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Background: Evidence suggests that supportive male engagement in health care services, including family planning, remains low in many countries, despite known benefits for female partners. In 2017–2018, the United States Agency for International Development Transform: Primary Health Care Project conducted a participatory gender analysis, collecting relevant data to better understand Ethiopian men’s lack of support for the uptake of family planning services. Methods: Qualitative data were collected through 96 unique participatory group discussions with community members via a semistructured discussion guide and participatory activity; data were disaggregated by sex, age, and marital status. In-depth interviews (91) conducted with service providers, health system managers, and health extension workers used semistructured guides. Discussants and interviewees were selected purposefully, drawn from 16 rural woredas in four project regions: Amhara; Oromia; Tigray; and Southern Nations, Nationalities, and Peoples’ Region. Data collectors took notes and transcribed audio recordings. The research team deductively and inductively coded transcripts to develop preliminary findings later validated by key technical project staff and stakeholders. Results: Findings reinforce existing knowledge on the dominant role of men in health care–related decision making in rural Ethiopia, although such decision making is not always unilateral in practice. Barriers at the societal level impede men’s support for family planning; these include norms, values, and beliefs around childbearing; religious beliefs rooted in scriptural narratives; and perceived adverse health impacts of family planning. Lack of efforts to engage men in health care facilities, as well as the perception that health care facilities do not meet men’s needs, highlight systems-level barriers to men’s use of family planning services. Conclusions: Findings indicate several opportunities for stakeholders to increase men’s support for family planning in rural Ethiopia, including systems-wide approaches to shape decision making, social and behavior change communication efforts, and additional research and assessment of men’s experiences in accessing health care services.
The Transform: Primary Health Care Project gender analysis included a review of relevant secondary data from published sources, and primary qualitative data collection in Amhara, Oromia, Tigray, and SNNPR. The primary objective of the gender analysis was to broadly assess gender equity in the Ethiopian primary health care system—in order to inform a comprehensive strategy for the Transform: Primary Health Care Project. As such, the qualitative data collection tools included questions about the role of men in health care–related decision making and the uptake of family planning, among other key areas. The qualitative study design was premised on the use of thematic analysis, in order to ensure that the research effectively identified and organized participants’ views and experiences as they help to elucidate a response to the aforementioned research question [21]. In support of this design, appreciative and participatory approaches informed all data collection efforts. All data collection tools were piloted and subsequently revised as part of a comprehensive training held for data collectors in October 2017. Data collection was conducted during November and December 2017 in 16 rural woredas of the aforementioned regions, and analysis was conducted in Rockville, Maryland, and Addis Ababa in February and March 2018. Research findings were validated in Addis Ababa in May 2018. Qualitative data collection included the use of two data collection approaches: in-depth interviews and participatory group discussions. In-depth interviews—held with health care providers, health facility managers, health extension workers, government representatives from woreda and zonal health offices, and representatives from the Women and Children’s Affairs Office—were semistructured and included appreciative questions. Relevant to this study, interview guides for health extension workers included questions pertaining to the reasons that men and boys access health care facilities; how they perceive men to understand and define quality health care; and men’s general engagement in family planning and maternal, newborn, and child health care in their facility. In addition to covering these topics, interview guides for health care providers and health facility managers also contained questions relevant to equity in the provision of health care services for men and women in their facilities. Participatory group discussions—an innovative approach to conducting traditional focus groups—used semistructured discussion guides with appreciative questions; community mapping; and a unique Paving Stones activity, which drew upon visual aids to help participants identify health resources as well as gender gaps and opportunities in the provision of health care services within their communities. The participatory group discussion guides included a series of 16 questions covering health practices; access to and supports for accessing health care services; and experiences while utilizing such services, including perceptions of quality. For the purposes of the Paving Stones activity, a group facilitator drew a number of paving stones on a blank flip-chart; based on inputs from participants, each paving stone was inscribed with something that aids or assists them in accessing health care services in their community. Ultimately, these paving stones formed a pathway that would successfully lead them to accessing health care facilities and their available services. The research team held participatory group discussions with married and unmarried women and men within multiple age groups: (a) married women ages 15–24; (b) married women ages 25–45; (c) unmarried women ages 15–24; (d) married men ages 15–24; (e) married men ages 25–60; and (f) unmarried men ages 15–24. Due to the demographic features of the target regions, where men tend to marry later and remain fecund until a later age, the older groups of married men included a broader age range than the corresponding female groups. The team convened groups of six to eight participants, which allowed for capturing unique health care–related needs and behaviors associated with differences in sex, age, and marital status. The research team held in-depth interviews and participatory group discussions in each of the four regions the study targeted. Overall, data collection was conducted in two high- and low-performing woredas in Amhara, Oromia, and SNNPR, as well as one high-performing and two low-performing woredas in Tigray. Woredas are deemed high- or low-performing based upon their performance in key RMNCAH-N indicators. For the purposes of this study, woredas were specifically selected in consultation with representatives from regional health bureaus and the project’s regional technical coordinators to ensure reasonable representation of the regions’ sociocultural and religious diversity, variations in gender norms, and differences in access to health care services. To support logistical needs, all selected woredas were accessible from zonal towns. Within each woreda, data were collected within one kebele administrative sub-division. In consultation with local representatives, the Transform: Primary Health Care Project’s regional gender officers purposefully recruited interviewees and group discussion participants in advance of data collection. Participant selection was informed by government or health facility data to the extent possible, and sociocultural variation was taken into consideration when forming discussion groups. Data collectors conducted recruitment in a face-to-face manner, speaking with potential participants using a predefined script. The research team also strived to recruit an equal number of male and female interviewees, to the extent possible. The research team conducted a comprehensive training for data collectors in October 2017. Prior to starting data collection, the team received ethical approval from EnCompass LLC’s internal Institutional Review Board committee and each region’s respective ethical review committee. Between November and December 2017, the research team conducted 91 in-depth interviews and 96 participatory group discussions (see Tables Tables11 and and22 below for a disaggregated sample), for a total of 187 data collection events. In-depth interviews by region 1Few health extension workers are male; they mostly reside in regions that fall outside the scope of this research effort. As such, all participating health extension workers were female Participatory group discussions with community members, by region Both in-depth interviews and participatory group discussions were conducted by a combination of regional staff members from EnCompass LLC and external consultants. Teams consisted of one interviewer or facilitator and a note taker. Male data collectors interviewed male key informants and facilitated groups with male participants. Similarly, female data collectors interviewed female key informants and facilitated groups with female participants. Data collectors were selected based on previous academic qualifications in relevant social sciences and a demonstrated interest in issues pertaining to gender equality. Interviews were held in private rooms or offices in health care facilities, and participatory group discussions were held in mutually agreed upon community locations that were accessible to the participants. No other individuals were present during data collection aside from the approved data collectors and selected participants. Data collectors provided all research participants with an overview of the data collection process and research objectives as part of the informed consent process. As previously noted, during each data collection event, one data collector was tasked with completing written notes. Interviews and group discussions were both recorded using electronic recorders, to fill gaps in electronic transcription of the notes as needed. At the end of each data collection event, a summary of the conversation was read to all participants, who were asked to confirm the accuracy of the summary and suggest any necessary corrections. In the data collection protocols, data saturation was not prescribed as a criterion for data collectors to continue or end a conversation. Each in-depth interview lasted approximately 90 min on average, and each participatory group discussion lasted approximately 120 min on average. Preceding data analysis, the research team conducted quality assurance checks of transcripts to ensure the completeness and coherence of content. If gaps or inconsistencies occurred, the respective data collectors were requested to correct them using their audio recordings. The researchers subsequently reviewed any revised transcripts a second time before inclusion in the data analysis process. Qualitative data analysis was conducted between February and March 2018. The research team used Dedoose Version 7.0.23, a web-based data management and analysis application, to both deductively and inductively code approved, translated transcripts. The process was guided by the use of a detailed codebook, which, during the first round of coding, included thematic codes defined in advance of the coding process, based upon pre-identified information that the research team deemed essential for answering the initial research questions. Using a codebook based on themes emanating from the first round of coding, the second round of coding was inductive. Eight coders engaged in this process; consistency amongst coders’ efforts was ensured through pilot tests, in which coders applied the deductive and inductive codebooks to the same transcripts and then convened to identify, review, and respond to any discrepancies in the application of thematic codes. Further, throughout the process, the data analysis manager conducted periodic spot checks to ensure that thematic codes were being applied in accordance with the definitions specified in the codebook. Subsequently, the team held a participatory data analysis and interpretation meeting in March 2018 to triangulate themes emanating from the data across the various stakeholder groups and generate draft findings. Four members of the research team presented draft findings to project staff and key stakeholders in a data consultation meeting in Addis Ababa on May 16–17, 2018. During the meeting, stakeholders had the opportunity to validate and interpret findings, draw conclusions, and devise recommendations to support the Transform: Primary Health Care Project’s gender integration efforts. Individual team members were tasked with collating feedback from each session held in the meeting; one team member was tasked with integrating feedback into the working version of the findings, and other technical staff provided inputs.
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