What Do You Want to Identify in Terms of Social Analysis

Workshop Report Social Analysis and Family Planning

Version: 10 April 2009

Date: 19 to 20 March 2009

Venue: CARE meeting room, Phnom Penh

Participants: CARE NGO Partners

Facilitator: Pou Sovann (Lead Researcher, SAA)

I. Introduction

CARE Cambodia has been implementing reproductive health program, as part of an integrated package of program activities for over 10 years. While the activities themselves have varied over this time, integrating SRH with HIV, family planning and gender messages and activities, using a rights based/empowerment approach has been the core focus.

CARE Cambodia has experience in implementing FP activities in both rural and urban settings, however the same issues and obstacles continue to reduce the impact of our work. We face continuing social or cultural barriers to family planning (and in the broader arena of SRH) where our reach is broad but our ability to achieve sustainable and real behavioural change is limited. This is particularly true in our ability to address myths surrounding FP choices.

Our beneficiaries are often able to verbalise the messages we disseminate through the various activities however our indicators such as conversion to modern methods, fertility rates, consistent condom use and access to health facilities for RH/FP visits reflect that the actual practice of women remains largely unchanged. This is where we see the value of Social Analysis.

Additionally, as is so often the case with tightly controlled budgets with demanding donors, the program team, including management, are often stretched beyond work capacity and do not have the resources or space to truly reflect on the impact of activities on the populations that we work with. Social Analysis offers that resources to step beyond the detailed and hectic implementation of activities and provides a space for reflection to achieve sustainable change.

Care Cambodia hopes that the SA will provide an opportunity to guide the work with men through the lens of the impact that men have on the FP decisions made by women. The specific objectives of the study were set as follows:

 To use a Social Analysis and Action (SAA) approach to increase understanding of critical sexual and reproductive health issues in the communities where we work through exploring the ways that women (and their partners) experience the sexual relationship, through the filter of family planning practices and beliefs.

1  To determine why among our two different populations (Koh Kong and Phnom Penh) the myths surrounding the various family planning options continue to dominate over the messages given through our activities and further explore social norms and structure which influence the women’s access to FP services, and to explore the role of men in women’s FP decisions.

The following are the Research Questions:

1. What are the social or cultural barriers to family planning? 2. How do myths and rumors influence choice and uptake of family planning methods? 3. Who is involved in the family planning decision? 4. How influential are men in the family planning decision?

The research study titled “Social analysis to enhance family planning in Phnom Penh and Koh Kong is conducted by using the Social Analysis and Action (SAA) approach, which CARE has developed, in order to seek to address the social, economic and cultural factors that influence health. SSA is an approach for working with communities through regularly recurring dialogue to address how their social conditions perpetuate their health challenges. SSA seeks to enable communities to identify linkages between social factors and health and then determine how to address them.

According to the CARE USA (2007) on the book titles “Ideas and Action: Addressing the Social Factors that Influence Sexual and Reproductive Health” explained that the key elements of SSA processes are (i) the process of exploring the social component of well being in order to create community understanding of how health is shaped by socio-cultural and economic factors, (ii) an understanding of the social complexities that aid or impede the fight for good health within the a programme context, and (iii) taking concrete steps to address health and social issues within a reflection-action cycle. Therefore, SSA can be framed as follows:

 Transform staff capacity  Reflect with community  Plan for action  Implement plans  Evaluate

Therefore, as part of SSA approach the consultative workshop with CARE NGO partner staff members in Phnom Penh were organized from 19 to 20 March 2009. This workshop was further built on the Reflective Practice Workshop organized in Phnom Penh from 11 to 13 March 2009 facilitated by Dr. Graeme Storer, VBNK Director to all concerned SCICH project staff members.

A two-day workshop with project staff aimed (i) to reflect on CARE work practice related to what does FP mean? What other words or terms describe FP? What are the barriers that cause people not to use FP methods? And what are the benefits of FP? What are beliefs (and myths) about family planning, (ii) exploring what are the key issues of social related to family planning and who are the key players, and (iii) to develop schedule for field data collection.

2 Prior to discuss the detail of study, the participants were briefly about the background of the study, SSA approach and how staff involved in the process of the study which needs the involvement of concerned staff members to facilitate the data collection.

II. Findings from the Group Discussions

In order to get understanding on the issues of family planning, the participants were divided into two groups to discuss the questions and the outputs of the groups were summarized as follows:

1. What does FP mean to you?

- it is about determination number of children – not having children accidentally - it is the determination period from one child to another - it is a plan which already prepared for family such as the determination of children numbers, budget, and necessary material at specific time. - the negotiation between husband and wife to determine number of children in the household - extension gap of having baby (2-3 years)

2. What other words or similar terms describe FP?

English Khmer Contraceptive karBnüakMeNIt Protection from having baby karkarBarkMueG aymankUn Closing kiln (sterilization) biTL Close factory (sterilization) biTeragcRkplit To yowl RKav No sex - Abstinence kan;sIl

Finally, the group finalized the term used with the community for Family Planning is Methods of Prevention from Having Pregnancy (meFüa)aykarBarkMueGaymanépÞeBa H¦.

3. What are the barriers that cause people not to use FP methods? Some rumors?

- Culture, tradition and religion: using family planning – block new born – do something evil

3 - Encouragement from supporters: burden from family members included husband, parent and parent-in-law, neighbors, friends. - Knowledge of the women on FP. Women themselves (Less confidence and low self esteem): does not use due to lack of knowledge of FP and available service allocated in loge distance, fear of effecting health, no dare to try new methods

- Power of man in the family. Woman fears to talk about FP with husband - Shyness and fear to talk/negotiate - Myths and rumors: uterus allergy, stunt uterus, infertility, to be bruised on the face, having small piece of meat in uterus, breast cancer, IUD and Norplant can move around in entire body and fallen IUD into uterus. - Economy. Man has business and generates income for the family. - Access to information system - Service providing. Health providers: did not provide accurate information about sign effects, advantages in period of using FP, how to use, using unfriendly words careless, look down due to poor economic status (discrimination), did not respect health providers ethnic, not enough skills, health providers did not use FP. - Cooperation and supports from concerned stakeholders

From the key issues identified by the groups, the group of 6 people were discussed the sub- questions related to each identified barrier. The following were some findings on sub-key issues/questions from the discussion:

N Key issues key questions 1 Belief and Religion - To what extend your community understand the protection of not having baby? - To what extend parents understand in arranging marriage for children at young age? - If there is a discussion about contraceptive, to what extend community understand/view this matter? - To what extend do you understand about contraceptive methods? 2 Fear to negotiate in family - If you want to use contraceptive methods – who do you consult with in the family? - Why do you need to consult with your family members in using contraceptive methods? - If you want to use contraceptive methods – how is your family member think about this? 3 Inaccurate information from - To what extend do you describe health providers health providers in factory? - To what extend do you describe health providers in health center - To what extend do you describe health providers in NGO clinics? 4 Rumors from influencing - What do you hear any words or information from people (Village and commune people who has used contraceptive methods?

4 chief, parent-in-law, parent, - How does your husband view about family relative, neighbors, teacher, planning? NGO staff, health providers, - How do your parents view about family planning? monk)

5 5 Lack of money/budget in - How do you think about family planning service seeking service fee? 6 Shyness in seeking family - How do you think if a woman seeks family planning services planning service? - How do you think if man accompanies his partner to seek family planning service? 7 No confidence and self esteem - How do you think about using family planning? in using contraceptive methods

8 Male power in family and - How does your husband view about family economic: family planning is planning? women’s affair, male has - If you discuss FP with your husband, how is his power in negotiation and reaction? decision making use or not use, man is shy to involve in FP, the criticism from society toward male (friend, supervisor....). In FP context, women is initiator in seeking service

9 Cooperation and support from - To what extent do you think about their supports concerned stakeholders are on the using of FP practices? limited (other key players)

4. What are the benefits of FP?

- having children as wishes - there have enough time to earn income - make living standard better - eliminate mortality rate - make women and children have good health - mothers have enough time to take care children - eradicate poverty (less spending on taking care children) - have happiness family

5. What are the contents of FP lessons and key message? How many hours to train FP to people?

1. Reproductive health a. organ of productive man and woman b. menstruation c. Birth spacing i. client rights ii. traditional methods iii. hormone (COC, POP) iv. Block

6 Condoms d. Other methods – IUD, e. Stop permanently f. Sterilization g. Site effects h. Pre- Anatal care i. Post- Anatal care j. Gender k. Roles and responsibility of CBD

Key Messages during the training were provided as follows:

- Having baby as wishes rather than accidence - Less children – make family happiness - Young married couple should seek FP - Contraceptive methods provide good health for mother and kids

6. What are myths or rumors influence on the decision of FP methods?

- Using family planning – block new born – do something evil. - Using FP methods had uterus allergy, stunt uterus, infertility, to be bruised on the face, having small piece of meat in uterus, breast cancer, IUD and Norplant can move around in entire body and fallen IUD into uterus.

7. What are factors that men are influential in the family planning decision and what is the social perception of this involvement?

- because men are the one who is head of the family - man has business (income generation for the family) - men thought that this is a task of women - men have power - women have no skills to negotiate with husband - men are shyness to join FP activities or accepted any FP methods - men get critics from the society (peers at work place, supervisor) - men is discriminated by peers if they know that you are supportive to FP

8. Personal Reflection on Family Planning

Based on the exercise of Most Significant Change (MSC) used during the Reflective Practice Workshop from 11 to 13 March 2009 all participants were asked to write their personal story on story related to family planning. There were total 16 MSCs written by CARE staff in Phnom Penh, Care staff from Smach Meanchey and Srer Ambel, Beer Promoter Solidarity Group and from NGO partner staff members. Only five were selected as the MSC. The following are some observation and the personal reflection from the stories as follows:

- A CARE staff member aged mid to late 40s declared that he was too old for family planning! When questioned he indicated that his wife had already reached menopause and so therefore they did not need to be concerned about family

7 planning anymore. The reflection from this is if powerful people in the family life believe that FP is not an issue then discussion or influence may impact on access to information or commodities or both. - During MSC a non-CARE participant from our local NGO partner told a story of her two abortions. Her story was selected as the most powerful of the group as it resonated with our work without directly involving us in having to actually experience. It was the very personal nature of the story that made it most powerful.

- One contentious statement challenging the filters of the group was whether you would give your 18 year old son a condom to ensure his sexual safety. Seemingly surprisingly a non CARE participant from our Young Urban Males program firmly stood his ground saying that he would not give his son a condom. When questioned why he said that if he were to truly want his son to look after his sexual safety then he would be better off learning where and when he could find a condom on his own rather than depending on his parents.

- The terminology of family planning implies that having sex is only for making or preventing a family. The use of the word family planning therefore excludes the action of sex for pleasure between non married couples.

- During story telling the concept of using a condom on your honeymoon was considered a humorous and inappropriate action. Reflecting upon this it may be interesting to explore why this would be inappropriate: condom reduces pleasure? Condom implies STI or HIV? Condom negates trust? Condom reduces passion?

- The current government of Cambodia has recently embarked upon a morality campaign for young people in order that the culture and moral values of Cambodia are sustained. This includes how young women dress and behave – encouraging virginity and humility. How has this campaign impacted on young unmarried women and does it differ urban vs rural?

- During the story telling, a female CARE staff member has noted that buying a condom at Private Pharmacy was responsible by her and in case she was busy her husband was shy to go and was always complaint to her and finally both of them (husband and wife) decided to use IUD.

- A female Care staff that had knowledge and skills on family planning while working for Care many years but she was not able to discuss FP with her husband after having two daughters because her husband preferred son to daughter. She could discuss about FP when she delivered a third child (son).

- A male Care staff decided to use condoms all the time while having sex with his partners after having blood test with negative HIV. Since then, he always tell and explain to his friends about condom uses not to prevent HIV/AIDS but also to prevent from pregnancy.

8 - A female Care staff told the story that she was happy because her husband decided to use condom as part of FP. He did not want his wife worry about other methods; he was the one responsible about this.

9. Who are the key players in the family planning decision? a. Women/wife b. Husband c. Father d. Mother e. Father-in-law f. Mother-in-law g. Relatives h. Neighbor i. Staff of NGOs (educator) j. Service provider k. Village chief l. Monk m. Abbot (Achar) n. Teacher

III. Reflection of the workshop by participants

After the two days workshop, the Facilitator asked all participants about their reflections and the following are the summary of the reflection:

- Method of SSA study is good but we need more time to involve and think about each issue. - Have good working environment and share information to the team - The participants have good experiences in providing inputs to the workshop - Having friendly working environment between Facilitator and participants - The group is provided based on the best knowledge we have from our experiences - The workshop gives as lessons for us and wait to get the finalize version from the facilitator and will improve in the future. - This is a participatory process that staff can involve in the research is very much appreciated for the staff members especially the training on data collection and research design will provide knowledge for us on participatory research.

IV. Concluding remarks

The workshop was successfully conducted and all participants were actively participating in answering, asking questions, and discussion to provide inputs for the topic of study. Moreover, they shared experience among each other about each topic. Most of participants indicated that the workshops provided them additional knowledge and skills and will be good for them in improving skills and knowledge on family planning.

The outputs of the workshop will utilize to develop a questionnaire based on the study objectives and research questions for FGD, In-depth interview, Key Informant Interview and Peers Ethnographic.

9 Annex A: Schedule for the workshop

CARE Cambodia – Social Analysis and Family Planning Workshop

Phnom Penh: March 19 – 20, 2009 at Care office in Phnom Penh

Objectives: During this 2-day workshop, participants will be able to:

. Reflect on their work practice related to what does FP mean? What other words or terms describe FP? What are the barriers that cause people not to use FP methods? And what are the benefits of FP? What are beliefs (and myths) about family planning . Exploring what are the key issues of social related to family planning and who are the key players . Develop schedule for field data collection

Thursday, 19 March 2009 Friday, 20 March 2009 8:30 – 12:00 Welcome and introduction Exploring what are the key issues of . Objective of SSA social analysis (Con’t) . What are the key social issues Discussion by using ARLP Tool related to FP? . What does FP mean to you? . What are sub-issues or key . What other words or terms questions to be developed? describe FP? . What are the barriers that cause people not to use FP methods? . What are the benefits of FP? What are beliefs (and myths) about family planning? 12:00 – 13:30 Lunch break 13:30 – 5:00 Exploring what are the key issues of Develop schedule for field data social analysis collection . What are the key social issues . Discuss the date for data related to FP? collection . What are sub-issues or key . Discuss the target groups questions to be developed? selected for FGD, KII, IDI, PER

10 Annex B: List of Participants

N Names Sex Position NGOs 1 Uk Meta F Team member KWCD 2 Nuon Ren F Team Leader (TL) WDA 3 Sat Sopheap F TL CHED 4 Chhim Pheavy F TL CWPD 5 Seang Seng F TL Solidarity Group, Adwood 6 Tek Somaly F TL CCWD 7 You Rat F Team member NAPA 8 Teng Sam Ath M Project Officer PHD