ACCESS TO FAMILY PLANNING SERVICES BY WOMEN WITH DISABILITIES IN MUKONGORO SUB COUNTY, KUMI DISTRICT

LIST OF ABBREVIATIONS

AIDS              –           Acquired Immune Deficiency Syndrome

HC                  –           Health Care

HIV                 –           Human Immunodefiency Virus

HSDP              –           Health Sector Development Plan

MDG               –           Millennium Development Goal

MOH               –           Ministry of Health

NUDIPU        –           National Union of Disabled Persons in Uganda

PWDs              –           Persons with Disabilities

S/C                  –           Sub-county

UBOS             –           Uganda Bureau of Statistics

UN                  –           United Nations

UNDHR         –           United Nations Declaration of Human Rights

UNHS             –           Uganda National Household Survey

UNICEF         –           United Nations International Children’s Emergency Fund

USDC             –           Uganda Society for the Disabled Children

VHTs              –           Village Health Teams

WHO              –           World Health Organisation

WWDs                        –           Women with disabilities

LIST OF TABLES

Table 3.1: Sample size- 16

Table 1: Background information of the respondents 19

Table 2: People who had Knowledge and used Family Planning Services. 20

Table 3: Ways in which people acquire knowledge on Family Planning Services. 20

Table 4: Factors that influence women with disabilities from accessing family planning services  21

ABSTRACT

The main purpose of the study was to investigate the access to family planning services by women with disabilities in Mukongoro Sub County, Kumi District. The objectives of the study were; to find out the social-economic factors that influence the access tofamily planning services by women with disability, to assess the challenges faced by women with disabilities in accessing family planning services and to suggest strategies to improve family planning services offered to women with disabilities.

The study employed a cross-sectional research design where a qualitative approach of data collection was employed to collect data from 18 respondents in Mukongoro Sub County. The participants were selected using two sampling techniques; purposive sampling that was used for selecting health workers whereas, snowball was used for WWDs. The data was collected using interview guide, focus group discussions and observation which was then analyzed descriptively.

It was found out that the most vital factors affected the access to family planning services were lack of sensitization and long term effects, long distance to health centres and negative attitude towards western methods. However, free distribution of contraceptives, health education, guidance and counseling can be used to improve access to these services.

It was concluded people in Mukongoro Sub County are aware of family planning services although there is still negative attitudes towards these Services. Therefore, there is great need for more awareness rising about Family Planning Services in all areas in the district and strengthening family planning services would also help Uganda achieve Millennium Development Goal (MDG) to improving maternal health and infant health.

The study recommended that the Ministry of Education and Sports should ensure the recruitment and training of Special Needs teachers about Family Planning Services to be distributed to all districts in different Health Centers to deal with People with Disabilities and also help enable them gain the required skills. Also ensure that Family Planning is a key component of all National strategies, including the National Development Plan. Thus by increasing allocations for contraceptive in National and district health budgets.

CHAPTER ONE: INTRODUCTION

1.0 Introduction

This chapter includes the purpose of study, objectives, and research questions, statement of the problem, scope of study, its significance, limitations and delimitations.

1.1 Background to the study

Having a disability places one in the world’s largest minority group. An estimated 10 percent of the world’s population lives with disability. The World Bank (2004) estimates that 20 percent of the world’s poorest people have some kind of disability, and tend to be regarded in their own communities as the most disadvantaged.

Globally, Disabled people comprise approximately 10% of the world’s population, 75% of whom live in developing countries, and constitute one of the most poor, marginalised and socially excluded groups in any society. Disabled people, irrespective of where they live, are statistically more likely to be unemployed, illiterate, to have less formal education, and have less access to developed support networks and social capital than their able-bodied counterparts (Munene, 2012).

According to the World Health organization-Department of Reproductive Health and research (WHO, 2007), there is a global concern about Reproductive Health Programmes/ Care (Family planning Services) for all women irrespective of their reproductive age and disability. It further suggests that Family planning remains unfinished.

Family planning refers to practices that help couples to avoid unwanted child birth, to regulate the intervals between pregnancies and to determine the number of children in the family. It is also the process of controlling the number of children you have by using family planning methods. According to Bankole et al. (2006), the role of family planning methods is to help women and men reconcile their sexual lives and their desire for children. There are several methods of family planning such as an implant, or an intra-uterine device, the pill, the injection and vaginal ring, condoms and diaphragms, fertility awareness, vasectomy and tubal ligation.

According to Alcala (2013), in developing countries today, particularly in Africa, couples have concluded that it is in their best interest to plan and limit the number at birth. Unfortunately, in situation particularly in Sub-Sahara Africa, extreme poverty, profound inequalities between men and women, and early marriages, severely limit women’s ability to achieve their child bearing goals.

Uganda, like any other developing country has challenges in making Family Planning Services accessible by all women (Uganda Service Provision Assessment – UPSA, 2007).  Despite USPA’s struggle to make Family Planning services accessible by women, 6.9% of Ugandan women still have about 7 children average.According to United Nations (2015) the government support for long term and permanent methods of Family Planning has been present since the time of introduction of services in Uganda. The feasibility of this government support through media and community based advocacy events has been limited.

Women with disability often cannot obtain even the most basic information about sexual and reproductive health (SRH). Thus they remain ignorant of basic facts about themselves, their bodies, and their rights to define what they do and do not want. They may have little experience relating to and negotiating with potential partners. Women with disability may be denied the right to establish relationships. They fit the common pattern of structural risks for HIV/AIDS and other sexually transmitted infections – e.g. high rates of poverty, high rates of illiteracy, lack of access to health resources or information, and lack of power when negotiating safer sex (Tonny, 2015).Women with disability face many barriers to care and information about SRH. There is the frequent assumption that persons with disabilities are not sexually active and therefore do not need SRH services. However, research shows that persons with disabilities are as sexually active as persons without disabilities (World Bank, 2004).

Uganda has several laws and policies that it has put across to ensure that women with disabilities have access to health services just like any other woman for example the PWD Act (2006) which stipulates that the government shall provide special health services required by PWDs including providing access to reproductive health services which are relevant to women with disabilities. However, family planning services are often inaccessible to women with disability for many reasons, including physical barriers, the lack of appropriate clinical services, and stigma and discrimination. In many situations, barriers to health services include: lack of physical access, including transportation and/or proximity to clinics and, within clinics, lack of ramps and adapted examination tables; lack of information and communication materials (e.g. lack of materials in Braille, large print, simple language and pictures, lack of sign language interpreters); health-care providers’ negative attitudes and; providers’ lack of knowledge and skills about persons with disabilities(Mosha, 2015).

Mukongoro is a sub county in Kumi district in Eastern region in Uganda. It has about 16 parishes and 46 villages. Kumi district has 2 hospitals, 1 health IV,5 health centre IIIs and 8 health centre IIs with a total of 16 health facilities. Access to health facility has increased slightly to 85% and the general service delivery and primary health care in the district has improved over the years. Mukongoro has 1 health centre III and 2 health centre IIs (Mukongoro NGO and Agaria), these are accessed by both women with and without disability (Kumi Local Government Statistical report, 2012).It’s upon this background that the study was carried out in MukongoroSub County to investigate the access to family planning services by women with disabilities.

1.2 Problem statement

There are still challenges in accessingfamily planning services by women with disability. However, women with disability, like all people, should enjoy human rights that are secured by laws and policies in Uganda for example the PWD Act (2006) which stipulates that the government shall provide special health services required by WWDs including providing access to reproductive health services which are relevant to women with disabilities.

Despite, the Government of Uganda, being a signatory to international laws and policies (such as the CRPD which declares that states parties need to ensure that persons with disabilities can decide freely and responsibly on the number and spacing of their children while retaining their fertility on an equal basis with others, Article 23) to ensure that women with disability enjoy their rights, there is still low number of women with disabilities accessing family planning in Mukongoro health III and II.Thus, the study was carried out in Mukongoro Sub County to assess the access to family planning services by women with disabilities.

1.3 Purpose of the study

The main purpose of the study was to investigate the access to family planning services by women with disabilities in Mukongoro Sub County, Kumi District.

1.4 Objectives

1. To find out the factors that influence the access tofamily planning services by women with disability in Mukongoro Sub County, Kumi District.
2. To assess the challenges faced by women with disabilities in accessing family planning services in Mukongoro Sub County, Kumi District.
3. To suggest strategies to improve family planning services offered to women with disabilities in Mukongoro Sub County, Kumi District.

1.5 Research questions

1. What factors influence the access to family planning services among women with disability in Mukongoro Sub County, Kumi District?
2. What challenges are encountered by women with disabilities in accessing family planning services in Mukongoro Sub County, Kumi District?
3. What strategies can be adopted to improve family planning services offered to women with disabilities in Mukongoro Sub County, Kumi District?

1.6 Scope of study

1.6.1 Content scope

The study investigated the accessibility of family planning services by women with disabilities. Specifically, the study identified factors thatinfluence the access to family planning services among women with disability, challenges faced by women with disabilities in accessing family planning services and suggested strategies to improve family planning services offered to women with disabilities.

1.6.2 Geographical scope

The study was carried out in Mukongoro Sub County, Kumi District. This was due to the easy access to the area. The study was carried out in four parishes out of 16parishes in Mukongoro sub county and these included; Agaria, Akadot, Kachaboiand Mukongoro.

1.6.3 Time scope

The study was carried out for a period of four months in 2017.

1.7 Significance of the study

To policy makers, the study will provide relevant information for them to put more effort on improving on the methods of family planning and increase their accessibility to women with disabilities.

To health care providers, the study will enable them realize the factors that hinder the accessibility of family planning services by women with disabilities.

NGOs will benefit from the findings of this study since it will provide them with relevant information that they can use to act upon improving health of women with disabilities.

Women with disabilities will be availed with information on what family planning services they can use.

The study will be relevant to the scholars in that it will add more literature base on the existing body of knowledge.

1.8 Limitation of the study

Financial resources were inadequate since the University was not in position to facilitate the resources to the researcher for typing, binding and other expenses like transport fees when using the area of investigation.However, the researcher obtained fund from family members i.e. parents and guardians plus friends to solve the problem of limited financial resources.

Unrealistic expectation from the respondents is also another problem the researcher faced. It was argued that very many people expected too much from researcher for example money etc, yet the researcher is totally student who does not have money. However, the researcher used the local leaders to convince the community members that researcher was here to gather information on the given problem which will help  in future use but don’t expect many things like money from her.

Non-participation of some respondents (non-respondents errors), the researcher anticipates non-participation from some of the respondents. The researcher however, will try all the means possible to convince the respondents by assuring them that information will be confidential and purely academic, and not for any kind of action against them.

CHAPTER TWO

REVIEW OF RELATED LITERATURE

2.0 Introduction

This chapter presents review of related literature by other researchers and educationalists on topic about the access to family planning services by women with disabilities. The related literature presented under this topic is based on the three of objectives.

2.1 Factors that Influence Women with disabilities from Accessing Family Planning services in Uganda

According to Byarugaba (2009), Family Planning services are available both in private clinics and government health centres but there are some challenges faced by women with disabilities in accessing it, hence some reasons for low turn up of women with disabilities for services like they have worries of the side effects. For example injecta-plan method, many women with disabilities suffer the consequences of chronic bleeding without ceasing or at times it cause obesity. Other beliefs such as religious affiliation for example Catholic have a negative attitude about Family Planning methods; they don’t use it but prefer bearing children till it is no more. The duration of the methods such Norplant method which after insertion, lasts for 5 years to expire and another one like Copper T-coil some expire after 10 years. Hence hinders the turn up of women with disabilities for services. Ignorance of both spouses is a challenge to access the service in the area.

Byarugaba further noted that some health centres have the services but they do lack skilled personnel for example, he once missed clients in his private clinic (Kireka Medical Centre), who had come for Norplant method and was away and all the nurses were unskilled to take on the procedure. However, perceptions of both community level and individual level quality could provide key insights for developing effective and efficient Family Planning programs.

World Health Organization (WHO, 2009) further stated that, reasons for unmet need are many and they are attributed to limited services and supplies, fear for social disapproval of partner’s opposition pose formidable barriers, worries of side effects and health concerns hold some people back, others lack knowledge about contraceptive options and their use.

In the traditional understanding, Family Planning was not an issue to be considered because a large number of children were seen as a blessing, security for the future and guarantee for continuity of lineage and clan. The more children a man had, the more he was respected and the more children a woman had, the more she was valued in the clan. If she is married to therefore the introduction of the new Family Planning practices was concerned as a plan to stop women with disabilities from bearing children which is interference to the plan of God as seen in some Kiganda expression, like “Muzaalemwale” meaning you can produce as many as possible.

Kumi district health service report (2010), pointed out that, in Uganda, though there is an effort to provide this Reproductive Health Programme, it is very weak because of the challenges it is still facing for example, the stereo type thinking and ignorance among the local people. Most women with disabilities have stereo types which have been constructed by the society in which they live. For example, they meet so many challenges and most often men, they are also ignorant of the importance of reducing Family sizes through Family Planning. This problem is worse when it comes to MukongoroSub County whereby women with disabilities are always in great fear to take up the services because they feel that they will get serious complication in the future. This problem leads to under development and the low socio-economic development of MukongoroSub County.

According to International Conference on Family Planning (2009), an estimated 41% of Ugandan Women with disabilities who would like to stop having children have no access to Family Planning Services. However, this has resulted into unintended pregnancies and bigger families. It further stated that in Uganda a woman will give birth to an average of 6 – 7 children in her life time. Such large families in developing countries are linked to poverty, poor nutrition, low education levels and even health dangers, for example a woman is at risk of maternal mortality increase with each birth.

According to the Uganda National Family Planning strategy (2005 – 2010), March, 2005, Development by the Ministry of Health over two thirds of Ugandan women with disabilities and men say that they want to space children or limit children bearing (71% of women with disabilities and 67% of men). However, they face many challenges which include the social, cultural, religious values which have strong influence on reproductive choices for women with disabilities in Uganda. Early frequent child bearing and large Family size reflect long standing societal norms among most segments of population.

According to the 1980’s law, further controversy emerge when social and religious conservatives began alleging that the very availability of Family Planning services promoted promiscuity and abortion, and that the provision of confidential services to teenagers encouraged the disrespect of parental authority (The Development Office of the Kenya Catholic Secretariat). The Catholic Church and some societies have always preached against use of Family Planning Services saying that it’s a sin and against Gods command that is to say “Go, subdue and fill the world”. These controversies initiated a big challenge to the delivery of Family Planning Services in most societies for example Mukongoro Sub-county where so many women with disabilities have bared   children as commended by the churches, their spouses, among others.

According to the MoH, (2009), the levels of understanding and acceptance of Family Planning Services is also a big challenge. According to the study of working women with disabilities and non-working women with disabilities in Bargladesh 59% of the working group who had acquired some education were employing contraceptives compared to 41.4% of non working group who had acquired less or no education at all. 45.1% of the non working group had never used contraceptives compared to 23.9% of working women with disabilities. 55.9% of the working women with disabilities participated in Family Planning decision making with their spouses as compared to 23.5% of the non workingwomen with disabilities. The level of understanding here influences acceptance that is to say the more people understanding the importance of Family Planning, the more they will be lured to adopt. In Mukongoro Sub-county, the level of understanding of Family Planning services is still very low and therefore acceptance to embrace it is still low.

The rising costs of some contraceptives and of state of the art medical technology complicated the delivery of Family Planning Services to the existing and at the same time, Family Planning Services (methods are inadequate). Also contributed to inaccessibility of Family Planning services by women with disabilities in Mukongoro Sub County. They’re just few (2 – 3) methods only in per Health centre out of different methods available in hospitals.

According to the Family Planning Global Handbook for providers (2008), some women with disabilities find it very hard to discuss their desires to use condoms or any other method of Family Planning. (To access the Family Planning Services). Men give different reasons why they           stop their women with disabilities to access Family Planning Services, therefore you find out that women with disabilities with low bargaining power end up being oppressed and exploited by their partners through convincing them to access Family Planning methods. This situation can be clearly seen in Mukongorosub county where women with disabilities often have inferiority complex with in them and always feel ashamed to talk about it hence leaving the decision to be made by men.

African Union Commission (2009), states that high fertility is directly related to child and early marriages. Other factors related to this are unmet needs for contraceptive services, lack of sexuality information and lack of Family Planning Services for the prevention of pregnancy. All these conditions make birth spacing difficult to manage and increase incidents of unwanted pregnancies. Hence may lead to MMR is IMR.

According to Ministry of Health, (Dr. Stephen O. Malinga), in the second National Health Policy of promoting people’s health to enhance socio-economic development Speech (July, 2010), he said health resources such infrastructure has grown from 1979 in 2004 to 2301 in 2010. However, inequity exists in the distribution of health facilities and most facilities are in a state of despair, inadequate transport is a major limitation especially newly created districts. He further said that rehabilitation of buildings and maintenance of medical equipment is not regularly done. Other challenges are shortage of basic medical equipment accommodation of staff, and transportation remains major challenges. He further stated that inadequate financial and human resources, only 30% of the essential medicines and health supplies required for the basic packages are provided for in the framework for medium expenditure.

This has increased dependency on the private sector and therefore most patients often find that medicines are not affordable. For that reasons, many mothers mentioned that the few Family Planning methods which are cheap have bad side effects and other best alternatives are two expensive for them to use.

2.2Challenges encountered by women with disabilities in accessing family planning services

Women with disabilities often encounter physical, attitudinal, and policy barriers in seeking to meet their health care needs. Physical barriers include the unavailability of transportation; stairs and narrow doorways into clinics, doctors’ offices, etc.; written information, such as intake forms and patient education materials, not available in alternative formats (i.e. Braille, tape, large print); high examining tables which prevent transfer by women using wheelchairs; mammogram machines which require patients to stand; and lack of personal assistance to women who need it during clinic visits. These barriers may be remedied through accessibility planning and modifications; availability of written materials in alternative formats; obtaining “adaptable” equipment such as tables which can be raised and lowered, and provision of trained, appropriate assistance in mobility and other personal care needs.

Higher rates of poverty and housing stress and lower levels of education and employment are experienced by women with disabilities, compared with men with disabilities, or women without disabilities. Women living with disabilities are more likely than those without disabilities to experience social and economic disadvantage and poverty. Contributing factors include lower levels of education and employment (46.9% compared with 59.9% for men with disabilities and 64.9% for women without disabilities). Lower income contributes to significantly more housing stress, food insecurity, poorer nutrition and higher rates of obesity and chronic disease (Beer and Faulkner, 2009).

Policy barriers may be imposed by hospital or clinic regulations; by insurance companies; or by other third-party payers such as Medicare and Medicaid. Some insurance providers discriminate against individuals with disabilities, by barring coverage for “preexisting conditions,” or by cost-capping services which may be essential for managing a disability. Another major barrier is that some necessary services — such as in-home personal assistance services, prescription medications, durable medical equipment, holistic health services, assistive technology, preventive care, certain therapies, or abortion services — may not be covered by private or government-funded insurance plans. Government and private policies may also have an “institutional bias” — i.e., they offer services primarily in nursing homes, rehabilitation hospitals, and other large long-term care facilities; but not in the disabled woman’s own home, where she can be part of her family and community. Ending this institutional bias, and securing more support for independent living (IL) and community-based rehabilitation (CBR), is a major focus of disability-rights advocates in many countries (Laura, 2000).

Lower levels of health knowledge among some women with disabilities may contribute to delays in obtaining treatment and lower participation in health promotion and prevention services. Lower levels of literacy and education also impact directly on health. It results in a poorer understanding of the way the body functions and the relationship between prevention and disease and early access to health services for treatment. This may be exacerbated by psychological factors e.g. low self-esteem, depression; cognition problems such as memory and organizational skills (Broughton & Thomson, 2000).

Health information is not provided in a range of accessible formats for women with disabilities. Proactive development of health information is needed using a range of formats (including print and emerging electronic technologies). The delivery of education / information must be paced to match the specific disability needs women have. Education needs to be delivered and repeated, if necessary, through all stages of women‘s lives. Women with disability need to be involved in the development of these resources (Burgen, 2010).

Primary carers and health care providers who do not see beyond the woman‘s disability, who fail to recognise her holistic health needs, or who do not adjust their care and services to meet those needs, exclude women from mainstream health services. Many people with disabilities rely on carers – family members and service providers – for intimate physical care as well as access to services. Women with these needs are in a particularly vulnerable position [Noonan and Heller, 2002]. De-institutionalization has meant that people with disability now have a physical presence in the community, however, access to externally provided support and opportunities is essential and the low expectations of others, including health service providers, can act as significant barriers.

Attitudinal barriers arise from negative societal beliefs about the worth of women with disabilities. These barriers may include the disrespect and/or discomfort of medical professionals; unwillingness to communicate with women whose speech or hearing is impaired; professionals’ lack of knowledge about particular disabling conditions; and focus upon the disability, to the exclusion of other health needs. Some practitioners wrongly believe that disability inevitably diminishes a disabled woman’s value or quality of life. They may therefore fail to explore or offer all treatment options, assuming instead that death is preferable to living with a significant disability. Doctors, nurses, and other clinic and hospital staff people may benefit from training and education in these areas. In addition, women with disabilities should be fully informed about their rights as patients (de Kretser, 2010).

Gender based violence is experienced by women with disabilities up to two to three times more often than women without disabilities, with lower rates of access to justice and health systems. High levels of dependency, cognitive and communication disabilities place women at higher risk of violence. Perpetrators are often known to women, they can be carers, residents or other providers of assistance. They may also be partners or family members [Murray and Powell, 2008]. In addition, Healey (2008) women with high degrees of physical impairment are more likely to perceive themselves as sexually inadequate and unattractive than women with mild impairment‘.

Access to health promotion initiatives, including screening is as important for women with disabilities as for women in general. However these programs, including those for mammography and Pap screening, are not currently meeting their service obligations for this group of women. This places women with disabilities at higher risk of delayed diagnoses of breast or cervical cancer [Carlson, 2002].

International, national and state policies enshrine the rights to health, freedom, respect, equality and dignity. However, discrimination on the basis of disability was the most common cause of complaint. These principles need to be translated into equitable and accessible services. Significant practical, attitudinal and organisational barriers to inclusive services for women with disabilities remain. Women with disabilities experience higher levels of disadvantage and discrimination, much of which is based in a lack of knowledge and sensitivity about disability among health care providers; the physical layout and paucity of appropriate equipment in health services; and a lack of appropriate policies, guidelines and information resources [Barr, 2008].

2.3 Strategies being used to Improve Access to Family Planning Services in Uganda

The main objective of strategy is to campaign is to accelerate the availability and use of university accessible quality health services including those related to sexual and reproductive health which are critical for reduction of maternal mortality. According to African Union Commissioner for Social Affairs AdrBience .P. Gawanas for the 4^th session of the conference of African Union Minister of Health (7^th May, 2009) said that the focus is not to develop more strategies and plans but rather to ensure co-ordination and the effective implementation of existing plans and strategies. He further stated that all efforts should be done to save the lives of women with disabilities who should not die while giving life. And also it is essential to establish accountability, of maternal, infant and child mortality and it’s the same happening Mukongoro sub county where the health sector strategic plan is trying all its best to promote people’s health.

According to Charves and German Rodnguez (2005), there is a strong understanding interest within population policy and Family Planning proof   circle in the potential impact on contraceptive behavior and reproductive preferences of mass media messages that try to inform and motivate people on the methods and advantages of regulating fertility these messages have taken many forms ranging from radio program and television designed to persuade women with disabilities on the advantages of smaller families. The same has also taken route in Mukongoro Sub County where mass media like the local radio stations have been used to hold talk shows in order to sensitize the people on the advantages of smaller families.

Tarletonand Ward (2007) states that removing cost as barrier to access of services through providing supports such as the free, accessible transport.

According to Carlson[2002] argues that more accessible health services require physical access including ramps, clear signage to assist navigating the environment, the building and the office, disability accessible facilities and examination table.

Parish (2006) argues that there is need for effective communication, informed and competent staff who are knowledgeable about the additional burdens that women with disabilities may face. Talking directly to the woman and where women do not have the capacity involving a designated family member or carer.

Additional time and resources, including flexible, longer and multiple appointments if necessary to gain a full understanding of the information and health needs of women, particularly those with intellectual and communication disabilities (Llewellyn, 2003).

Acknowledging the important role of carers, family and friends, but not to the exclusion of primary decision-making resting with women themselves (except if this not possible).

A holistic approach to health care for women with disabilities requires services that recognise women‘s broader health needs beyond those related to their specific impairment, and the recognition of their rights to live full sexual and reproductive lives.

Further research about the barriers faced by women with disabilities in accessing health services. This includes data collection describing women‘s use of health services and research protocols that mandate the inclusion of women with disabilities.

Professional development for health service providers that addresses attitudes and prior assumptions. Gaps in knowledge and skills have been shown to result in a reluctance to provide health services to women with disabilities. Evidence demonstrates that training by women with disabilities is most effective in improving knowledge and skills.

Health information which is clear and concise with appropriate health messages about treatment, screening and lifestyle issues. Multimedia methods of disseminating health information are required. Use of reminders, recall systems or other mechanisms to ensure women receive the necessary information and feel included as part of the program are also required.

Multi-disciplinary teams and cooperation between services, practice nurses, social workers, disability workers and others can facilitate continuity of care and advocacy. This may require the development of inter-agency policies and procedures such as domestic violence, sexual assault, justice, housing and health services (treatment and preventative), which respect the privacy of clients.

Mbonye (2008) stated that repeated dissemination of information will have more of an impact than random images and massages such repeated massages on public transport billboard, television, radios may act to reinforce such behavior change. Whereby reinforcement is the key element of behavior change and maintenance. He further gives solutions to that, to avoid unwanted pregnancy if you are sexually active, seek Family Planning Services and counseling, comprehensive reproductive health services and also increased awareness about unwanted pregnancy and Family Planning Services.

In conclusion, the literature reviewed above shows both the modern and traditional understanding of Family Planning. It also reviewed literature related to the importance of Family Planning, challenges facing the use of Family Planning and the strategies being used to promote the knowledge of Family Planning. This reviewed literature therefore has been compared with the situation on ground in MukongoroSub County.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter presents about the research design, sampling procedures, sample size, data collection instruments used, procedure and data analysis.

3.1 Research Design

Accordingly, Mouton and Prozesky (2005), a research design is ‘a plan or blue print of how a researcher intends to conduct a study’’. This involves plans for data collection, the instrument for gathering information, how gathered information would be processed and analyzed to give meaning to research finding. The study used a cross-section research design. Qualitative method was used to acquire information on the study under investigation; this enabled the researcher to gather a wide range of information required by the objectives of the study.  Hennik et al., (2007) qualitative approach is an approach that allows a researcher to examine peoples experience in detail, by using a specific set of research methods such as interviews, observation, focus group discussion, content analysis. It also allows a researcher to identify issues from the perspective of his participants, and understand the meanings and interpretations that they give.

3.2 Area of Study

The study was carried out in Mukongoro Sub County, Kumi District. This is due to the easy access to the area. The study was carried out in four parishes out of 16parishes in Mukongoro sub county and these included; Agaria, Akadot, Kachaboi and Mukongoro.

3.3 Target Population

According to Baron, (2011), population constitutes people-individuals, organizations, groups, communities or other units that provide information for the study. The population included: all women with disabilities, men from 18-45years (who are husbands to WWDs) and health workers (health in charge and 3 midwives) within Mukongoro Sub County.

3.4 Sample size

A sample size is a part of a population methodologically selected for purposes of drawing a conclusion about a population and its characteristics (Allan, 1962). In this case therefore, the sample size was made of 18 respondents.

Table 3.1: Sample size

Women with disabilities were involved in the study because they were the main culprits; LC1 Chairperson was selected because he/she has concern in affairs in the community. Men were selected because they are involved in family affairs such as deciding on whether to use family planning. Health workers were selected because they are aware of the health issues affecting women with disabilities.

3.5 Sampling Procedure or Technique

William M.K Trochim, (2006) defines sampling as the process of selecting units (for example, people, and organizations) from a population of interest so that by studying the sample the researcher may fairly generalize findings back to the population from which they it was chosen; when choosing a sample there are two ways such as; random and non-random sampling. For the case of this study, the researcher used non-random sampling using purposive and snowball sampling techniques.

Saunders et al, (2012) purposive sampling (also known as judgmental, selective or subjective) is a sampling technique in which a researcher relies on his or her own judgment when choosing members of population to participate in the study. It’s convenient enough because of cost and time effectiveness (Saunders et al, 2012). Purposive sampling was used in selecting knowledgeable participants (information rich participants). Participants are usually selected based on pre-determined criteria (inclusion criteria). This technique was used to health workers (health in charge and mid-wife).

Ashley Crossman, (2016) a snowball sample is a non-probability sampling technique that is appropriate to use in research when the member of a population are difficult to locate. A snowball sample is one in which the researcher collects data on a few participants of the target population he can locate, then asks those participants to provide information needed to locate other members of that population whom they know. This was only used in selecting WWDs; the researcher intended to select one WWD well known to her in the area of study and after would lead her to other colleagues from other parishes. This was done mainly to exploit the knowledge of the WWD, his/her colleagues and to save time.

3.6 Data collection and instruments

3.6.1 Interviews

Cohon and Manioh (1989) qualify interview to be a conservation initiated by the interviewer for specific purpose of obtaining research relevant information and focuses on content specified by research objectives of specific description. Semi-structured interviews were used to generate additional information from the respondents. This method is chosen because it helps in the collection of more data as it allows the interaction of both the researcher and the respondents. It is cheap and does not waste much time.

An interview guide was used for the in-depth interviews with health workers. Unstructured interview guide was developed based on the objectives. They were designed in English language.  It was used because it promotes greater depth of response which is not possible through other means and it allows the researcher to get information concerning feelings, attitudes in relation to research questions. It is also cheap and easy to administer.

3.6.2 Informal observation

Informal observation is usually done when the researcher has little knowledge of a population and its behaviour. The main purpose of informal observation is to create hypotheses to be tested later, in a survey or using for a survey. This method involves watching and listening to people.

Under this method, the researcher included in her observation checklist issues such as; health services available, nature of beds, physical access and also the expertise of the health workers.

3.6.3 Focus group discussions

Focus group discussions were used due to the capacity of the short period of time. Focus group discussions were used on WWDs.  This will enable the WWDs to debate and discuss on the study directed by the few questions set and followed. The instrument to be used is the focus group discussion guide where questions was set and followed. The study involved 3 focus group discussions (in groups of 5 WWDs) and took about 30 minutes each.

3.7 Data Collection Procedure/ethical consideration

An introduction letter was obtained by the researcher from the university at the Department where it was used to introduce the researcher to the heads of the community where the study took place. The introductory letter was used to seek for permission for the researcher to carry out research in the area. The researcher collected data upon seeking respondents’ consent after revealing the type of information needed and the purpose to avoid potential concealment of vital information. The researcher also maintained confidentiality of respondents’ information; and reported the true findings of the study without any bias.

3.8 Data analysis

Data was qualitatively analyzed using quick impression which was done by summarizing the key findings; content analysis included recording and reviewing of the recorded information in order to understand data better and on a broader context, thematic analysis was also used. Here the researcher identified relevant information and classify it into relevant topics.  These techniques were exploratory in nature since they were highlighted, sorted, scrutinized and reviewed data better to ensure accuracy in the data collected.

CHAPTER FOUR

PRESENTATION AND DATA ANALYSIS

4.1 Introduction

The purpose of the study was to investigate the access to Family Planning Services by women with disabilities in Mukongoro Sub County, Kumi district. This chapter therefore presents the findings of the study which are organized and analyzed according to the objectives of the study. The information in each table is described at the end of the table.

4.2 Background Information of the Respondents

This section presents the background on the studied characteristics of respondents used for the study. A total of 18 respondents participated in the study.

Table 1: Background information of the respondents

Respondents were asked information relating to their age and the majority revealed that they were between the age of 18-25 years, others claimed that they were between 25-30 years of age and a few claimed that they were above 30 years of age.

Relating to the education background, the majority of the respondents were “O” leavers, very few had made it to degree level, A” level certificate level and primary level, regarding the religious affiliation, most of the respondents were Muslims, some of them were Catholics and a few were protestants, regarding sex, most of the respondents were females and only few were men. Finally, respondents were asked to give information about their occupation and the majority were not working while a few were working.

4.3 Factors influencing access to family planning among women with disabilities

Research objective one aimed at finding out factors that influence access to family planning services by women with disabilities and the responses are reflected below.

Table 2: People who had Knowledge and used Family Planning Services.

Table 2 above, (18) respondents knew about family planning, 7 respondents understood it as ways taken to space children, (4) respondents looked it as ways used not to have unwanted pregnancies while 7 respondents understand it as the agreement between spouses on the number of children they want to have and stick by that through the use of family planning.

From the table above,13 respondents have ever used family planning services, while 5 said that they know of it but have never used any method. In fact one lady said that, “ipupi iso nu ikamanara kede famile pulanningi, id ikoto aitoswam konye isio idumunit nu ikamunitosi famile pulaningi otoma aidulesi”, meaning that they know about it and they would like to use it only that they lack proper explanation from the health workers.

When the student asked the respondents about how they acquired the knowledge about family planning services they had this to say as seen in table 4 below;

Table 3: Ways in which people acquire knowledge on Family Planning Services.

Majority of respondents (8) agreed that they acquired knowledge on family planning services through workshops, 5 respondents got information from friends or peer groups, 2 said that they got the knowledge through mass media that is radios, televisions, news papers among others. 1 respondent said that Straight talk programmes and 2 agreed that skits and drama was their source of information.

One respondent was quoted saying; “abu apaperika olimoki eong nu ikamanara kede famile pulaningiewanyu ngesi ebe awurieri eong atipet atipet, ido obu ngesi inyamaki eong adekis” meaning that; she was not spacing her children and her friend  got concerned and told her about family planning and in fact she escorted me to my first visit the health center.

The researcher further asked the respondents the factors that hinder women with disabilities from accessing family planning services and the responses are reflected in the table below.

Table 4: Factors that influence women with disabilities from accessing family planning services

From table 4above, majority of respondents said sensitization and long term effects, followed by attitude about western methods, illiteracy, availability of facilities (methods) and skilled personnel each was supported by 3 respondents respectively. Respondents stated that some women tend to forget the returning date back for another dose because they do not know how to read and write, Factors like fear of long term effects like condoms they think it will rupture into a woman’s vargina, and end up being taken to theatre for operation.

Key informant interviews with health care providers yielded the same sentiments, suggesting that negative health workers’ attitude is a major barrier to WWDs access to family planning services.

Others like Pillplan, there is a fear of deformed children after birth, intra-uterine device (coil) will tear the cervix which will result into removal of uterus and among others. After its use one lady said that he was told by her husband that

“mam eong akoto ijene nu ikamunitos famile pulaningi” meaning that he didn’t want to know anything about Family Planning Services and distance from home to health centers and supported by 2 respondents, religion and infrastructure available were supported by 1 respondent each.

On distance to health centers;

‘‘………WWDs face a lot of challenges here because as a Sub County, we do not have H/Cs in every parish as compared to some S/Cs in the district with H/Cs. And therefore, these WWDs have trouble to go there and come back’’ (key informant)

Reaction of spouses was the least supported factor as it was supported by 1 respondent, the researcher found out that most of the people had knowledge about Family Planning Services and they cannot use them because of the reaction of spouses (husbands) towards it, husbands do not appreciate very much the family planning services by the government, but they have different perception.

Respondents also argued that the infrastructure available do not favour WWDs in accessing family planning services. For example there is lack of ramps in Agaria health centre II which limit the movement of WWDs.

‘‘almost all the health facilities in our amidst have steps and therefore moving upwards to the rooms is very hard for us. For example qualified staff, it is not easy for us to access….’’ (WWDs).

‘‘I would have liked to accompany my wife to access the family planning services, but it is just too hard for me to climb steps. Even when health workers are to assist, they usually ignore us (men). May be we are not expected to go there….’’

‘‘Even if you have money, if you are an expecting woman who has physical disabilities particularly us with hip joints or round legs, you may never give birth from the raised labor bed which is safest place to deliver from. Climbing there is not easy…’’

One respondent made a comment stating what a husband said when she raised an issue of Family Planning Services said that, “If you know that you’re wife make sure never to go for Family Planning Services and not to take my children for immunization.”

4.4 Challenges encountered by women with disabilities in accessing family planning services

Research objective two aimed at determining challenges encountered by women with disabilities in accessing family planning services and the responses are reflected below.

Table 5: Challenges encountered by women with disabilities in accessing family planning services

From table 5, negative attitude about western methods and lack of sensitization about the services were supported by 3 respondents respectively. Illiteracy levels were supported by 3 respondents; they tend to forget the returning date back for another dose because they do not know how to read and write, Factors like fear of long term effects like condoms they think it will rupture into a woman’s vargina, and end up being taken to theatre for operation.

Others like Pillplan, there is a fear of deformed children after birth, intra-uterine device (coil) will tear the cervix which will result into removal of uterus and among others. After its use one lady said that he was told by her husband that

“mam eong akoto ijene nu ikamunitos famile pulaningi” meaning that he didn’t want to know anything about Family Planning Services and lack of skilled personnel were supported by 1 respondent. Inadequate  facilities (methods) was supported by 2 respondents, 1 respondents  supported religion as a factor, poor infrastructure for disabled and  long distance from home to health center to assess family planning services were supported by 1 and 2 respondents respectively.

Reaction of spouses was the least supported factor as it was supported by 1 respondent, the researcher found out that most of the people had knowledge about Family Planning Services and they cannot use them because of the reaction of spouses (husbands) towards it, husbands do not appreciate very much the family planning services by the government, but they have different perception.

One respondent made a comment stating what a husband said when she raised an issue of Family Planning Services said that, “If you know that you’re wife make sure never to go for Family Planning Services and not to take my children for immunization.”

4.5 Strategies to improve access to family planning services by women with disabilities

The study aimed at finding out the strategies to improve the accessibility of family planning services by women with disabilities and the responses are reflected in the table below.

Table 6: Strategies to improve family planning services

Findings reveal that, majority of respondents (5)  suggest distribution of contraceptives freely, followed by  health education talks and public sensitization with 4 respondents, provision of adequate health facilities with 3 respondents, 3 respondents  agreed with guidance and counseling, effective follow up and monitoring was supported by 1 respondents, conducive environment for women with disabilities with disabilities  and involvement of women with disabilities in leadership scored 1 respectively.

Majority of respondents agreed that the contraceptives should be given out freely because most of these rural women with disabilities don’t have financial power to buy thus hindering their use.

One respondent said that; “ejok famile pulaningi konye ebeyi ededenge” meaning that; family planning is good but expensive yet we don’t have money.

Other respondents suggested that health education talks and public sensitization should be improved to help women with disabilities to get informed and get rid of the myths they have about family planning services.

As one respondent said that; “elimokiten eong ebe etoswam eong famile pulaningi awuniei eong iduwe lu erasi ingwasikii nesi mam eong etwasiama famile pulaningi”. Meaning that; I was told that if you use family planning you give birth the lame children, that is why I don’t use them.

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

This chapter presents a discussion on the major findings of the study, conclusions and gives recommendations. This was done according to objectives as earlier.

5.1.1 Discussion of Results

5.1.1 Factors influence access to family planning services by women with disabilities

In this study, most of the women with disabilities showed distance from home to Health centers and sensitization and long term effects were the major factors that influence accessibility to family planning services. Many WWDs have found it difficult to access health care services due to poor roads (rough terrain), lack of sidewalks and ramps that has hindered the use of wheel chairs by the crippled and crawling WWDs. This is in line with Byaruhanga (2009) who stated that family planning services are available both in Private Clinics and Government Health Centres, but there is a poor low turn up of women with disabilities for services. He further stated that majority have a fear of the side effects of Family Planning methods which are along term and short term effects all these comes as a result of lack sensitization about the services. This also goes in line with what some mother say if they could be taught first and understand what is all about Family Planning Services

Another finding showed that attitude about western Methods was another major factor that influences the accessibility of family planning services. This finding is supported by District Health Services (DHS, 1995) which states that fertility may indicate a need for Family Planning methods to be used but most women with disabilities have negative attitudes derived from limited knowledge misconception, and myth surrounding the methods. Hence it has prevented men and women with disabilities from making decision to adopt the services others include social norms for fertility, child bearing and gender images also affects the attitude towards the Family Planning Services.

5.1.2 Challenges encountered by women with disabilities in accessing family planning services

In this study, lack of sensitization was the major challenge encountered by women with disabilities in accessing family planning services. Lack of sensitization leads to many hindrances in the accessing of family planning services as people will have no knowledge of the benefits of family planning services and side effects. In the end, WWDs may be discouraged by the experiences of others who have used some of the family planning methods thus, may fear to use it. These findings are in agreement with Byarugaba (2009) who argued that sensitization about the existing health services is fundamental to increased accessibility.

Another finding was that poor infrastructure is another challenge that affects accessibility of family planning services by WWDs. It’s not surprising that WWDs as well as the whole community crowd in the H/C III. This situation is however different from the GOU (2004) and MOH (1996) that emphasized that all districts should have H/C at all levels and equipped with relevant services. No wonder long queues, pressure on the health workers leading to abuse of patients among others are some difficulties encountered by WWDs and the general community.

Another finding was that the aspect of poverty among WWDs has greatly hampered their access to family planning services. Most WWDs do not have economic activities that can help them earn money to meet the minimal costs in the H/C. This study is in line with Tonny (2007) that states that most of the WWDs are poor and have no money to afford the special treatment and care from private clinics since most of the rural H/Cs do not have medicine to work on certain disabilities.

5.1.3 Strategies to Promote Access to Family Planning Services by Women with disabilities in Mukongoro Sub County

In this study, distribution of contraceptives freely is the major strategy that can promote access to family planning services by women with disabilities. This is in line with, African Union Commissioner for Social Affairs Adr Bience .P. Gawanas for the 4^th session of the conference of African Union Minister of Health (7^th May, 2009) said that the focus is not to develop more strategies and plans but rather to ensure co-ordination and the effective implementation of existing plans and strategies. He further stated that all efforts should be done to save the lives of women with disabilities who should not die while giving life. And also it is essential to establish accountability, of maternal, infant and child mortality and it’s the same happening Mukongoro Sub County where the health sector strategic plan is trying all its best to promote people’s health by distributing free contraceptives.

Another finding revealed that health education talks and public sensitization is another major strategy that can be employed to improve accessibility to family planning services. This is in line with Charves and Rodnguez (2005) who argued that there is a strong understanding interest within population policy and Family Planning proof circle in the potential impact on contraceptive behavior and reproductive preferences of mass media messages that try to inform and motivate people on the methods and advantages of regulating fertility these messages have taken many forms ranging from radio program and television designed to persuade women with disabilities on the advantages of smaller families.

Another strategy revealed is the construction of health centres in all parishes. This can help reduce the burden of long distance, congestion, and easy access to health care services, when services are far it de-motivates the PWDs and other people seeking health care services. Another study by the GOU (2004) and MOH (1996) pointed that all districts should have H/Cs offering equitable affordable health care services at all levels. This means that even these parishes are subject to this indication and it’s the only way the researcher seems to see their difficulties being solved.

5.2Conclusion

Accessibility to family planning services has played a big role in improving the livelihoods of the people in Mukongoro Sub County. However, access to family planning services is influenced by sensitization and long term effects, attitude towards western methods, distance to health centres. There is great need for more awareness raising about family planning services in all areas in the district and strengthening family planning services would also help Uganda achieve millennium Development Goal (MDG) to improving maternal health and infant health.

5.3 Recommendations

The researcher recommends the following:

The Ministry of Education and Sports should ensure the recruitment and training of Special Needs about Family Planning Services to be distributed to all districts in different Health Centers to deal with People with Disabilities and also help enable them gain the required skills.

Some local people at the grassroots should be trained to volunteer as promoters to enhance the services and regularly issue public statements supportive of Family Planning to mobilize both political and people’s support. Hold meetings to harmonize and rationalize implementation of policies with stakeholders involved in Public Health services.

Ensure that Family Planning is a key component of all National strategies, including the National Development Plan. Thus by increasing allocations for contraceptive in National and district health budgets.

Increase involvement of the private sector in the provision of Public Health Services. They should be invited to Ministry of Health/District training and workshops benefits from supportive supervision and have feed on their activities the existence of illegal/non immersed private sector service providers must also be addressed. It is difficult at this time to control the price charged by private sector by Public Health service providers.

Improve use of existing policies and guidelines by increasing number of copies, improving on distribution methods and implementing a system of resupply that ensures availability support supervision should be used to check compliance to guide lines as well as drawing attention to use existing guidelines.

Ensure that Family Planning is a key component of all national strategies, including the National Development Plan thus by increasing allocation for contraceptive in National and District Health Budgets.

The government through the Ministry of Health should increase funding and investment in the population control through family planning provision. Between 2011 – 20015, if the government increases investment in Family Planning Services to US$ 10 million meeting the need for Family Planning substantial savings could be realized.

Guidance and counseling services should be conducted regularly to both mothers and community. And intensify advocacy and awareness raising at all levels for Public Health services.

5.4 Areas of Further Research

The research recommends the following areas for further research;

The role of sensitization and awareness in changing people’s attitudes towards the use of Family Planning services.

REFERENCES

African Population and Health Research Center (2001). Contraceptive Use Dynamics in Kenya: Further Analysis of Demographic and Health Survey (DHS) Data. Macro International Inc. Calverton, Maryland USA

Bankole, K.C. (2006). Special Issues in Contraception: Caring for Women with Disabilities. J Midwifery Women’s Health. Elsevier Science, Inc.

Broughton, N. K., and Thomson, L. (2000). “Reasons for Not Using Contraceptives: An International Comparison” Studies in Family Planning 15 (2): 92.

Burgen, A. (2010). Components of Unexpected Fertility Decline in Sub-Saharan Africa. Demographic and Health Surveys Analytical Reports no. 5.

Byarugaba, M. (2009). A Global Handbook for Providers, A World Health Organization Family Planning Cornerstone.

Family Planning Association of Uganda (2007), Golden Jubilee, 50 Years Moving Generations to Reproductive Health Rights.

Laura, J (2000). A framework for analyzing the proximate determinants of fertility” Population and Development Review.

Ministry of Health (2005); National Family Planning Advocacy Strategy 2005 – 2010.

Ministry of Health (2010). In the second National Health Policy of promoting people’s health to enhance socio-economic development Speech.

Mosha, H. (2015). Social economic influences on health rehabilitation of Physically Handicapped Rural Children: A case study in Kayunga S/C, Mukono, MUK press

Munene, R. W. (2012). Contraceptive Use among Women with Disability in Kenya. A research project submitted to the population studies and research institute in partial fulfilment for the degree of Master of Arts in population studies, University of Nairobi.

Tonny, D. (2015). The Need for Training in FPAU, in a Family Planning Association of Uganda (FPAU) Annual Newsletter.

United Nations Enable (2015). Fact sheet on persons with disabilities. New York, United Nations.

United Nations Statistics Division (1990). Disability Statistics Compendium, Series Y; No. 4. New York, United Nations.

Westoff, C (2005). Recent Trends in Abortion and Contraception in 12 Countries. DHS Analytical Studies. Princeton, NJ: Office of Population Research, Princeton University; and Calverton, MD: ORC Macro, No. 8.

WHO. (2009). Health indicators in Uganda’s Health sector; Special interest groups inclusive, Kampala

World Bank (2004). HIV/AIDS and disability: capturing hidden voices: Report of the World Bank/Yale University Global Survey on HTV/AIDS and Disability. The World Bank, Washington, DC.

APPENDICES

Appendix I: Letter of Informed Consent

Dear respondent,

I am Asire Sarah, a student of Kyambogo University pursuing a bachelor degree in Community Based Rehabilitation and as part of the requirement for the fulfillment of the award, I am carrying “access tofamily planning services by women with disabilities in Mukongoro Sub County, Kumi District”.

For the completion of this study, you have been identified as one of the key respondents for this study. Therefore, I request for your cooperation. You will not be forced to answer any question that is against your will, you may not also need to mention your name incase you don’t need to be recognized. The information you will provide will be treated with utmost confidentiality and will only be used for academic purposes.

Therefore, I request you to answer the questions that follow.

Thank you for your time.

Appendix II: Interview guide for WWD

Section A: Background Information

Age: ……………………………………

Village:………………………………………………………………………

Occupation:………………………………………………………………….

Level of Education:…………………………………………………………..

Religion:……………………………………………………………………….

Section: B

1. What do you know about Family Planning?
2. Have you ever used Family Planning Services?
3. If yes, what method did you use exactly?
4. Was it effective to you?
5. If yes, how has it been effective?
6. What are some of the side effects/barriers to use of Family Planning Services in your community?
7. What are the reactions of your spouse on the use of Family Planning Services.
8. Any other information that you wish to add concerning Family Planning Services.
9. What are the factors that hinder women from accessing  family planning services?
10. What are the strategies to improve family planning services?

THANK YOU FOR COMMUNITY

Appendix III: Interview Guide for Health Workers

Section A: Background Information

Age: ……………………………………

Village:………………………………………………………………………

Occupation:………………………………………………………………….

Level of Education:…………………………………………………………..

Religion:……………………………………………………………………….

Section: B

1. What do you know about Family Planning?
2. Have you ever used Family Planning Services?
3. If yes, what method did you use exactly?
4. Was it effective to you?
5. If yes, how has it been effective?
6. What are some of the side effects/barriers to use of Family Planning Services in your community?
7. What are the reactions of your spouse on the use of Family Planning Services.
8. Any other information that you wish to add concerning Family Planning Services.
9. What are the factors that hinder women from accessing  family planning services?
10. What are the strategies to improve family planning services?

THANK YOU FOR COMMUNITY

Appendix IV: Focus Ground Discussions for WWD

1. What do you know about Family Planning?
2. Have you ever used Family Planning Services?
3. If yes, what method did you use exactly?
4. Was it effective to you?
5. If yes, how has it been effective?
6. What are some of the side effects/barriers to use of Family Planning Services in your community?
7. What are the reactions of your spouse on the use of Family Planning Services.
8. Any other information that you wish to add concerning Family Planning Services.
9. What are the factors that hinder women from accessing family planning services?
10. What are the strategies to improve family planning services?

THANK YOU FOR COMMUNITY

Appendix V: Introductory Letter

Appendix VI: Map of Kumi District

Appendix VII: Map of Kumi District showing Mukongoro Sub County