Workshop Report
Social Analysis and Family Planning
(Version: April 10, 2009)
Date:24 to 25 March 2009
Venue:CARE meeting room, Koh Kong province
Participants:CARE project staff members (See list of attendants)
Facilitator:Pou Sovann (Lead Researcher, SAA)
I. Introduction
CARE Cambodia has been implementing reproductive health program, as part of an integrated package of program activities for over 10 years. While the activities themselves have varied over this time, integrating SRH with HIV, family planning and gender messages and activities, using a rights based/empowerment approach has been the core focus.
CARE Cambodia has experience in implementing FP activities in both rural and urban settings, however the same issues and obstacles continue to reduce the impact of our work. We face continuing social or cultural barriers to family planning (and in the broader arena of SRH) where our reach is broad but our ability to achieve sustainable and real behavioural change is limited. This is particularly true in our ability to address myths surrounding FP choices.
Our beneficiaries are often able to verbalise the messages we disseminate through the various activities however our indicators such as conversion to modern methods, fertility rates, consistent condom use and access to health facilities for RH/FP visits reflect that the actual practice of women remains largely unchanged. This is where we see the value of Social Analysis.
Additionally, as is so often the case with tightly controlled budgets with demanding donors, the program team, including management, are often stretched beyond work capacity and do not have the resources or space to truly reflect on the impact of activities on the populations that we work with. Social Analysis offers that resources to step beyond the detailed and hectic implementation of activities and provides a space for reflection to achieve sustainable change.
Care Cambodia hopes that the SA will provide an opportunity to guide the work with men through the lens of the impact that men have on the FP decisions made by women.The specific objectives of the study were set as follows:
- To use a Social Analysis and Action (SAA) approach to increase understanding of critical sexual and reproductive health issues in the communities where we work through exploring the ways that women (and their partners) experience the sexual relationship, through the filter of family planning practices and beliefs.
- To determine why among our two different populations (Koh Kong and Phnom Penh) the myths surrounding the various family planning options continue to dominate over the messages given through our activities and further explore social norms and structure which influence the women’s access to FP services, and to explore the role of men in women’s FP decisions.
The following are the Research Questions:
- What are the social or cultural barriers to family planning?
- How do myths and rumours influence choice and uptake of family planning methods?
- Who is involved in the family planning decision?
- How influential are men in the family planning decision?
The research study titled “Social analysis to enhance family planning in Phnom Penh and Koh Kong is conducted by using the Social Analysis and Action (SAA) approach, which CARE has developed, in order to seek to address the social, economic and cultural factors that influence health. SSA is an approach for working with communities through regularly recurring dialogue to address how their social conditions perpetuate their health challenges. SSA seeks to enable communities to identify linkages between social factors and health and then determine how to address them.
According to the CARE USA (2007) on the book titles “Ideas and Action: Addressing the Social Factors that Influence Sexual and Reproductive Health” explained that the key elements of SSA processes are (i) the process of exploring the social component of well being in order to create community understanding of how health is shaped by socio-cultural and economic factors, (ii) an understanding of the social complexities that aid or impede the fight for good health within the a programme context, and (iii) taking concrete steps to address health and social issues within a reflection-action cycle. Therefore, SSA can be framed as follows:
- Transform staff capacity
- Reflect with community
- Plan for action
- Implement plans
- Evaluate
Therefore, as part of SSA approach the consultative workshop with CARE SRH staff members from SMC and Srer Ambel were organized from 24 to 25 March 2009. This workshop was further built on the Reflective Practice Workshop organized in Phnom Penhfrom 11 to 13 March 2009 facilitated by Dr. Graeme Storer, VBNK Director to all concerned SCICH project staff members.
A two-day workshop with project staff aimed (i) to reflect on CARE work practice related to what does FP mean? What other words or terms describe FP? What are the barriers that cause people not to use FP methods? And what are the benefits of FP? What are beliefs (and myths) about family planning, (ii) exploring what are the key issues of social related to family planning and who are the key players, and (iii) to develop schedule for field data collection.
Prior to discuss the detail of study, the participants were briefly about the background of the study, SSA approach and how staff involved in the process of the studywhich needs the involvement of concerned staff members to facilitate the data collection.
II. Findings from the Group Discussions
In order to get understanding on the issues of family planning, the participants were divided into two groups (one group from Smach Meanchey and another group from Srer Ambel) to discuss the questions and the outputs of the groups were summarized as follows:
- What does FP mean to you?
-is the result of the discussion between husband and wife in making decision to have children and efforts to buy other materials/equipments
-planto get pregnant
-is the way to think on the benefits within the family
-is the plan to discuss between husband and wife on the possibility of having children, income generation, expenses, health care, supporting to children to school, have improve living condition
-decision in having children
-having children based on the plan
-consideration between husband and wife
-rights of women to access good health
-take longer time before having children
-seeking information related to FP decision
-protecting not having pregnant by chance
-stop and reduce abortion
-having children based on plan and the gap of two years interval for having children
- What are other words or similar terms describe FP?
-plan, projection, think in advance on FP
-future plan of FP
-do not have children
-do not have too short period interval of having children
-having children based on the plan
-limit the number of children
-plan the family
-stop birth
-do not want children
-want to have less children
-having children on the needs
-protection from having children
Finally, the group finalized the term used with the community for Family Planning is Birth Spacing.
- What are the barriers that cause people not to use FP methods?
-geographical location: storm and isolate island, and flood
-social: surrounding ideas did not support, no encouragement, rumours
-traditional: religion, shyness, no talk openly
-family: relatives, husband did not allow to use, majority wife is used by themselves
-knowledge: low knowledge, limited dissemination, do not know how to wear condom
-consequences: bleeding, having irregular menstruation, no menstruation, fat, thin, having spot on face, not remember,
-shyness of the women
-influence of rumors
-lack of informationsystem
-limited knowledge
-providing service is limited/did not reach
-no responsible by men
-confusion with the wrong conclusion made by the using of FP methods
-no support and motivation from family
-cooperation and support are limited.
After the groups presented their outputs of the discussion, the Facilitator did a summary of Barriers for both groups as follows:
-rumors and myths
-no encouragement from people surrounding (siblings, relatives, father and mother, etc)
-traditional and Religion
-shyness and fear to talk openly
-consequences made from FP uses
-low education
-low income (to spend for transportation and fee for FP methods)
-service providing is limited
-lack of information system
-confuse on the conclusion of FP use (people died from other disease while using FP methods – they think of the FP methods not from other diseases)
-limited cooperation and support from concerned stakeholders
From the key issues identified by the groups of Q.3, both groups were divided into two groups to discuss the sub-questions related to each identified barrier. Each group picks up six barriers to work in the group. The following were some findings on sub-key issues/questions from the discussion:
N / Key issues / key questions1 / Culture and Religion (people value and belief) / -What do you know about Birth Spacing? Through what ways?
-Do people have BS? If yes, why? And If no? why?
2 / No encouragement from people surrounding (relatives, husband, father and mother) / -Who are the key playersto make decision for FP methods in your family?
3 / Tradition
TMenomTMlab;-RbéBNI
and religion / -Does BS have some impacts on religion?
-How BS have some impacts on tradition?
4 / Shyness of women and fear to talk openly / -If someone asked about BS, what do you feel?
-When you go to access the FP methods within the crowd, what do you feel?
-Do you dare to talk about FP methods with your family?
5 / Consequences made from FP uses / -Why there are some people give up BS?
6 / Low education (Knowledge) / -What do you know about the BS?
-When you go to seek BS methods, where do you go?
-Who can provide FP services?
-When having FP methods, what are the benefits?
7 / Low income (to spend for transportation and fee for FP methods)
(Economy factor) / -What do u think about the fee you spend for having BS methods? (buying IUD, non plant, Condoms)
-What are problems encountered apart from fee if you want to get access to FP methods?
8 / Providing service is limited / -Who are the service providers on FP methods in your village?
-What do you think about the distance to service provider?
-What do you think about services provided in the village? (CBD and HealthCenter staff)
-What do you think about the service in HealthCenter?
9 / Information system is limited
(Access to information---
IEC, Mass media, Agents) / -How can you get access to information on BS?
-What do you think which source of information system do u think that the best one for you to get easy to access?
No responsibility of men
(Power of male) / -How many children do you have?
-How many children do you want?
-Did you ever use FP methods?
-Do you use every day?
-If u used, which method?
-Do you discuss with your husband?
-If discuss, what does your husband think?
-If no discuss, why don’t you discuss?
-If you do not use FP methods, do you want to use it?
10 / Confuse on the conclusion of FP use (people died from other disease while using FP methods – they think of the FP methods not from other diseases)
(Misunderstanding of the knowledge on FP) / -What are the consequences of having FP methods?
-Do you think that the consequences are true?
-What do you think about these consequences?
-To what extend do you believe this confusion?
11 / Cooperation and support from concerned stakeholders are limited (other key players) / -Who supported and cooperated in BS in your village?
-To what extent do you think about their supports on the using of FP practices?
- What are the benefits of FP?
-having happiness family
-mother and children have good heath
-have time to do business and other activities
-take care children
-can send children to school
-generate more income
-can work in the society
-reduce poverty
-family has enough time to take care children
-reduce the death rate of infants and children
-good health for mother
-pamily has better living conditions
-Children had warm family and have more knowledge
-man has enough time to do any businesses
-reduce abortion
-having children based on plan
-have equal rights in making decisions
- What are the contents of FP lessons and key message? How many hours to train FP to people?
- Reproductive health
-organ of productive man and woman
-menstruation
-Birth spacing
- client rights
- traditional methods
- hormone (COC, POP)
- Block
Condoms
-Other methods – IUD,
-Stop permanently
-Sterilization
-Site effects
-Pre- Anatal care
-Post- Anatal care
-Gender
-Roles and responsibility of CBD
- What are myths or rumors influence on the decision of FP methods?
-Take medicine made the face had black spot and getting thin and virginal discharge elbfñaMeFVIeGayCaMmux eFVIeGaysÁmrIgér: eFVIeGayekþARTUg nigFøak;sr
-Take medicine made the next baby difficult to deliver and having uterus cancer
elbfñaMeFVIeGaykUneRkayBi)aksMral elbfñaMeFVIeGaymharIks,Ún
-Injection made stunt uterus, made virginal discharge, made tough uterus and not want to have sex with partner (husband)
fñaMcak;eFVIeGayRkins,Ún eFVIeGayFøak;s eFVIeGaydMueBaH sVits,Ún mankUneRkayBi)akekIt suxsVit CaMmux manGarmµN_mincg;rYmePT.
-Using condom made uterus ulcer, virginal discharge and inside condom has AIDS and made cancer uterus
eRbIeRsameFVIeGayrlaks,Ún Føak;s manemeraKeGds_kñúgeRsam eFVIeGaymharIks,Ún
-Using condom does not use with wife but use with outside women (sex workers)
eRsamGnam½yminEmneRbIsMrab;RbBnæeT sMrab;eRbICamYyRsþIenAxageRkA ¬RsþIrksIupøÚvePT¦.
-Using IUD made virginal discharge, cancer and having painful while having sex (male)
dak;kgs,Ún eFVIeGayFøak;s mharIk QWcab;eBlrYmePT ¬burs¦
-IUD made uterus break
dak;kg eFVIeGayFøays,Ún
-Norplant made it move inside the whole body and made women died
dak;kgéd eFVIeGaykgrt;eBjxøÜn naMeGayRsþIenAGacsøab;
-Male sterilization/female sterilization made man and woman having more pleasure sex
cgbMBg;Twkkam¼cgéds,ÚneFVIeGayburs nigRsþImancMNg;
-Male sterilization made the penis died
cgbMBg;TwkkamnaMeGaybursgab;GatUntUc
-Birth spacing like establish a fence not allow for the one who died to be born again
BnüakMeNIt dUceFVIrbgXaMgmineGayGñksøab;mkcab;Cati)an.
- What are factors that men are influential in the family planning decision?
-because men are the one who has Income generation
-Culture and tradition – women cannot have two or three husbands so that they fear to negotiate as such afraid of her husband to divorce.
-Family gives more power to man
-Head of the family
-Gender – they do not understand the role of man and woman?
-Social norms not to empower women, the people surrounding did not support for family planning (if the woman has bleeding when using IUD and while the man wants to have sex he cannot have sex so that her husband are angry)(Khmer culture provides prestige to man, society give priority to man)
-Low knowledge on BS (both man and woman did not get enough information on BS)
-Dis-encouragement of women (low level of self-esteem) --- fear to negotiate
-Power of man – man did not give power to woman
-Woman did not have job or occupation so that they relied on husband.
- Consider male involvement in the FP decision and what is the social perception of this involvement?
-Society does not value and encourage the support of man(why you need to join FP training, it is a task of woman)
-Is the responsibility of woman – no need to participate any training or activity related to FP.
-Man is responsible for supporting the economic to family
-Is not the task of man
-Is tiny task so that it is suitable for a woman
-No capacity to feed children so that they need BS
-Is discriminated by peers not to support FP
- Personal Reflection on Family Planning
Based on the exercise of Most Significant Change (MSC) used during the Reflective Practice Workshop from 11 to 13 March 2009 all participants were asked to write their personal story on story related to family planning. There were total 16 MSCs written by CARE staff in Phnom Penh, Care staff from Smach Meanchey and Srer Ambel, Beer Promoter Solidarity Group and from NGO partner staff members. Only five were selected as the MSC. The following are some observation and the personal reflection from the stories as follows:
-A CARE staff member aged mid to late 40s declared that he was too old for family planning! When questioned he indicated that his wife had already reached menopause and so therefore they did not need to be concerned about family planning anymore. The reflection from this is if powerful people in the family life believe that FP is not an issue then discussion or influence may impact on access to information or commodities or both.