Since the UPTAKE Project sought to bring together community and health systems efforts in increasing met needs for contraception, these findings were of major importance in situating and understanding the context in which the proposed intervention would be implemented. Furthermore, these findings facilitated identification of bottlenecks and facilitators to contraceptive provision and use at both community and health systems levels to inform intervention activities to increase met needs. Below, we discuss the findings around the two core thematic areas of community and health systems barriers and enablers to family planning and contraceptive services provision and use.
Barriers to family planning and contraceptive services provision and utilisation
While these findings underline government commitment to extend health services to remote areas, long distances to some health facilities still remain a challenge to access and use of contraceptive services in many rural areas. Community efforts to leverage this includes using local structures to distribute and generate demand for contraceptives. However, many of these local structures still face numerous challenges, such as lack of incentives (for example bicycles) to function optimally . Appropriate incentives, as well as effective management strategies that enhance local structures’ capacity to deliver FP/C services can help increase met needs for contraception .
Though most Zambian policies on SRH do recommend provision of adolescent-friendly services, contraceptive provision in schools is still not allowed [20,21,22], suggesting the need for a policy framework that builds community support for adolescent contraceptive provision and use in all settings, including schools . These findings highlight the need for further discussions and possible readjustment of policy on FP/C provision in schools as adolescents are unable to freely access these services at health facilities due to stigma and negative provider attitudes.
Stock-out of preferred methods affects demand and sustained use of contraceptives. Gaps in commodity supply have also been reported elsewhere [23,24,25], and are said to be as a result of the mismatch between supply and demand projections on most occasions . Reducing incidences of contraceptive stock-outs will require strengthened commodity supply chain management, and balancing of demand projections and real-time availing of commodities [26, 27].
Experiences with contraceptive side effects shape choices and sustained use of methods [28,29,30,31,32,33]. Side effects have also been reported to perpetuate myths and misconceptions [34, 35]. For instance, inability to experience periods is associated with blood accumulation in the womb, leading to cancer or fibroids. Adopting innovative and context-specific community engagement strategies that aim at neutralising myths and rumours, and provide detailed information about side effects, may help address this barrier.
Enablers to family and contraceptive services provision and utilisation
The study findings demonstrate that couples counselling services targeting male involvement in contraceptive choices are important enablers to contraceptive services provision and use. Such counselling services allow for increased male participation and support for family planning and contraceptive choices. Various studies have underlined that male partners are key decision makers [36, 37]. Hence couples counselling services help to educate and encourage male partners to support their spouses in using FP/C services .
Availability of personnel to offer a minimum method mix (barrier, short and medium acting) is an enabler, as it provides for choice among clients. However, the results also show limited LARC options in some health facilities due to non-training of their staff in this particular method. Strengthening of District level training and mentorship of personnel in LARC services at all health facilities will help improve access to this method.
Though found to be an enabler, integration of SRH interventions into community health systems remains complex , due to diverse norms, values, as well as the less formal mechanisms which shape coordination, accountability, health practice and health-seeking behaviour . Key factors to consider at the community level may include the community’s capacity to engage and participate in the implementation process, commit and sustain health actions and ensure the development of effective partnerships between a complex array of actors involved in the intervention .
The findings also reveal high levels of knowledge about FP/C methods/services, which is consistent with the Zambia Demographic Health Survey (ZDHS) findings . The desire to delay pregnancy is another community level enabler. Though high knowledge levels and desire to delay pregnancy provide an enabling environment for FP/C methods/services provision, they do not necessarily translate into utilisation, as evidenced by the low national CPR of 47% and high TFR of 5.3 births per woman .
The need to address some of the barriers suggested above cannot be overemphasised if we are to improve FP/C services practices among community members. Indeed, involving key community stakeholders (parents, teachers, churches and HCPs) in identifying, planning, implementation, monitoring and evaluation of FP/C services interventions, as proposed by the UPTAKE project, will contribute to improved service delivery and community support for contraceptives use. Furthermore, Interventions targeting provision of contraceptives in settings other than family planning clinics, strengthened integration of FP/C services, and training that addresses communication, counselling skills and cultural values clarification will be crucial to enhancing contraceptive use [23, 27, 40].
Strengths and limitations
The collection of data from various categories of community members, HCPs and key stakeholders enabled gathering of a wide range of views, which allowed for strengthened data triangulation on key thematic areas. Community perspectives on barriers/enablers to FP/C methods/services uptake are not well explored, so this study adds to this perspective. Additionally, the qualitative team comprised professionals from various academic backgrounds, which further strengthened critical analysis and interpretation of the data.
However, there were also limitations to this research. Conducting the study in one setting/district per country, the use of a small sample of respondents, as well as, using only qualitative approaches, limits the generalisability of study findings. Though generalisability was not the intention, the rich description of the phenomena (community and health systems barriers and enablers to contraceptive provision and use), led to an in-depth account of barriers/facilitators to FP/C services in Kabwe district of Zambia. We believe this provides a valuable contribution to the body of knowledge on FP/C services provision and use in Low and Middle-Income settings.