Iud Contraceptive Use Among Women of Reproductive Age

IUD CONTRACEPTIVE USE AMONG WOMEN OF REPRODUCTIVE AGE:

A QUALITATIVE STUDY AT THE FAMILY PLANNING CLINIC OF NAKASEKE GENERAL HOSPITAL

NAMBALIRWA TEDDY

15/U/20585/PS

SUPERVISOR:

Dr. SCOVIA NALUGO MBALINDA (PhD, MSc, BScN)

A DISSERTATION SUBMITTED TO MAKERERE UNIVERSITY DEPARTMENT OF NURSING IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR AWARD OF A DEGREE OF BACHELOR OF SCIENCE IN NURSING OF MAKERERE UNIVERSITY

MAY, 2019

DECLARATION

DEDICATION

I dedicate this dissertation report to my father Mr. Male Alozious, my brother Kayongo Joseph and my husband Mr. Ddumba Richard who have been a great source of encouragement and financial supporters throughout my academic years.

ACKNOWLEDGEMENT

I thank the almighty God, for the love, grace, guidance, wisdom, understanding, providence and strength He has granted me to make this study a reality.

Throughout the writing of this dissertation, I have received a great deal of support and assistance.

I would first like to thank my supervisor, Dr. Mbalinda Nalugo Scovia, whose expertise was priceless in formulating research topic and methodology in particular and helped me to do this wonderful study on the topic IUD use among WRA, which has helped in doing findings and to know many of the women‟s experiences.

A would also like to express my special thanks of gratitude to my colleagues in year four 2019 nursing school for their wonderful collaboration. You supported greatly and were always willing to help me.

I would also like to thank my tutors for their valuable guidance. You provided me the tools that I need to choose the right direction and successfully completed my dissertation.

In addition, I would like to thank my father, my brothers, my sisters and my husband for their wise counsel and sympathetic ear. You are always there for me. Also, to my friends there, who were of great support in providing happy distraction to rest my mind outside my research.

Finally, I thank the school of health of health sciences, Department of nursing and Nakaseske general hospital for approving this study.

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TABLE OF CONTENTS

DEDICATION ...... ii ACKNOWLEDGEMENT ...... iii TABLE OF CONTENTS ...... iv LIST OF FIGURES AND TABLES...... vii OPERATIONAL DEFINITIONS ...... ix ABSTRACT ...... x CHAPTER ONE: INTRONDUCTION ...... 1 1.1 Introduction ...... Error! Bookmark not defined. 1.2 Back ground ...... 1 1.3 Statement of the problem ...... 2 1.4 Justification of the study ...... 2 1.5 Objectives ...... 3 1.5.1 General objective...... 3 1.5.2 Specific objectives...... 3 1.5.3 Research questions ...... 3 1.6 Conceptual frame work ...... 3 CHAPTER TWO: LITERATURE REVIEW ...... 6 2.1 General information on family planning ...... 6 2.2 Contraceptive IUD ...... 6 2.3 Experiences faced by WRA using IUD...... 8 2.4 Motivations...... 9 2.5 Barriers limiting the IUD take up ...... 10 CHAPTER THREE: METHODOLOGY ...... 13 3.0 Study design ...... 13 3.1 Study population ...... 13 3.2 Study site ...... 13 3.3 Selection criteria ...... 13

3.3.1 Inclusion criteria ...... 13 3.3.2 Exclusion criteria...... 13 3.4 Sample size and sampling procedure ...... 13 3.5 Data collection...... 14 3.5.1 Data collection tool ...... 14 3.5.2 Data collection procedure...... 14 3.6 Quality control measures ...... 15 3.6 Data analysis ...... 15 3.7 Ethical consideration ...... 15 CHAPTER FOUR: RESULTS ...... 16 4. 0 Introduction ...... 16 4.1 Description of the study participants...... 16 4.2 Experiences faced by WRA using IUD contraceptive ...... 18 4.2.1 Method related experiences ...... 19 4.2.2 Procedure related experience ...... 19 4.2.3 Health workers related experiences ...... 20 4.2.4 Client related experiences ...... 21 4.3 Motivations to choose IUD contraceptive ...... 24 4.3.1 Method related ...... 25 4.3.2 Client related...... 26 4.3.3 Use of media ...... 27 4.4 Barriers influencing the use of IUD contraceptive ...... 27 4.4.1 Client related...... 28 4.4.2 Myth and Misconception ...... 29 4.4.3 Health system factor ...... 31 4.4.4 Procedure related ...... 32 4.4.5 Method related ...... 32 4.4.6 Peer influence...... 33 CHAPTER FIVE ...... 34 5.0 Discussion ...... 34 5.1 Experiences faced by WRA using IUD contraceptive ...... 34

5.2 Motivations to choose IUD contraceptive ...... 36 5.3 Barriers influencing the use of IUD contraceptive ...... 37 5.2 Conclusion ...... 39 5.3 Recommendations ...... 39 5.4 Limitations ...... 40 APPENDICES ...... 47 Appendix 1: consent form ...... 47 Appendix 2: INTERVIEW GUIDE PART I FOR IUD USERS ...... 51 INTERVIEW GUIDE PART II FOR FGD...... 53 Appendix 2: Luganda version of the consent form ...... 55 Appendix 3: Translated interview guide (Luganda) ...... 59 Appendix 5: The Time Frame ...... 64

LIST OF FIGURES AND TABLES

LIST OF FIGURES

Figure 1:Conceptual framework ...... 5

LIST OF TABLES

Table 1: A summary of socio-demographic characteristics of the IUD users ...... 16 Table 2: Socio-demographic characteristics of women using other contraceptive methods but not IUD...... 17 Table 3:Summary of codes, subcategories and themes derived under experiences...... 18 Table 4:Summary codes, subcategories and themes which were derived under motivations...... 24 Table 5: Summary of codes, subcategories and themes derived under barriers...... 27

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LIST OF ACRONYMS AND ABBREVIATIONS

IUD Intra Uterine Device

IUC Intra Uterine Contraceptive

LARC Long Acting Reversible Contraceptive

MMR Maternal Mortality Rate

UBOS Uganda Bureau of Statistics

USA United States of America

WHO World Health Organization

WRA Women of Reproductive Age

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OPERATIONAL DEFINITIONS

Contraceptive: This is a birth control method in form of a device, chemical agent or sexual practice that interfere with the normal process of ovulation, fertilization, and implantation when used by women to prevent them from getting pregnant (WHO ,2018).

Contraceptive IUD: This is a small, flexible plastic frame with sleeves or wires around it in a T form which is inserted into a woman‟s uterus through her vaginal and cervix to cause chemical change that damages sperm and egg before they can meet (WHO,2018).

Experiences: These are perceptions, realities and knowledge a person can air out after observing, encountering or undergoing same period of time passing through some situations or using something and have an understandable meaning (Merriam-Webster).

Barriers: The process that makes it difficult for mothers to use IUDs.

Family planning: Family planning is a practice that allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births (WHO, 2018).

Long acting reversible method: This is a method used by women for a long period of time (more than 1 year) in order to prevent them from being impregnated (WHO, 2015).

Unmet need for family planning: These are women who are fertile and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child and the unmet need points to the gap between women's reproductive intentions and their contraceptive behavior (WHO, 2018).

ABSTRACT

Back ground: Uganda has a high Maternal Mortality Rate (MMR) of 343 per 100000 live births. This could be due to unwanted pregnancies thus leading to major complications such as abortions, hemorrhage. However, to reverse this high maternal death, long acting reversible contraceptives (LARC) which includes Intra Uterine Devices (IUD) had been proposed in the developing countries. Despite availing the necessary contraceptive, Uganda still has a very low uptake of (IUD) among women of reproductive age at 0.6 percent and their discontinuation rate in the first three months of use is also high.

Objective: The general objective of this study was to explore the reasons why women don‟t want to take up contraceptive IUD through assessing the barriers that may influence their use and experiences they face.

Methodology: An exploratory qualitative study was employed using in depth interviews and Focus Group Discussions (FGD) to collect data of experiences, barriers and reasons attached, from women of reproductive ages (WRA) in the family planning clinic of Nakaseke General Hospital. A purposive sample of 8 women were interviewed. A thematic analysis was applied to analyze the data.

Results: Mothers using IUD reported positive experiences including remaining with sexual feelings, satisfaction with the method, long term method, preventing against un wanted pregnancy and normal menstrual periods. However, some reported negative experiences which included; pain after insertion, bleeding after insertion, UTI and continuous virginal examinations. The study also revealed different motivations using IUD which included, information from health workers, friends and media. For mothers who were using other methods of family planning reported that barriers which prevent them from using IUD included; fear due to what IUD users have experienced, myths and misconceptions and financial constraints. Conclusion: The experiences were mixed, both positive and negative, but generally women were satisfied with the IUD use. The motivators were their drivers to the method and barriers were reported to influence the IUD use. There is need for mothers who have used IUD and are

x satisfied with the method to talk to other mothers so that we can increase IUD use as a method of Family planning.

CHAPTER ONE: INTRONDUCTION

1.1 Back ground Worldwide, about 830 women die from pregnancy- or child birth related complications every day (World Health Organization, 2018). Out of these 99% occur in developing countries including Uganda (WHO, 2018). Although the risk of women dying during child birth is declining around the world, in sub-Sahara maternal mortality and morbidity is still high (WHO 2015).

Globally, one of the major causes of maternal mortality is abortion which is estimated to be at 7.9% (Global health, 2014). Lack of family planning leads to unintended pregnancies which in turn result into unsafe abortions (Dragoman et al., 2014).

Family planning reduces women‟s health risks as a result of abortion, hemorrhage, uterine perforation, cervical injury, medical complications which lead to death and infections due to incomplete abortion. This helps in reduction of maternal morbidity, mortality and slows population growth. However, only 14.3% of women of reproductive age are using intra uterine contraceptive worldwide. It is lower in developed countries which stands with only 7.6% and in Africa Intra Uterine Device (IUD) use is only at 4% of women of reproductive age and this distribution is still reasonably very low as compared to the number Women of Reproductive Age (WRA) (Buhling, Zite, Lotke, & Black, 2014).

Much as efforts is put through different programs about Long Acting Reversible Contraceptive (LARC) family planning methods to increase their uptake (WHO, 2015). In Uganda IUD use is still low, it was 0.2% in 2006 slightly increased to 0.4% in 2011, and there is a gradual increase from 0.6 % in 2014 to 1.1% in 2016 (UDHS, 2016). Although there is a slight increase, IUD use is still very low despite its effectiveness, long lasting and need no mother‟s adherence. And this has reduced on the numbers of maternal morbidity and mortality rate through avoiding un intended pregnancy (Rowe, Farley, Peregoudov, Piaggio, & Boccard, 2016). A study done by (Twesigye, Buyungo, Kaula, & Buwembo, 2016) showed most women reported negative attitudes, misconceptions and misinformation about IUD as compared to positive attitudes. Therefore, in this qualitative study there is need to understand why there is low uptake of IUD

1 contraceptives by listening to women experiences while using IUDs and what exactly prevent them from using them.

1.3 Statement of the problem The fertility rate in Uganda of 5.71 children born per woman (UBOS, 2017) and maternal mortality rate of 343 deaths per 10000 live birth is also high (UNICEF, 2015). The high mortality rate could be due to the unwanted pregnancies, short birth intervals and a high risk of obstetric complications associated with low contraceptive use (Nalwadda et al 2010). Uganda demographic and health survey showed high level of unintended pregnancies (44%) with unsafe abortion estimated to be 62 per 1000 women of age between 15-49 years which accounts for 26% of maternal deaths in Uganda.

Like other districts in the country, Nakaseke through Ministry of Health (MOH) has availed efforts scaling up family planning in reaction to unwanted pregnancies. Different strategies have been established in the public sector as interventions through training provider per selected facility. In addition, one reproductive health focal person per district in IUD service delivery and use of community extension workers have also been recognized to help those not accessing the IUD services due to economic, social and geographical areas (MOH, 2014).

Despite the comprehensive efforts by MOH to increase IUD uptake, it has continued to be very low 1.1% with about 10% of early discontinuation in the first 90 days of insertion (UDHS, 2016). With this health system effort in perspective, there is need to understand different barriers, motivations and explore experiences of users of IUD.

1.4 Justification of the study This study adds to the understanding of the barriers to utilization of contraceptive IUD and factors responsible for the high rates of premature removal of IUDs in Uganda as well as experiences being faced by women using them.

Exploring both positive and negative experiences may contribute to development of appropriate programs, health talks or outreaches to strengthen IUD use since most of women largely depend on opinions and experiences of friends and family when making reproductive health decisions (Gedeon et al, 2015).

The study contributes information to the health providers to address and disclose them to the IUD users during counseling. And this may serve as a stepping stone in improving IUD utilization.

1.5 Objectives

1.5.1 General objective The main objective this study was to explore women‟s experiences of using IUDs, in order to develop specific strategies to improve IUD uptake.

1.5.2 Specific objectives 1. To explore women‟s experiences of using IUD as a method of contraceptive

2. To identify motivating factors for use of IUD as a method of contraception

3.To identify barriers to the use of IUD as a contraceptive method

1.5.3 Research questions 1. What are the experiences faced by WRA using IUD contraceptive?

2. What are the motivations to choose IUD contraceptive?

3. What are the barriers influencing the use of IUD contraceptive?

1.6 Conceptual frame work The conceptual frame work indicates how IUD contraceptive decision making can be influenced from different angles, through woman‟s back ground, the perceived barriers (consequences), experiences encountered by those currently using and not using IUD and perceived motivations.

Back ground: The background factors such as age, number of children, marital status and demographic factors may influence IUD contraceptive use positively and negatively. Positive outcomes include: low mortality, low morbidity and reduced cases of infertility (Diana et al., 2014; Foster et al., 2014).

Experiences of those using IUD: Women, who get positive experiences such as effectiveness of IUD, long term use, prevention of pregnancy despite the side effects insist and choose IUD. These is because of its efficacy and are more likely to continue with the IUD and those who get negative experiences such as PID, bleeding, requiring a medical procedure for IUD withdraw from using IUD (Coombe, Harris, & Loxton, 2016; Diedrich et al., 2018)

Perceived motivations: Women with perceived barriers from health workers or personalized are hindered from using IUD. But with increased health education by the health providers and increased media information increase the uptake (Madden et al., 2013).

Perceived barriers: Perceived barriers such as child spacing, myth and misconceptions contradict with the family planning methods. The limited knowledge about IUD contraceptive use affects its uptake and also nulliparous women and those wanting pregnancy soon are also found of not using the contraceptive IUD due to fears of outcomes (Luchowski et al., 2018)

DEMOGRAPHIC PERCIEVED BARRIERS CHARACTERISTICS EXPERIENCES OF Myth and Age THOSE USING IUD misconceptions P Education Negative Child spacing Marital status experiences

Knowledge and Friends and relatives Positive experiences E beliefs about pregnancy Religious affiliations

Health provider’s Demographic area knowledge Number of the children

IUD CONTRACEPTIVE DECISION MAKING

PERCIEVED MOTIVATIONS Personal and health provider

Education by the health provider

Sensitization by MOH

Figure 1:Conceptual framework

CHAPTER TWO: LITERATURE REVIEW

2.1 General information on family planning In the whole world, there was an increase in contraceptive use from 1990-2010 as (54.8% - 63.3%) and the unmet need for family planning decreased from 1990-2010 (15.4%-12.3%) ( Alkema, Kantorova, Menozzi, & Biddlecom, 2013). The same study showed small increases in contraceptive use in Africa and Uganda as 17.4%-30.9% ,6.9% -28.4% respectively but this still very low.

Worldwide, about 26% of WRA die as a result unwanted pregnancy due to major complications, unsafe abortion being one of them and this accounts for 39 abortions per 1000 in women aged 15-49(UNICEF, 2015). This implies that there is a high unmet need for family planning (FP) as well as high contraceptive discontinuation rate which contribute to the high fertility rates that in part are due to unplanned pregnancies (Kibira, Muhumuza, Bukenya, & Atuyambe, 2015). Studies show that in sub-Sahara almost all maternal deaths can be prevented (UNICEF DATA, 2017), emphasizing LARC which includes IUDs has been proved to be highly effective method of contraceptive which does not depend on woman‟s motivation and adherence, allows rapid return to fertility, prevent against endometrial cancer(Stoddard, 2013) and in addition, IUD can completely be reversed unlike the sterilization method which totally terminate the woman‟s fertility, (Sonfield, Siddiqui, & Okunlola, 2007) thus this study aimed at understanding why there was low usage of IUD, early discontinuation through exploring experiences of women ; identifying the barriers of IUD and understanding women‟s reasons.

2.2 Contraceptive IUD Worldwide IUD use among WRA is estimated to be 14.3% (Buhling et al., 2014), its proved to be a perfect device in preventing unplanned pregnancy and probably should be taken as the first- line contraceptive choice for any woman with no medical contraindications (Bahamondes, & Bahamondes, 2013). The mostly seen models currently being applied are the TCu380A

6 intrauterine device and the levonorgestrel-releasing intrauterine system and they are referred to as „long-acting reversible contraceptives reason being that they sustain contraception for more than 3 years, they have very low rates of contraceptive failure regardless of the age, they are safer, with little side effects, have a high continuation rate and can be used irrespective of age or parity (Bahamondes & Bahamondes, 2013) and in spite of their importance, up to now many healthcare professionals are not advising adolescents, young women and nulligravidae to take them up, even though WHO makes no boundaries for them.

These intrauterine contraceptive IUC can prevent pregnancy by stimulating a sterile inflammatory response in the uterine cavity that can be toxic to the sperm and also the ova and in so doing , it alters the composition of the uterine fluid , the morphology of the endometrium through stimulating a cytotoxic inflammatory reaction that is highly spermicidal and thus hinders fertilization (Mishell Jr, 1998)

IUDs can not only provide effective protection against unintended pregnancies for a long period of time (5-10 years), but also don‟t require daily adherence and save users from adverse effects of contraceptives such as pills and injectable (Peipert, Madden, Allsworth, & Secura, 2012).

Africa has by far the lowest percentage of women using birth control (33%) (United Nation, Department of Economic and Social Affairs, 2015) where most of these are Short term methods such as Depo-Provera, pills, condoms and others which have several side effects and highly misused, (United Nation, Department of Economic and Social Affairs, 2015) and this still reveals the unmet need for FP and all these call for more interventions to Increase the very low update of Long Acting Reversible Contraceptive ( LARC), IUD being inclusive which is in the position to reduce the rate of unintended pregnancy (Buhling, et al., 2013) since they are effective, long lasting and need no mother‟s adherence thus reducing on the numbers of maternal mortality rate through avoiding un intended pregnancy. Recently studies show a significant increase in IUD users to 3.8% (Twesigye et al., 2016) and the long acting reversible contraceptive, IUD being one of them increased from 6% to 9% total modern method use (WHO, 2016) this evidences a very low increase in the uptake of IUD worldwide as a modern method and with high efficacy and less side effects .

A recent study revealed that copper-bearing intrauterine device( IUDs) and the levonorgestrel( LNG) medicated IUD are one of long and efficacious reversible contraceptive methods which can provide protection against unwanted pregnancies for at least 5years to 10 years, whereby they don‟t need daily or coital adherences and thus women did not immediately turn back to the clinic after being inserted (Winner et al., 2012 ; Rowe et., 2016). This study does not differ from some study done in 2013 which showed satisfaction among LARC users who continued with their IUDs after the first year (Madden, Eisenberg, & Secura, 2013). Yet another study showed that several women were concerned with where exactly the IUD is placed in their private reproductive tract and whether their partners are able to feel it during sex intercourse (Fergurson et al., 2015).

From a study conducted in USA showed that IUDs can be effective to an extent of having only 0.14% and 0.7% of unintended pregnancies reported within the first year of insertion of women using LNG IUD or copper IUD respectively and within the same study few contraindications are faced thus most of the WRA are eligible to IUD use (Winner et al., 2012).

Also another study conducted in European countries showed that women using IUD were faced with uterine perforation but this was at a very rare incidence especially in non-breastfeeding mothers (Luchowski et al., 2018).

2.3 Experiences of using IUD A recent quantitative study carried out to examine the qualities of a contraceptive that make them attractive or un attractive to the users revealed that most LARC users were satisfied with their chosen method at 3 and 6 months follow up; however, increased cramping, bleeding volume and bleeding frequency was associated with decreased short-term satisfaction (Diedrich et al., 2018) similarly , in another study (Coombe, Harris, & Loxton, 2016) pain , bleeding problems, expulsions, and the where its located in the body were commonly reported as negative effects , more women continued to use IUD at one year however several of these women discontinued due to the side effects and pregnancy with the IUD in place. Women who had removed IUD in addition to the above effects cited symptoms like ; vaginal discharge, yeast infections, UTI, cramping and these didn‟t match their expectations because they were more severe ,lasted for so long than expected (Amico, Bennett, Karasz, & Gold, 2016).

It was also found that Nulliparous women were less likely to use an IUD despite of their efficacy, not interrupting sex ,being cost effective and discrete (Coombe et al., 2016) majority of women were interested in IUD self-removal ,and having this option increased their likelihood of recommending the method to others (Diana et al., 2014; Foster et al., 2014), these studies are more like other results which revealed less advocate for IUD use in nulliparous women who are more likely to keep IUD in as compared to the multipara women whom discontinue earlier (Dickerson et al., 2013). Women were also un clear about where within the reproductive tract an IUD was placed and whether the partners would be able to feel it during intercourse (Ferguson et al., 2015). This study evidenced the low knowledge about IUDs and interest in this method was not greatly improved by the provision of information (Fleming et al., 2010).

In some other study Perceived benefit of using LARCs was protection against pregnancy for a long period of time but this did not stop them from raising concerns like discomfort with the IUD inside, lack of self-control over it as its only depended on health work during insertion and removal, wondering where exactly the IUD is placed all expressed the gap in knowledge (Rubin & Winrob, 2010).

Although women were concerned with the potential side effect, There was a number one benefits noted by women; ease to use; they would not have to think about these contraceptive methods every time or remember to take them every day like pills, were able go back to their regular periods or not having periods at all and having no worries that one is pregnant (Spies, Askelson, Gelman, & Losch, 2010) while another study showed women‟s concerns being pelvic discomfort, heavy bleeding ,spotting and irregular periods, cramping, and so many others had tempted to remove the IUD by themselves yet others who were satisfied and preferred a professional worker to remove it (Foster et al., 2014).

2.4 Motivators. A study done in 2013 showed satisfaction among LARC users who continued with their IUDs after the first year (Madden, Eisenberg, & Secura, 2013). This depended on the health provider‟s decisions to select IUD among others due to slight side effects IUDs have. Yet in another study there were benefits noted by women; ease to use; they would not have to think about these contraceptive methods every time or remember to take them every day like pills, were able go

9 back to their regular periods or not having periods at all and having no worries that one is pregnant (Spies et al., 2010) and this highly facilitated their continuation with the IUD.

2.5 Barriers to uptake of IUD Various studies have been conducted in several parts of the world to examine the different barriers associated with IUD use in WRA. And through these studies, it is revealed that many obstetricians -gynecologists still do not consider the IUD as an appropriate contraceptive method for some groups of women such as adolescents and nulliparous (Luchowski et al., 2018). Unintended pregnancies are more observed in adolescents and even their knowledge and experience towards postpartum insertion is limited (Luchowski et al., 2018) . Yet in another study it was revealed that most clinicians promoted family planning methods of their own choice. It was observed that clinicians advocated for those with high efficacy but these had unexpected irregular bleeding which occurred in the first year of insertion (Weisberg, Bateson, McGeechan, & Mohapatra, 2014)

In a study conducted among homeless young women showed limited knowledge about LARC methods. Pain, complications and reproductive pressure were also a big problem (Dasari et al., 2016). However, it was observed that the major concerns were; women perceived providers deliberately choose to leave out some key information about the side effects or possible complications in order to attract them to select the contraceptive and women had no clear information about early discontinuation of LARC. Women also showed a strong desire in visual aids to help them understand better which should be accompanied by verbal counseling done by health providers (Dasari et al., 2016)

A study conducted on female undergraduates at a large mid-western university in USA revealed that women‟s perceived knowledge was low as compared to measured knowledge (Stidham et al., 2018). This indicated misperceptions about side effects, pain, serious health problems and how eligible the method is. Most women were not aware of the presence LARC and also women preferred having a self-controlled method and never wanted a foreign object in their bodies (Stidham et al., 2018). Another internet based study which surveyed 1982 women revealed some associated factors hindering IUD use being race, program and year of study, religious affiliation and service attendance, employment status, sexual orientation and contraceptive histories being part of the determinants of IUD take up (Hall et al., 2016). In the same study the

10 commonly perceived barriers associated with IUD use included; not wanting foreign object in their body, not knowing enough about the method, worried about pain, side effects, serious health problems, cost ranged and not being in a long-term marriage or relationship.

Also, another study conducted in United States revealed several barriers to contraceptives in adolescents and most of these adolescents still used short term methods such as condoms, coitus interruptus, and this was due limited knowledge about IUD, negative perceptions about LARC particularly from peer groups. Many of obstetrician- gynecologists did not consider IUD as the first line choice of contraceptive this is because they fear inserting them to nulliparous women since historically IUDs were marketed for porous women thus becoming a barrier to adolescents (Browne et al., 2018). In the same study, adolescents were less interested with the IUD uptake because of their perception that maybe PID, and infertility can develop due IUD insertion. While some were concerned about the menstrual cycle disturbance, pain, fear and cost which contributed to less up take of IUDs and premature / early discontinuation of the IUDs (Browne et al., 2018).

Yet another study conducted in Uganda showed that some of the negative factors that affect contraceptive use among young people were irregular contraceptive stocks, poor service organization, and the limited number of trained personnel, high costs, and unfriendly service. This study showed that most providers were not competent enough to provide long-acting methods, had misconceptions about contraceptives, negative attitudes towards the provision of contraceptives to young people, but had no evidence based on age restrictions and consent requirements this revealed that most of providers were not prepared, and thus were just not in position to render young people contraceptives. Again in the same study, Short-acting methods were considered acceptable for young married women and those with children instead of LARCs (Nalwadda, Mirembe, Tumwesigye, Byamugisha, & Faxelid, 2011)

A different study done in France reported very few women with future child-bearing being current users of IUD, this was because of fear to return quickly to fertility as a misconception and also the need to always see a health worker for insertion and removal was alarming and even the physician themselves being reluctant in providing IUD to nulliparous women (Moreau, Bohet, Hassoun, Ringa, & Bajos, 2014).

Despite their safety and efficacy, IUD utilization in Uganda is still low at 1.1% (UDHS,2016) due to high discontinuation rates in the first three months at 10% and 4.5% being expelled out (Reiss, Nantayi, Odong, & Ngo, 2012). Furthermore, another study done in Rubaga division showed that women had higher knowledge about LARC but it was more about myths and misconception. which shows a gap in knowledge and this reveals the very low uptake and so more studies need to be carried out since this study was done in just a portion of urban area and thus results are not reliable (Anguzu et al., 2014). In addition previous studies carried out in USA indicated myths and side effects as the major barriers to long reversible contraceptive methods (Nelson & Massoudi, 2016) however these studies were not specific for IUDs use in Uganda thus more qualitative studies are needed to understand deeply what really cause the low up take.

CHAPTER THREE: METHODOLOGY

3.0 Study design An exploratory qualitative study. This qualitative approach provided an in depth understanding of the user‟s experiences both negative and positive thus participants were able to express their views freely in their own terms to clearly bring out the meaning they attach to their experiences.

3.1 Study population The study included Women of Reproductive Age (WRA) that is 15-49 years at family planning clinic in Nakaseke general hospital.

3.2 Study site

The study was conducted in Nakaseke General Hospital which is located in Nakaseke district. It is located approximately 61 kilometers by road, from Kampala city. Nakaseke hospital is a rural hospital built in the 1960s. It serves Nakaseke District together with some the neighboring districts Luweero, Wakiso, Nakasongola, and Mityana. The hospital has the following services: family planning, antenatal, surgical, obstetric, pediatric, dentistry, outpatients, emergency conditions (casualty). The family planning clinic operates from Monday to Friday and receives approximately 40 mothers per day.

3.3 Selection criteria

3.3.1 Inclusion criteria To be included in the study, a woman must have been of a reproductive age (15-49), using any of the family planning method at the family planning clinic in Nakaseke hospital and must have been in position to speak English or Luganda fluently.

3.3.2 Exclusion criteria

Those who were very sick were excluded from the study.

3.4 Sample size and sampling procedure Purposive sampling was used to recruit women who had come for IUD family planning method. It was also used to recruit women who have come for any family planning method so as to get participants who could participate in FGDs depending on their related characteristics such as age

13 groups of teens, mid-twenties and late thirties. This was done in seven days of the working hours. Four (4) Focus Group Discussions (5 to10 participants per group) were held to get the barriers and reasons why women don‟t want to take up IUD until saturation. This provided various opinions of the study participants. Also (8 participants) were interviewed to obtain a deeper understanding of experiences of IUD users and this also depended on saturation of information received from them.

3.5 Data collection

3.5.1 Data collection tool An in-depth interview guide composed of open-ended questions was used by the principal researcher. The interview guide was developed in English, translated into Luganda and consisted of questions about; biographic data, motivations and experiences with contraceptive IUD use, barriers that limit IUD use and reasons attached. The interview generally started by obtaining the participants biographic data, followed by contraceptive and reproductive health history, motivations, experiences with the IUD use, then barriers plus reasons why they were not interested in IUD use.

3.5.2 Data collection procedure.

The principal researcher contacted women who presented for any family planning method. This was to explore their experiences, why they are not using IUDs but other methods. Interviews took place from Monday to Friday during clinical working hours at the waiting area. At the beginning of each clinic day, clients usually first converge together in a common area for a group counseling session. Women were approached while here to participate in the interviews while waiting for group counseling session. Participants were recruited by face to face after an informed consent about the nature, benefits, risks, and purpose of the study. Information on voluntary participation, rights to withdraw and consent were made known to study participants and a written informed consent was obtained from each participant, and then moved to a quiet and private place. The interviews were conducted either before or after the counseling session, depending on the participant‟s choice. Also, the principal researcher could first obtain permission from the participants before initiation of an interview to record their voices during the interview

14 for each participant so as to avoid missing out some information. The researcher also used a pen and book to note down key emerging topics from the interviews.

3.6 Quality control measures The interview guide for IUD users was pretested before data collection at the family planning clinic of Nakaseke hospital with one participant and the first FGD conducted was used to pretest the FGD interview guide. This was done before the actual data collection to enable the researcher know how much time shall be spent on each participant and FGD. And also, to verify whether information from participants is corresponding with what the researcher intends to measure. The Principal investigator personally conducted all the interviews and moderated the FGDs. This was done by taking a participant in quiet and private place to ensure privacy. interviews and FGDs were audio recorded and transcribed verbatim to capture all the information from participants.

3.6 Data analysis This was partly done concurrently with data collection, and this helped a researcher to know how, when and what to ask next for the subsequent participants. After data collection, all audio data were transcribed verbatim on a regular basis and a thematic analysis was used to assign codes according to the messages in the content. The researcher made sure that she was very much familiar with all the content from each participant and the information was typed in Microsoft word program and checked against the recorded audio to prevent missing out information. Similar and frequent data was organized and grouped into meaningful groups and labeled with codes.

3.7 Ethical consideration The study proposal was approved by Makerere University Department of Nursing and Makerere University School of Health Sciences Institutional Review Board and a clearance was obtained from the administrative board of Nakaseke regional hospital. Prior to data collection, the researcher could seek for permission through a written consent from all potential participants and information obtained was used only for research purpose. The recorded information was only and only accessed by the researcher and only made accessible to the supervisor; no any other individual was allowed to access the information.

CHAPTER FOUR: RESULTS 4. 0 Introduction This chapter provides the results of the study that was carried out to explorer the experiences, motivations and barriers of WRA, those using IUD and those using other methods but not IUD. The findings were from eight (8) participants who were interviewed using in depth interview to explore their experiences and motivations towards IUD contraceptive. And four (4) FGD were carried out in this study with women using other contraceptive methods but not IUD to find out the barriers and reasons attached why they were not using IUD contraceptive. The material from FGs and individual interviews were analyzed as one set.

4.1 Description of the study participants. A total of eight participants were interviewed with WRA using IUD with age between 24-40 years and all were married apart from one who was a sex worker. Three of them attained a secondary level of education, three stopped in primary level and two reached tertiary level. All participants were Christians and all of them except one (1) were in working class, had more than one child. The rest of the characteristics were as shown in table 4.1 below.

Table 1: A summary of socio-demographic characteristics of the IUD users

Participant Age Marital Occupation Religion Level of No of Address number status education children 1 29 Married Health protestant Diploma 2 Nakaseke town worker 2 24 Married Not Protestant S.4 1 Kyamukakata working 3 39 Not Sex worker Catholic P5 2 Kapeeka married 4 39 Married Business Catholic P7 6 Kapeeka woman 5 32 Married Business Born S.4 2 Nakaseke

woman again 6 30 Married Health Catholic Diploma 3 Matugga worker 7 29 Married Hair dresser Catholic S.4 3 Kiggegge 8 40 Married Peasant Catholic P7 7 Nakaseke Centre

Also, four FGD were conducted with WRA who were not using IUD contraceptive but other methods with the age between 18-39 years, and Christians carried the highest number of twenty (20) participants, followed by Moslems nine (9) participants and the rest were Seventh Day Adventists (3). Most of them were married twenty-five (25) and only seven (7) were not married. Those who were working were twenty-five and those who were not working ended up to seven (7). Fourteen (14) attained secondary level, fifteen (15) stopped in primary level and three were illiterate, as shown in table 4.2.

Table 2: Socio-demographic characteristics of women using other contraceptive methods but not IUD.

Variables Category Frequency Percentage (%)

Age 15-25 20 63 26-35 10 31 36-45 2 6 Region of residence Central region 32 100

Occupation Working 25 78 Not working 7 22

Marital status Married 25 78

Not married 7 22 Religion Christians 20 63

Moslems 9 28

Seventh day 3 9 Adventists

Level of education Primary level 15 47

Secondary Level 14 44

Not educated 3 9

4.2 Experiences of using IUD contraceptive

Table 3:Summary of codes, subcategories and themes derived under experiences.

Theme Theme Experiences faced by WRA using IUD contraceptive

derived Sub experiences related Method experiences related Procedure experiences related work Health Client related experiences

categories

Codes derived Codes Long term method Pain due to Mistrust of health Contentment and satisfaction about IUD No change of body procedure worker Encouragement from IUD users image due to the Good insertion Support from Fear of infection from un faith full relationship method with expert health worker Need to be faithful in a relation ship

Convenient with provider Information given Fear of feeling of strings the method/use Bad insertion with is for only Normal menstruation period No need to adhere non-expert health positives not Informed about the method Better than other provider negatives Fear of misplacement of IUD method Discomfort due to Health workers Un certainty about what to do next for the consequences Concerned about procedure choice Satisfaction with the method side effects of Bleeding due to Remain with normal sexual feelings other methods like procedure Conflicting information from friends and health workers injectaplan Cancer screening Concerned about frequent virginal examination Remain with before the Encouragement of nonusers to go the hospital for more information normal sexual procedure Provision of information before insertion feelings Pain after Lack of enough information about the method (where its placed) insertion Prolonged menstrual periods in the first weeks Bleeding after Remain with libido, Fewer side effects insertion Worried about having sex intercourse with the husband Heavy bleeding

4.2.1 Method related experiences Experiences for mothers were assessed and both positive and negative experiences were reported. The positive experiences which were reported by women included; IUD is a long-term method of family planning; remain with their normal sexual feeling, women said that IUD stays for a period you want and that the sexual desires are not disrupted. This was emphasized by a mother.

“That for it you insert it for a period you want as long as the person who has inserted it inserts it well it can be there for that period until when you reach time when you are tired of it!” (participant 1)

“Mmm I am asking why they say that it‟s good you remain with feelings and indeed its true am also experiencing it!” (Participant 3)

Women also reported that the method was convenient and comfortable for them, it does not need adherence like other methods and that they were concerned about the side effects of other methods like injecta plan (depovera) which had treated them badly. Most of the women were comparing it with other methods as being better than others.

“Ok let me say I have a weakness because they need to be used in time for example pill plan what they swallow, me I cannot swallow them in time I can easily forget them” (participant 1)

“pills were giving me nausea and for the case of injector plan I would always be bleeding abnormally but for it (IUD) my menstrual days stay normal as there is nothing like missing my periods” (participant 4)

4.2.2 Procedure related experience Some women reported that they were first screened for cervical cancer before the procedure and this created awareness of their status which they believed was good for their health.

“of course, they first screened me for cervical cancer well…… and they confirmed that I was ok they inserted it” (participant 1)

The negative experiences which were reported by women included pain on insertion, discomfort and bleeding after insertion and these narrated how they experienced discomfort, pain and bleeding during the procedure and after the procedure.

“By the way nurse it can also cause prolonged menstrual bleeding like for two (2) additional days. I experienced prolonged bleeding for the first three (3) weeks when I had just started using it but it finally normalized “(participant5)

“now there is a friend of mine who went for cervical cancer screening, for her she says it was painful, so she thinks even inserting it can be painful” (participant 7)

4.2.3 Health workers related experiences Most women received support from health workers. Some health providers they re-assured them when they had concerns while using IUD by providing them with knowledge, their personal experiences for those who had used IUD, sensitizing and counseling them.

“The health worker who worked on me also had IUD for the last 5 years so she told me; I shouldn‟t worry that happened because of heavy bleeding. She also told me that if I happen to see again heavy bleeding, I should take Ibuprofen to reduce on the blood, that also candida disrupts IUD, so she emphasized the importance of personal hygiene, and that if I get it I should make sure I take medicine to avoid infections because its problem is infection” (participant 8)

Some women had good experience with experienced health provider on the first attempt and then bad insertion with un experienced health provider.

“at first for my first time, the health workers had experience because I didn‟t get any problems. But this 2nd one, it was inserted in by the students of that health facility, one of her colleagues was a nurse it seems she was still a student...How do they call them? Those instruments they use to insert it, she first hurt me when she was enlarging the cervix, this thing which is broad and enlarge it… yea speculum, she touched me with the speculum and it hurt me and brought in some bleeding, so they kept on wiping” (participant 1).

However, some mothers reported that some health providers do not give them information about the negative side of IUD, they only provide them with positive information which seemed to be biased on their side and another woman narrated how she developed mistrust from health workers of a certain hospital and ended up going to another hospital.

“for them (health workers) they don‟t talk about the negative side of it, for them they talk about positive side only” (participant 2)

“I had to go to another hospital, I told health workers and after checking, they also saw that the strings were hanging, they shortened them so that‟s the problem I encountered” (participant 1)

4.2.4 Client related experiences Fear was expressed by women who were not using IUD. These fears included; misplacement of IUD, fear of getting pregnant, abnormal fetus when the IUD is misplaced, contracting Cancer due to its long use up to 12 years, fear of strings getting stack and fearing to have sex with their husband because it would cause injury to the cervix. These resonated a lot in these quotes;

“they(friends) tell us that it causes cancer when it over stays in you, it can burn you {she laughs} things like those” (participant 4)

“the other thing which used to worry me I could say may be it can move away from where they had placed it and it moves deeper in the body, another one was maybe when you are playing sex with your husband and he knocks on it I thought he could injure the cervix” (participant 2)

“the 2nd one, people do get missing strings so sometimes, I also think I may end up missing mine too, that all nothing else” (participant 6)

The other concerns about IUD which were reported by the women were; the heavy bleeding, prolonged menstruation periods especially in the first three months after insertion, itching due to IUD and fear to get infections.

“what can worry me, {she thinks} is that health providers told us that if you we got into our periods, we can always check on the strings on daily basis and sometimes the IUD can get dislodged out with heavy bleeding on rear occasions” (participant 5)

Some women reported having felt pain (lower abdominal pain), back pain after the IUD insertion as their experience while others were concerned about the frequent vaginal examinations.

“…mmmm I had pain on one side of the lower abdomen,” (participant 8)

“…eeeh but most of these days have been suffering from pain in my abdomen {she touches her lower abdomen} then I thought may be its bent” (participant 3)

Women reported men being uncooperative when it reaches to the use of FP, one of them narrated how she inserted IUD secretly without the husband‟s awareness and the friends. She did this because she was fearing conflicts in her family, so she decided to do it independently, she reached a point when she was uncertain about the consequences of disclosure to the husband and she ended up consulting a friend.

“hmmhm there like three who know about it, it‟s between me and my best friend , reason being my husband doesn‟t know and I don‟t want him to know, so I don‟t want any other person to know, my husband for him he tells me you give birth every child has his or her own blessings She narrates „‟ imagine nurse what I went through when my IUD got misplaced, I had only 10000 with me, I couldn‟t ask anybody money, my husband didn‟t know about it, because I had lied to him that it‟s an infection, I was so... scared but if the same problem happens to others, they may end up discontinuing and decide to give birth to children. Some may be doing It secretly, lack money even to take them to the hospitals”

Also, women described how they got the information from their peers before insertion of IUD. This encouraged them get informed about the method from health workers and most of them were even able to report some of the benefits of method.

“it was my friends when we were still studying, when they used to say that IUD is good then I said let me also use it and see” (participant 2)

“ok me I always stay with health workers so I ask them whether it‟s possible, and for them they say it always get misplaced in the first three months because it has not gotten used with the body, but if it gets used with the body the chances of it moving there not there” (participant 7”)

“they think she can get cancer but me what I know IUD prevents cancer when someone uses it”. (Participant 6)

So as a result, they reported passing on information about IUD to friends through encouraging them to visit the nearby health facilities where they can access the different FP methods

“me the advice I give them is to go to the experienced health care providers to teach them so that they can understand because this way some people lack information, they have never seen IUD and they just hear about it” (participant 4)

“…I went to the hospital and they taught me about FP (participant 5)

Some women expressed their concerns when they reported need to be faithful with their partners and the demand for extreme hygiene while using IUD which seemed to be perturbing on their side.

“… you are supposed to be trusting your husband that he has only you, and you are supposed to first discuss it with your husband” (participant 1)

“…the health providers always remained us about our personal and general hygiene” (Participant 5)

Some women expressed a number of satisfaction measures about IUD when they reported that their body image remained the same, normal menstruation periods, method being hidden and convenient, remain with libido, fewer side effects as compared to other methods and that they can be able to properly look after their children with love.

“…have not experienced over weight like the way other hormonal methods do, have not over experienced those complications of bleeding, have not experienced problems in short,” (participant 6)

“ok ... it is like this {she thinks} ooh how can say? {she laughs] it does not give hard time, because there is nothing like that, I can touch on it the way it is for that of arm, yes like that” (participant 7)

“the better yet my children will be able to grow up happily. Remember whenever you give birth consecutively, love goes down” (Participant 8)

4.3 Motivations to choose IUD contraceptive

Table 4:Summary codes, subcategories and themes which were derived under motivations.

Theme Motivations to choose IUD contraceptive

derived categories Sub Method related Client related Peer methods ty of the Availabili

- related

Codes derived Long term method No change of body image Information media from social Motivated Concerned about side effects of Encouragement from IUD user from other methods like injecta plan Information about IUD from friends

Convenient method health worker Non hormonal method Ignoring other people‟s words Unavailability of other methods Trusting health workers Prevent un planned pregnancy Fewer side effects with IU

Not worried of getting pregnancy

It‟s important to consider the strength of women's fertility motivations when determining who has a need for family planning services. In this study women were asked what motivated them to use IUD despite the fact It is the least taken up method in Uganda and the different themes were

24 identified; Method related, client related factors and availability of the IUD services at the facility,

4.3.1 Method related All women reported different ideologies towards the IUD inspirations and among all the most cited ones were; remaining with sexual desires or libido while using IUD. the method being a non-hormonal one and protecting you from pregnancy for a long. Some reported also encouraging others to seek advice from health facilities as reported below;

“ok they used to tell us that you remain with your feelings {she laughs...} …those who were teaching it on TV {she again laughs} we used to watch adverts, yet the other methods you lose sexual feelings and it can be forceful {she bursts into laughter‟s}” (participant 7)

“…Once it is removed from the body, nothing remains. It‟s not like pills, injector plans where hormones remain in the blood. Even the implanon they insert in the arm they told us hormones stay in the blood so I decided to choose IUD” (participant 5)

“…but I advised her to go the hospital so as to be taught.” (participant 8)

Side effects of other family planning methods such as irregular bleeding, change in body size, motivated the women to use IUD

“for 1st born I was using injectaplan and I could not manage it then I stopped… I was not menstruating… ok it also used to make me have a headache… for the 2nd born I used implanon… even with it I was not menstruating, and it used to bring headache and pulsations” (Participant 7)

“what motivated me to use it, depending on how they told us as they were teaching us, because I first attended a teaching session before inserting it, what mostly motivated me was that .... I have a problem, let me say ok a weakness of using other methods because they need to be used in time for example pillplan what they swallow, me I can‟t swallow them in time I can easily forget them” (participant 1)

“there is nothing like changing my body, I expect nothing since the method does not cause any body changes (participant 8)

Failure of the other family planning method motivated some clients to use IUD.

“and then in December last year, I had a customer the condom burst, then I got pregnant and before that pregnant ,I had undergone a C-section ( for that last born), they don‟t allow you to give birth to another child when the child is not yet 3 years, by then he was like one month so I got pills from the hospital and aborted. Then again in the same period I got another customer and again the condom burst, I got pregnant again Then I asked myself why? Condoms which I have used for so long have become problematic! What can I use now? I went to the hospital and I wanted to use inject plan since am a sex worker, the FP health worker told me it was banned use IUD.” (participant 3)

Health providers helped them make choice to IUD by providing them with information. Some women shared their experiences how the health providers told them that the IUD is a long-term method, can stay in for a long period of time which was one their motivators to use IUD.

“In that period when I had not given birth again, I went to the hospital and they taught me about FP and realized that IUD will be easier for me…. the health providers said it is for ten (10) years” (participant 5)

4.3.2 Client related Peer influence and relying on the information provided by the health providers motivated some mothers to use IUD.

“what also motivated me was that it has no problem in the body the way health providers teach us, right now I also feel free as if I don‟t have anything in my body, there is nothing like pulsations, (participant 8)

“it was my friends when we were still studying, when they used to say that IUD is good then I said let me also use it and see” (Participant 2)

“No…. me I no longer listen to them (friends); I took my health care providers advice as she told me to stick on it and resist from listening to those who do not have knowledge about it…me the advice I give them is to go to the experienced health” (participant 4)

Others motivators included: convenience to use IUD, used for a long period time and fewer side effects;

“the reason is that the 7 children are many depending on the Ugandan situation which needs money for everything, yet for us we don‟t have support to look after children who are more than that. We need to give birth to children whom we can manage to support” (Participant 8)

4.3.3 Use of media Use of media such as advertisements, TV shows and fliers influenced the women to use IUD. Some women received information through media and they opted for IUD. This was emphasized in the quote below;

“ok they used to tell us that you remain with your feelings {she laughs...} … those who were teaching it on TV {she again laughs} we used to watch adverts, yet the other methods you lose sexual feelings and it can be forceful {she bursts into laughter‟s)” (participant 7)

4.4 Barriers influencing the use of IUD contraceptive Table 5: Summary of codes, subcategories and themes derived under barriers.

Theme Barrier influencing the use of IUD contraceptive

Mmmss derived categories Sub related worker Health Client related factors system Health related Procedure related Method Peerrelated

Codes derived of healthMistrust worker. Inadequate knowledge about FP with use. servicesInaccessibility to FP and costs associated services.Costly Fear to get ashamed. Fear to get infection. Fear painful. that is it Discouragement from friends/ Knowledge deficit about IUD. Financial constraints. Discouragement from friends or peers.

Fear of misplacement of IUD Fear of injury during sexual intercourse

Fear of unplanned pregnancy with the method, fear of consequences, such as pregnancy, side effects.

Perceived risk of cervical cancer. peers Myths from friends Perceive can burn her eggs, Perceived risk of rusting of IUD Lack of social support

The decision to use or not to use FP services is the product of a number of demographic and service-related barriers. In this study the following themes were identified as barriers; Health worker related, Client related, health system related, method related factors and myth and misconceptions

4.4.1 Client related Mothers reported financial constraints, social support, preference of other family planning methods, complications of IUD and knowledge deficit about IUD hindered them from using IUD. Below are some of the quotes emphasizing about client related hindrances

“it‟s a difficult method because for it is not like condoms, implanon, when you face any problem it can be difficult to realize and seek medical attention urgently, but for the implanon you feel it, and for the condom you can see in case of any problem” (FGD 2)

“I heard that they want to remove FP methods, most regions don‟t have FP and working on you they ask 20000” (FGD 4)

„‟ imagine nurse what I went through when my IUD got misplaced, I had only 10000 with me, I couldn‟t ask anybody money, my husband didn‟t know about it, because I had lied to him that it‟s an infection, I was so... scared but if the same problem happens to others, they may end up discontinuing and decide to give birth to children. Some may be doing it secretly, lack money even to take them to the hospitals” (participant 8)

“and indeed, me I started using it before internalizing all about it, I went there because of the condoms‟ burst because I was scared of getting pregnant when have not planned for it and when I reached there, the health worker chose for me” (Participant 3)

4.4.2 Myth and Misconception Rumors about contraceptives are spread by and among women themselves, often through their informal social networks. In this study a number of myth and misconceptions were identified and this prevented the mothers from using IUD.

Fear of pain during insertion

Most women reported that why women do not want to use IUD is because they fear pain and hurting them during insertion.

“… most of them say they would experience pain and feel hurt when they are inserting it” (participant5)

“they are just fearful, {she laughs} now there is a friend of mine who went for cervical cancer screening, for her she says it was painful, so she thinks even inserting it can be painful. She also says that when they screening for cervical cancer, they cut off some piece of cervix {biopsy}” (participant 7)

Fear of getting cancer

Women reported fear of cancer which they attached to the long stay of the method in the body, this was also emphasized by the FGD when a participant mentioned the related idea.

“problems may be what I heard was that if it over stays in you it can bring cancer but me it didn‟t treat me bad” (Participant 2)

That IUD nurse has one part which has metal so whenever it stays longer in you it rusts and brings you cancer of the cervix, FGD 4

Fear that IUD causes fibroids

Women said that IUD causes fibroids on the uterus. This was said on behalf of friends as their perceived concerns towards IUD use.

“and it also causes fibroids on the uterus” (FGD 1)

“Some tell us that we get tumors because of FP” (participant 8)

Fear that it burns organs

Fear about burns of internal organs was also reported by one participant when she said that friends tell them when it over stays, it can burn them.

“they tell us that it causes cancer when it over stays in you, it can burn you {she laughs} things like those, those who are not health workers… they have the perception that it can cause cancer, death and very many other things like burning lungs, uterus things like those” (participant 4)

Fear that IUD can get stuck in the uterus or misplaces in the body.

Some participants expressed their worries with IUD when they reported that they perceive it can move away or get stuck there. Others also reported on behalf of their friends what they perceive. And this was also narrated by one participant in one of the FGD.

“then others think it will get stuck inside, others think it will move and go to the heart ...” (participant 6)

“the other thing which used to worry me I could say maybe it can move away from where they had placed it and it moves deeper in the body” (participant 2)

“I think it can be bad because it is inside in the uterus so it can spoil it, and brings me problems” (FGD 2)

Fear that it causes infertility and injury during sex or gets displacement.

Participants reported how friends say that IUD can burn someone‟s eggs and then one participant had fear of physical harm during sexual intercourse. While one participant reported that it got dislodged and another perceived it was bent.

“and others say it burns their eggs among others” (participant 6)

“everybody brings her own opinions like someone said it can rust (she laughs) ... that it can get displaced from the uterus when you play sex with your man” (participant 5)

“Another one was maybe when you are playing sex with your husband and he knocks on it I thought he could injure the cervix” (participant 2)

4.4.3 Health system factor The cost attached to IUD service provision, Incompetent health providers and lack of special Family planning units prevented them from using IUD.

“some say money… if you go to other nongovernment hospitals, most of them sell it, and indeed they sell it because there is a clinic I have ever gone to and the gynecologist was asking 100000shs in order to insert it,” (participant 1)

“since have not used it (IUD) for so long, I always think it can be like the 1ST one, and if at all it happens, I will need to pay again for it since inserting it for the first time is free but replacing it you have to pay. And yet what motivated me to use it was because of; It is a long acting purpose and it being free… exactly when I went back, they made me to pay 20000 because I did not have a card, it means you have to keep some money for such instances” (Participant 8)

4.4.4 Procedure related The process the women go through to insert IUD prevented them from using IUD. The issues to do with undressing and pain they experience during the insertion. This was emphasized in the FGD when participants said that IUD is placed inside

“women whom I hear of fear to be seen (their private parts)” (participant 6)

“… going and un dress, squat for the health worker, {she loughs} when you have not gone to give birth” (Participant 7)

“it is a difficult method because for it is not like condoms, implanon, when you face any problem it can be difficult to realize and seek medical attention urgently, but for the implanon you feel it, and for the condom you can see in case of any problem…some say it enters there down in your uterus” (FGD 2)

4.4.5 Method related Infection, back pain, Lower abdominal pain and abdominal cramps related to IUD use prevented the mothers from using IUD. Also mothers reported how health providers reminded them about personnel hygiene whenever they could show their concern about the strings on the IUD.

“eeeh but most of these days have been suffering from pain in my abdomen {she touches her lower abdomen}” (participant 3)

“what can worry me is, because they taught us that incase a man goes and gets another woman and he gets UTI not UTI, sorry STI you can also get it, and immediately you contract it you have to remove eeeee that‟s where my fear is and that‟s why they say „you are supposed to be trusting your husband that he has only you, and you are supposed to first discuss it with your husband” (participant 1‟)

“Even me I heard about it with a woman when we were in the market, she told me for her she was using it … ok. She was married but complaining about it, saying “it does not want a second man you are supposed to use only one man” that‟s how I heard her saying {hahahaaha she laughs}” (FGD 4)

4.4.6 Peer influence. Participants reported one of the things that can prevent women from using IUD is the information they get from other women who have faced challenges with IUD say. They said that same people do exaggerate the information thus scaring non users.

“for example, what happened to me if am to narrate to another person I will not tell her the exact thing which happened, I can also exaggerate that when you go back you pay a lot of things. like those ones. In other words, if some gets a problem, she can over exaggerate it. I remember when they were teaching us, one woman said that for her she had squatted to urinate and the IUD dropped off since then she has never used it again” (Participant 8)

“for me have ever seen someone... it seems they had inserted it badly when she was complaining that it hurt her uterus and they were almost removing it, there is also another one who got pregnant with it, yea they say women get pregnant with it” (FGD 1)

“There at my place there two women whom I know of they got pregnant with IUD and I think right now the children are 6 years, so even us who use FP we started getting worried because we go for FP to stop un wanted pregnancies and again we end up getting them” (FGD 3)

While other participants said that for them their friends who were using the method say that it causes side effects like backache,

“some say it makes you feel back pain when you are going into periods” (Participant 2)

CHAPTER FIVE 5.0 Discussion This study has tried to explore women‟s experiences, their motivations and barriers associated with IUD. The negative experiences and the rumors from IUD users were considered as the most barriers for IUD use. The positive experiences are the women‟s satisfactory measures and health providers, side effects of other methods, peer influence and use of media were the motivators to start using IUD.

5.1 Experiences faced by WRA using IUD contraceptive According to Ugandan guidelines, women are supposed to be screened first for cervical cancer before IUD insertion. In this study the women appreciated knowing their cervical cancer status although they had only come for IUD insertion. This is a good strategy promoting service integration where a woman can receive more than one services in one place or even better in one procedure. WHO recommends the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system (Berwick, Nolan, & Whittington, 2008). This involves identifying the population, attending to it universally and an integrator responsible to implement it on the specified population (Berwick et al., 2008). This aims at improving the individuals experience of care, the health of population and reducing the costs of care for the population. We need a comprehensive, integrated approach to service delivery. We need to fight fragmentation.” WHO Director-General, 2007. Studies have shown that integration of services increases client satisfaction, its cost effective and it reduces the issues to with governance and resources (Heyeres, 2016; Ridde, 2010). This calls for more studies to integrate services about IUD and aspects of life as one.

Peer support has powerful potential to improve health behavior change and peer influences can also have a negative effect on health behavior. In this study some women received information from their friends that made them use IUD. Studies have shown that peer support can; enhance access to health behavior information and resources, practice and apply problem-solving skills

34 with group feedback and support, discuss health behavior challenges and barriers, sharing health behavior changes, sharing perceived health outcome improvements and benefits, feelings of belonging and being cared for, and addressing health of family and community (Lee et al., 2018). This is what exactly happened in this study. However, for mothers who experienced challenges and side effects discouraged other mothers from using IUD. This is in agreement with a study done in Ghana which found out that the willingness and ability of young women to use FP methods and services were affected often negatively, by factors operating within and across each level and some of those factors included peer influence, non-spousal support and support and lack of support from relative. (Challa et al., 2018). It also indicates a need to increase on socializing ability of the women using the method with those not yet using the method to proof their good experiences so as to increase on the IUD usage. A study done on interest in and experience of self IUD removal showed similarly how women could freely pass on the good experience they had encountered to their peer friends (Anderson et al 2014; Foster et al., 2014).

Intra Uterine Device (IUD) has a lot of advantages however in this study the women who used IUD liked it because it was convenient, they didn‟t have to keep taking the pill, their body image didn‟t change as compared to hormonal methods and they also acknowledged that their sexual desire or libido did not change. These are very important advantages from the perspective of women because studies have shown women usually move from one method of family planning because of change in body size and other related side effects. Studies have shown that most people switch methods mainly because of method related side effects (Atnafe, Assefa, & Alemayehu, 2016; Barden-O‟Fallon, Speizer, Calhoun, & Corroon, 2018). Women will use a method if they don‟t experience a lot of side effects and if they are comfortable with the method.

Women remained with their IUD in situ despite the constant UTIs experienced, pains and itching. This further explains the benefits which were outweighing the side effects. Some were given analgesics to relieve pain and the recurrent UTIs could be due to poor hygiene by the women themselves and may be multiple partners. Women reported being helped by their health providers whenever they could approach them with different concerns, things like analgesics, antibiotics were mentioned as the side effects‟ relievers. This calls for more sensitization about the method necessities and various solutions against side effects should be made available to health providers to alleviate concerns from IUD users. In contrast a study done by family

35 medicine on IUD discontinuation revealed that many women could not persevere with the side effects for so long (Amico et al., 2016). This could be due to poor counseling and management done by the health providers when faced with women of various challenges.

5.2 Motivations to choose IUD contraceptive It‟s important to consider the strength of women's fertility motivations when determining who has a need for family planning services. In this study women highlighted the reasons why they were using IUD. Most of them said that IUD has fewer side effects as compared to injectable family planning, others said that their body size didn‟t change and they had normal libido unlike when they were using hormonal methods like implants and injectable(Higgins, Ryder, Skarda, Koepsel, & Bennett, 2015). Similarly studies have showed related information, that IUD does not require daily adherence and save users from adverse effects of the methods containing hormones such as injectaplan (Madden et al., 2013; Spies et al., 2010b).

Other women highlighted its convenience where you don‟t have to take it every day or return to the health facility for another dose. Similarly (Peipert et al., 2012) showed related information, that IUD does not require daily adherence and save users from adverse effects of the methods containing hormones such as injectaplan. This remains one of the strong incentives why women chose IUD contraceptive. The encouragements to use IUD can now depend on disseminating levels and measures about its benefits. Likewise, in this qualitative study (Higgins et al., 2015) women said how they had faced no interference with their sexual feelings though some were not sure whether it is due to IUD use or not. To most of these women using IUD, these motivations were the basis for the uptake of the method. This still explains the importance of IUD over other methods.

Media plays a huge role in passing on or disseminating health care messages. In this study women acknowledged that they first saw TV adverts and heard radio announcements before they made up their mind to use IUD. This shows that if more media sources are involved in disseminating of information about IUD can increase usage. In the quantitative study done in Europe and united states showed a need to worker toward improved media (Hong, Montana, & Mishra, 2006; Hoopes, Gilmore, Cady, Akers, & Ahrens, 2016; Sonfield et al., 2007) showed the importance of using media to increase IUD use. It is however important to educate the public directly, through government supported campaigns can be a positive promoting IUD use. This

36 can help in reducing government health care expenditures on unwanted and unintended pregnancies and postnatal care

5.3 Barriers influencing the use of IUD contraceptive Although, most countries have made great strides in increasing access to and voluntary use of family planning including Uganda since the landmark International Conference on Population and Development in Cairo. In this study women expressed fear to use IUD and most of the issues raised were myth and misconception. The fear that IUD causes cancer, causes fibroids, can get stuck in the uterus discouraged women from using IUD. Studies done in some urban cities in Africa found similar myths like contraceptives can harm your womb and in another study both in Rwanda and Ethiopia mother expressed fear of IUD disappearing in the uterus during sexual intercourse and fear of procedure thus limiting them from taking up family planning especially IUD (Endriyas, Eshete, Mekonnen, Misganaw, & Shiferaw, 2018; Gueye, Speizer, Corroon, & Okigbo, 2015; Farmer et al., 2015). The main point communicated in this study was that fear play a very important part in hindering IUD use. This could explain why Uganda still has a low IUD use rate and a need is required to increase its use. Several studies have been done and revealed fears of different categories which also were considered to be barriers for the uptake of IUD. These included hurting of the reproductive tract (Dasari et al., 2016) and expulsion of the IUD (Reiss et al., 2012). This implies that more effort is needed in training the health providers and intense counseling and teaching should be done during the teaching sessions of these mothers. This can be fruitful when even community outreaches are done because some mothers are taught at facilities but most of them do not come to health facilities. Also, private clinics/ facilities must be availed with all the necessary resources to also target those attending them and better approaches during FP sessions must be availed to dispel the myths and misconceptions. Furthermore, IUD is still believed to be second line method in failure of other methods, good use when other contraceptive methods have been failed. This explains why IUD use is still very low. Similarly a study has been done which indicate the related information were women opted to use IUD after failing with other methods (United Nation, Department of Economic and Social Affairs, 2015)

Financial support remains a very important aspect in regards to access of maternal and child Health especially use of IUD. This study revealed the financial implications as being one of the

37 leading barriers to pick up IUD. Given the insufficiencies in the public health system FP users are likely to seek treatment for side effects from private health facilities which may not be affordable to most of them. It is important that in the interest of equitable centered services, provision of free public sector FP services should be accompanied by readily available therapies for side effects. The importance of involving men in reproductive, maternal and child health programs is increasingly recognized globally. In most maternal and child health services including family planning do not actively engage men were reported as being less involved in the female‟s reproductive decisions making yet they majorly depend on their husbands. This is because most of these women do not work and those who work earn little. Many studies revealed the same aspect as the barriers towards using IUD these generally included perceived knowledge about method being very low and they were concerned about the costs (Nalwadda et al., 2011; Stidham et al., 2018; Weisberg et al., 2014). This calls for men involvement in the FP programs. The immediate negative financial implications may dominate this long-term benefit if there is a gap in empowerment and public sector support. Further research to understand the financial impact of FP side effects is recommended.

During family planning provision it mandatory to provide holistic information about the method. In this study women highlighted that the providers only provided the advantages and the good things about IUD and they never provided information on side effects. This made mothers change the method because of side effects (Dasari et al., 2016). It is important to effectively talk about the negatives and positives of the method to avoid premature discontinuation of the method. This was also showed in the results found in the study conducted on female undergraduates at a large mid-western university in USA which indicated that women‟s perceived knowledge about IUD was inadequate as compared to knowledge found out (Stidham et al., 2018).

The procedure of providing IUD include exposure of private parts. Many mothers also reported their concern and fear to see their private parts during the procedure. The anxiety expressed is most felt when they had not gone to give birth, do not have any health illnesses of their private parts. These results are corresponding with a phenomenological study which revealed that women embarrassment is mainly during the procedure by other staffs rather than the principal

38 inserter (Fevriasanty, Lyneham, & Mccauley, 2013). This anxiety can be reduced by explaining fully about the procedure and ensuring mother‟s privacy.

5.2 Conclusion The study identified experiences both positive and negative. IUD users were fond of disseminating knowledge and information about IUD. The information was either encouraging or discouraging. Particularly, the contraceptive motivators included IUD being non hormonal, no need to adhere, does not cause menstrual irregularities, long term method and having few side effects as compared to other method. Women were in place to influence others for the method and to the experienced consultants. Among the barriers found out, myth and misconceptions were the most reported and these included perceive it can cause cancer, get displaced, burn internal organs and getting pregnant while using the method. This created a lot of fear in them and it was seen as still a bigger barrier. This information is important in the clinical setting, as it provides practitioners with a greater understanding of the various experiences, motivators and barriers and see where to add and not to. Discussion about the barriers and bringing IUD used mothers during conversations about contraception may increase rates of uptake, by providing women with balanced information about both the potentially negative aspects of IUD (i.e. irregular bleeding), as well as the positives (i.e. lack of interference with sex, body image and being easy to use).

5.3 Recommendations 1. IUD non users expressed their concerns about fears of cancers, misplacements, unwanted pregnancies caused by IUD. Although more research is needed, researchers and health providers may need to teach more about myths and misconception during their counseling and emphasize the need to routinely visit health facilities after insertion of IUD.

2. Health worker provider should reassure women that the side effects due to the method will subsidize with time and should be in position to manage them in order to reduce the levels of premature removal of IUDs.

3. In order to increase levels of contraceptive IUD, more awareness shall be done in different communities such as universities, colleges and urban areas to embed them with information and knowledge about the method.

4.Also there is need to involve male partners in decision making about family planning so that couple counseling for contraceptive becomes easier

5. There is need to put special clinics for FP where women can go for consultation in case of any problems with the method and should be free of charge so as to encourage mothers to continue with the method.

6. Mothers before using the method should thoroughly be explained both the positive sides and negative sides of the method so as even when they get problems, they are aware and know which step to do next.

5.4 Limitations 1.Since women were selected purposively, only WRA who came to the facility on days when principle researcher was conducting research had the chance to participant in the study.

2.There is no confidence that other themes would not be identified if data collection was continued, however am confident that the themes identified were better enough to consider the findings of this study as important.

REFERENCES

Alkema, L., Kantorova, V., Menozzi, C., & Biddlecom, A. (2013). National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. The Lancet, 381(9878), 1642- 1652. doi:10.1016/S0140-6736(12)62204-1

Amico, J. R., Bennett, A. H., Karasz, A., & Gold, M. (2016). “She just told me to leave it”: Women‟s experiences discussing early elective IUD removal. Contraception, 94(4), 357– 361. doi.org/10.1016/j.contraception.2016.04.012

Anderson, Nora, Jody Steinauer, Thomas Valente, Jenna Koblentz, and Christine Dehlendorf. "Women's social communication about IUDs: a qualitative analysis." Perspectives on sexual and reproductive health 46, no. 3 (2014): 141-148. doi:1363/46e1814

Anguzu, R., Tweheyo, R., Sekandi, J. N., Zalwango, V., Muhumuza, C., Tusiime, S., & Serwadda, D. (2014). Knowledge and attitudes towards use of long acting reversible contraceptives among women of reproductive age in Lubaga division, Kampala district, Uganda. BMC research notes, 7(1), 153. doi:10.1186/1756-0500-7-153

Atnafe, M., Assefa, N., & Alemayehu, T. (2016). Long-acting family planning method switching among revisit clients of public health facilities in Dire Dawa, Ethiopia. Contraception and reproductive medicine, 1, 18. doi:10.1186/s40834-016-0028-z

Bahamondes, L., & Bahamondes, M. V. (2013). Considering the risks and benefits of intrauterine devices: should clinician advice now be changed?. Clinical Practice, 10(1), 19. doi:10.2217/cpr.12.72

Barden-O'Fallon, J., Speizer, I. S., Calhoun, L. M., & Corroon, M. (2018). Women's contraceptive discontinuation and switching behavior in urban Senegal, 2010-2015. BMC women's health, 18(1), 35. doi:10.1186/s12905-018-0529-9

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health affairs, 27(3), 759-769. doi: 10.1377/hlthaff.27.3.759.

Browne, M., Barrett, S., Icenhour, L., Reich, S., Gimpert, R., & Esinhart, T. (2018). Barriers to Use of Long-Acting Reversible Contraceptives in Adolescents. Physician Assistant Clinics, 3(3), 339-352. doi.org/10.1016/j.cpha.2018.02.003

Buhling, K. J., Zite, N. B., Lotke, P., & Black, K. (2014). Worldwide use of intrauterine contraception: a review. Contraception, 89(3), 162-173. doi: 10.1016/j.contraception.2013.11.011.

Challa, S., Manu, A., Morhe, E., Dalton, V. K., Loll, D., Dozier, J., … Hall, K. S. (2017). Multiple levels of social influence on adolescent sexual and reproductive health decision- making and behaviors in Ghana. Women & health, 58(4), 434–450. doi:10.1080/03630242.2017.1306607

Coombe, J., Harris, M. L., & Loxton, D. (2016). What qualities of long-acting reversible contraception do women perceive as desirable or undesirable? A systematic review. Sexual Health, 13(5), 404. doi.org/10.1071/sh15189

Dasari, M., Borrero, S., Akers, A. Y., Sucato, G. S., Dick, R., Hicks, A., & Miller, E. (2016). Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women. Journal of Pediatric and Adolescent Gynecology, 29(2), 104–110.

https://doi.org/10.1016/j.jpag.2015.07.003

Dickerson, L. M., Diaz, V. A., Jordan, J., Davis, E., Chirina, S., Goddard, J. A., … Carek, P. J. (2013). Satisfaction, early removal, and side effects associated with long-acting reversible contraception. Family Medicine, 45(10), 701–707.

Diedrich, J. T., Desai, S., Zhao, Q., Secura, G., Madden, T., & Peipert, J. F. (2018). contraceptive method satisfaction. The American Journal of Obstetrics & Gynecology, 212(1), 50.e1-50.e8. https://doi.org/10.1016/j.ajog.2014.07.025

Dragoman, M., Sheldon, W. R., Qureshi, Z., Blum, J., Winikoff, B., Ganatra, B., & WHO Multicountry Survey on Maternal Newborn Health Research Network. (2014). Overview of abortion cases with severe maternal outcomes in the WHO M ulticountry S urvey on M aternal and N ewborn H ealth: a descriptive analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 121, 25-31. doi: 10.1111/1471-0528.12689

Endriyas, M., Eshete, A., Mekonnen, E., Misganaw, T., & Shiferaw, M. (2018). Where we should focus? Myths and misconceptions of long acting contraceptives in southern nations, nationalities and People's region, Ethiopia: qualitative study. BMC pregnancy and childbirth, 18(1), 98. doi:10.1186/s12884-018-1731-3

Farmer, D. B., Berman, L., Ryan, G., Habumugisha, L., Basinga, P., Nutt, C., … Rich, M. L. (2015). Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District. Global health, science and practice, 3(2), 242–254. doi:10.9745/GHSP-D-14-00198

Fevriasanty, F. I., Lyneham, J., & McCauley, K. (2013). Phenomenology: Exploring Women‟s Experiences of First Time IUD Insertion. Nurse Media Journal of Nursing, 3(2), 569-579. doi: 10.14710/nmjn.v3i2.6005

Fleming, K. L., Sokoloff, A., & Raine, T. R. (2010). Attitudes and beliefs about the intrauterine device among teenagers and young women. Contraception, 82(2), 178–182. doi:10.1016/j.contraception.2010.02.020

Foster, D. G., Grossman, D., Turok, D. K., Peipert, J. F., Prine, L., Schreiber, C. A., ... &

Schwarz, E. B. (2014). Interest in and experience with IUD self- removal. Contraception, 90(1), 54-59. doi: 10.1016/j.contraception.2014.01.025.

Gideon, J., Hunter, B. M., & Murray, S. F. (2017). Public-private partnerships in sexual and reproductive healthcare provision: establishing a gender analysis. Journal of International and Comparative Social Policy, 33(2), 166-180. doi:10.1080/21699763.2017.132915

Gueye, A., Speizer, I. S., Corroon, M., & Okigbo, C. C. (2015). Belief in Family Planning Myths at the Individual and Community Levels and Modern Contraceptive Use in Urban Africa. International perspectives on sexual and reproductive health, 41(4), 191–199. doi:10.1363/4119115

Hall, S. K., Ela, E., Zochowski, M. K., Caldwell, A., & Moniz, M. (2016). I Dont Know Enough About IUDs and Implants to Feel Comfortable Using Them womens knowledge and perceived barriers to LARC on college campuses. Journal of Adolescent Health, 58(2 Suppl), S78.

Heyeres, M. (2016). The Complexity of Health Service integration : A Review of Reviews Search Strategy for the Identification. 4(October). https://doi.org/10.3389/fpubh.2016.00223

Higgins, J. A., Ryder, K., Skarda, G., Koepsel, E., & Bennett, E. A. (2015). The Sexual Acceptability of Intrauterine Contraception: A Qualitative Study of Young Adult Women. Perspectives on sexual and reproductive health, 47(3), 115–122. doi:10.1363/47e4515

Hong, R., Montana, L., & Mishra, V. (2006). Family planning services quality as a determinant of use of IUD in Egypt. BMC health services research, 6, 79. doi:10.1186/1472-6963-6-799

Hoopes, A. J., Gilmore, K., Cady, J., Akers, A. Y., & Ahrens, K. R. (2016). A Qualitative Study of Factors That Influence Contraceptive Choice among Adolescent School-Based Health Center Patients. Journal of Pediatric and Adolescent Gynecology, 29(3), 259–264. https://doi.org/10.1016/j.jpag.2015.09.011

Kibira, S. P., Muhumuza, C., Bukenya, J. N., & Atuyambe, L. M. (2015). “I spent a full month bleeding, I thought I was going to die…” a qualitative study of experiences of women using

modern contraception in Wakiso District, Uganda. PloS one, 10(11), e0141998.

Lee, S., Schorr, E., Hadidi, N. N., Kelley, R., Treat-Jacobson, D., & Lindquist, R. (2018). Power of Peer Support to Change Health Behavior to Reduce Risks for Heart Disease and Stroke for African American Men in a Faith-Based Community. Journal of racial and ethnic health disparities, 5(5), 1107-1116. doi: 10.1007/s40615-018-0460-7

Luchowski, A. T., Anderson, B. L., Power, M. L., Raglan, G. B., Espey, E., & Schulkin, J. (2018). Obstetrician – Gynecologists and contraception : practice and opinions about the use of IUDs in nulliparous women , adolescents and other. Contraception, 89(6), 572–577. https://doi.org/10.1016/j.contraception.2014.02.008

Madden, T., Eisenberg, D., & Secura, G. (2013). Continuation and Satisfaction of Reversible Contraception. 117(5), 1105–1113. https://doi.org/10.1097/AOG.0b013e31821188ad.Continuation

Mishell Jr, D. R. (1998). Intrauterine devices: mechanisms of action safety and efficacy. Contraception, 58(3 Suppl), 45S-53S.

Moreau, C., Bohet, A., Hassoun, D., Ringa, V., & Bajos, N. (2014). IUD use in France: women's and physician's perspectives. Contraception, 89(1), 9-16. doi: 10.1016/j.contraception.2013.10.003.

Nalwadda, G., Mirembe, F., Tumwesigye, N. M., Byamugisha, J., & Faxelid, E. (2011). Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives. BMC health services research, 11(1), 220.

Nelson, A. L., & Massoudi, N. (2016). New developments in intrauterine device use: focus on the US. Open access journal of contraception, 7, 127–141. doi:10.2147/OAJC.S857555

Peipert, J. F., Madden, T., Allsworth, J. E., & Secura, G. M. (2012). Preventing unintended pregnancies by providing no-cost contraception. Obstetrics and gynecology, 120(6), 1291– 1297. doi:10.1097/AOG.0b013e318273eb56

Reiss, K., Nantayi, L., Odong, J., & Ngo, T. D. (2012). Providing long-acting and permanent contraceptives through outreach in rural Uganda. (January 2012).

Ridde, V. (2010). Is the Bamako Initiative Still Relevant for West African Health Systems? International Journal of Health Services, 41(1), 175–184. doi.org/10.2190/hs.41.1.l

Rowe, P., Farley, T., Peregoudov, A., Piaggio, G., Boccard, S., Landoulsi, S., … IUD Research Group of the UNDP/UNFPA/WHO/World Bank Special Programme of Research; Development and Research Training in Human Reproduction (2016). Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: a 7-year randomized comparative study with the TCu380A. Contraception, 93(6), 498–506. doi:10.1016/j.contraception.2016.02.024

Rubin, S. E., & Winrob, I. (2010). Urban female family medicine patients' perceptions about intrauterine contraception. Journal of Women's Health, 19(4), 735-740. doi: 10.1089/jwh.2009.1549

Sonfield, A. (2007). Popularity disparity: Attitudes about the IUD in Europe and the United States. Guttmacher policy review, 10(4), 19-24.

Spies, E. L., Askelson, N. M., Gelman, E., & Losch, M. (2010). Young women‟s knowledge, attitudes, and behaviors related to long-acting reversible contraceptives. Women's health issues, 20(6), 394-399. doi: 10.1016/j.whi.2010.07.005.

Stoddard, A., McNicholas, C., & Peipert, J. F. (2011). Efficacy and safety of long-acting reversible contraception. Drugs, 71(8), 969–980. doi:10.2165/11591290-000000000-00000

Hall, K. S., Ela, E., Zochowski, M. K., Caldwell, A., Moniz, M., McAndrew, L., … Ernst, S. (2016). "I don't know enough to feel comfortable using them:" Women's knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus. Contraception, 93(6), 556–564. doi:10.1016/j.contraception.2016.02.007

Twesigye, R., Buyungo, P., Kaula, H., & Buwembo, D. (2016). Ugandan Women's View of the IUD: Generally Favorable but Many Have Misperceptions About Health Risks. Global health, science and practice, 4 Suppl 2(Suppl 2), S73–S82. doi:10.9745/GHSP-D-15-00304

United Nation, Department of Economic and Social Affairs, P. D. (2015). Trends in contraceptive use Worldwide 2015. In Contraception.

doi.org/10.1016/j.contraception.2012.08.029

Weisberg, E., Bateson, D., McGeechan, K., & Mohapatra, L. (2014). A three-year comparative study of continuation rates, bleeding patterns and satisfaction in Australian women using a subdermal contraceptive implant or progestogen releasing-intrauterine system. The European Journal of Contraception & Reproductive Health Care, 19(1), 5-14.

Winner, B., Peipert, J. F., Zhao, Q., Buckel, C., Madden, T., Allsworth, J. E., & Secura, G. M. (2012). Effectiveness of long-acting reversible contraception. New England Journal of Medicine, 366(21), 1998-2007. doi:10.1056/NEJMoa1110855

APPENDICES

Appendix 1: consent form Proposed study title:

Intra Uterine Device use among women of reproductive ages: A qualitative study at the family planning clinic of Nakaseke general hospital

Principal investigator: Nambalirwa Teddy, email address; [email protected]

CONTACT: 0777512914

Study sponsor

The principal researcher will not have any body to facilitate her everything will be covered with herself.

Back ground:

The number of women dying is absolutely very high and IUD is still very low and yet very few studies have been done to rule out this.

Study purpose:

This study therefore will aim at exploring reasons for the low up take of IUD by studying the users‟ experiences plus the barriers which influence their use.

Study procedure:

Voluntarily after accepting to participate in the study and to have your interview audio recorded, the study investigator will request you to answer questions from the interview guide. You‟re requested to respond sincerely because your responses will be recorded and kept confidentiality. The interview will contain questions on your demographics, reproductive health history, your experience with the IUD and the perceived barriers you have ever had about the IUDs that may affect their effective utilization.

Who to participate in this study and where the study is going to be conducted?

Women who have come to get family planning methods at the family planning clinic of Nakaseke General Hospital, 7-20 participants using IUD shall be interviewed one on one for 20 minutes and three FGD of about 6 -10 participants shall be interviewed on all family planning users for not more than 30 minutes.

Risks:

There are no any predicted risks at a moment but you may encounter a few sensitive situations as you try to narrate your experiences.

Benefits:

You may not benefit as an individual directly from the study but later on alone the information yo provide will be important in developing measures to improve utilization of IUD in Uganda and the study may also benefit other countries as literature for review and for study purposes

Cost:

There is no any form of payment or any other material from your participation.

Compensation for participation in the study:

There shall be no compensation like in terms of money or any material as the study will not cause any harm. The study is entirely voluntarily and verbal appreciation shall be used.

Reimbursement:

No transport refund shall be offered but participants shall be given a bottle of soda and a cake as refreshment for keeping them for more than they expected.

Questions

If you have a question as a participant, you are free to ask the investigator now or contact her if you get the questions later on; +256 777512914, email address; [email protected].

Questions about Participant’s rights

In case of any question concerning participant‟s rights, you can call the chairperson School of Health Sciences Institution Review Board (Mak SHS IRB) chairperson Dr. Paul Katyabami Tel +256772404970 or +256020090786).

Feedback on study findings and progress of the study

The research participants will get feedback on the findings and progress of the study at Nakaseke general hospital and any new information which will have been developed and is beneficial will be passed to the participants through their health providers.

Statement of voluntariness:

Your participation in this study is completely voluntarily, so you are free to choose take part or not. You are also free to withdraw from the study at any time as you desire without penalty.

Approval of the research study

This study sought approved from Makerere University School of Health Sciences Research and

Ethics Committee/ IRB

Confidentiality:

The results of this study will be kept strictly confidential and used only for research purpose. My identity will be concealed in as far as law allows. My name will not appear anywhere on the coded forms with the information. Paper and computer records will be kept under lock and key and with password protection respectively.

The interviewer has discussed this information with me and offered to answer my questions. For any other questions, I may contact the Chairperson of the School of Health Science Research and Ethics Committee (MakSHSREC) on (+256) 777-404970/ (+256) 0200903786/ or Uganda national council of sciences and technology. Tel: (+256)-041-4705500).

STATEMENT OF CONSENT

Nambalirwa Teddy has described to me what is going to be done, the risks, the benefits involved and my rights regarding this study. I understand that my decision to participate in this study will not alter my usual medical care. In the use of this information, my identity will be concealed. I am aware that I may withdraw at any time. I understand that by signing this form, I do not waive any of my legal rights but merely indicate that I have been informed about the research study in which am voluntarily agreeing to participate. A copy of this form will be provided to me.

Name ...... ………… Signature/thumbprint of participant…………………Age......

Date (DD/MM/YY) ......

Name of witness……………………….....Signature of witness…………………………

Date (DD/MM/YY)………………………….

Name...... signature/thumbprint of parent or guardian for minors......

Date (DD/MM/YY) ......

Name …………...... Signature of interviewer…………………......

Date (DD/MM/YY)………………………………………

Appendix 2: INTERVIEW GUIDE PART I FOR IUD USERS TITTLE OF PROPOSED STUDY: THE IUD USE AMONG WRA: AQUALITATIVE STUDY AT THE FAMILY PLANNING CLINIC OF NAKASEKE GENERAL HOSPITAL.

Name of investigator: NAMBALIRWA TEDDY

Demographic data:

Initials……………………………………… Age ……………………………………………

Address ……………………………. Marital status …………………………..

Occupation ……………………………… Religion …………………………………

Level of education ………………………..

General questions

1 How many children do you have? And how old are they?

2 what contraceptive methods do know about and which ones have ever used?

3 For how long have you been using Contraceptive and how` much do you know about it?

Questions on experiences with IUD

1 Tell me about your experience with IUD contraceptive

Probe: health provider, side effects, motivation to use, period of IUD use, positive experiences, challenges, reason of removing (if she has come for removal).

2 what do you think are some good things about IUD?

3 What worries might you have about using IUD?

Questions on perceived barriers

1) What do your friends and health providers think about IUD in this community?

Probe: please tell me more what they say can happen to one who uses it, what do you think of them?

2) What other aspects have you heard that may influence IUD use?

3) Do you have any thing you would like to share with me about family planning?

THANK YOU FOR TAKING TIME TO TALK TO ME

INTERVIEW GUIDE PART II FOR FGD TITTLE OF PROPOSED STUDY: THE IUD USE AMONG WRA: AQUALITATIVE STUDY AT THE FAMILY PLANNING CLINIC OF NAKASEKE GENERAL HOSPITAL.

Name of investigator: NAMBALIRWA TEDDY

Before we start, I would like to remind you that there is no right or wrong answers in this discussion. We are interested in knowing what each of you think, so please feel free to be open and to share your point of view, regardless of whether you agree or disagree with what you hear. It is very important that we hear all your opinions.

You probably prefer that your comments not be repeated to people outside of this group. Please treat others in the group as you want to be treated by not telling anyone about what you hear in this discussion today. Let's start by going around the circle and having each person introduce herself. (Principal investigator also introduces herself)

Demographic data:

Initials………………………………… Age ………………………………………………....

Address ……………………………. Marital status ………………………………......

Occupation ……………………………………Religion ………………………………………

Level of education ……………………….

1) What are some of family planning methods you know of? (probe: IUD, inject plan)

2) In your family, who makes the decisions about the number of children, spacing of birth? How are these decisions made? (Probe: Husbands? woman? Mother-in-laws? Religious or community leaders? Others?)

3) According to you, what are the reasons for: Having a lot of children? Having few children? Waiting a certain amount of time between pregnancies?

4) Have you heard of the IUD? I‟d like to hear more of your thoughts and opinions about the IUD.

5) What barriers prevent use of the IUD method we have discussed? Please explain?

6) Let‟s summarize some of the key points from our discussion, Is there anything else?

7) Do you have any questions?

THANK YOU FOR TAKING TIME TO TALK TO ME

Appendix 2: Luganda version of the consent form

OKIWANDIIKO EKISABA OLUKUSA

Omutwe ogw’okunonyereza;

Okunonyereza mubakyala engeri gye bakosesamu akaweta ko mumwa gw‟anabaana emu kunkola yakizaalaggumba kumatenitti mu dwaliro lye Nakaseke ely‟abbona.

Omunonyereza omukulu;

Nambalirwa Teddy, [email protected]; omuyizi mutendekero lye makerere, College of Health Sciences, Department of Nursing, ennamba y‟esimu 0777512914

Anateekamu ssente;

Tewali ajja kutekamu sente.

Omusinji n’omugaso gw’okunonyereza;

Wano mu Uganda, abantu abeyunira akawetta k‟omumwa gwa n‟abana nga emu kukola zakizaala ggumba bakyali batono ddala. Naye tewali kunonnyereza kumaala kukoledwa kuzuula lwaki abantu tebagyetanira nnyo.

Okunonyereza kuno kugenda kuyambako okutegeera lwaki abakyala tebetanira kawetta ka n‟abaana ate nga y‟emu kukola yekizaala ggumba esinga kuba nga eziyizza embuto eziteteketedwa mu bakyala abatuuse okuzaala. Kino kigenda kukolebwa nga tuzuula egeri akawetta gyekayisamu abakyala abakakozesa, ebibakwatako,biki ebyabasikiriza okakozesa,biki ebibaziyiza okukkozesa saako n‟okunonyereza engambo,embeera y‟omumaka n‟ebyalo, n‟ebyobuwangwa ebiyiza okulemesa abakyala okwetanira enkola eno.

Omugaso.

Okunonyereza kuno kugenda kuyamba okuteegera lwaki abakyala tebetanira kawetta k‟omumwa gwa n‟abaana nga tunonnya esonga lwaki, ebibaziyiza nebibasikiriza okakozesa nensonga ezekusa ku byo.

Enambika y’okunonyereza;

Bwoba okirizza kyeyagalire okwetaba mukunonyereza kuno,saako n‟okutuwa olukusa okukwata by‟ogenda okutubulira nga nkonzesa akuma akakwata amaloboozi, omunonyereza ajjakusaba oddemu ebibuuzo byanaba akubuziza nga akozesa olukalala lweyategese. Osabibwa okuddamu ebibuuzo mubutuufu bwabyo era mu bwesimbu kubanga by‟ogenda okutubulira bigenda kuumibwa nga by‟akyama. Ebibuuzo bijja kutandika n‟bitonotono ebikwatako,egeri gy‟otambuzamu obulamu bwo obwekizadde, engeri akawetta k‟omumwa gw‟anabaana gye kakuyisamu, tusembyeyo engmbo, embeera z‟omumaka n‟emubyalo saako eby‟obuwangwa ne nonno ebiyiza okuziyiza oba okuletera abantu okwetanira akawetta komumwa gw‟anabaana.

Abantu abaneetaba mukunonyereza kuno;

Abakyala abali mumyaka egyokuzaala abanaba bazze kunkola yakizaala ggumba.

Obulabe;

Tewali bulabe busubirwa, wabula wakati mukuddamu ebibuuzo oyinza okwesanga nga olina okutubulira kubintu ebimu eby‟ekyama ebiyinza okuba eby‟ensonyi, naye kino tekigenda kuba nabulabe kubulamu bwo wadde obujja njabi bw‟ogenda okufuna.

okuganyurwa;

Ng‟omuntu oyinza obutaganyurwa buterevu, wabula byogenda okutubulira bijja kweyabisibwa okusala amagezi okutumbula enkola y‟ekizaala ggumba saako n‟okulaba nti abantu abetanira akaweeta ko mumwa gwanabana mu Uganda beyongera obungi.

Okusiima olw’okwetaaba mukunonyereza;

Tewali kusasulwa kwona mu ngeri ya ssente oba ekintu ekirala kyona ekigenda okuwebwa olw‟okwetaba mu kunonyereza kuno.

Okudizibwawo;

Ogyakuwebwa okyokunnya nga soda oba amazzi ne cake nga okunonyereza bwekugenda masso.

Ebibuuzo;

Bwooba olina ekibuuzo kyonna ekikwata kuddembe lyo nga omuntu ojakwannukulwa oba ng‟okunonyereza kuwedde osobola okwogera nakulira okunonyereza kuno – Nambalirwa Teddy, 0777512914, [email protected]

Ebibuuzo ku ddembe ly’omuntu eyetabye mukunonyereza;

Oliwaddembe okumanya essonga ezekusa ku ddembe lyo nga omuntu eyetaba mukunonyereza bwoyogera n‟omukulembeze w‟akiiko ka Makerere University, School of Health Sciences Research and Ethics Committee (MakSHSREC) ku nnamba z‟essimu (+256) 772-404970 / (+256) 0200903786

Obubaka obunaava mukunonyereza;

Oliwaddembe okumanya ebinaba bivudde mukunonyereza kuno era ojjakusobala okubisanga ku ndwaliro ery‟anakasese ery‟aboona abakyala webafuunira ekola zakizaala ggumba.

Okukiriza okwetaaba mukunonyereza kwakyeyagalire;

Okweetaba mukunonyereza kuno sikyatteeka, osobola okusalawo nga bwosimye era oliwaddembe okwekutula mukunonyereza obudde byonna woyagalira.

Olukusa olw’okunonyereza ;

Okunonyereza kuno kwakiriziddwa ekibiina ekifuga okunonyereza ekiyitibwa Makerere University Research and Ethics Committee.

Okukuma ebyama;

Ebinnava mukunonyereza kuno bijjakuba byakyama era nga bijja kozesebwa mu kunonyereza kwokka. Ebikukwatako bijja kukweekeba ng‟eteeka bweriragira. Erinnya lyo terijja kulabika wantu wona ku lipoota yonna. Empapula n‟ebyakompyuta bijja kuterekebwa n‟ekufulu era ne pasiwaadi.

Anonyereza amaze okumbulira kubikwata kukunonyereza kuno era yewadde yo okuddamu ebibuuzo byange. Nsobola n‟okubuuza ssentebe w‟ekitongole kya Makerere University, School of Health Sciences, Research and Ethics Committee (MakSHSREC) ku nnamba z‟essimu zino wamanga (+256) 772-404970 / (+256) 0200903786.

EKIWANDIKO KY’OKUKIRIZA NGA SIKAKIDWA

Nambalirwa Teddy .ambulidde ebikwata kukunonyereza kuno nga mwemuli obuzibu bwennyinza okusanga, kyengannyulwamu, n‟eddembe lyange. Nkimanyi nti okweetaba mukunonyereza kuno tekijja kuleetawo nkyukankyuka mubeera yange eyobulamu. Mukukozesa obubaka obuvudde mukunonyereza, sijja kumanyibwa. Nkimanyi nti nsobola okwekutula kukunonyereza obudde byonna wenjagalidde. Nkimanyi nti okuteeka omukono kundagaano eno, tekinzijako ddembe lyange naye kiraga nti ntegezeddwa ebikwaata kukunonyereza kuno era nensalawo okukwatabamu nga sikakiddwa. Gyakusigaza koopi y‟ekiwandiiko kino.

Erinnya lyange ……………………… siginikya oba ekinkumu…………………………… Emyaka jjange …………………….... ennaku zo‟mwezi ……../……./………......

Erinnya lyo‟munonyereza…………………… siginikya ………………………ennaku zo‟mwezi…….../……../………

Appendix 3: Translated interview guide (Luganda) EBINABUZIBWA MU KITUNDU KY‟O LUGANDA EKITUNDU EKIISOKA:

ERI ABAKYALA ABAALI BAKOZESEZAKO AKAWEETA KO MUMWA GWANABANA.

Omutwe ogw’okunonyereza;

Okunonyereza mubakyala engeri gye bakosesamu akaweeta ko mumwa gw’anaabana emu kunkola yakizaalaggumba kumatenitti mu dwaliro lye Nakaseke ely’abbona.

Omunonyereza omukulu; Nambalirwa Teddy

Ebikwogerako:

Erinnya lyange ………………………...... Emyaka jjange …......

Gy’obeera...... Oyimiridde otya mu bufumbo ......

Omulimu gwange...... Eddiini yange......

Nasoma kyekanaki...... ennaku zo’mwezi ……../……./……….

Ebibuuzo by‟awamu

1) Oyina abaana bameka?, balina emyaka emeka? 2) Nkolaki ey‟ekizaala ggumba gyomanyi era waali okozesezako nkolaki? 3) Omaze bangaki ngokozesa ekola eno ey‟akizaala ggumba era biki byajjimannyiko?

Ebibuzo ku bumanyirivu bw‟akaweeta ko mumwa gw‟anabaana

1) Bbulira ku bumanyirivu bw‟olina ne kozesa eno eyakizaala ggumba?(okugeza; eri abasawo ababutekamu, ebizibu oba ebirungi byako, ebyakusikiriza, esonga yokukajjamu) 2) Biiki byosubira ebirungi kunkola eno ey‟kaweeta ko mumwa gw‟anabaana? 3) Biiki ebiyiza okukwerarikiriza kukola eno eyakaweeta ko mumwa gwanabaana?

Ebibuzo ebikwata kundabamu eyakaweeta komumwa gw‟anabaana

1) Mikwano gyo era n‟abasawo eb‟enkola yakizaala ggumba baloowozaki ku kaweeta kano ak‟omumwa gw‟anabaana mukituundu kinno? 2) Bagabaki ebiyiza okuutuka ku mukyala ali okakozesa? ( mbulira byona byomanyi, era gwe oby‟ogerakoki?) 3) Biiki ebilaala byowulira oba byowulidde ebiyiza okuggotannya ekozesa eno ey‟akaweeta? 4) Olina ebirala by‟oyagala okumbulirako ebikwataggana ne nkola yona eyakizaala ggumba?

WEBALE NNYO KUMPA KUBUDDE BWO.

EBINABUZIBWA MU KITUNDU KY‟O LUGANDA EKITUNDU EKY‟OKUBIRI:

ERI EKIBIJJA KY‟ ABAKYALA MUNGERI YOKUBAGANYA EBIROWOZZO ABAZE NKUKOLA YONA EYAKIZAALA GGUMBA

Omutwe ogw’okunonyereza;

Okunonyereza mubakyala engeri gye bakosesamu akaweeta ko mumwa gw’anaabana emu kunkola yakizaalaggumba kumatenitti mu dwaliro lye Nakaseke ely’abbona.

Omunonyereza omukulu; Nambalirwa Teddy

Nga tettunatandiika nsaba kubajjukiza nti; tewali kidibwamu kituffu oba ekitali kittuffu mukukubaganya ebirowozo. Gyagala kumanya bulindowooza yabulikinomu. Sso oliwaddembe

61 okuttubulira ekyo kyowuulira muli nga gwe oba okiriziganya nekyo ekibuzidwa oba tokiriziganya nakyo kijjakuba kyamugaso okuwulira buli kyomanyi.

Buli omu wanno yadyagadde obutawulira byatubulidde wano muntu mulaala atali wanno sso ebyobettukubaganyizako ebirowoozo tubireke wanno.

Tugenda kweyajjulako bulyomu amanye munne.( nze assoka) nga tugoberera bino wamanga.

Ebikwogerako:

Erinnya lyange ………………………...... Emyaka jjange …......

Gy’obeera...... Oyimiridde otya mu bufumbo ......

Omulimu gwange...... Eddiini yange......

Nasoma kyekanaki...... ennaku zo’mwezi ……../……./………......

1) Nkolaki ez‟akizaala ggumba zomanyi? (empiiso, akaweeta, ...... ) 2) Mu maaka go ani esaalawo kumuwendo gwabaana abalina okuzalibwa , nebanga lyokubazaako okusaalawokuno kukolebwakutya? (okugeza; mukaz?, musajja?, n‟aazalawo?, bakulubenze b‟adiin?i...... ) 3) Gwe nga gwe nsonga ki zowa ;okuba nabaana abangi?, okuba n‟abaana abatono?, okulidawo akabanga nga tonaffuna lubuto lulala? 4) Wali owuliddeko kunkola yakizaala ggumba ey‟akaweeta? Nandyagadde o kuwulira ebisingawo kundowoozayo ne neteesayo kunkola eyo. 5) Biiki ebiziyizza ekozesa yakawetta k‟omumwa gwanabaana? Nsaba onyonyole. 6) Ka tugezeko okumakuma ebivvudde mutesaganya yaffe. 7) Olina ekibuzo kyona

Mwebale kutwalabudde n‟emwogerako nange.

Appendix 4: The budget

ITEM NO. OF ITEMS UNIT COST (shs) TOTAL COST (shs)

Audio recorder 1 45000 45000

Printing and binding 2 6000@ 12000 of the proposal

Photocopy of consent, 55 100@ 5500

Interview guides 4 200@ 800

Transport 7 days 12000@ 84000

Ream of paper 2 20000 40000

Flash disk 1 40000 40000

Cakes for participants 55 500@ 27500

Lunch for principal 7 days 4000@ 28000 investigator

Soda for participants 2 cartons (60 bottles) 22000@ 44000

Accommodation 7 days 15000@ 105000

Total 431800

The principal researcher went to Nakaseke hospital for seven days from a nearby town in order to collect data from at least fifty-five (55) participants. This required her have seven days accommodation. FGD of (6 to 10) and one on one interview of (10 to 20) participants were held until saturation. Every participant was explained and provided with a consent form for a written consent as an approval that she has understood and accepted. A cake and a bottle of soda was given to each participant. Four copies of interview guides were printed (2 for English and 2 for Luganda versions)

Appendix 5: The Time Frame

ACTIVITY SEPTEMBER OCTOBER NOVEMBER FEBRUARY MARCH APRIL MAY

PROPASAL WRITING IRB APPROVAL

DATA COLLECTION DATA ANALYSIS REPORT WRITING DISSERTATION SUBMISSION