diverse African contexts.

"As we have gathered with a common problem, so we seek a solution": exploring the dynamics of a community dialogue process to encourage community participation in family planning/contraceptive programmes.

BACKGROUND: Community dialogues have been widely used as a method for community engagement and participation to cover a broad range of areas. However, there has been limited documentation and evaluation of the process, particularly as a method towards achieving family planning and contraception (FP/C) programme goals. As part of the development of an intervention package aimed at increasing community and health care provider (HCP) participation in the provision of FP/C, feasibility testing of the intervention approach (a community dialogue between communities and health facilities) was carried out. Our findings offer a systematic description and evaluation of the community dialogue process, with key recommendations towards future implementation. METHODS: The dialogue was evaluated in three ways: 1) through participant observation during the community dialogue, 2) via a standardised feasibility testing tick-list for all observers of the dialogue, and 3) through three focus group discussions (FGDs) consisting of different groups of stakeholders who participated in the community dialogue. In total, 28 community members, HCPs, and key stakeholders attended the community dialogue (22 females, 6 males). Twenty-seven of the community dialogue participants participated in one of 3 FGDs held after the dialogue. Six evaluators assessed feasibility of the dialogue process. RESULTS: There was good attendance, representation and participation amongst community and provider sectors based on the participant observations using the standardized feasibility check-list. The community dialogue process received positive feedback in the FGDs and was demonstrated to be feasible and acceptable. Key factors contributing to the success of the community dialogue included a skilled facilitator, good representation of participants, establishing ground rules, good timekeeping, and using a Theory of Change to facilitate goal identification and dialogue. Issues to consider are the underlying power differentials related to age, profession and gender which caused initial feelings of anxiety amongst some participants. CONCLUSIONS: Our formative findings offer a systematic description and evaluation of a community dialogue process with key recommendations that may be considered when constituting similar community dialogues in the future.

Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia.

BACKGROUND: Unmet need for contraception results in several health challenges such as unintended pregnancies, unwanted births and unsafe abortions. Most interventions have been unable to successfully address this unmet need due to various community and health system level factors. Identifying these inhibiting and enabling factors prior to implementation of interventions forms the basis for planning efforts to increase met needs. This qualitative study was part of the formative phase of a larger research project that aimed to develop an intervention to increase met needs for contraception through community and health system participation. The specific study component reported here explores barriers and enablers to family planning and contraceptive services provision and utilisation at community and health systems levels. METHODS: Twelve focus group discussions were conducted with community members (n = 114) and two with healthcare providers (n = 19). Ten in-depth interviews were held with key stakeholders. The study was conducted in Kabwe district, Zambia. Interviews/discussions were translated and transcribed verbatim. Data were coded and organised using NVivo 10 (QSR international), and were analysed using thematic analysis. RESULTS: Health systems barriers include long distances to healthcare facilities, stock-outs of preferred methods, lack of policies facilitating contraceptive provision in schools, and undesirable provider attitudes. Community level barriers comprise women's experience with contraceptive side effects, myths, rumours and misconceptions, societal stigma, and negative traditional and religious beliefs. On the other hand, health systems enablers consist of political will from government to expand contraceptive services access, integration of contraceptive services, provision of couples counselling, and availability of personnel to offer basic methods mix. Functional community health system structures, community desire to delay pregnancy, and knowledge of contraceptive services are enablers at a community level. CONCLUSIONS: These study findings highlight key community and health systems factors that should be considered by policy, program planners and implementers in the design and implementation of family planning and contraceptive services programmes, to ensure sustained uptake and increased met needs for contraceptive methods and services.

Participatory approaches involving community and healthcare providers in family planning/contraceptive information and service provision: a scoping review.

As efforts to address unmet need for family planning and contraception (FP/C) accelerate, voluntary use, informed choice and quality must remain at the fore. Active involvement of affected populations has been recognized as one of the key principles in ensuring human rights in the provision of FP/C and in improving quality of care. However, community participation continues to be inadequately addressed in large-scale FP/C programmes. Community and healthcare providers' unequal relationship can be a barrier to successful participation. This scoping review identifies participatory approaches involving both community and healthcare providers for FP/C services and analyzes relevant evidence. The detailed analysis of 25 articles provided information on 28 specific programmes and identified three types of approaches for community and healthcare provider participation in FP/C programmes. The three approaches were: (i) establishment of new groups either health committees to link the health service providers and users or implementation teams to conduct specific activities to improve or extend available health services, (ii) identification of and collaboration with existing community structures to optimise use of health services and (iii) operationalization of tools to facilitate community and healthcare provider collaboration for quality improvement. Integration of community and healthcare provider participation in FP/C provision were conducted through FP/C-only programmes, FP/C-focused programmes and/or as part of a health service package. The rationales behind the interventions varied and may be multiple. Examples include researcher-, NGO- or health service-initiated programmes with clear objectives of improving FP/C service provision or increasing demand for services; facilitating the involvement of community members or service users and, in some cases, may combine socio-economic development and increasing self-reliance or control over sexual and reproductive health. Although a number of studies reported increase in FP/C knowledge and uptake, the lack of robust monitoring and evaluation mechanisms and quantitative and comparable data resulted in difficulties in generating clear recommendations. It is imperative that programmes are systematically designed, evaluated and reported.