Sampling and data collection.

We conducted a cross-sectional survey in July 2019 which recruited 2,533 women of reproductive age (15–49 years) from host and South Sudanese refugee communities in Kiryandongo and Arua. The survey was designed to complement qualitative data collected as part of this study. The survey took an average of 40–45 minutes and collected information on the demographic characteristics, household expenditures, health seeking behaviour, utilisation and affordability of SRH services.

Sample size was calculated by assuming the proportions as 0.5, margin of acceptable error of 4%, design effect of 3.9 (intra cluster correlation of 0.10) and confidence interval of 95% level. The sampling was done at two stages. First, 20 villages each were randomly selected from host and refugee settlements in Arua and Kiryandongo. Second, approximately 30 women of reproductive age per village were interviewed by the team of enumerators. Respondents were recruited following a random walk in the village. The two-staged random sampling ensures that our sample is representative of the host and refugee women of reproductive age across the two study settings. Over the course of the study, the research team interviewed greater number of respondents to adjust for a potential non-response rate of 8%.

Data analysis.

For the purpose of this study, we restricted the sample to women aged 15–49 years who have ever had sex and were married or in union, so we report results from 1,533 women (Table 1). Descriptive statistics on respondent and household characteristics, knowledge, access and utilisation of FP methods were analysed using Stata 15 software.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Number of respondents by district and refugee status.

https://doi.org/10.1371/journal.pgph.0000348.t001

Recruitment and data collection.

We conducted focus group discussions (FGDs) and in-depth key informant interviews (KIIs) with local stakeholders (local authorities, NGOs, UN and multilateral agencies, health workers, religious leaders), as well as South Sudanese refugees living inside and outside of refugee settlements in Kiryandongo and Arua. We conducted 34 FGDs and 129 KIIs (Table 2). This number of participants was considered achievable, given practical considerations, and adequate to gain insight into the topic. This qualitative research was designed to complement the cross-sectional survey conducted as part of this study.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Number of focus group discussion and key informant interviews by respondent type.

https://doi.org/10.1371/journal.pgph.0000348.t002

We identified South Sudanese refugees and host community members via the following two channels: (i) ongoing BRAC programmes within Arua and Kiryandongo and (ii) community representatives and local community groups. We identified local stakeholders using snowball sampling and investigator contacts. To participate, refugees needed to be of South Sudanese origin and registered within Arua and Kiryandongo refugee settlements. Local stakeholders needed to be working in or involved in governance or service provision for refugees in Arua and Kiryandongo refugee settlements. Potential participants were given an information sheet written in the vernacular language for those who were not fluent in English, fully detailing the study objectives and explaining all aspects of participation, including the right to withdraw from the research.

Qualitative research procedures included a member of the research team introducing the respondent to the study, its objectives and the KII or FGD to take place. If they agreed to take part, the study team members obtained informed consent from the respondents through a written consent form. After obtaining consent, study team members conducted KIIs or FGDs following a semi-structured interview guide in English or relevant local languages depending on interviewees’ preferences, using interpreters if needed to facilitate translation. KIIs and FGDs were audio recorded and reflective notes were recorded by the researchers. KIIs and FGDs were conducted in a private location convenient for participants, and in quiet environments away from clinical areas for health workers. KIIs lasted between 45–60 minutes, and FGDs lasted between 50–90 minutes. South Sudanese refugees and host populations were compensated with 29,000 UGX (approximately $8 USD) for their time to participate in the study.

South Sudanese refugees and host populations were asked about their experiences of sexual and reproductive healthcare access and utilisation, and local authorities and stakeholders were asked about various aspects of governance or provision of sexual and reproductive health services to refugee and host populations. Interview topic guides were developed for this study after pilot testing with respondent groups.

Data analysis.

Interviews were transcribed verbatim and analysed thematically in NVivo 12 software using the following stages outlined by Braun and Clarke [31]: data familiarisation, coding and theme identification and refinement. Analytical rigour was enhanced by NSS, AS and SMJ discussing coding approaches and data interpretations. Interviews were coded using a framework approach whereby a priori and emerging themes were applied, and then data were revisited using the analytical framework (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Analytical framework adapted from Mosley’s conceptualisation of research for unmet need for family planning [33, 34].

https://doi.org/10.1371/journal.pgph.0000348.g001

We followed Noble and Smith’s recommended steps to enhance the validity and reliability of qualitative data collection and analysis, including accounting for personal biases, frequent communication with all researchers in the study team, and ongoing critical reflection of methods to ensure sufficient depth and relevance of data collection and analysis [32].

Ugandan and refugee populations’ knowledge of FP.

The majority of refugee (71.1%, n = 730) and host (76.4%, n = 629) respondents reported knowledge of FP methods (Table 4). Compared to refugee women, more Ugandan women reported using any method including FP to delay or avoid pregnancy (33.7% vs 24.7%, p<0.001) (Table 4), which was also confirmed by a midwife: ‘Mostly we have the Nationals [Ugandans] who are actively involved in family planning. Refugees, ah, ah. They are there but few in number” (KI126). The most popular forms of contraception by both groups included hormonal injections (31.7%, n = 145), hormonal implants (20.1%, n = 92), and male condoms (18.6%, n = 85).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 4. Results from cross-sectional survey on modern family planning knowledge and use amongst partnered South Sudanese refugee and Ugandan women in Kiryandongo and Arua, Northern Uganda.

https://doi.org/10.1371/journal.pgph.0000348.t004

Women also noted the importance of making informed choices, including delaying sexual activity with their partners if they are not able to obtain FP commodities: “I just dodge him [her husband], if I did not get the medicine [FP] I just dodge him, I know the way to dodge him to avoid that pregnancy” (FGD13, Ugandan female).

Respondents also noted that FP is more acceptable to more educated women and to refugees who have spent more time in Uganda.

Except if you find someone who is at least educated like these ladies here and they understand what is family planning. But other [less educated] community, even talking to them about family planning it is like seeing shy people.

(FGD26, male refugee leader)

But the refugees at least totally they have a very poor attitude about it [FP]. Mm, so, the attitude between Nationals [Ugandans] and Refugees, it is the refugees who completely have no, they do not have that zeal to get family planning. Though there are those few who have stayed like I have said those who came in the 90s, at least they have stayed for some time in the country. They can buy the idea of family planning.

(KI121, health worker)

Positive role of health education and engaging local champions.

Respondents widely agreed on the positive influence of health education provided at the community and facility levels on FP knowledge and use in both refugee and host communities. The majority of refugees (80.5%, n = 66) and Ugandan women (87.0%, n = 167) reported attending FP information sessions at health facilities, whereas 13.4% of refugees (n = 11) reported attending these sessions at NGO offices, and 6.3% (n = 12) of Ugandan women reported doing so at hospitals (Table 4). In particular, key informants agreed on the benefits of FP service providers engaging in two-way dialogues with communities to facilitate open question and answer sessions about FP (KI113, NGO).

We are talking to the women, the pregnant women, the women in reproductive age about their health. Because we realise that they did not have a lot of information about their health. They think that you can get pregnant… and you produce twenty people, twenty children, one after the other. But when we went for discussions, and we have programmes where [we are] technically leading explanations to the women. When they know that the uterus has limited spaces on which the baby can plant, and any additional babies will now start to implant in the scars of the previous ones, the women start to think a lot. They say ‘eeh this is serious.’ So, you can manage to have maximum of five spaces, any other pregnancy will be in the scars of the previous ones. Then the women start to say this is serious. No one had ever told some; so, because the thinking has been that aah health workers knew that; maybe [they] thought that the women who are not educated, they cannot understand these things.

(KI119, multilateral organisation)

Now, these Peer Educators and the Village Health Teams [community health workers] are the very people helping us to transmit the knowledge in the community.

(KI109, NGO, Arua)

More Ugandan women (45.0%, n = 183) compared to refugee women (33.9%, n = 176) reported having FP discussions with their partners (Table 4). Almost half the respondents (47.3%, n = 734) reported deciding on number of children to have with their partner, with more Ugandan women reporting this (53.6%, n = 441) compared to refugees (40.1%, n = 293) (Table 4). Community leaders, local authorities, health and NGO workers also emphatically agreed on the importance of engaging men and local champions with influence such as religious and other local leaders to increase the acceptability, knowledge and use of FP in both refugee and Ugandan populations.

It has reduced on the biasness the negativity about the [FP] services… we have engaged the Peer Educators, the Village Health Teams, the local leaders, the cultural leaders and religious leaders. Okay? Then the politicians around there… the people who heads the families.

(KI109, NGO, Arua)

Respondents also emphasised the importance of male engagement groups and working with male role models as they “know their community much better” than external actors and “give their testimonies” to influence and educate refugee and host communities on a range of gender and health issues including FP (KI117, NGO, Kiryandongo).

Availability of FP methods.

Stock outs of FP commodities, in particular at governmental health facilities, were reported by both FP service users and providers in Arua and Kiryandongo (KI111, NGO; KI121 health worker; KI65 male refugee; KI31 Ugandan female). Few survey respondents reported unavailability of FP commodities as a reason for not using them, though more refugee women reported this (5.2%, n = 38) compared to Ugandan women (1.3%, n = 11) (Table 4). An NGO which charges for FP commodities during mobile outreaches reported these stock outs as part of their motivation to provide FP in Arua and Kiryandongo.

But also, the other factors are more of system factors beyond what we do. Facilities having stock outs, maybe there are no providers, government providers who have been trained to provide contraception. That is where we are now coming in trying to bridge that gap.

(KI114, NGO)

In particular, several FP providers in governmental and NGO facilities reported running out of “those emergency [contraception]pills,” (KI118, NGO), which meant that populations “mostly… go to [private] clinics” to obtain them (KI113, NGO).

Interruption in FP supplies was also reported as a barrier to accessing FP services from governmental facilities and a reason for those who can afford it to get FP commodities from private providers.

Yeah, that is now what disturbs people at times I may start, now if I start [FP] today, maybe it will be after six months or what? I don’t know, when I go [to the health facility] they say it is not there we don’t have the [family] planning so you come next week, next will come, you come still you cannot get it there, so these people say that these people are saying that let us do family planning we go to the hospital but we did not get, but a person who has interest will maybe squeeze herself and get something [privately].

(KI45, female refugee Christian leader)

Provider-client relationships.

The majority of women reported that health workers in governmental health facilities were often unwilling to give them FP commodities without their husband’s permission, with a female refugee in Arua reporting that if a woman’s husband is in South Sudan or living elsewhere for work, “the [governmental] health centre will like tell them ‘you go to your leaders in the community to write for you a chit [note] so that we prove that really your husband is not there’” (KI116, female NGO community volunteer). However, a few women reported that health workers especially in private health clinics “cannot ask about your husband, if you wish [to pay for FP] they can just give you” (FGD5, refugee female).

Several respondents reported not trusting health workers and finding interactions with them “rude and harsh” (KI29, Ugandan female), with a refugee male going further to state that “sometimes in this society people do not believe in the health workers injecting the women [with FP]… they think they [health workers] want to kill our people.” (KI70).

An NGO worker partially attributed health workers’ interaction style to language differences and reported trying to address the issue through trainings with health workers.

P: … you know at times they [health workers] may sound rude, but that is how they are

I1: Why do you think they sound rude? or why do people think they sound rude?

P: I think the environment they have been living in

I1: Okay

P: It was a harsh environment and also communication gap

I1: What do you mean by communication gap?

P: Aah at times we have differences in our languages. How we speak, I feel it is a little different because when I first came here [Northern Uganda] also, I found, eeh, they don’t know how to approach even greetings alone!

(KI117, NGO)

Religious opposition.

Both refugee and Ugandan communities, including religious leaders, noted the key role that Islam and Christianity plays in hindering the use of FP, though only 1.6% of survey respondents (n = 25) reported religion as a reason for not using modern FP methods.

P: No no I will not encourage you to put on condom because it is not allowed in the religion [Islam]

I: It is not allowed in the religion?

P: It is not allowed yes you know God said he has not provided for us this sperm to spoil

I: Ehh it is not for wastage?

P: Yes, it is not for wastage it has a use

(KI100, Muslim leader)

Refugees are complicated. I think uhmm they are not so much into family planning. And just by virtue of their [religion], most of these Dinka are Arabic. I think uhmm Arabic Muslims, family planning is not in their teaching.

(KI132, health worker)

The authority that religious leaders command in the community influences the choice to seek FP, as was reported in a FGD with Ugandan village leaders: “If you decide to go for family planning, the Father [Catholic priest] will say you have killed the children because God said, ‘you produce! Even 100 [children]’”‘ (FGD25).

Some respondents noted that while training community leaders in the importance of FP was useful, religious leaders were being missed out despite them having greater influence on communities’ decision-making:

Because sometimes you know, church leaders speak bigger. People consider them to be spiritual leaders, so, if we can also pick them and give them the knowledge alongside other leaders in the settlement, I think it can work much better. Even in our own secondary schools.

(FGD27, refugee leader)

Cultural opposition and the role of conflict on FP use.

Several respondents noted that “cultural tradition does not allow them [refugees and Ugandans] to go for family planning” (KI122, health worker). FP was viewed as contrary to both Ugandan and South Sudanese culture, with more refugee survey respondents noting modern FP as being culturally inappropriate compared to Ugandan women (11.8% vs 4.7%, p<0.001) (Table 4).

“Ehh our culture does not support family planning. Because the African culture said, you must produce the children”

(FGD25, Ugandan village leader).

Let me have a say on this. Like my colleague said, ahh [modern] family planning, it is not a new thing this is something people heard, people went through, it is there in South Sudan. And the resistance [in South Sudan] is still the same like what is happening here at the refugee settlement. So, like he said, culture is deeply involved in this [opposition to family planning].

(FGD27, refugee representative)

The majority of respondents also noted the role of the conflict in South Sudan hindering refugees’ FP use, as “they feel they should deliver the number of their people who have died in the war” (KI122, health worker). In particular, more recently resettled South Sudanese refugees were reported as being more reluctant to use FP because “they have lost very many people, so they do not want to [use it]” (KI121, health worker).

The desire amongst some South Sudanese populations to replace those lost in the war was so great, that a female refugee representative reported if a woman’s husband is away for a few years, then it is culturally acceptable for his relative to impregnate her:

They said that most of the children have died in the war so they need to replace, that is why others even if the husband is in South Sudan and you don’t communicate with the woman if it takes more than three years, another person who is here related [a relative] to the husband will go with this woman and produce the children for that man. Until you marry your own wife, even if you have a wife, you go with this woman after producing the children belong to that man. The children are nicknamed [given] the name of that man [and] even when they go to school, they will write the name of that man.

(KI41, female refugee representative)

Compared to Ugandan women, a higher proportion of refugee women surveyed also reported desire for a child as a reason for not using FP (19.6% vs. 14.1%, p<0.001).

Male opposition and perpetration of violence.

Male partner objection to FP was a significant barrier to FP use highlighted by all respondent groups. A higher proportion of refugee women reporting male or family opposition to using modern FP methods (37.4%, n = 273) compared to Ugandan women (25.5%, n = 210) (Table 4).

Participant 2: Men don’t support women in family planning. That is why you see they [women] are hiding. They want to come for [FP] injections. There was a young man who brought the woman here. The woman came without telling him. But the next day he saw, they came that they wanted to see the person who inserted that method. So, we told them it is [private provider], they took off from here, they went up to town following [private provider]. They should remove that thing. I think they removed from town. [The man said] That the lady is still young, and he is still young, they want to produce [children]. They don’t want anything like family planning. Why? He married the woman to come and produce [children].

Participant 3: Most times men they now want children.

Participant 2: When they have 10 [children], they still want more.

(FGD29)

You know some men they do not want you to put on family planning they will say you want to make their home die… you will have to produce children… but when somebody sees you putting in [FP] and the person brings the information to your husband sometimes they bring problems and some men they also decide to take their [wives] back to the health centre, to where they have put it in and that nurse who put it in the wife will have problems with them.

(KI1, refugee female)

Although men reportedly refuse their partners using FP methods, they were also reported as being reluctant to use short-term or permanent FP methods.

Men don’t want [a] vasectomy, they know their manhood will [laughs and gives a single clap]. The fear is about losing their manhood. They say, ahh, how do you? How do you cut the wire? The problem is that…that is how they call it. They say, how do you cut the wire. Yeah! [laughs] then when you cut the wire do you expect the wire to be there.

(KI132, health worker)

Participant 5: Yeah you [his wife] bring condom. How can you come and talk something like sex to me! (laughs)

Participant 7: How can I use condom to my own wife that I have married with money?

(FGD26, male refugee leaders)

Male desire to control female fertility and FP use often translated into the threat or perpetration of sexual- and gender-based violence (SGBV) toward their partners if their desires were not followed, with a refugee woman stating that “if you use it [FP] alone, it will bring fighting at home…and sometimes he will beat you” (KI10). A refugee traditional birth attendant further explained that South Sudanese men have fertility expectations linked to the dowry they pay when marrying: “When you [are] a Dinka woman [and] you refuse [sex]…they [men] marry them with cows so if you refuse the man will beat you” (KI54).

Reports of SGBV caused by FP use was also confirmed by male respondents and health workers:

It [FP] has also led to a lot of family domestic violence, for example if a woman uses a [FP] method of 5–10 years without conceiving, now the man begins demanding for a child and ends up insulting the woman and even chasing her away hence [leading to] family break down and divorce. (KI89, Ugandan male)

Aaaah I think the husbands, the, men are not supportive enough to take decisions on family planning, [whether] she would put it [on] now, by the following week she will come back [saying] my husband has beaten me, he doesn’t need family planning. (KI130, health worker)