Results
Improvement in child health and the changing perception of reproduction
The study generally revealed an improvement in child health in the last 10 years. These improvements according to respondents were attributable to immunization of children, exclusive breast-feeding, health education given to mothers on childcare, growth monitoring of children and an improvement in access to health care. Both IDIs and FGDs alluded to the fact that immunizations have drastically reduced the incidence of childhood diseases that were fatal in the past. Examples of such diseases were given as measles, poliomyelitis, tuberculosis and whooping cough. Growth monitoring during Child Welfare Clinics (CWCs) also resulted in the early detection of growth challenges and measures taken to ameliorate any adverse effects of such growth challenges. The following responses by respondents support this assertion:
“In the past children were dying from polio but now there is polio vaccination most of the time. The nurses also go round to inject the children to prevent them from getting the killer diseases. Mothers are also educated on the type of food to give to their kids”- (A female, FGD in a community with CHPS).
“First was whooping cough. The children can cough to the extent that all their ribs will be paining them. Second, was a disease that results in skin rashes, which make children skin to develop sores, and at the end of the day the child becomes very weak but now due to the medicines that our CHOs have been giving to the children it is better than the past 10 years”- (A female, FGD in a community with CHPS).
“ …. I will say that it (child health) has really improved by God’s Grace; my reason for saying that is because we get help from our health facilities and some medicine they give to our children in the form of immunization like “ntenkyem” (measles)… things have improved better than ten years ago”- (A male, FGD discussant in a community with CHPS).
Another reasons adduced by respondents as having contributed to the improved health status of children is health education in areas such as nutrition and exclusive breastfeeding. Good nutrition provides the children with nutrients required to build a stronger immunity to fight against diseases. The health benefits of exclusive breastfeeding to both parents and the child were significantly mentioned in both IDIs and FGDs. Exclusive breastfeeding as a contraceptive method (Lactational Amenorrhoea Method) was also stated. The use of mosquito nets as a measure in reducing the incidence of malaria in children was stated as another factor that has contributed to the improved child health.
“We are advised not to give food or water to our babies for the first six months after birth, and this prevent the children from diarrhea, which in the past was responsible for the death of many children”- (A mother, FGD in a community with functioning CHPS).
Another factor articulated by respondents as contributing to better child health is an improvement in both geographical and financial access to health care. To respondents, the CHPS system has brought health care to their doorsteps. The doorstep model has resulted in prompt reporting, reducing delays in seeking health.
“If a child is feverish he/she is immediately brought to the clinic and the CHO takes care, so the mother who previously could not send her child to the “big hospitals” because of money and the distance now bring their children to the clinic to be taken care of. The herbs they previously gave to their children through the instructions of their husbands have also stopped”- (A CHO, IDI in a community with functioning CHPS).
“The health of children is now better than before because formally we did not have a clinic here and the nurses were also not coming around to educate us. However, now the nurses come around to educate us on disease prevention”- (A male, FGD in a community with functioning CHPS).
“…the CHO and the CHV are very close to us (mothers) in the community, so if you go to them with your problem, they will provide you with the necessary assistance”- (A mother, FGD in community with functioning CHPS).
The CHPS system has also improved on follow-up of care as the health workers are resident in the community and can easily visit people who report to the clinic for care. This according to respondents was also instrumental in the improvement in child health.
“If you are sick and you attend the CHPS clinic, the nurses will follow you up to the house to monitor how you are taking your drugs and also ensure that your health is improving. If they (nurses) see that your condition is getting worse, they refer you to the hospital”- ( A woman, FGD in a community with functioning CHPS).
Although the general perception in the community was that, the health of children was relatively better than before as a result of the various interventions initiated by the health sector, malnutrition was still a major problem in the community. Discussants attributed this to high level of poverty in the community.
The significance of Lineal systems on women’s autonomy
Three main lineal systems are practiced in Ghana: patrilineal, matrilineal and a hybrid of the two. The patrilineal system is mostly practiced among people from the Northern and Volta Regions of Ghana. Matrilineal system is practiced in the middle belt mostly among the Akan-speaking Regions and duo-lineal system is practiced among the people from the Greater Accra Region of Ghana. The study therefore explored the effects of lineal systems on women’s autonomy. It was generally perceived that women in matrilineal systems have better autonomy in reproductive decision-making including the decision to use FP. In the matrilineal system, children born to the male partner in the wedlock are supposed to inherit from the maternal lineage. As a result of this, men appear not to be very much concern about the number of children their wives procreate. Since some men openly state this opinion in public, women in matrilineal systems have often used this practice as a liberating factor to gain some autonomy in reproductive decisions. The upbringing of children in the matrilineal system is more a responsibility of the woman and her lineage. The effect of matrilineal system has been summarized by a statement made by a mother in a FGD.
“If it had occurred to me earlier, I would have given birth to one or two children because the men in this community do not take care of their children. The men are constantly advised to take care of their nieces and nephews so it makes it difficult for them to take care of their biological children. Twenty (20) out of 100 men take care of their biological children in this community”- (A mother, FGD in community with less functioning CHPS).
Social derision and dispute between men and women as a result of the use of Family Planning
Respondents indicated that some community members disrespect and ridicule men and women who do FP. To be able to escape these ridicules, couples are compelled to either do FP in secret or stay away from it.
“In my community they love to gossip especially about people who are using FP methods, low self esteem is also a challenge since some shy away from accessing the service centres because they would be seen by their neighbours, some hide their cards from their spouse and family to avoid gossips”- ( A male CHV, IDI, Community with functioning CHPS).
Male respondents in communities without functioning CHPS were firmly of the opinion that endorsing the use of contraceptives was an affront to their authority, as this amounts to giving what a male respondent described as “power to their wives”
“The health workers are trying to give power to the females through the use of FP. Now your wife can tell you that I do not feel like having children anymore….I would marry another wife”- (A male, FGD in a community with less functioning CHPS).
Another drawback to the use of FP by women was the perception that contraceptive use was associated with promiscuous lifestyle. Men therefore perceived the use of contraceptives as an antidote against unplanned pregnancy that could result from extramarital affairs by women. This was a major issue as majority of the men in these communities are engaged in fishing and it was customary for the men to be away from their homes for several weeks in the sea fishing.
“Women who use contraceptives become promiscuous because when you go and have sex with another man, there will be no pregnancy. So if you do FP you will be encouraged to have sex with other men when your husband is not around”- (A man, FGD in community without CHPS).
Three main subthemes emerged in inter-spousal communication on FP. One was an egalitarian discussion, which can result in consensus in either to use or not to use contraceptives. High adherence rates and harmony may be expected in such a situation if couples decide to use. However, in a situation where they both agree not to use, there may be the propensity towards the use of natural method such as having sex only during the safe periods in the woman’s menstrual cycle. This according to respondents has some religious undertones, as some religious sects do not allow their members to use artificial contraceptives.
On the other hand, there may be disagreements in such inter-spousal dialogue on issues regarding contraceptive use. Respondents indicated two scenarios: the man agreeing to the use of contraceptive whiles the woman disagrees or the woman proposing to use contraceptives to the disagreement of the male, each scenario with its ramifications. In a situation where the man disagrees and the woman goes ahead to do FP, according to respondents quarrels have always ensued, which in some instances could result in a break in the marriage. According to respondents, women who use hormonal contraceptives discharge a lot of vagina fluids or become “wet under” which is noticeable by the man as it takes away the pleasure in sex. To female respondents, this could push the man towards engaging in extramarital affairs to get the pleasure the wife is incapable of providing.
“The reason why it is important to go with your husband to do FP is that, usually when a woman does FP, she easily become wet under, so if the husband have sex with her, he does get the pleasure any longer. This can lead to extramarital affairs by the man and in some instances could lead to divorce because the man does not enjoy sex with the wife any longer”- (A woman, FGD in a community with functioning CHPS).
If on the other hand the woman refuses to oblige to the husband request to use contraceptives, the man may refuse responsibility for any pregnancy and the child that may result.
“If your husband asks you to do FP and you refuse and become pregnant, he will deny the pregnancy and neither take care of you nor the child that would be born”- (A mother, FGD in a community with CHPS).
Male involvement in family planning
FGDs with women revealed diverse views on the level of male involvement in FP. Some women indicated that their husbands have embraced FP, whiles others stated that their husbands despise FP. Generally, women from communities with functioning CHPS indicated that their men were more accepting of FP than their counterparts from communities without functioning CHPS.
“My husband has helped me a lot, I have used FP for almost three years and he has even advised that I should go in for a 10 years long method if any”- (A woman, FGD in community with functioning CHPS).
“My husband accompanied me to the nurse to listen to the talk on FP and since that time, he has been encouraging me”- (A woman, FGD in a community with functioning CHPS).
“I think the men who like FP are now more than those who do not like it. More men are beginning to like FP now because they say that life is difficult, hence many would like to space their children as well as give birth to less children”- (A man, FGD in a community with CHPS).
Focus group discussions with men in communities with functioning CHPS revealed that men who have knowledge on FP advocate for other men to accept FP. This according to the men is very essential especially in a society where men feel superior and are prejudiced against women.
“The men who have knowledge on FP are very helpful, just like what teacher was saying about the family of eight children, all living in one room, if you have FP knowledge and you do not educate others on what you know, it is not good. In fact, one family should not have more than three children in one room because when the room is too congested, it can bring about diseases. In my area, those who have knowledge on FP tend to be very helpful, sometimes they bring teachers and midwives/nurses to the churches to give us health education”- (A man, FGD in a community with functioning CHPS).
“When I realized that the children were becoming too many, I sat with my wife and had a discussion with her on the need for FP to preserve our strength to take care of the children we already have. This is important so that our children would grow to become better than us. So that was how I supported my wife”- (A man, FGD in a community with CHPS).
Male chauvinism and Family Planning use
Male dominance in decision-making affects all aspects of marital life including reproductive issues. Males often prejudice females as inferior and incapable of taking important decisions concerning their life. This emerged as a reason that affects contraceptive use.
“I think the men think it is all a waste of time, I tell them that making babies is the responsibility of you and your wife, so if you really want to plan your family, it has to be done by both husband and wife. Therefore, even if you come with your wife and she forgets something, you can remind her. However many still refuse to accompany their wives to the clinic”- (A male CHO in IDI in community with less functioning CHPS).
“Most of the men think FP is not their responsibility to do, but it is only for women that is why many do not get involved”- (A woman, FGD in a community without CHPS).
“The men feel big and see us women as inferior to them, so you cannot tell them what is good for them”- (A mother, FGD in community with less functioning CHPS).
The study generally revealed that knowledge on contraceptives was universally high amongst males. However, this knowledge has not transformed the thinking of men about women on matters regarding the use of contraceptives or behavioural change. Cultural beliefs and societal perception that FP is “women’s affair”, coupled with various religious beliefs have played a major role in male involvement in FP services. These factors make men feel superior to women, a situation that makes it inappropriate for women to initiate inter-spousal communication on FP.
Social autonomy, gate keeping and family planning use
Heads of lineage and clans in a typical cohesive family system affect social autonomy and decision-making by members of the family. However, as the extended family system becomes more diffused, leadership, power and authority is increasingly being conferred on husbands who act as heads of nuclear systems. Evidence from this study has shown that husbands still play a major role in the social autonomy of their wives. However, in some instances, where in-laws live with the couple, they can influence all facets of the couple’s life including the decision to use contraceptives. Focus group discussions have revealed that couple whose parents have used contraceptive before either positively or negatively influenced the decision of the couples on contraceptive uptake. Though spousal consent is not required in FP, majority of respondents acknowledged that it was important to seek approval from your partner especially for women because of the benefits in a collective decision as observed by a female respondent:
“My husband accompanied me to the nurse to listen to the talk on FP and since that time he has been encouraging me to take the pills”- (A female, FGD in a community with functioning CHPS).
Female respondents attested to the benefits in involving their partners in their FP intentions and use, as men could be very useful when educated to accept FP.
“My husband reminds me about review dates when I forget and any time we think I am not safe because I have missed a pill, we use a condom”- (A woman, FGD in a community with functioning CHPS).
Non-use of Family Planning, pregnancies and abortions
When the discussion turned to the effects of non-use of FP, respondents expressed the view that one of the major consequences in the non-use of contraceptive is an unplanned pregnancy. The study revealed that such unplanned pregnancies ended up been aborted through self-induction using unsafe methods or in private health facilities that perform abortion. FGD discussants stated that women do abortion using traditional and unhygienic methods, which sometimes results in serious complications. Often the women take these drastic actions because they are uncertain of the reaction of family members.
“…I know a woman who had many children and did not do FP and became pregnant again, she did not want any more children so she wanted to abort the pregnancy and took some medicine and that resulted in her death”- ( A man, FGD in community with less functioning CHPS).
Common drugs mentioned by respondents, as abortificients were cytotec (misoprostol) which is a drug recommended for medical abortion by the World Health Organisation (WHO), u-pill and herbal preparations such as eclandudua, adutwumwaa bitters. Apparently, these herbal preparations have been licensed by the Food and Drug Authority in Ghana for the management of other diseases but are contraindicated in pregnancy. Adverts for these herbal preparations specifically mentions that women who are pregnant should avoid taking them, and so these drugs have been misconstrued as abortificients and used by community members to induce abortion.
“Now most of the women when they become pregnant and they do not want to give birth they do abortion. They take in different types of medicines”- (A man, FGD in a community with less functioning CHPS).
Community perception on the use of contraceptives determines their acceptance or rejection of contraceptives and was therefore explored in this study. Three main subthemes emerged regarding community perception from IDIs and FGDs. These were misconceptions, side effects and perceived benefits of contraceptives.
Misconceptions
The use of contraceptives was associated with various misconceptions that prevented couples especially women from using them. A key misconception that emerged from the respondents was the ability of contraceptives especially intrauterine contraceptive devices (IUCDs) which are inserted into the cervix of a woman to ascend to the heart to cause what respondents described as “uncontrollable heartaches”.
“The contraceptive that are inserted into the vagina can travel to the heart to give you heartache and other discomfort”- (A woman, FGD in a community with less functioning CHPS).
Regular menstrual flow (menses) were also perceived to prevent uterine fibroids, hence since the use of hormonal based contraceptives resulted in amenorrhoea (absence of menstrual flow), it was perceived by the community members as predisposing women to uterine fibroids.
“…I know another lady who did it (FP) and stopped menstruating, later on it developed into fibroid and ended up in surgery”- (A male participant, FGD in a community with less functioning CHPS).
“Every drug has its way of working, but my observation is that majority of the clients do not get their monthly menstrual flow due to the mechanism of action of the drugs. The women therefore feel that the lack of monthly menses can cause fibroid or block their tubes and prevent them from having children in future”- ( A male CHO, IDI in a community with less functioning CHPS).
“My little sister went to do the implant and she changed drastically, that is, first, she was fat but after doing the FP, she grew very lean. Because of what happened, my mother asked her to stop the FP and as soon as she stopped the FP, she gained her weight back” - (A female, FGD in a community without CHPS).
Side effects
Just as other medications, hormonal based contraceptives have some adverse reactions when taken by some individuals but this was often over generalized. This was reported as one of factors inhibiting women from using contraceptives. Some of the common side effects that respondents reported were headache, excessive bleeding (menorrhagia), palpitations and dizziness. In principle, not every woman who uses the hormonal contraceptive methods experience these adverse reactions, however the general perception in the community was that all contraceptives except condoms have these side effects.
“Many also complain about heart and waist problems so many people are scared. In fact, my wife was on FP but she was complaining that anytime she takes the pills she gets palpitations. So she stopped taking the pills and went back after 2 years but still she feels very weak and complains of heartaches, so I have even decided that I would let her give birth to another child after which we would go in for a permanent method through surgery”- (A man, FGD in a community with functioning CHPS).
Closely related to the side effects is delay in return to fertility following the use of hormonal based contraceptives, which was perceived to be secondary infertility. Respondents generally believed that the use of hormonal based contraceptives could result in secondary infertility.
“I know someone who has done FP before and after she stopped using it, she is struggling to become pregnant again”- (A woman, FGD in a community with no CHPS).
Some respondents also indicated that the use of condom takes away the pleasure during sex and therefore not appropriate if one was concerned about the pleasure in sex. Some male respondents when to the extent of suggesting that condom use was not a subject worth discussing between couples.
“In fact, for the condom we should not talk about it because couples would not enjoy sex when they use the condom. The condom is not nice to use during sex”- (A man, FGD in a community without CHPS).
Perceived benefits
There are many inherent benefits in the use of contraceptives to the health and social wellbeing of the couple and the child and this was explored in this study. Respondents that have used or are still using contraceptives stated some of the benefits of using FP methods as helping the couples to space their children, enabling couple to control the number of children they wish to have; making the couple more productive as they have time to concentrate on their work, and improvement in the health of children.
“FP has helped us to space our children and also provide them with education. It has also improved our productivity since we get time to do our work on time, so it is good”- (A woman, FGD in a community with CHPS).
“For me…. I gave birth to two children and became pregnant in less than two years. I later discussed with my husband about FP. He accepted the idea and went to the clinic with me. In the clinic, I was referred to the doctor, who ordered for a test on my blood and urine and he advised me that the injectables would not be good for me but rather I should do the IUD and I did it for 5 years. I actually wanted another boy so I went to remove it and I got pregnant. Even though I was scared that something could happen to me but nothing happen, the only thing is that I put on some small weight, which made me to look very nice and God being so good I had my baby boy. After giving birth to that boy I just told the doctor that I have 5 children so he should ‘cut me’ (sterilize) so I wouldn’t make any more babies again which he did”- (A woman, FGD in a community with CHPS).
Barriers to the use of Family Planning
Women reported disapproval by men as a major barrier to the use of contraceptives, which sometimes results in concealed use. However, the perception that women that are using contraceptives discharge too much vagina fluid during sex which is detectable by the husband; it makes it difficult for women to engage in concealed use. Inadequate counseling to make informed choices, correct method use and failure to differentiate between myths and fact were also identified as barrier in the use of contraceptive.
Inadequate method-mix mostly for men emerged as a constrain for men. Male methods covered by the national FP programme are condom and vasectomy. National programmes ignore the traditional methods of withdrawal and periodic abstinence. The result is that men have limited alternatives of the methods of contraception. Another barrier in the use of FP method is the cost of the methods. Even though many respondents stated that contraceptives were affordable, other said contraceptives were expensive and not affordable for them.
“… you have to pay for the contraceptive but not everybody who want to use them has the money, I met a woman who was interested in doing FP but complained that she did not have money. It is not very expensive but it is not everybody who can afford it; some people do not have money so it becomes a hindrance to accessing the service”- (A Senior Health Manager in IDI).
Shortages were also cited as a barrier to FP patronage. As some participants stated that sometimes, the health facilities run out of stock of the method of their choice. FP services providers also affirmed this finding. To avert this problem, an electronic stock management system using a short message service on mobile telephone known as the early warning sign system was introduced. In this system, various FP service delivery points are expected to send a text message to their supervising institutions at 2:00GMT every day stating the stock levels of the various FP products, so that prompt supplies could be sent to the facility before they are depleted.
Sex preferences and ideal age of marriage
There was no consensus on the preferred sex and the age for marriage in the community. FGDs generally indicated that both male and female were a product of God’s blessings and therefore should be acceptable to couples. However, a few respondents did indicate a preference for either a male or female for a child. Reasons cited for preference for the male sex include; their ability to progress to higher educational levels and high school dropout rates for females in the community. The high dropout rates according to community members make any investment in girl child education fruitless. In contrast, respondents who preferred daughters to sons cited reasons such as the propensity of male children to become unruly and indulge in social vices such smoking, stealing that bring ignominy to the family.
“For me I think girls are better than the boys because some of the boys are “crazy”…. For the boys easily fall prey to peer pressure and indulge in drinking, smoking, and womanizing and at the end of the day nothing good comes out of them”- (A woman, FGD in a community with CHPS).
Some respondents also buttressed their preference for daughters by referring to a statement made by one of the illustrious sons of Ghana, Dr. Kwegyir Aggrey.
“Please for me I think giving birth to girls is better than giving birth to boys, because there is a saying that when you educate a man you educate one person but when you educate a woman, you educate the whole nation”- (A female, FGD in a community with functioning CHPS).
The study further explored the community’s view on the ideal age for marriage. Generally, participants agreed that the ideal age for marriage especially for females was between 20–26 years even though they acknowledged that some woman even marry before celebrating their 18th birthday. This age range according to respondents was ideal because the female would have been physically and emotionally matured enough to face the challenges of pregnancy, childbirth and child rearing. One of the considerations in determining the ideal age for marriage is the ability to cater for the children up to some point before proceeding on the mandatory pension age of 60 years in Ghana. To respondents if one does not marry early and give birth, you were more likely to give birth to what respondents described as “pension babies or pension children”. A pension child is a generic term used to describe children who are still in formal educational institutions whilst their parents have attained the age of 60 years.
“Please some of the women wait till their late thirties before giving birth, which I think one will give birth to pension babies. Because the woman is already old before giving birth, within the shortest period of time she is on pension”- (A Female, FGD in a community with functioning CHPS)
Sources of knowledge on Family Planning
Communication of information and education on FP to both women and men is an important determinant in contraceptive uptake. Awareness of FP methods was universal and, on an average, every participant had heard of contraceptives in the community. The main sources of information on FP methods for men were friends, mass media, non-governmental organisations and health workers. However, male respondents general perceived home-based health education and FP services as more appropriate.
“The nurses in the community almost always talk about it (contraceptives). If you go to the CHPS compound, she (CHO) talks to you about FP. She also comes to talk about FP using the public address system”- (A male respondent, FGD in a community with functioning CHPS).
“When we attend child welfare clinic, the nurses educate us that when we breast feed the children, it contains food and water, so we should do exclusive breast feeding for six (6) months which is also a form of FP for the mother”- (A female respondent, FGD in a community with functioning CHPS).
“For us men we prefer health education in our homes…if you come to my house to offer me FP service, nobody in the community will know and I will be comfortable”- (A man, FGD in a community with less functioning CHPS).
CHPS and the provision of FP services
The Primary Health Care (PHC) system requires that health delivery system be decentralized and accessible to all individuals irrespective of their geographical location and socio-cultural background. To this end, CHPS was introduced to make health accessible to communities without hospitals, clinics and health posts. The study therefore explored the role of the CHPS in the provision of FP services.
The role of development partners and NGO in service delivery
Health delivery system involves several stakeholders from both governmental and non-governmental institutions. Effective collaboration between these stakeholders is important in achieving the desire goals in any health care intervention. Several community based non-governmental organisations were mentioned as promoting reproductive health interventions including the use of contraceptives in the study areas. The contributions of these institutions were vivid in the minds of community members and collaborated by the Health Managers in the community.
“….There are NGOs and agencies like Marie Stopes International helping. Two years ago they were with us and many women came to do the long-term methods”- (A Health Manager in IDI).
“Yeah, networking, we use the community volunteers, you know we have some NGOs who are working on the ground, CODISOT is there, they are also doing FP”- (A Senior Health Manager in IDI).
“In my church, the nurses are often invited to come and educate us on FP methods and contraceptive use. Now the pastors are preaching that if you do not take care of the children you bring into this world, you will have to give account to God when you die. We have embraced FP in our church and receive information and advice in the church”- (A woman, FGD in a community with functioning CHPS).
Contrary, some respondents indicated that some religious sects do not allow their followers to use contraceptives. This according to respondents was a drawback to advocacy on the use of contraceptives.
“We have a church by name…. they worship on Saturdays and preach against contraceptives. They say that a woman should allow the husband to have sex with her anytime he wishes”- ( A woman, FGD in a community without CHPS).
The study further explored the implementation of the CHPS and FP services in the community examining it from the political, community and health sector involvements.
Respondents stated that they sometimes make appeals to the governmental institutions to provide them with logistics for the CHPS compound and this emerged as a well-entrenched theme in the implementation of the CHPS systems.
“Some communities request for hospitals but when they are unable to get it, they get the CHPS facility instead. They become intermediaries between the hospital and the community to treat minor ailments”- ( A man, FGD in a community with functioning CHPS).
The District and Municipal Assemblies also assist in the CHPS programme by providing the infrastructure for the programme and accommodation facilities for the health workers. This was however not without challenges. Lack of funding to support the activities of CHVs was given as a major challenge resulting in high attrition rate for CHVs. Funds were also unavailable for refresher training to update the knowledge of both CHVs and CHOs.
“We are unable to organize periodic training for volunteers because of lack of funding….Even money to motivate the volunteers is a problem. Some of them say they need bicycles to enable them go round the communities which are unavailable”- (A Senior Health Manager, IDI).
The CHPS programme is a community-based health intervention strategy. This therefore implies that communities would have to be involved and actively participate at all levels of discussions leading to the establishment of the CHPS compound, recruitment of staff and the management of the CHPS compounds. Respondents generally believed that the communities were involved in the establishment of the CHPS facilities. Participants also stated that FP was an integral part of the activities of the CHOs and CHVs included FP.
“We had a meeting at our community and discussed it (CHPS) and asked those who were interested and have the desire to work as volunteers to submit their names, so we chose the most knowledgeable amongst them. Whenever a volunteer travels or is no longer interested we choose another person to take over”- ( A man, FGD in a community with functioning CHPS).
“The communities are doing their best; they provide infrastructure, maybe a room or two to start the CHPS program. About three communities have been here, they want the CHPS, they have seen the importance of CHPS, and they want it in their community by providing us with a facility”- (A Senior Health Manager, IDI).
The community sometime also assists the health workers that are posted to the health facilities. The communities can even organize durbars and invite the health workers to give them health education or for them to discuss how to improve on the health situation in the community.
“Our durbars are usually organised by the community leaders and anytime there is a problem and we report to them, they come to our aid”- (A CHO, IDI in a community with functioning CHPS).
c.
Health sector involvement
Two main subthemes emerged in the health sector involvement namely; training and deployment of Community Health Officers (CHOs) and the training and deployment of Community Health Volunteers (CHVs).
ci. Training and deployment of Community Health Officers
Community Health officers are Community Health Nurses who have completed a two-year training programme in an accredited institution and duly registered by the Nurses and Midwives Council of Ghana. They are also given additional training to be officially recognized as CHOs. Hence, all CHOs assigned to CHPS compound have received formal training to manage minor ailments and to refer promptly to the next level, cases above the training. The major challenge was in the area of deployment of the staff. Community members generally believed that they were not often involved in the deployment of staff to the community. The effect of this is that communities sometimes receive people who are not familiar with the local practices and norms within the community.
“Sometimes they bring people here who cannot speak the language and you have to tell them your problem through an interpreter….This I think is not good enough”- (A woman, FGD in a community with CHPS).
cii. Selection, training and deployment of Community Health Volunteers
The study revealed that there were two main ways Community Health Volunteers (CHV) were selected. The communities either selects a person within the community who is deemed desirable for this responsibility or an old CHV could be interviewed by local health managers and deployed to their own community. In each of these recruitment strategies, the community is involved.
“Yes, it is the community that selects the volunteers. Mostly what we do is we go to the assemblyman, unit committee members and then the chiefs to put the request before them. Generally, they often select a community member who can at least read and write and is devoted to community work. A community member who is well known by community members. The person is then recommended to us to train”- (A Senior Health Manager, IDI).
“My colleague and I are interested in health promotion activities in the community, so we were chosen by our community to be trained and we have come back to help the community”- ( A CHV, IDI in a community with functioning CHPS).
Concerning training, all CHV are either formally trained in a structure-training schedule or are sent for mentorship by CHO or to understudy CHV in a CHPS compound.
“Yes, I have been trained as a volunteer. We come here (CHPS Zone) for training almost every month”- (A male CHV, IDI in a community with functioning CHPS).
“We train the CHV for 5 days and organize periodic training for them. Those we are unable to train, we send them to the CHPS compounds to understudy CHOs and trained CHVs”- (A Senior Health Manager, IDI).
The study probed further to ascertain whether the training of CHV covers contraceptive methods. It was revealed that FP was part of the training of CHV. However, interviews with CHV revealed that their knowledge on FP was low especially regarding adverse reactions.
“The Ghana Health Service actually train them for a maximum of about two weeks, and the area covered in the training are management of minor ailments, the CHPS concept itself, home visiting, volunteerism, community participation, community mobilization, and family planning”- (IDI, Senior Health Manager).