Nancy E. Williamson

A Qualitative Study of Condom Use among Married Couples in Kampala, Uganda

Twenty-five years into the HIV/AIDS epidemic, condom use among married/stable couples remains low and under-researched in developing countries, even countries with high HIV prevalence. Introducing condoms into a long-standing relationship, in spite of HIV risk, is likely to be awkward. We conducted a qualitative study in Kampala, Uganda, with 39 couples reporting 100% condom use in the previous three months. The women were recruited from among women in a clinical trial who were using condoms and whose partners also agreed to participate. Twenty-two of the women and six of the men reported having taken the initiative to suggest condom use; the remaining couples disagreed who raised the subject first. Women used insistence, refusal to have sex, persuasion, and condoms for family planning or to protect children, which helped to deflect distrust and get their partner to agree. Some men resisted initially but their reactions were often more positive than expected. Men’s reasons for accepting condoms were to please their partner, protect her from HIV, protect their children, protect themselves and, in some cases, continue having other partners. Although condom use is a couple behaviour, an encouraging environment and condom availability are all crucial to increasing condom use by couples in settings like Uganda. Résumé Vingt-cinq ans après le début de l’épidémie de VIH/SIDA, l’utilisation des préservatifs par les couples mariés/stables demeure faible et suscite peu de recherches dans les pays en développement, même avec une forte prévalence du VIH. Introduire les préservatifs dans une relation durable peut être délicat. Nous avons réalisé une étude qualitative à Kampala, Ouganda, auprès de 39 couples ayant notifié une utilisation à 100% de préservatifs les trois mois précédents. Les femmes ont été recrutées parmi les femmes d’un essai clinique qui utilisaient des préservatifs et dont les partenaires avaient accepté de participer. Vingt-deux femmes et six hommes ont indiqué avoir pris l’initiative de proposer un préservatif ; les autres couples ne savaient pas qui avait soulevé la question en premier. Les femmes faisaient preuve d’insistance ou de persuasion, refusaient d’avoir des rapports, invoquaient la planification familiale ou la protection des enfants, ce qui aidait à endormir la méfiance et à obtenir le consentement du partenaire. Certains hommes commençaient par résister, mais leurs réactions étaient souvent plus positives que prévu. Les hommes acceptaient le préservatif pour faire plaisir à leur partenaire, la protéger du VIH, protéger leurs enfants, se protéger et, dans certains cas, continuer d’avoir d’autres partenaires. L’utilisation de préservatifs est un comportement de couple, mais un environnement encourageant et la disponibilité de préservatifs sont des facteurs essentiels pour relever l’utilisation de préservatifs par les couples dans des pays comme l’Ouganda. Resumen Tras 25 años de epidemia del VIH/SIDA, el uso del condón entre las parejas casadas/estables continúa siendo bajo y subinvestigado en los países en desarrollo, incluso en los países con alta prevalencia de VIH. Probablemente resulte difícil asimilar el uso del condón en una antigua relación, pese al riesgo de contraer VIH. Realizamos un estudio cualitativo en Kampala, Uganda, con 39 parejas que informaron utilizar el condón el 100% durante los tres meses anteriores. Las mujeres fueron reclutadas de entre mujeres en un ensayo clínico quienes usaban condones y cuyas parejas también acordaron participar. Veintidós de las mujeres y seis de los hombres informaron haber tomado la iniciativa de sugerir el uso del condón; las otras parejas discreparon en cuanto a quién fue el primero en plantear el tema. Las mujeres utilizaron insistencia, denegación de sexo, persuasión y condones para la planificación familiar o para proteger a los niños, lo cual ayudó a desviar la desconfianza y lograr que su pareja estuviera de acuerdo. Algunos hombres se resistieron inicialmente pero sus reacciones a menudo fueron más positivas que lo esperado. Los motivos de los hombres para aceptar el uso del condón fueron: complacer a su pareja, protegerla del VIH, proteger a sus hijos, protegerse a sí mismos y, en algunos casos, continuar teniendo otras parejas. Aunque el uso del condón es un comportamiento de pareja, un ambiente de apoyo y la disponibilidad del condón son fundamentales para incrementar su uso en lugares como Uganda.

The effect of husband counseling on NORPLANT® contraceptive acceptability in Bangladesh

A pilot study of the effect of husband counseling on NORPLANT contraceptive acceptability was conducted at four family planning clinics in Bangladesh. The study objectives were to compare discontinuation rates and user satisfaction among acceptors whose husbands received counseling about the method versus those who did not. Of a total 617 subjects enrolled in the study which began in 1988, about two-thirds (408) of the husbands were counseled at admission or at the one-month follow-up visit while the remainder of the husbands (209) were not counseled. Follow-up visits were scheduled at one and six months after NORPLANT implants insertion, and every six months thereafter until the close of the study in 1991. Some evidence was found that counseling husbands of NORPLANT implants acceptors may reduce discontinuation rates. At the end of 36 months, a difference of 10 percentage points in total discontinuation rates was observed between the husband-counseled group (32 per 100 women) and the husband-not-counseled group (42 per 100 women). The husband counseling had the most impact at clinics with higher discontinuation rates. Based on Coxs proportional hazards regression model results, the hazard for discontinuation among the acceptors in the husband-not-counseled group. Satisfaction with NORPLANT implants did not differ between the two groups. Although these results are not striking, they do suggest a potential positive effect of husband counseling on NORPLANT contraceptive accept-ability. In future studies, the counseling of husbands should be more intensive and standardized.

Characteristics of condom use and associated problems: experience in Bangladesh.

Data from the 1983 Bangladesh Condom User Survey (BCUS) are analyzed for patterns of condom use and various problems directly influencing their effectiveness. The survey was undertaken to explain an apparent gap between reports of the number of condoms distributed in certain areas compared with prevalence of users as reported in contraceptive prevalence surveys. These data are analyzed from behavioral and management perspectives to identify various factors influencing utilization, with potential implications for understanding and improving family planning and AIDS/STD prevention service systems. Patterns of use are related to differences in source of supply through public, free or private-priced systems, differences in urban or semi-rural place of residence, and differences in perceptions of men or women. The problem with condom use most often identified by the respondents was breakage.

An attempt to reduce infant and child mortality in Bohol, Philippines.

This discussion describes the experience of 1 local area, Bohol, Philippines, that, despite an active maternal and child health/family planning (MCH/FP) program, failed to experience a decline in mortality during the project period (1975-1979). The specific health services to be delivered were determined during the early years of the project. The project managers believed that a package of basic primary health services with an emphasis on MCH would make a measurable impact on child health and, hopefully, on mortality. It was felt that increased use of family planning, particularly on the part of high risk mothers, would also contribute to a decline in infant and child mortality. The project recruited and trained 44 new midwives and others were added later. By 1979, 100 small Primary Health Care Centers, each staffed by a midwife had been established in the project area. 50 small community drugstores were also opened. The 4 public health hospitals and 21 rural health units, 1 in each town of the project area, participated in the project. The Bohol project increased the number of health staff, supervised them, and provided logistic support. As an immediate goal, the project sought to reach all children under age 5 with basic health services. Based on census and survey data, it is probably safe to say that mortality declined in Bohol between 1970 and 1975-79, but during the project period the crude death rate for the project area showed only a slight but statistically insignificant downward trend. Even though improvements were demonstrated in health service coverage in the project area, these improvements might have worked against other trends, thus explaining the lack of a clear decline in infant and child mortality during the project period. The project collected information on trends in fertility, abortion, nutrition, breastfeeding, and general living conditions. Although the results were at times mixed, none of the 5 appeared to have had a major effect on mortality trends. Except fertility, little change was noted. Although fertility declined, it was not clear whether higher or lower risk births were being prevented. A number of plausible explanations are evaluated as to why infant and child mortality failed to show a clear decline in Bohol: health services were of inadequate quantity or quality; midwives had too many tasks; there was a lack of fit between health services and local health conditions; local health problems were intractable to current technology; resources were insufficient to provide comprehensive primary health care; the MCH program was used primarily as a vehicle for family planning; too little attention was given to curative services; MCH programs are not designed to have a demograhic impact, and the project had too short a time period to have a demographic effect on such a large population.

Natural family planning: development of national programs.

This monograph which arises out of the proceedings of a seminar with delegates from natural family planning (NFP) programs in 35-40 countries focuses on NFP programs their development needs and characteristics. The goal in this monograph is to reflect the reality of developing national NFP programs on a worldwide basis and to analyze the development aspect. Specific characteristics and developmental approaches including various resources and instruments are described as an aid to the establishment of new programs. The monographs 1st section presents some 20 or more developing programs. 9 major programs were selected in the 4 geographical regions or zones of the International Federation for Family Life Promotion (IFFLP) -- Africa the Americas Asia-Oceania and Europe -- for detailed analysis. Another dozen programs are presented in a summary form. The more representative program descriptions were chosen from among 40 IFFLP affiliates. For the most part NFP programs and services have been developed in a private network outside the major public family planning programs and a majority of programs have a religious origin and basis of operation. The 2nd section of the monograph analyzes in greater depth program development training and service development and program evaluation. In addition to the presentations of the major themes comments were invited from additional speakers. The presentation on program development by Marie-Paule Doyle former IFFLP president from Canada introduces a discussion or primary orientations philosophy structure leadership and funding. Dr. Thomasina Borkman a social scientist offers a challenging analysis of the dominant characteristics of existing NFP programs and suggests a mechanism for monitoring the impact of new developments on NFP programs. There are 2 presentations on the quality training of NFP teachers and educational services. Dr. John Laing illustrates several years of research analysis in the Philippines on the demographic impact of rhythm and its potential as an integral part of the national family planning program.

The Bohol project and its impact.

A pilot project on the island of Bohol was initiated to provide MCH/FP (maternal and child health and family planning) services. The project objectives were: improving mother and child health care, improving family planning services, improving MCH/FP personnel training, and undertaking operational and other studies to determine the optimal resources to obtain the best program results. In conjunction with RHUs (Rural Health Units), midwives are staffing PHCCs (Pprimary Health Care Centers) to provide vaccinations; health and nutrition education; prenatal, delivery, and postpartum care; and family planning counseling and supplies to approximately 3000-5000 persons. In addition, there are more than 600 trained birth attendants to assist. Of 47,900 women, 88% have obtained some health services. The rate of infant deaths due to tetanus neonatorum has decreased but the maternal mortality rate has shown no statistical decline. 82% of the children are receiving health care with 3000-4000 well chidlren and 2500 sick children seen monthly suggesting preventive care is being given. Despite the increase in contraceptive usage and sterilization procedures over a 27-month period, the fertility decline cannot be attributed to the health services as the decline began before the services were available. This project has had no vital demographic impact on vital rates of the 420,000 population, but it has shown the feasibility of setting up the MCH/FP project with midwives as the major providers of services.

Utilizing research to manage a family planning project.

Nancy E. Williamson served as the Population Council Evaluation Advisor to the Bohol Maternal and Child Health/Family Planning Project from 1976 to 1980. In this paper, she describes a number of ways in which evaluation research can assist a family planninglhealth program, citing specific examples from the Philippines. She then identifies general factors that may hinder or facilitate the use of research.

The hospital environment and infant feeding: results from a five country study

As the proportion of mothers in developing countries giving birth in hospitals increases slowly the potential for hospital personnel and practices to affect infant feeding preferences is also likely to increase. Information for this study was obtained from 144 obstetrics-related employees of 26 hospitals in 5 countries whose profiles showed considerable variation in factors such as urbanization infant mortality and % of hospital births. All countries showed high initial breastfeeding prevalence but prevalence after 12 months ragned from 22% in Jamaica to 88% in Bangladesh. Hospital breastfeeding prevalences were high in all 5 countries: more than 90%. In 23 hospitals normal healthy babies were given to their mothers immediately after birth. Few hospitals would reunite mother and child quickly in cases of maternal or perinatal complications. By concensus mothers on antibiotics could breastfeed; 1/2 of the respondents felt mothers with low fevers could also but fewer felt mothers on intravenous units or receiving narcotics should. Most respondents were aware of the importance of colostrom and combination of breastfeeding with oral rehydration therapy. Other topics explored were milk allergies let-down reflex breast shape mastitis feeding frequency and nutrition. Bottle feeding was promoted for healthy babies and mothers in very few hospitals. The study covered infant feeding and contraception the most prescribed agents being barrier agents. Hospitals can influence breastfeeding prevalence by promoting early and constant contant. Formula use should not be actively promoted especially to less sophisticated populations. The recently developed progestogen pill which appears not to affect lactation could be an effective postpartum contraceptive. Hospitals should formulate clearly articulated policies for breastfeeding promotion.