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Regional contraceptive use differentials are pronounced in Ghana, with the lowest levels occurring in the Northern Region. Community-based health services, intended to promote maternal and child health and family planning use, may have failed to address this problem. This paper presents an analysis of qualitative data on community perspectives on family planning “readiness,” “willingness,” and “ability” compiled in the course of 20 focus group discussions with residents (mothers and fathers of children under five, young boys and girls, and community elders) of two communities each in two Northern Region districts that were either equipped with or lacking direct access to community health services. The study districts are localities where contraceptive use is uncommon and fertility is exceptionally high. Results suggest that direct access to community services has had no impact on contraceptive attitudes or practice. Widespread method knowledge is often offset by side-effect misperceptions. Social constraints are prominent owing to opposition from men. Findings attest to the need to improve the provision of contraceptive information and expand method choice options. Because societal acceptance and access in this patriarchal setting is critical to use, frontline worker deployment should prioritize strategies for outreach to men and community groups with prominent attention to social mobilization themes and strategies that support family planning.
The qualitative data were taken from a larger data corpus generated from a baseline CHPS+ qualitative systems appraisal that replicated studies conducted early in CHPS implementation to gauge community perceptions of the program and seek stakeholder advice on ways to improve its services. The entire study spans five years (August 2016 to July 2021) with baseline data collection taking place in the first year. This appraisal was conducted over the April to May 2017 period in four districts across the Northern, Oti, and Volta Regions of Ghana. These four districts were selected as SLDs for the CHPS+ program and would become “centers of excellence” in CHPS operations for their respective regions. For the larger qualitative study, eight CHPS zones comprising various rural communities in the four SLDs for the Northern (Gushiegu municipal and Kumbungu district) and Volta (Central Tongu district) and Oti (Nkwanta South municipal) Regions of Ghana were selected as the study settings. The qualitative systems appraisal sought to evaluate the functions of the primary healthcare system in the three regions prior to interventions to strengthen the health system. Thus, focus group discussions were conducted with study participants in the four SLDs. Participants for this larger study included community members across various age and gender categories, community health volunteers, frontline health workers (community health nurses, community health officers, midwives, and enrolled nurses), and district health management team members. The interview guides used for community member group interviews consisted of information on a range of topics: community members’ health seeking behaviors, ratings of CHPS/other health facility services, ratings of service providers, challenges in healthcare provision, solutions to healthcare challenges, issues on maternal and child mortality, and issues on fertility and family planning. Community health volunteers, frontline workers, and district health management team members were also interviewed on their assessment of CHPS. However, in this paper, we limit our analyses solely to the data collected from community members in four CHPS zones in the Northern Region. Analyses are also limited to data emerging from discussions of fertility and family planning. To protect the identity of participants who contributed to the study, we term the four zones as communities A, B, C, and D, respectively. Communities A and C are functional CHPS zones in their respective districts while communities B and D are not1. Community members were recruited purposively by frontline workers who have service responsibilities in selected communities and were usually aided by community health volunteers. They mobilized community interest in the study through announcements or personal visits to homes. The participants were informed of the day and time for the FGDs which took place at various locations in the communities, including at a chief’s palace, at basic schools, at CHPS compounds, and in open community spaces. At the specified interview times, community entry protocols were carried out by the field team, then eligible community members who had turned up on the day of the discussions convened for the group discussions. The plan was to engage a maximum of eight participants per group, but as indicated in Table Table1,1, the numbers sometimes went slightly below or above this. The community focus groups were formed to discuss a range of topics related to healthcare access, health seeking behavior, and perceptions about CHPS in addition to family planning and fertility which are the focus of this paper. The team encountered no obstacles regarding topics discussed in each meeting. Further details on recruitment during the CHPS+ baseline qualitative systems appraisals are indicated in other studies (Kushitor et al., 2019; Wright et al., 2020). Number of participants distributed across the five groups by community A study team of ten, consisting of one supervisor, six male interviewers, and three female interviewers, travelled to the various communities and facilitated the conduct of FGDs. For each community, all six FGDs were conducted in a single day so that group discussions spanned four days. To ensure rigor in the data collection process, various features in the study design related to interviewer selection were taken into consideration. The nine interviewers had some form of tertiary education and were proficient in Dagbani, the local language that all group interviews were conducted in. In addition, interviewers had knowledge of customs in these settings, and they all had experience conducting focus group discussions. Males interviewed young boys, fathers, and elders while females interviewed mothers and young girls. For this community-based study, these interviewer characteristics were important to invoke community trust. Employing same-sex interviewers was especially important in ensuring participants were comfortable enough to share societal views on the sensitive subject of reproduction. The interview guide used for the FGDs was semi-structured, enabling a systematic approach to questioning while allowing for probes to obtain a depth and range of responses. To ensure the validity of the instrument, the guides were assembled by experts in the field and were then screened and refined prior to use. The group discussions were held at various locations with venues selected in consultation with frontline workers. Session durations ranged from 50 to 140 mins. Focus group discussions were conducted with five groups of community members in each of the four communities: (1) mothers of children under age five, (2) fathers of children under age five, (3) male youth without children (ages 15 to 24 years), (4) female youth without children (aged 15 to 24 years), and (5) community leaders/elders (see Table Table11 for a list of the groups with numbers of participants). The majority of participants in all four communities were Muslim. While mothers and community leaders/elders had no formal education, all youth had some form of secondary education, and fathers had a mix of none, junior, and senior secondary education. The average ages of mothers, fathers, young girls, young boys, and elders/community leaders in Kumbungu were 33 years, 37 years, 17 years, 20 years, and 56 years, respectively; while in Gushiegu, average ages of group discussion participants were 32 years, 30 years, 17 years, 18 years, and 58 years, respectively. Furthermore, there was an average parity of 4, 5, and 8 children among Kumbungu mothers, fathers and elders, respectively, and a respective average of 4, 4, and 10 children among mothers, fathers, and elders in Gushiegu. The group discussions were recorded and later translated, transcribed, and back translated for accuracy. The four transcribers were participants in the field team that conducted the group discussions. Using thematic analysis (Braun & Clarke, 2006), the transcripts were analyzed aided by the qualitative data analysis software, Atlas.ti versions 7.5.1 and 7.5.18. Three researchers (three of the authors) jointly generated codes for a sample of the transcripts and through this developed a coding frame which was used to guide the coding of subsequent transcripts, and thus established inter-coder reliability. The entirety of the transcripts were coded, bearing in mind the research questions, while also paying attention to inductive codes that would emerge. Codes generated on family planning and fertility topics were examined and grouped into their peculiar themes (Kushitor et al., 2019; Wright et al., 2020). To gauge the possible impact of CHPS exposure on family planning discussion, analyses were further conducted by observing patterns and comparing responses between communities with and without functioning CHPS compounds. Responses that were unique to communities either with or without CHPS were noted as differences between them. The study protocol was reviewed by the Ghana Health Service Ethical Review Committee, Accra, and by the Columbia University Institutional Review Board in January 2017. Written informed consent was obtained from literate study participants with oral parental consent obtained for all girls and boys who were under 18 years of age. Participants who were illiterate were asked to thumbprint the consent forms to indicate their consent. Refreshments and soap were provided to all study participants as reciprocity.
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