Family Planning: Fact or Fiction?

In this project, we would like to develop and evaluate health education films on family planning in two areas of Uganda.

Every year, thousands of women and children in Uganda die as a result of problems during pregnancy and childbirth. Our research in 2011-2015 showed that about 20% of these deaths could have been avoided by use of contraception, to prevent unwanted pregnancies. Many women never return to a health facility after giving birth, but there is a crucial opportunity to provide them with contraception while they are still at the health facility, after giving birth. Although several projects have trained health workers to provide the contraceptive coil immediately after delivery, few women go home with a method of family planning in Uganda.

To understand why, our team interviewed 80 women, men and health workers in Uganda in 2015. We found that many women wanted time to discuss contraception with their husband (who was often absent at the time of delivery) and to recover from the birth. Women feared side-effects such as bleeding, and the impact these would have on their marriage; men were also concerned about side-effects and the cost of managing these. Several people believed scare stories, for example that the coil could travel to other parts of the body or cause cancer.

Many people we interviewed suggested that more awareness-raising on family planning was needed, and that women who have successfully used family planning should share their experiences with others. Some people suggested that men should accompany their wives to antenatal clinics (which rarely happens in Uganda) to discuss future family planning with a health worker. Although health education materials exist on family planning, low levels of literacy in rural Uganda mean that written materials are not suitable, but people could access health information through films. Previous health education documentaries and dramas have been made, but with very little, if any, involvement of local people. We also do not know whether people would respond better to a documentary (with interviews of real people) or a drama.

In this project, we would like to test whether health education films are feasible and acceptable to people from different ethnic groups, in two different languages, in two areas of Uganda. In each area, we will make one short (5 minute) documentary and one short drama. These will aim to dispel some of the commonest myths on contraception, to encourage men to attend at least one antenatal clinic with their wives, and to discuss with a health worker whether they would like a method of family planning after the delivery. We will seek to assess whether factual or fiction films make a more significant impact.

A partnership is crucial to the success of this project, by bringing together experts in African theatre and film with experts in community health and family planning and experts in behavioural change interventions. We will involve local Ugandan men and women by interviewing them for the film, and creating a culturally appropriate drama. We will get feedback on the first, second and final versions of the film from different focus groups of local men and women, and will use this opportunity to explore their understanding of contraception. Each version will be edited and improved based on their feedback. This is called the "person-based approach" which has been used for developing health promotion materials in Europe, but not yet in Africa.

The health education films we develop could be shown in health centre waiting rooms during antenatal clinics, in community meetings, and even on television. It would be possible to disseminate these in Uganda, and to test their effect in a larger trial, to see whether people who saw the film are more likely to use family planning after giving birth. This is part of a broader programme of work which is already improving provision of family planning by training health workers in Uganda.

Although this is a pilot project, the films developed by the end of the project should be of a standard which would already enable their use in health facility waiting rooms and during community meetings. The key outputs will be short films (about 5 minutes each) focusing on the most important barriers to uptake of post-partum contraception in each locality. The target audience will be the groups with the highest unmet need for contraception, namely poor women in both rural and urban areas, and their male partners. In the course of the project, the films will be screened to 48 focus groups each of 10 people, so messages will already reach 480 people.

After the project, these films will be made freely available to health clinics and can also be posted on Youtube so that they will be freely available for others to use. This will be done by the USHAPE project partners and Margaret Pyke Trust. Two of our team are involved in the implementation of the USHAPE health partnership funded by the Tropical Health and Education Trust and recently validated as highly cost-effective by DFID.

The results of the scientific research, particularly on the question of acceptability of documentary versus drama films, and on the adaptation of the person-based approach to the development of health education materials in low and middle-income countries, will be written up and submitted for publication in a peer-reviewed scientific journal (such as Studies in Family Planning, Journal of Applied Theatre Research). We will also submit abstracts to relevant conferences such as the Uganda national Family Planning conference. We hope to apply for subsequent funding to test the impact of the films on a larger scale.