Table 4 Key Findings from community-engaged research methods to develop the family health = family wealth intervention, 2020, Uganda

Data identified specific community norms and beliefs that influence large family size and impede contraceptive use that need to be reshaped through transformative communication to increase family planning acceptance. Key beliefs identified and included in intervention content are listed below:

Beliefs to reshape among both men and women

• Each child brings their own “luck,” therefore, one must have many children to increase the chances of having a lucky (or successful) child

• Women’s/Men’s status is tied to the number of children they have

• It is a women’s role to take care of children, while it is a man’s role to provide for the family

• It is a man’s final decision on whether a couple should use family planning. If he does not want his wife to, she must obey

• Contraceptive methods have dangerous side effects and reduce women’s sex drive

Beliefs to reshape among men only

• A man must continue the clan and match the number of children his father had

• Men must have children from multiple women to increase the chances of a “lucky” child

• Men are meant to have more than one wife, and therefore should not limit their number of children

• A woman who is using family planning is probably unfaithful to her husband

Beliefs to reshape among women only

• When your relationship is in trouble, having a child will help save the marriage

• Having a child to please your husband will prevent him from having children with other women

• In facilitated community dialogue in Session 1, facilitator presents each belief and guides participants to identify how these beliefs can hurt “family health and wealth” – together the group reshapes the belief to align with gender equity and family planning (women and men’s separate groups)

• Specific contraceptive method myths and misinformation identified debunked through family planning education provided by the midwife in session 2 (women only) and session 3 (couples session)

Strategies to engage men in intervention sessions and increase their acceptance of family planning

Men respect the opinions of community leaders and are influenced by them

• Mobilization of men should involve respected leaders in the community

• Community leader endorsement of the program and family planning integrated at the beginning of the program (Session 1) and the end of the program (Session 4)

Men are interested in the economic benefits of family planning

• The economic benefit of family planning was the primary facilitator identified for family planning acceptance among men.

• Men have a general interest in learning about economic development; greatest interest was expressed in the proposed content focused on “economic health” among men

o “Men are always pre-occupied with wanting to find ways of making money to cater for their families. So, within the topics you are planning, make sure that in the men’s session, you include one which caters for income generating ventures, that seeks to improve the standard of living in families.” (Community Leader KII)

• The benefits of family planning to “economic health” promoted throughout the program

• Economic training (budgeting, advice from a local business expert) included in Session 2 and Session 3 to engage men’s interest

Men will not attend sessions if packaged as a “family planning” program

• Family planning viewed as a “women’s issue,” making men unlikely to attend a “family planning” intervention

o “So, my husband will come for the first session but will not come back for the second session once he hears about family planning issues. He will think it is for women.” (Women’s FGD)

• Needs to be packaged in a way that makes family planning secondary

o “It is a good program and good to participate in but you have to start with these other components [economic content, etc.] you have mentioned then later you bring in family planning. If you don’t do that, you will not get respondents.” (Men’s FGD)

• Family Health = Family Wealth theme used throughout, focused on physical, economic, and relationship health, with family planning highlighted as important to all three areas

• “Family Planning” redefined as being broader than contraceptive use, but planning for one’s family in all three areas of health

Men will expect incentives to attend

• Small incentives typically given for attendance of community meetings, and therefore expected

• ISC confirmed that community dialogues by the health facility would include a small monetary incentive, deemed scalable within health system if small ~(5,000–10,000 Ugandan Shillings)

• 5,000 Ugandan Shillings provided for attendance of each session

Acceptability of community leader participation

Community leader participation in the intervention viewed as an effective way to endorse the program and increase family planning acceptability to community members

• Participants agreed that community leader endorsement of the program and family planning would improve community acceptance of the intervention and contraceptive use

o “In our community, the local council chairmen are highly listened to. Their opinions matter to the people. The people are used to them and believe in them.” (Village Health Worker KII)

• Religious and elected leaders identified to endorse the program is Sessions 1 and 4

• Local leaders with expertise in intervention content selected to co-facilitate specific intervention content following a script

o Midwife: Family Planning Education (Session 2, women and Session 3, couples)

• Influential leaders identified that would be willing to endorse program included: Christian and Muslim leaders, local elected leaders, leaders within the health system, and local business people

Leaders can endorse the program, and leaders with specific expertise can co-facilitate content-specific session, but should follow a specific script to stay on message

• Mobilizing and co-facilitating scripted aspects of the session considered an appropriate role, but not leading sessions directly as originally planned

• Important to ensure the intervention was not viewed as politically affiliated (with elected leader involvement), making it important to control leader messages through intervention scripts

o Local Business Experts (male and female): Advice on Starting a Family Business (Session 2, men and women’s groups)

o Community Development Office: Community Action Plan (Session 4, couples)

Managing gender dynamics and minimizing risk of unintended negative consequences of participation

Concern was raised about content creating conflict within couple and about women’s ability to openly participate with partner present; strategies to mitigate risk and ensure equitable participation were elicited

• Facilitators will have to meet with men separately first to sensitize them on the content before having couples attend together

o “I see that this kind of strategy [community dialogues] would not be effective unless you first provide counseling and education to men separately and women separately and make sure that their spouses are in agreement.” (Village Health Worker KII)

• Some concern about women’s ability to openly participate in dialogues with their partner present

o Content and facilitator training must include efforts to create a safe space for equitable dialogue

• For couples where violence is already occurring, concern raised that discussions about family planning and gender equity could increase women’s risk of violence

o Need for appropriate training of facilitators to monitor and handle high-risk cases, and for procedures built into study protocol to monitor the occurrence of unintended negative consequences to participation

• Findings confirmed the acceptability of the proposed format, including two gender segregated groups (women and men groups separate) before two gender-integrated groups (groups of couples together), with importance placed on sensitizing men to the content ahead of the gender-mixed groups

• Facilitators trained to set tone for equitable participation between couples, and to identify and handle inequitable participation

• Intimate partner violence monitoring methods developed to continuously monitor for unintended negative consequences of participation and to identify couples at higher risk based on a history of violence

• Data Safety Monitoring Board established to review safety data throughout the trial

Difficulty engaging couples from polygamous marriages

• Deemed acceptable as long as the woman and man both agree to participation

• Barriers to family planning were identified that were specific to a polygamous community, e.g., women’s fear of their spouse finding another wife if she chooses family planning, women deciding to having children to “compete” with co-wives, and men choosing to having children with many women before being able to cater for the ones he has

• Issues related to navigating family planning decision-making within the context of a polygamous community were integrated into intervention content (e.g., promoting being able to care for the children one has before having children with another woman)

Intervention format and structure

Information elicited to inform the ideal format and structure of the intervention

• Number of sessions: four total sessions acceptable

• Gender mixed deemed acceptable (discussed above), as well as mixed ages

• Duration of and spacing between sessions: 1 to 1.5 h, 1–2 weeks between sessions

• Timing: Most people work in the gardens in the morning; making afternoon ideal

• Location: Must be centrally located in the community

• Four sessions (two gender segregated, two gender mixed) conducted 1–2 weeks apart held in the afternoons at a central location like the health facility

Acceptability and feasibility of linking community-based family planning distribution to intervention sessions

The delivery of short-term contraceptive methods during group sessions is feasible and was deemed acceptable by community members if made explicitly voluntary

• ISC and health workers in KIIs confirmed the feasibility of approach, using only short-term methods (i.e., condoms, oral pill, injectables)

• Community members felt approach was acceptable, but should be made optional, at the end of sessions, making it easier to opt out of the service if uninterested.

• Midwife to offer counseling and short-term contraceptive methods after Sessions 3 and 4 (couple sessions) for those who opt to stay after for the service

The need to strengthen providers’ family planning capacity and monitor family planning stock

Health system gaps that could hinder the effectiveness of the intervention were identified that needed to be integrated into the intervention’s content and study procedures.

• Health workers within the local Health Centre’s did not feel comfortable providing all contraceptive methods and forms of counseling. Specific knowledge gaps identified included intrauterine device (IUD) insertion and removal, as well as how to counsel patients on side effect management.

o “We lack the personnel that is especially skilled in offering those long term methods.” (Health Worker KII)

• Stocks outs of methods were identified as common within the district.

• Intervention content enhanced to address capacity gaps through a 2-day training provided to health care providers at the participating Health Centres to build capacity on the delivery of family planning counseling and contraceptives methods; emphasis on gaps identified, e.g., insertion and removal of IUD

• Methods integrated into the intervention trial to monitor the contraceptive stock at the clinics in the intervention and control villages and notify the health district to ensure restock during the intervention trial