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Background: Sexual and Reproductive Health and Rights (SRHR) is a concept of human rights applied to sexuality and reproduction. Suboptimal access to SRHR services in many low-income countries results in poor health outcomes. Sustainable development goals (3.7 and 5.6) give a new impetus to the aspiration of universal access to high-quality SRHR services. Indispensable stakeholders in this process are healthcare practitioners who, through their actions or inactions, determine a population’s health choices. Often times, healthcare practitioners’ SRHR decisions are rooted in religious and cultural influences. We seek to understand whether religious and cultural influences differ significantly according to individuals’ characteristics and work environment. Objective: The purpose of this study was to examine the role of healthcare practitioners’ individual characteristics and their work environment in predicting normative SRHR attitudes and behaviours (practices). We hypothesized that religion and culture could be significant predictors of SRHR attitudes and practices. Methods: A quantitative cross-sectional study of 115 participants from ten low-income countries attending a capacity-building programme at Lund University Sweden was conducted. Linear regression models were used to assess for the predictive values of different individual characteristics and workplace environment factors for normative SRHR attitudes and SRHR practices. Results: Self-rated SRHR knowledge was the strongest predictor for both normative SRHR attitudes and normative SRHR practices. However, when adjusted for other individual characteristics, self-rated knowledge lost its significant association with SRHR practices, instead normative SRHR attitudes and active knowledge-seeking behaviour independently predicted normative SRHR practices. Contrary to our hypothesis, importance of religion or culture in an individual’s life was not correlated with the measured SRHR attitudes and practices. Conclusion: Healthcare practitioners’ cultural and religious beliefs, which are often depicted as barriers for implementing full coverage of SRHR services, seem to be modified by active knowledge-seeking behaviour and accumulated working experience with SRHR over time.
This study was conducted at the beginning of the four-week international training program (ITP) taking place at Lund University, Sweden. The program was commissioned by the Swedish International Development Cooperation and aimed at improving access to quality SRHR services in low-income countries through a rights-based framework [20]. A central component of the ITP program was to improve knowledge about current international SRHR policies in order to facilitate positive attitudes and behaviours towards different aspects of SRHR among the participants. Participants in this study were healthcare practitioners working in medical facilities and civil society organizations in private and public sectors in low-income countries. They were purposively selected to participate in the ITP, because their individual profiles and the positions they held suggested that they were influential decision makers in their respective health systems. Participants were from Ethiopia, Zambia, South Sudan, Zimbabwe, Bangladesh, Uganda, Kenya, Tanzania, Myanmar and Liberia. Each country team consisted of 4–6 members. They included male and female individuals, midwives, nurses and doctors, middle-level managers, and policy makers. A total of 115 health practitioners participating in the ITP were enrolled in this study, 58 in October 2017 and 57 in October 2018. A quantitative cross-sectional study design was used. To determine participants’ individual characteristics, attitudes and practices, a self-administered structured questionnaire was used. The questionnaire contained items regarding the participants’ age, gender, level of education, sector and category of employment, and number of years working with SRHR at the time of the study. In addition, the questionnaire was used to assess self-rated SRHR knowledge, normative SRHR attitudes and normative SRHR practices. The elements assessing knowledge, attitudes and practices were developed based on a combination of the Knowledge Attitudes and Practices (KAP) model and the Transtheoretical Model (TTM). The questionnaire was piloted in a non-study sample consisting of two master’s students in the Public Health programme at Lund University (SRHR healthcare practitioners from low-income countries) and necessary adjustments were made before the study was conducted. The first and the second authors approached the participants in a group to provide information about the study, explain the study objectives and ask for their participation. Written informed consent was obtained according to the principles of Helsinki declaration [21]. A detailed consent form is available as supplementary information. A self-administered questionnaire was filled in on the first day of the training programme-precisely after the introductions and before any program content was introduced to the participants. The study was conducted in English, which is the language of instruction in the training program. A total of 115 participants completed the questionnaire, representing 100% of the ITP participants. The study was approved by the Regional Ethical Review Board in Lund, Sweden, and given ethical approval number DNR 2017/823. No compensation was given for participating in this study. The independent variables were participants’ individual characteristics and SRHR work environment. Individual characteristics were age, gender, education, self-rated knowledge and perceived importance of religion or culture in one’s life. Age was reported as ‘equal or less than 40 years’ or ‘more than 41’ (reference category) and gender as ‘male’, (reference category), ‘female’ or ‘other’. Level of education was defined as ‘completed high school or its equivalent’, ‘completed bachelor’s degree or its equivalent’ (reference category), ‘completed master’s degree or its equivalent’, or ‘completed doctorate/PhD or its equivalent’. SRHR self-rated knowledge was assessed on the basis of the participants’ responses to the following question, “How do you rate your knowledge regarding the following items (components of SRHR included in ITP): ‘comprehensive sex education’, ‘contraception’, ‘abortion’, ‘cervical cancer screening’, ‘the lesbian, gay, bisexual and trans-gender community’s health’, ‘sexual orientation and gender identity’, ‘sexual coercion and violence’, and ‘health policy regarding SRHR?’ The responses for each of the items were coded on a scale of 1–5, where 1 = Very Low, 2 = Low, 3 = Neither high nor low, 4 = High and 5 = Very High. Each participant’s responses to each of the SRHR aspects were summed up to yield a composite score for the SRHR self-rated knowledge variable. Scores equal to or less than the mean were categorized as ‘low self-rated knowledge’ (reference category) and scores greater than the mean as ‘high self-rated knowledge.’ This scale was developed for the purposes of this study. In addition, participants were asked to respond with ‘yes’ or ‘no’ to the questions, ‘Does religion play an important role in your life?’ and ‘Does culture/tradition play an important role in your life?’ SRHR work environment was assessed as sector of employment, level of employment, area of operation, working years with SRHR and perceived influence of religion and culture on SRHR decision making. Sector of employment was defined as either ‘public health sector’, ‘private health sector’, ‘public education sector’, ‘private education sector’, ‘non-governmental organization’ or ‘other’. The sector of employment was aggregated into two categories, ‘public sector’ consisting of public health and public education sectors and ‘private sector’ (reference category) consisting of private education and private health sectors, non-governmental organizations and ‘others’. Level of employment was defined as ‘senior management’, ‘program officer’, ‘service provider’, or ‘others’. Two aggregated categories were created for this variable; ‘senior management and program officers’ and ‘service providers, and others’ (reference category). Area of operation was reported as ‘local’, ‘intermediate/regional’, and ‘national’ (reference category). Experience of working with SRHR was reported as number of years, and dichotomized as ‘seven years or less’ and ‘eight years or more’, based on mean of seven years. The influence of religion and the influence of culture on SRHR decisions making were assessed by the following questions, to which participants responded with either ‘yes’ or ‘no’: ‘Does religion influence your decision making with regard to SRHR?’, ‘Does culture/tradition influence your decision making with regard to SRHR?’. The outcome variables were normative SRHR attitudes, active SRHR knowledge-seeking and normative SRHR practice. To assess normative SRHR attitudes, participants were asked to indicate their level of agreement with the following statements: ‘I believe that abortion is a woman’s right’, ‘I believe that young people should have access to contraception’, ‘I believe that all young people should have access to comprehensive sex education’, ‘I believe that the LGBT community should have equal access to HIV/STI care like anyone else’, ‘I believe that both men and women are affected by sexual violence’, ‘I believe that sexual orientation and gender identity is a human right’, and ‘I believe that inequality is responsible for poor maternal and neonatal health outcomes’. The responses were coded on a scale of 1–5, where 1 = Strongly disagree, 2 = Disagree, 3 = Not sure, 4 = Agree and 5 = Strongly agree. Each participant’s responses from the above questions were summed up to yield a composite score for the variable ‘normative SRHR attitudes’. High SRHR attitude scores were interpreted as having ‘normative attitudes’ towards SRHR as defined in international policy guidelines [1], while low-attitude scores were interpreted as having ‘non-normative’ attitudes. This scale was developed for the purposes of this study. The normative SRHR practice and active SRHR knowledge-seeking practice instruments were developed based on constructs derived from the Transtheoretical Model (TTM) [19]. The Transtheoretical Model describes change in behaviour as a deliberate process that happens over time through a cyclic process of 5 stages; pre-contemplation, contemplation, preparation, action, and maintenance stages. In the pre-contemplation stage, individuals have no intention to act within a foreseeable time, are often not mindful of the negative effect of their behaviour and undervalue the advantages of changing. In the contemplation stage, individuals have an intention to take action and acknowledge that their behaviour may have negative consequences but are still hesitant about change. Individuals in the preparation stage are ready to act often in small steps, while, in the action stage, individuals have recently taken action and intend to keep moving forward. During maintenance stage, individuals have continued their behavioural change for a while and intend to uphold the behaviour. The Transtheoretical Model is constructed on the belief that behavioural change is a process that involves a common set of change processes that are almost similar across a broad range of health behaviours and has been used in interventional studies to encourage adaptation of healthy behaviours such as smoking cessation, engaging in active lifestyles, and choosing of healthy nutritional diet. Its utility in understanding decision-making process has been reported [22,23]. Active SRHR knowledge-seeking was defined as an individual’s intention to seek more knowledge about enhancing access to SRHR services. This was assessed by the following question: “What are your thoughts about getting more knowledge concerning the following: ‘abortion’, ‘cervical cancer screening’ ‘youth access to contraception’, ‘youth access to comprehensive sex education’, ‘health policy regarding SRHR’, ‘LGBT community’s health needs’, ‘sexual coercion and sexual violence’ and ‘sexual orientation and gender identity’? The responses for each component were ordered on a scale of 1–5 as follows: 1 = ‘I have not thought about seeking out more information in the next 6 months’, 2 = ‘I am considering seeking out more information in the next 6 months’, 3 = ‘I have decided to take steps to gain more information in the next 30 days’, 4 = ‘I have taken steps to acquire more knowledge in the last 6 months, not including ITP’, 5 = ‘I have taken steps to acquire more knowledge for more than 6 months, not including ITP’. Each participant’s responses to the questions corresponding to the different SRHR components were summed up to yield a composite score for the variable active SRHR knowledge-seeking practice. High scores were interpreted as ‘active knowledge seeking’ and low scores as ‘less active knowledge-seeking’ practice that enhances access to SRHR services. Normative SRHR practice was defined as individuals’ intention to enhance access to SRHR services. It was assessed from participants’ responses to the following question, “Which of these statements best describes your behaviour towards the following: ‘access to abortion’, ‘cervical cancer screening’, ‘youth access to contraception’, ‘youth access to comprehensive sex education’, ‘equal access to health’,‘LGBT community and their access to HIV/STI care’ and ‘sexual violence’? Participants were asked only to respond to questions corresponding to the aspects of SRHR that they had ever worked with. The responses to each aspect were ordered on a scale of 1–5 corresponding to the stages of change according to the Transtheoretical Model: 1 = Pre-contemplation (‘Is not something I have thought about’), 2 = Contemplation (‘Is something I have thought about as being important’), 3 = Preparation (‘I have decided to take steps about it’), 4 = Action (‘I have taken steps in the last 6 months about it’), 5 = Maintenance (‘I have taken steps for more than 6 months about it’). Each participant’s responses were summed up to yield a composite score for the variable normative SRHR practice. High scores were interpreted as ‘more likely to take steps’ i.e. normative SRHR practices towards improving access to sexual and reproductive health and rights and low scores as ‘less likely to take steps’ or non-normative.
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