KNOWLEDGE, ATTITUDES AND PRACTICES OF POST NATAL MOTHERS ON FAMILY PLANNING IN NYENGA HOSPITAL

ABBREVIATIONS

FP                                : Family Planning

WHO                          : World health organisation

IUCD                          : Intrauterine Contraceptive Device

LAM                           :Lymphangioleiomyomatosis

CPR                             : Contraceptive prevalence rate

PPFP                           : Postpartum Family Planning

DEFINITION OF KEY WORDS

Fertility                       :

CHAPTER ONE:

1.0 Introduction

This chapter presents the introduction of the study, background of the study, problem statement, purpose, specific objectives, research questions and justification of the study.

1.1 Background information

According to Trussell, J.et al (2007), family planning”, means enabling individuals and couples to determine the frequency and timing of pregnancies, through the use of modern and traditional (also called natural) contraceptive methods.

Indeed, postpartum family planning services (PPFPS) are regarded as a basic human right to attain the highest standard of sexual and reproductive health by post-natal mothers, free of discrimination, coercion and violence (UNFPA, 2003). Globally, use of PPFP has risen slightly, from 54% in 1990 to 57.4% in 2014. Regionally, the proportion of post-natal mothers aged 15–49 reporting use of PPFP  method has risen minimally or plateaued between 2008 and 2014. In Africa it went from 23.6% to 27.6%, in Asia it has raised slightly from 60.9% to 61.6%, and in Latin America and the Caribbean it rose slightly from 66.7% to 67.0%.

However, PPFP services are facing a complicated process, entangled in social, political, moral and cultural network in many African countries, including Tanzania (Richey, 2008). For example, Tanzania is among the sub-Saharan African countries with the highest total fertility rate at 5.4 births per woman (TDHS, 2010). Indeed, high percentage of postnatal mothers are sexually active and practice unsafe sex, consequently , the majority of them are highly vulnerable to unwanted pregnancy, immediate conception after child birth unsafe abortions, (TDHS,2010).

Unsafe abortion is a significant problem to post mothers who conceive immediately after birth (Plummer et al. 2008). Nearly a quarter (24%) of sexually active married and unmarried women has an unmet need for PPFP, according to the most recent DHS (Khan and Mishra 2008). Promotion of condoms for disease prevention might be contributing to this unmet need by associating the method with infection and promiscuity (Plummer et al. 2006).

Uganda, an east African nation, shares cultural, social, economic, and demographic characteristics with other African countries, including; rapid population growth mainly characterized by high levels of fertility, generally attributed to low use of PPFP services. There are many reasons why mothers do not use PPFP services during the postpartum period. Lack of access to family planning services and information is often a barrier rural mothers with unmet need for PPFP services during the postpartum period are more likely to conceive immediately after birth than their urban counterparts due lack of access as a reason for not using PPFP .

Among postnatal mothers with unmet need for PPFP, commonly cited reasons for not using FP include personal or partner opposition to use (26%), breastfeeding or having recently given birth (26%) and fear of side effects (22%). These reasons suggest that many postnatal mothers lack accurate information about PPFP, including its mechanisms of action, safety, side effects, efficacy and ease of use.

1.2 Problem statement

According to  ICF International, (2012), Uganda struggles with a low contraceptive prevalence rate (CPR) of 30%, which is lower than that of her neighbours, Kenya, Rwanda, and Tanzania, which have a CPR of 46%, 52%, and 34% respectively, at the time of their last surveys.

Despite the enormous efforts put in place to improve family planning methods, for example by health education, supply of contraceptives in all health facilities and Inter sectoral organizations efforts to improve maternal health services, the use of family planning remains a challenge in Nyenga Hospital due to a low turn up of mothers for post natal services and especially on utilization of postpartum family planning services/methods. With this background this study will aim at determining the knowledge, attitude and practice of its methods among mothers attending post-natal clinic in Nyenga Hospital in order to suggest ways of encouraging its utilization.

1.3

The purpose of the study is to generate information that will contribute towards designing strategies aimed at improving the use of family planning services among mothers attending postnatal clinics.

1.4 Specific objectives of the study

2. To establish the delivery of family planning services/methods to post-natal mothers in  Nyenga Hospital
3. To establish the socio-economic factors associated mothers attending postnatal clinic in Nyenga hospital.

1.5 Research questions.

1. What is the knowledge and attitude of post natal mothers on family planning services in Nyenga Hospital?
2. What are the different family planning services delivered to post-natal mothers in Nyenga Hospital?
3. What are the methods of family planning offered in Nyenga Hospital
4. What are the socio-economic factors associated with post-natal mothers attaining family planning Nyenga Hospital?

1.6 Justification of the study.

This research will aid the Ministry of health and other stake holders to come up with strategies to improve contraceptive use by creating knowledge on its benefits to mothers, their children, families and the country at large.

The study will provide a reference point to  future researchers who will carry similar studies this will also act as a sensitizing tool for all community members on the importance of contraceptive use.

The study will be of great help to the nursing profession to develop plans and procedures of managing postnatal mothers’ in relation to their anticipated side effects of contraceptives.

CHAPTER TWO: LITERATURE REVIEW

2.0 Introduction

This chapter presents litereature presented by other scholars, it’s

2.1 Knowledge and attitude of mothers attending post-natal clinic on family planning

All over the world, sexual behaviour is a complex issue influenced by numerous variables, such as individual desire, social and cultural relationships, environmental and economic dynamics (Njau et al., 2006; Ochieng et al., 2011). Their socio-demographic characteristics (Upreti et al., 2009), perception of Postnatal mothers (Mahat et al., 2006; Puri, 2006), level of knowledge and their attitudes towards their sexual and reproductive health during their post-partum period (Rondini & Krugu, 2009) may impact greatly on whether or not they have sex, the types of sexual relationships they form and utilization of postpartum family planning services (UNICEF, 2006).

Around the world, successful reproductive health programmes among mothers are those that equip post-natal mothers with Knowledge and skills that will keep them safe from getting pregnant during the postpartum period (Paluku et al., 2009).

According to C Mubita-Ngoma, (2010), in his study about Knowledge and use of modern family planning methods by rural post-natal mothers in Zambia, found out that a larger number of Zambians had heard about modern contraceptive methods mainly from a health worker. This study also found out that the most popularly known and used method of contraceptive was a male condom followed by a pill.

In  another study  on contraceptive  use  in  mothers  enrolled  into  preventive  HIV  vaccine  trials reported  insufficient  knowledge  of  certain  methods  to  be  among  the  reasons  for  not  using contraception and that misconceptions related to family planning  methods and their incorrect use, might have led to inconsistent use resulting in undesired pregnancies during the postpatum (Kibuuka et al., 2009)

Another  survey  conducted  in  14  countries  among  7000  mothers irrespective  of  their  HIV  status between 14 and 40 years showed that knowledge gap in family planning methods restricts women’s contraceptive choices and hence use, and that mothers fail to take advantage of new contraceptive methods due to lack of knowledge and stay with the familiar options (Rossella, 2006).

A study carried out in Tanzania also stated that, both users and non-users of family planning often held mixed views of modern FP methods, recognizing both the benefits for limiting and spacing children, but also expressing strong fears and beliefs about contraceptive use such as: caused cancer, weight gain or loss among mothers, continuous bleeding, cessation of periods all together. This is seen as harmful to the post-natal hence not using PPFP. (Plummer et al., 2008)

Also a study carried out in Kenya by Shabiby. et al, (2015), revealed that,  Most participants were aware about modern methods of FP with inject able contraceptives and contraceptive pills being the most commonly known FP methods, followed by IUCD, male condom and implants. Natural FP methods such as Lactation Amenorrhoea (LAM) and rhythm methods were among the least known FP methods and only about a quarter of all participants knew about female sterilisation (Mufida et al., 2015).

According to Nanvubya et al, (2015), in their study about use of Modern Family Planning Methods in Fishing Communities of Lake Victoria, 88%of the respondents knew about modern FP methods, with women and older respondents having more knowledge.

It is also noted the same survey of Uganda Demographic and Health Survey (UDHS) (2011), that Uganda has a young population (52% below age 15, and 17% are age 15-24) and a high total fertility rate (TFR), of 6.2 children per woman.

2. 2 Establish the delivery of family planning services/ methods to post-natal mothers

The days and weeks following childbirth the postnatal period is a critical phase in the lives of mothers and newborn babies WHO. (2014). Major changes occur during this period which determine the well-being of mothers and newborns. Yet, this is the most neglected time for the provision of quality family planning services/methods. Lack of appropriate care during this period could result in pregnancy during the postpartum period. Rates of provision of skilled family planning services are lower after childbirth when compared to rates before and during childbirth. WHO. (2014).

Uganda still struggles with a low contraceptive prevalence rate (CPR) of 30%, which is lower than that of her neighbours, Kenya, Rwanda, and Tanzania, which had a CPR of 46%, 52%, and 34%, respectively, at the time of their last surveys, (ICF International 2012).

While family planning (FP) is important throughout an individual’s and couple’s reproductive life, postpartum family planning (PPFP) focuses on the prevention of unintended and closely spaced pregnancies through the first 12 months following childbirth (Rutstein 2008).

Effective delivery and uptake of modern family planning methods depends a lot on the competency and attitudes of the providers particularly for the long acting and permanent methods Babalola, S. (2012). According to Kasedde S, (2010) some of the constraints observed in postnatal family planning delivery include lack of trained staff or transfer of trained and motivated staff resulting in decrease of commitment of the remaining staff. In addition, there is poor information provision ranging from poor display of education and communication materials, to limited disclosure of methods and counseling about modern postnatal FP methods especially the long term and permanent ones (Kasedde 2010). Also documented are the negative attitudes of service providers, poor accessibility to services, and inadequate family planning supplies at the health facilities (Mbonye 2013). Other service factors that may also hinder FP service utilization include: long waiting times, unofficial fees in the public sector, and limited quantity of information provided during care (Jitta 2011).

Postnatal Family planning services can be made more accessible and convenient to mothers if they take into account other service needs of the potential clients. Integration of postnatal FP services for postnatal mothers who frequently use Maternal and Child Health (MCH) and reproductive services would lower costs to clients and reduce missed opportunities for service delivery (Katherine W 2010). A study conducted in Kumi District, Uganda found out that only about 18% of mothers attending postnatal clinics received messages regarding postpartum family planning services and yet 71% intended to use PPFP in the future (Mbonye 2013).

2.3 The socio-economic factors influencing the use of family planning among mothers attending postnatal clinic

According to Timothy et al, (2011), long distance account partly for the use of contraceptives amongst women in the rural area. Also lack of awareness could be attributed to lack of access to information regarding the services. The inability to access such important information is bound to affect the woman’s ability to make an informed decision on uptake of postpartum family planning services/methods (Timothy et al., 2011).

Kumar et al (2011), in their article about Family planning practices and methods among women of urban slums of Luck now City India, sited that, modern PPFP use by a respondent or their sexual partner was reported in just over a third of the respondents with more females than males reporting use. Short-acting reversible contraceptive methods such as oral contraceptives and Depo-Provera were used by three quarters of the respondents as compared to one quarter who used the long-acting reversible methods such as intra-uterine devices and implant. (Kumar et al., 2011)

In Tanzania, More than half of the respondents who reported knowing about modern PPFP methods were not using them. PPFP use increased with education level, with the lowest use of PPFP reported by those without any formal education and the highest use by those who had attained secondary or higher level of education. Muslims were less commonly using modern PPFP methods despite having knowledge. (Plummer et al., 2006).

According to a study done in Kenya among postnatal mothers , 51 per cent of the respondents were using PPFP services. In the same study, those using the PPFP services  cited  various  reasons  ranging from  managing  the  family, preventing un wanted pregnancies  to   promoting child spacing (Timothy et al., 2011)

Still in Kenya, in terms of methods, the study reveals that the most commonly used PPFP services were condoms, pills, injection and IUD, (Timothy et al., 2011).

In Uganda as in many other countries, major factors associated with PPFP services use are mothers who are educated, and in good socioeconomic status. Ugandan mothers who are more educated and wealthier are more likely to use PPFP services compared with illiterate and less wealthy women, (UBOS and Macro International 2007)

In the  Ugandan  context,  only  10%  of  all  Ugandan  mothers  and  14%  of  married  women  age 15 to 24 is using any contraceptive method, (UBOS and Macro International 2007)

CHAPTER THREE:  METHODOLOGY

3.0 Introduction

This chapter presents the description of the study design, study area, study population, sample size determination, sampling techniques, data collection procedures, study variable, data collection tool, data presentation, data analysis, ethical considerations and quality assurance.

3.1 Study Design

This will be a cross sectional descriptive study design employing both qualitative and quantitative methods in which a questionnaire will be used to collect data. The   Participants will be recruited once in the study and interviewed once during the study to allow completion of the study within the academic schedule.

3.2 Study Setting

The study will be conducted at St. Francis Hospital Nyenga, commonly known as Nyenga Hospital which is affiliated to the Roman Catholic Church. Nyenga is located in Buikwe District, approximately 18 Kilometres, by road, north east of Buikwe, the location of the district headquarters; it is also located approximately 7.5 kilometers by road, southwest of Njeru, the largest metropolitan area in buikwe District. The coordinates of Nyengaare 00⁰22’48”N33”09’00”E, in the central part of Uganda. The other towns in the district include, Buike Municipality, Lugazi Municipality, Njeru Municipality, Ngogwe Municipality and Nkonkonjeru Municipality. It provides medical services in paediatrics, maternity/gynaecology, internal medicine, surgery, Public Health, and HIV Care and Treatment.

3.3 Study population

The study will focus specifically on mothers attending postnatal clinic at Nyenga Hospital. Buikwe District Uganda, has many patients to a tune of  300 patients in a day among which 86 are expectant mothers and easily accessed from surrounding towns. The study’s target population will be postnatal mothers especially those attending postnatal clinic of Nyenga Hospital.

3.5 Sample Size Determination

The study will consists of a sample size of 30 respondents who will be found in Nyenga Hospital

3.6 Sampling Procedure

The study will employ a non-probability convenience sampling approach where the interviewer will administer questionnaires to any available respondents who meet the required inclusion criteria and have consented and accepted to participate in the study.

3.7 Inclusion Criteria.

The study will consider all postnatal Mothers, especially those attending postnatal clinic of Nyenga Hospital.

3.7.1    Exclusion Criteria.

This will include any mother are not attending the post-natal clinic of  Nyenga hospital

3.8 Study Variables

The main variable of interest (dependent variable) will be modern contraceptive use, which is binary in nature (non-use or use). Modern methods of family planning refer to safe, effective and legal methods to prevent pregnancy such as the pill, condoms, injectables and the Intra-Uterine Device (IUD).

The explanatory (independent) variables in the study are women’s education, wealth index, exposure to family planning messages on radio, television, or newspapers, desire for children, husband’s education, women’s empowerment, ability to refuse sex, and visited health facility in the past 12 months.

3.9 Research Instruments

The questionnaires will be used and will comprise of both structured and unstructured questions. The purpose of the study will be comprehensively explained to the respondents within the questionnaire.

3.10 Data Collection Procedure

An introductory letter from the school administration will be obtained and presented to the Nyenga Hospital Administration for permission to conduct this study. The Questionnaires will be administered to the respondents who will fill them at their time of convenience and then collected after three weeks. During data collection, the rights of individuals will be respected.

3.11 Data Management

Data collected will be tabulated and calculated into percentages, then, data will be presented using frequency tables, graphs and pie charts.

3.12 Data analysis

After collection of data, responses from the questionnaires will be studied so as to make sure that the information obtained is complete, consistent, accurate and reliable. Analysis of the data will be done using both qualitative and quantitative methods in order to make the findings easy to understand and make conclusion to the stakeholders. Quantitative data will be processed by coding and sorting it to ensure that they match with study objectives. After this, it will be entered into computer and then will be analyzed using SPSS and later interpretation derived using mean scores which later will be used to interpret the findings. A higher mean score for a positive statement will mean that majority of the respondents tended to agree with such a statement and vice versa. For negative statements a lower mean score will mean that majority of the respondents agreed to the statement and vice versa.

3.13 Ethical Considerations.

The study will be done following guidelines of the Uganda Nurses and Midwives Examination Board standard research guidelines for Diploma Nursing Program Development of the research proposal and the report will be under supervision of a staff assigned by Kyambago Public Health Nurses’ College which will issue a letter introducing the researcher to Nyenga Hospital. The same letter will be taken to the relevant officials for purposes of granting permission to interact with the participants. After getting a later from the college that grants the researcher permission to curry out the research, the researcher will go ahead to obtain a concent form from the hospital that will allow the researcher to proceed with collecting data from the respondents. Only respondents who will be willing to take part in the study based on the four “basic” ethical principles of autonomy, justice, benevolence and non-male ficence and related ethical concepts.  Besides, a consent form will be designed because a consent form is only signed after through explanation and one accepts to fill and sign. All sources of information will be respected and considered vital.

3. 14 Quality Control

Discussion of the research tools will be done with the research supervisor and pre-testing of the research tools will be done before the questionnaire is adapted for final data collection.

3.15 Limitations of the study

Since research is an expensive exercise, financial resources might be inadequate.

There is also a problem of limited literature specific to the subject under study especially in Buikwe District. The available data is old and out-dated.  Current data will have to be obtained from Internet and recent journal articles.

Access to new material on Internet is not easy since some files require one to have a password and username in order to access them and at times not easy to understand

3.16 Dissemination of Results

A report of findings of this study will be compiled, four copies of the report will be produced and distributed to the following people; one copy will be handed to the research supervisor at Nyenga Hospital, another to my research supervisor, one to UNMEB and I will retain one.
REFERENCES

Trussell, J., & Guthrie, K. (2007). Choosing a contraceptive: efficacy, safety, and personal considerations. Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive technology. 19th revised ed. New York (NY): Ardent Media, Inc, 19-47.

McVeigh, R. (2013). Artificial and Natural Forms of Birth Control: A Comprehensive Analysis.

Blanc, A., A.,Tsui,  T.  Croft.,& J.  Trevitt.(2009).Patterns  and  Trends  in  Adolescents’  Contraceptive  Use  and  Discontinuation  in  Developing  Countries  and  Comparisons  with Adult Women. International Perspectives on Sexual and Reproductive Health 35(2)

C Mubita-Ngoma, (2010).Knowledge and use of modern family planning methods by rural women in Zambia: Department of Nursing Sciences, School of Medicine, University of Zambia,

ICF International: (2012). MEASURE DHS STATcompiler.Available at http://www.statcompiler.com.

2009. Park. Park’s Text book of Preventive and Social Medicine, 18th edition, Bhanot publishers 2009.

Kibuuka  H,  Guwatudde  D,  Kimutai  R,  Maganga  L,  Maboko  L,  Watyema  C et al,  2009. Contraceptive use in women enrolled into preventive HIV vaccine trials: experience from a phase I/II trial in East Africa. PubMed – indexed for MEDLINE (online). 4(4):  Available from: http://www.ncbi.nlm.nih.gov/sites/entrez

Kumar et al: Family planning practices and methods among women of urban slums of Lucknow City, Indian Journal of Community Health, Vol. 23, No. 2, July 2011- Dec. 2011

Nanvubya, A., Ssempiira, J., Mpendo, J., Ssetaala, A., Nalutaaya, A., Wambuzi, M., …Kiwanuka, N. (2015). Use of Modern Family Planning Methods in Fishing Communities of Lake Victoria, Uganda.PLoS ONE, 10(10), e0141531. http://doi.org/10.1371/journal.pone.0141531

Plummer, M.L.; Wamoyi, J.; Nyalali, K.; Mshana, G.; Shigong, Z.S.; Ross, D.A.; Wight, D. (2008). Aborting and suspending pregnancy in rural Tanzania. Studies in Family Planning, 39(4):281-292.

Plummer, M.L.; Wight, D.; Wamoyi, J.; Mshana, G.; Hayes, R.J.; Ross, D.A. (2006). Farming with your hoe in a sack: Condom attitudes, access, and use in rural Tanzania. Studies in Family Planning, 37(1):29-40.

Rossella N., (2006). Knowledge Gap Restricts Women’s Contraceptive Choice; Women’s health/gynaecology, (online), Available from: http://www.medicalnewstoday.com/articles/57430.php

S M Joshi, S B Patil, Knowledge & practices of family planning in an urban slum of Mumbai, Indian Journal, Preventive Social Medicine, volume 38, No. 1& 2, Jan to June 2007

Schuler, S., E. Rottach, and M Peninah.(2009). Gender norms and family planning decision making in Tanzania: A qualitative study. Washington, DC: C-Change.

Shabiby, M. M., Karanja, J. G., Odawa, F., Kosgei, R., Kibore, M. W., Kiarie, J. N., &Kinuthia, J. (2015). Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals. BMC Women’s Health, 15, 62. http://doi.org/10.1186/s12905-015-0222-1

Sileo, Katelyn M., “Determinants of Family Planning Service Uptake and Use of Contraceptives among Postpartum Women in Rural Uganda” (2014).Master’s Theses. Paper 602. http://digitalcommons.uconn.edu/gs_theses/602

Tanzania Journal of Health Research Doi: http://dx.doi.org/10.4314/thrb.v15i1.3 Volume 15, Number 1, January 2013

Timothy C. OkechDr. Nelson W. WawireDr. Tom K. Mburu, (2011). Contraceptive Use among Women of Reproductive Age in Kenya’s City Slums .International Journal of Business and Social Science Vol. 2 No. 1; January 2011

Uganda Bureau of Statistics (UBOS),  and Macro International Inc. 2007. Uganda Demographic and Health Survey 2006. Calverton, MD, USA: UBOS and Macro International Inc.

W (2009) Family planning. Collins English Dictionary, 10th ed: http://www.collinsdictionary.com/dictionary/english/family-planning

WHO (2015)  Family planning. Available from: http://www.who.int/topics/family_planning/en/5.Collins http://www.medical-dictionary.org/definitions-f/family-planning.

APPENDIX I: CONSENT FORM

STATEMENT O F CONSENT

I ………………………………………………have freely consented to participate in the study about Knowledge, attitude and practices of Family planning in Nyenga hospital. This study has been clearly explained to me and has been assured that am free to participate in the study or refuse it and can withdraw anytime. My decision will not affect my rights to any research studies.

In charge Postnatal Clinic………………………………………

Date………………………………..

Place……………………………

APPENDIX II: QUESTIONNAIRE

Introduction and Purpose

My name is Namazzi Pouline a student from Kyambogo School of Health from Kampala district pursuing a diploma in Midwifery.

Tick (√) against the answer of the respondents choice or fill in the blank spaces where applicable.

SECTION A: BIO DATA

1. Age…………………………………………………………………………………………………….
2. Do you know to write and read?
3. Yes
4. No
5. Level of education that you have attained?
6. No formal education
7. Adult education
8. Primary education
9. Secondary education
10. Collage education
11. Religion?
12. Muslim
13. Christian
14. Tribe …………………
15. Marital status?
16. Single
18. Divorce
19. Widow
20. Separated
21. Occupation?
22. House wife
23. Peasant
24. Pastoralist
25. Self employed
26. Employed by Government
27. What is your husband’s Occupation?
28. Peasant
29. Pastoralist
30. Self employed
31. Employed by Government

SECTION B: KNOWLEDGE, ATTITUDE AND PRACTICES OF FAMILY PLANNING USE           

9. Have you ever had of family planning?
10. Yes
11. No
12. If yes, what is the main source of your information on family planning?
13. Over the mass media like newspapers, radio or TV
14. Hospital or health unit
15. From a nurse

SECTION D: ESTABLISH THE DELIVERY OF FAMILY PLANNING SERVICES/METHODS TO POST-NATAL MOTHERS

11. Do attain postnatal family planning services in this health centre?
12. Yes
13. No

16 if yes what postpartum family planning methods are you offered in the postnatal clinic?

1. Pill,
2. Condoms,
3. Injectables
4. Intra-Uterine Device (IUD)
5. Natural methods
6. Other specify

17 How do you receive this family planning information?

1. Through mass media like newspapers, radio or TV
2. Through charts displayed at the health centre.
3. Through counselling
4. From a nurse

SECTION C: THE SOCIO-ECONOMIC FACTORS OF MOTHERS ATTENDING POSTNATAL CLINIC

12. How many children do you have?
13. 1 to 2 children
14. 2 to 3 children
15. 3 to 4 children
16. 4 and above
17. What does your society say about woman having many children?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

14. How many people are living with you in your house hold?
15. 4 people
16. 3 people
17. 7 people
18. 9 and above
19. How far is your home from the health facility?
20. ½ a Kilometre to 1 Kilometre
21. 2 to 3 Kilometres
22. 4 and above Kilometres
23. How much transport cost do you spend travelling to the health facility?
24. 500/- to 1000/-
25. 1500/- to 2000/-
26. 3000/- and above
27. How much do you earn in a month?
28. 10,000/- to 20,000/-
29. 25,000/- to 30,000/-
30. 40,000/- and above

What is the quality of health service delivery?

1. Good
2. Very good
3. Fair
4. Poor

APPENDIX III: WORK PLAN

APPENDIX IV: BUDGET