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Empowering women culturally and addressing men’s concerns about reproductive health services in a rural Empowering women culturally and addressing men’s concerns about reproductive health services in a rural community mobilization programme in northern Ghana Philip B. Adongo Ph. D University of Ghana School of Public

The Navrongo Community Health and Family Planning programme To assess the demographic impact of The Navrongo Community Health and Family Planning programme To assess the demographic impact of Family Planning and improved health care delivery in a rural setting

BRINGING HEALTH TO THE DOORSTEP OF RURAL PEOPLE BRINGING HEALTH TO THE DOORSTEP OF RURAL PEOPLE

Background • • • Government’s desire to improve health status of Ghanaians Poor performance Background • • • Government’s desire to improve health status of Ghanaians Poor performance of health sector over the years Recognition of the need for a change in health delivery strategy

Keys issues in health care delivery • Accessibility • Quality of care • Community Keys issues in health care delivery • Accessibility • Quality of care • Community involvement • Gender equity • Efficiency in resource utilization

Origin of Research Question • Large unmet need for family planning 1992/3 • MOH Origin of Research Question • Large unmet need for family planning 1992/3 • MOH redesigning national plan for community -based FP services • MOH Focus Group Discussions in 1993 • “Let our children live first” • Collaboration between researchers and MOH bureaucracy

The Social Context • Constrained women’s autonomy • Long birth intervals due to prevalent The Social Context • Constrained women’s autonomy • Long birth intervals due to prevalent practice of breastfeeding and postpartum abstinence • Poverty, dispersed settlement • Male-dominated society • Gender relations impeded family planning • High mortality • Low educational attainment

Treats to the CHFP programme • it became apparent that the goals of the Treats to the CHFP programme • it became apparent that the goals of the CHFP could not be fully realized unless men were engaged more actively as key players • A purely woman-to-woman approach to health and family planning outreach would not be effective unless complementary, malefocused strategies were simultaneously implemented

Three Main Strategies 1. Mobilizing the health care system – Reorienting and relocation of Three Main Strategies 1. Mobilizing the health care system – Reorienting and relocation of health staff to communities

The Community Health Officer (CHO) The Community Health Officer (CHO)

Three Main Strategies cont’d 2. Mobilizing the social institutions and networks – community consultations Three Main Strategies cont’d 2. Mobilizing the social institutions and networks – community consultations for, and involvement in, health service delivery

Three Main Strategies cont’d 3. Mobilizing the formal political institutions – Dialogue with District Three Main Strategies cont’d 3. Mobilizing the formal political institutions – Dialogue with District Assembly, Town and Area Councils, and Unit Committee members

Strategies cont’d Strategies cont’d

Cells in the experimental design Mobilizing traditional community organization Mobilizing Ministry of Health outreach Cells in the experimental design Mobilizing traditional community organization Mobilizing Ministry of Health outreach No Yes Comparison 4 Zurugelu only 1 Community health nurses in village locations 2 Combined 3 = 1 & 2

Cell 1 Cell 2 Cell 4 Cell 3 Cell 1 Cell 2 Cell 4 Cell 3

Communities mobilised for health service delivery Strategies cont’d Communities mobilised for health service delivery Strategies cont’d

Impact • Higher health coverage • Improvements in child health • Emerging changes in Impact • Higher health coverage • Improvements in child health • Emerging changes in reproductive behaviour • Steady FP uptake

 • To compare the male attitudes towards the autonomy and empowerment created by • To compare the male attitudes towards the autonomy and empowerment created by the programme activities across the four experimental cells

methodology • Qualitative methods of data collection – Focus Group Discussion – In the methodology • Qualitative methods of data collection – Focus Group Discussion – In the community mobilization arm of the experiment and the comparison arm • Married women aged 16 -38 • Married men aged 25 and above

Are male fears and anxiety eroding among experimental cells? • Timing of next pregnancy Are male fears and anxiety eroding among experimental cells? • Timing of next pregnancy was much easier • Desire to have fewer children as a result of poverty • Health fears related to family planning

 • However, if you have many children, one will be disrespectful the other • However, if you have many children, one will be disrespectful the other will be respectful, another will be a fool and the other intelligent, another will be a rich and the other poor… that is why some people oppose family planning and prefer to give birth to many children. ” (Male community member, Cell IV)

 • I will never agree to what my friend has just said. As • I will never agree to what my friend has just said. As for me I will give birth to my children and God will provide them food. …In the past if you had many children, you were seen as a chief so I will give birth to many children in order to be given that status. I won’t agree to give birth to only two children so that they will look stronger. What will happen if the children are not stronger? (Male community member , Cell I)

Changing perceptions of women’s autonomy • Freedom to use contraception • Control of women Changing perceptions of women’s autonomy • Freedom to use contraception • Control of women autonomy

 • There are other men who oppose family planning because some women over • There are other men who oppose family planning because some women over delay in spacing their births. For some women, their children grow as big as one who can shepherd cattle and yet she still does not want to become pregnant. This happens because most women who delay their births have become used to dressing up nicely and looking good always. As a result they do not want get give birth again and get dirty or always cleaning dirt as a nursing mother” (Male community member, Cell II)

 • “. . . People think family planning is about given birth to • “. . . People think family planning is about given birth to two or three children. With the family planning pills you can sleep with you wife without she becoming pregnant until the time you want her to have children. … but if you want to give birth to many children you space them out well. If you marry your wife and she takes the pills it will prevent you from going out for other women and the risk of contracting diseases to kill you and your wife and leave the children alone. . . ” (Male community member, Cell III) •

Gender-based violence • Women were more acceptable to use family in the community mobilization Gender-based violence • Women were more acceptable to use family in the community mobilization arm of the experiment

 • “. . . the reason why I will beat my wife if • “. . . the reason why I will beat my wife if she tells me that she wants to use family planning is that if I have only two children, both of them can die over night. I can also die as well; so if I allow my wife to use family planning for five years and my children die, one day what will I do if Addah’s (referring to a fellow participant) children come to attack my house? That is why I will not let her do it. If I see her using it I will beat her”. (Male community member, Cell II)

 • “Some couples do discuss family planning, and when they are all convinced • “Some couples do discuss family planning, and when they are all convinced that family planning is good, the man gives the wife the go ahead to use it. Even if it gets to a situation that the woman goes to the nurse and she asks her for her husband to come, the man goes with his wife”. (Male community member, Cell III)

Key Lessons learnt • Community participation improves access to quality health care • Using Key Lessons learnt • Community participation improves access to quality health care • Using communities channels to resolve their concerns leads to men accept change that empowers women

conclusions • Involving men and discussing their views about health and family planning intervention conclusions • Involving men and discussing their views about health and family planning intervention leads to fundamental transition in male beliefs surrounding family planning and gender roles and a concomitant shift in the autonomy and empowerment of women exposed to such intervention.

THANK YOU! THANK YOU!