KAMPALA – In many low- and middle-income countries, the lockdown strategy was implemented to decrease the rate of the COVID-19 outbreak. Although lockdown strategies across many countries have been effective for decreasing the spread rate of contagious viruses, there have been other negative impacts reported globally; these concerns become worse in countries across Africa.
In COVID-19 containment, Uganda in March 2020, a lockdown was declared which introduced measures such as transport restrictions, quarantine, social distancing and ban on weekly markets
Also, the National Taskforce on Covid-19 came up with a list of essentials services which among others excluded Family Planning (FP) which a group of scientists including; Dr. Allen Kabagenyi, Dr. Agnes Kiragga, Dr. John Mark Bwanika & Dr. Betty Kyaddondo felt it was of great impact in the community and the country.
Speaking to the PML Daily on Monday, April 19, 2020, the Principle Investigator Dr. Allen Kabagenyi, PhD Department of Population Studies, School of Statistics & Planning, College of Business and Management Sciences- CoBAMS Makerere University, said that they conducted a survey in December 2020 to examine the use of telehealth services to support the continuity of Family Planning information, access, and utilization during the Covid-19 pandemic in Uganda. The research team also sought to assess the impact of Covid-19 lockdown on family planning service utilization.
Globally, limitations to access and utilization of family planning services often result in increased fertility rates, unplanned pregnancies, and induced abortions. An estimated 47 million women in low- and middle-income countries were projected to not use modern contraception (UNFPA, 2020). In Uganda, the 2016 Uganda Demographic Health Survey (UDHS) showed that 52% of currently married women experienced an unmet need for modern methods of family planning, while 45% of episodes of contraceptive use were discontinued within 12 months and high fertility rate of 5.4.
Research has shown that the unmet need for family planning results in induced abortions, unwanted pregnancies, and an increase in fertility rates. The third National Development Plan (NDP III) recognizes family planning-FP as a key and integral factor in poverty reduction, the realization of the Demographic Dividend, and a key pillar for Uganda to attain middle-income status by 2040.
Dr. Kabagenyi said that the COVID-19 pandemic worsened access to health facilities by disrupting and limiting health services to COVID-19 cases and complex health issues.
“We explored the use of telehealth services to examine the discontinuity of family planning services during the lockdown, provided information on the continuity, access, and utilization of family planning services during the covid-19 pandemic in Uganda. Telehealth services including were provided through the Medical Concierge Group (TMCG), which is one of the leading digital health companies in Uganda,” she said.
TMCG operates a telehealth platform with over 250,000 members in Uganda that was fitting of the project sample profile. These are distributed throughout the country and have functional mobile phone numbers.
Dr. Kabagenyi told us that a sample size of 1,065 participants aged 18 years and above across all the regions in Uganda was selected for this study. They had ethical approval from the Mildmay Uganda Research Ethics Committee (MUREC) and the Uganda National Council of Science and Technology (UNCST).
Impact of COVID 19 on access to Family Planning
The survey shows that in Uganda, access and utilization of family planning services were disrupted due to the COVID-19 mitigation measures that led to the absence of health workers at health facilities, or lack of transport due to lockdown measures. The majority of reproductive health services including the provision of family planning were not among the essential services during the lockdown that was instituted in March 2020.
“We found that during the lockdown, persons in the community lacked access to health providers with whom to discuss challenges related to family planning. Some of their challenges included stock-outs of family planning commodities, fear of side effects and frustrations experienced while accessing family planning services,” she said.
She further said that one of the key informants on the study said “…around March- April, we had a big challenge where all our family planning outreaches were suspended for a month and a half ..(KI 7).
The study was carried out in three phases:
Phase 1 involved a baseline survey of the study participants regarding their FP knowledge, access during the COVID lockdowns, and also the challenges faced while accessing the services. In phase 2, information on family planning was disseminated through Short Message Services (SMS) and voice platforms. Family planning Informational, Motivational, and Behavioral (IMB) messages were sent out to the participants every week for a period of three months. At TMCG, a 24-hour standby call-in center was available with medical professionals dedicated to handling all family planning-related voice calls in and out of the center to the study participants. Additional interviews were conducted with health care workers and policymakers to understand the challenges in health service provision and program implementation during the lockdown. In the last phase, a second electronic survey was conducted to assess the impact of telehealth services on family planning.
Figure 1 shows the location of the telehealth participants during the study period. Participants from 115 districts took part in the study with the biggest proportion from the north (29%, n=33), followed by eastern (28%, n=32), western (27%, n=31) and lastly central region (16%, n=19).
The majority of (75%) of the study participants were male (75%), approximately half (49.5%) were aged between 20-29 years. (Figure 2). Having more males in the study was extremely advantageous given the known low engagement of men in reproductive health services including involvement and support of family planning services.
According to the research, less than half (43%) of the participants consistently used contraceptives following the two time periods (baseline and post-intervention), while13% discontinued family planning services. The main reason cited for the discontinuation of contraceptive use was the desire to have more children.
Also, 23% of the participants were not using contraceptives at baseline but had initiated or resumed the uptake after getting information through the telehealth services.
The study also showed that 1 out of 5 respondents started using family planning for the first time as a result of the intervention approaches like massages and a 24-hour toll-free phone call line (Figure 4). These findings emphasize the need for innovative methods for the promotion of family planning services, particularly during difficult times like lockdowns.
Barriers to contraceptive use
The data shows among the study participants they mentioned failure to get transport to access health facility (39%) and fear of security personnel/lack of pass go to the facility (20%) were the main hindrances (Figure 5). Other challenges encountered were; stock-outs at the health facilities, fear of contracting COVID-19 as well as lack of money or increased prices of different FP services, including commodities.
Similary, the health workers too got frustrations in accessing the health facilities to provide the services required. One of the district health worker who participated as a key informant mentioned “ The lockdown affected the movement of health workers. Police used to block so many doctors and nurses going to work. Travel restrictions affected the availability of health workers at the facilities..” (KI 2)
Besides, long distance to the health facility, lack of information/counselling, fear of side effects, community misconceptions or partner opposition as well as fear of contracting Covid-19 were some of the other challenges the participants faced in fully accessing and utilizing family planning services during the lockdown (Figure 6).
Despite the frustrations and the hindrances encountered, the telehealth services equipped the participants with knowledge on different contraceptive methods and provided an opportunity for counselling on FP which we hope were beneficial. Results of the study revealed that respondents who did not have any knowledge on family planning at baseline were at least equipped with one or more method(s) of contraceptives after the intervention.
The highest proportion of participants (35%) knew at least four methods of family planning, 25 % knew only three methods, 30% knew only two methods while a smaller percentage (10%) knew only one method of family planning. Therefore, if the population is equipped with the required knowledge on how to limit or space their births, this can translate into reductions in unmet needs of FP services, and prevention of unintended pregnancies (Figure 7).
? Family planning service provision and utilization were disrupted during the lockdown.
? Well-developed and appropriately packaged family planning messages increase the acceptance and utilization of contraception.
? Telehealth services are feasible and can support continuity of services during pandemics.
? Telehealth services boosted the participation of males and most especially, the young people in the survey and improved their access to family planning information.
? Family planning should be considered as one of the essential services for the population if the country is to achieve the development aspirations and vision 2040.
? The government should promote the use of Long-Acting Reversible Contraception (LARC) among women given its associated benefits, especially during the lockdown and the considerable cost savings to the healthcare system.
? There is a need to utilize telehealth platforms to increase family planning information and service utilization among the population. Utilizing telehealth services as an intervention in situations of lockdown and any future pandemics is pertinent in addressing the adverse events of the unmet need for family planning.
? Telehealth has the potential to boost self-care, which the Uganda Ministry of Health has integrated to promote health, easy access to health services with a focus on SRH and HIV prevention, care and support., especially for people who either can’t access or don’t want to come into health facilities.
This study was funded by the Government of Uganda through the special COVID-19 funding to the Research and Innovations Fund (RIF) of Makerere University. Special thanks to the study participants, Key Informants and research assistants including; Mr. Ronald Wasswa, Mr.Julius Sseninde, Ms. Joy Banonya, Ms. Evelyne Nyachwo, Ms. Enid Kabajungu, Mr. Edward Muwonge and Mr. Grace Banturaki.
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