Translation Across Cultures
“We had to understand, was the community receptive to research? Were there people there who would be able to administer a study? Really simple things: What does the consent process look like?” says Dougherty. She met with ACCESS stakeholders,
as well as with providers at the nearby district hospital, including John Mundaka, M.D., an obstetrician/gynecologist at Makerere University in Kampala. The team conducted surveys and organized focus groups to gauge local attitudes to both contraception
and incentives, and used theater testing, relying on Ugandans who would be conducting the intervention, along with observers, to point out anything that might not translate culturally, inappropriate wording, and even whether the use of incentives
would be welcomed and appropriate. There was pushback initially, with some saying financial incentives might be viewed as coercive, or that a woman might be given money, only to have her husband take it from her.
“We had to get them comfortable
with [the idea] because they were going to be the ones doing the work,” says Heil. “If you do incentives wrong, they don’t work and it’s a waste of everyone’s time and effort and money.”
Even Mundaka, whose training
included a fellowship at McMaster University in Ontario, says the idea of paying people to come to the clinic seemed questionable at first. Eventually, however, with support from Uganda’s Institutional Review Board (IRB) and an understanding
that incentives would be commensurate per capita with those offered in the United States, everyone was on board.
“[Women] would get a 10,000 Ugandan shilling voucher and then they could go to the local shop and buy flour or sugar
or soap or diapers if that’s what they needed,” says Dougherty. “It gave them choice about what they could select. And it also gave the women the ability to have some more control over how it got spent.” The incentives had
nothing to do with the actual use of contraception, but rather, were related to each woman’s attendance at information sessions. The education was provided one-on-one, as research showed Ugandan women preferred this format over group settings.
“The program is based on the assumption that if people have fact-based education and individualized counseling around family planning with multiple meetings—multiple points of contact—they are more likely to accept family
planning. What’s incentivized is coming for visits where you can talk about family planning and ask questions, and if you’re using family planning, someone can help you troubleshoot if you’re having side effects,” says Dougherty.
Women could technically come to all three of the visits in the pilot trial, take the vouchers, and ignore everything related to family planning. “But as it turns out, when you do this kind of education and you address the locally held myths
about family planning, you have an increased uptake in family planning use,” she says.
Another cross-cultural component that needed to be considered was traditional gender roles in Uganda, where two-thirds of married women report
decisions around contraception are made either with their male partner or by the latter alone. Yet women have a greater knowledge base on the subject than men, who rarely get information from a healthcare worker. While men may understand some of the
side effects of various methods of contraception, many are resentful, as when an injectable method causing bleeding, for example, necessitates additional trips to the hospital. In addition to not wanting to pay for those visits, a man may be upset
by the interference to the couple’s sex life. Many men in Uganda also incorrectly fear contraceptives will lead to cancer.
Those beliefs were enumerated in a study Dougherty, Heil, and Mundaka published in 2018. Although the sample
size of 178 was small, nearly all the men had heard of family planning. However, most did not get information from healthcare workers, but from radio ads and community events where religious leaders routinely speak about the use of contraception.
For many men, long-acting reversible methods such as IUDs and implants were unfamiliar; they were most accustomed to male condoms, though some knew about birth control pills and injectables.
For the current study, outreach was geared toward
encouraging the men to take an active role. The researchers hosted a couple of special local soccer matches, with a goat the trophy for one and soccer jerseys going to the winner of the other. At half-time, nurses shared family planning information
and took questions from the men in attendance. Throughout the study, men were encouraged to join their partners on their family-planning visits. Women whose partners opted not to come with them were provided with pictorial handouts describing different
contraception methods and myth-busting information to bring home.
An early surprise finding was that even those women whose partners stayed away were able to make contraception decisions alone at their first visit. After that, the majority
used some form of reversible and effective contraception: pills, injectables (the most commonly used form of contraception), implants in the upper arm, or IUDs. Given the relatively high rate of HIV in the area, condoms were offered at every visit,
as was emergency contraception, which is not in widespread use.
Mundaka, who served as study site director, says family planning has not historically been a focus of Ugandans’ research, especially in rural areas like Nakaseke, where
more than 75 percent of the population lives. He’s effusive in his praise of Dougherty and Heil: “They’re amazing people. The love and interest they have in having these key measures being improved in our country is quite amazing.”
And for Mundaka, working with the UVM researchers has helped him understand how to better meet the needs of his own patients.
“When we gave [study participants] a one-on-one based approach, giving them details of each of the methods
and highlighting both the side effects and what can be done for all those side effects, they [were] convinced,” he says. Having time to ask questions helped even more, “an eye opener that we might go in a more focused, detailed manner
in offering family-planning education—as opposed to a general approach of mass education awareness, which is failing us and failing the uptake and continuity” of contraceptive use. Because most ob/ gyns are in urban settings, they don’t
always grasp the reality of life for the majority of the population, or why family planning is so often underutilized. Mundaka has made a point of sharing that information with his gynecology colleagues, explaining that taking even as little as 10
minutes to talk about family planning with patients can have a positive effect.
“These same mothers are the ones that go out there and give the same knowledge or awareness we’ve given them to their most trusted friends,”
he says. Focused discussions with mothers have shown that women trust the information their friends provide—anyone who has used a particular method is automatically considered an expert. A woman who has successfully used an IUD, for example,
could answer her friends’ questions, and it would be seen as the “golden truth.”
“It’s the little discussions that we have with these mothers…that can take away the misconceptions that are in the community
when they go out there and discuss with their friends,” says Mundaka.