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Objective To determine whether women or men should be preferred as the target group of the family planning education.
Design Community trial (educational intervention study).
Setting Three villages having similar characteristics in Gaziantep, Turkey.
Population Currently married women aged between 15–49 and their husbands in these villages.
Methods Family planning education was given only to women in the first village, only to men in the second village and to both women and their husbands in the third village.
Main outcome measures Changes in knowledge, attitudes, the behaviour of married women and their husbands between surveys performed before and after family planning education.
Results Important changes in knowledge, attitudes, and behaviour were determined in all intervention groups after family planning education. The rate of effective contraceptive usage among women using any one of the contraceptive methods described significantly increased in all groups, especially where family planning education was given to both sexes.
Conclusions Family planning education given to one of the couples may easily affect the other. Consistent and regular education is more important than selecting target gender groups for family planning education.
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There are many kinds of intervention studies on family planning1–5. Family planning education was given to different sex groups in these studies1,3,5, but a review of related literature does not allow one to determine whether family planning education is more effective if provided to one sex, compared with the other.
This study aimed to determine whether gender selection improved the results of those given family planning instruction. By selecting three similar villages, we provided family planning education only to women living in the first village, only to men living in the second village, and to both women and their husbands living in the third village. After three education tours in a two-year period between June 1996 and July 1998, the effects of the family planning education were assessed for each intervention group.
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In Turkey, primary health care services are being given by health centres in which at least one doctor, one nurse, one health personnel named ‘saghk memuru’, one sanitary technician, and two to four nurse-midwives are employed. Each nurse-midwife provides care at smaller health stations, which are subunits of the health centres. All of primary health care services, including family planning, are carried out by all personnel, but family planning education and application is particularly the duty of nurse-midwives at the health stations to which they are assigned.
Villages were selected according to similarity of geographical status, distance to nearest city, use of contraception, distance to a village with a health centre and the presence of health facility. It is 20 km from the target villages of Atalar to Isikli, 8 km from Isikli to Yamaçoba, and 15 km from Atalar to Yamaçoba, It is 40 km from Atalar to Gaziantep (the city that was the base for this research), 25 km from Isikli to Gaziantep and 20 km from Yamaçoba to Gaziantep. The majority of the people living in these villages are agricultural workers planting their own land.
Considering the distance between these villages and their occupation, cross-contamination was unlikely. We felt that longer distances between these villages could have led to cultural differences to the degree which would effect the conclusion. The selection of these villages was not carried out randomly, in order to pressure social, economical and cultural homogeneity of the population. Selected villages and some of their characteristics are shown in Table 1.
Table 1. Characteristics of villages selected for family planning education (FPE) in the Acaroba Health Centre region. Values are given as n, unless otherwise stated. Group 1 = Atalar (FPE to women only; Group 2 = Isikli (FPE to men only); Group 3 = Yamacoba (FPE to men and women); FP = family planning.
|Background characteristics||Group 1||Group 2||Group 3|
|No. of households||250||325||210|
|Distance to city centre (km)||40||25||20|
|No. of subjects in 15–49 age groups||692||882||592|
|Type of health facility in village||Health station||Health station||Health station|
|Type of health personnel in village||Midwife||Midwife||Midwife|
|Number of health personnel who received FP course||0||0||0|
|Distance to a health centre which contains any personnel who received FP course (km)||14||5||8|
|Percentage of women who use contraception||6.3||6.3||6.3|
The researchers (three specialists in public health; one female, two male) prepared a questionnaire and trained the health personnel who took part in the study and 26 final year students of the medical faculty in Gaziantep University on the design of the research and the application of the questionnaire. After this training, we went to the selected villages to conduct a base-line survey. Under our supervision the 26 medical students interviewed people by distributing the questionnaires one by one to all the currently married women aged between 15–49 and their husbands. Interviews with men were carried out by 13 male students and with women by 13 female students, separately in their houses. There were no incentives.
After the base-line survey, we gave family planning education only to women at the village named Atalar, only to husbands at the village named Isikli, and to both the women and their husbands at the village named Yamçoba. Family planning education had been given by the staff of the health centres or health stations of the same villages. We contributed to family planning education by encouraging active participation of the staff of the health centres and health stations. Standard education materials on family planning education, obtained from the local health office, were used for this purpose. Following the initial instruction, family planning education was repeated twice at one year intervals in the same villages by the same staff. Family planning education was given a total of three times.
After the last instruction of family planning, we applied the same questionnaire to women and their husbands in these villages. By comparing the data of this survey with the data of the first survey, the effects of family planning education given to the different groups were evaluated.
During the period of our family planning instruction there were no initiatives by other health care providers. There were some efforts by radio and television, but they were not considered as confounding factors, because the entire population of Turkey is exposed to these broadcasts.
Data were analysed by using SPSS (version 6.0) and the hypothesis test for a proportion6. The results labelled as (+) indicate a positive change; (−) denotes a negative change; and (0) shows no change at all, based on observations of the subject, knowledge, attitude and behaviour as a response to family planning education, with a significant statistical difference in each intervention group (see Table 6).
Table 6. Directions of changing knowledge, attitudes and behaviours within all groups before and after family planning education (FPE) by gender. Group 1 = Atalar (FPE to women only); Group 2 = Isikli (FPE to men only); Group 3 = Yamaçoba (FPE to men and women). += positive change; −= negative change; 0 = no change.
| ||Among women||Among men|
|Changes||Group 1||Group 2||Group 3||Group 1||Group 2||Group 3|
|Knowledge|| || || || || || |
|Persons who said ‘the interval between two pregnancies should be two years or more’||0||+||+||+||0||0|
|Persons who gave wrong answer to the question ‘under which age should a woman not get pregnant’||0||0||0||0||0||0|
|Persons who gave the answer ‘It's wrong to get pregnant after the age of 35’||0||0||+||0||0||+|
|Persons who don't know any contraceptive methods||+||+||+||+||0||0|
|Attitudes|| || || || || || |
|Wanting no more children||+||0||0||0||0||0|
|Ideal number of children (median)||0||0||0||0||0||0|
|Persons who said ‘the number of children should be decided together by couples’||0||0||+||0||—||−|
|Persons who had said “Couples should decide to use FP methods together”||0||0||0||+||0||0|
|Persons who had said “Yes, I want sterilisation after I have had enough children”||+||0||0||0||0||−|
|Behaviours|| || || || || || |
|Women who had spoken with their husband about the number of children they will have||+||0||+|| || || |
|Women who had obtained their FP knowledge from a health Personnel||+||0||0|| || || |
|Women who had ever used any contraceptive method||0||0||0|| || || |
|Women currently using any contraceptive method||0||0||0|| || || |
|Effective contraceptive users among women who are currently using a contraceptive method||+||+||+|| || || |
|Women who had decided to use this contraceptive method together with their husbands||0||0||0|| || || |
|Women using a contraceptive method proposed by a health personnel among all current users||0||0||+|| || || |
|Women using a contraceptive method provided by a primary health service among all current users (except withdrawal)||0||+||−|| || || |
|Women using a contraceptive method by self purchase among all current users (except withdrawal)||0||+||0|| || || |
|Reasons for not using any contraceptive method among current nonusers of contraceptive methods|| || || || || || |
| Pregnant||0||0||0|| || || |
| Breastfeeding||+||+||+|| || || |
| Husband opposed||—||0||0|| || || |
|Lack of knowledge about contraception||+||+||+|| || || |
|TOTAL||+4||+5||+4|| || || |
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During the first survey before the first instruction in family planning education, we reached 387 households in three villages and interviewed 237 men and 366 women. During the last survey after the last instruction in family planning education we reached 350 households and interviewed 155 men and 322 women (Table 2). To check for the homogeneity of the intervention groups which received questionnaires before the first and after the last family planning education, we compared groups by education, age and profession (Table 3). Statistically important differences were not found among men interviewed during the first and last surveys by education and age, but the number of farmers were statistically lower only at Isikh during the second survey (P < 0.05).
Table 2. Number of women, men and households interviewed before and after family planning education (FPE) by villages. Values are given as n.
|Village||No. of men interviewed||No. of women interviewed||No. of households interviewed|
|Atalar|| || || |
| Before FPE||84||132||136|
| After FPE||49||102||111|
|Isikli|| || || |
| Before FPE||75||129||141|
| After FPE||58||112||130|
|Yamaçoba|| || || |
| Before FPE||78||105||110|
| After FPE||48||108||109|
|TOTAL|| || || |
| Before FPE||237||366||387|
| After FPE||155||322||350|
Table 3. Some characteristics of interviewed persons by villages. Values are given as % or mean (SD), unless otherwise stated. FPE = family planning education.
|Men who graduated from primary school or higher|| || || |
| Before FPE||84.4||85.1||85.8|
| After FPE||84.0||88.2||87.6|
|Mean age in men (years)|| || || |
| Before FPE||34.0 (9.5)||35.6 (11.1)||33.1 (10.8)|
| After FPE||33.4 (8.7)||34.5 (10.4)||33.1 (10.0)|
|Subjects who had a social security facility|| || || |
| Before FPE||5.4||16.9||13.2|
| After FPE||6.7||23.6||19.0|
|Subjects who work as farmers|| || || |
| Before FPE||62.8||59.2||69.8|
| After FPE||59.2||48.0*||67.6|
|Women who graduated from primary school or higher|| || || |
| Before FPE||12.00||19.4||32.4|
| After FPE||22.5*||25.6||34.8|
|Mean age in women (years)|| || || |
| Before FPE||30.0 (8.8)||32.5 (9.1)||29.4 (9.3)|
| After FPE||28.3 (7.4)||30.8 (9.1)||29.8 (9.2)|
When the data from surveys were compared, there were no statistically significant differences among women in all intervention groups by age or profession between two surveys. However, women in Atalar had a statistically higher education level (primary school or more) during the second survey compared with that of the first. All of the women interviewed during the two surveys were housewives. Changes in knowledge and attitude before and after family planning education are shown in Table 4. Change in behaviour is shown in Table 5. Table 6 shows the directions of changing knowledge, attitude and behaviour related to family planning within all groups between the first and last survey by gender.
Table 4. The knowledge and attitudes of currently married women and their husbands before and after family planning education (FPE). Values are given as %, unless otherwise stated.
|Knowledge|| || || || || || || || || |
|People who said ‘the interval between two pregnancy should be > 2 years’|| || || || || || || || || |
|People who gave wrong to the question ‘under which age a women should not get pregnant?’|| || || || || || || || || |
|People who had given the answer ‘It's wrong to get pregnant over the age of 35’|| || || || || || || || || |
|People who did not know any contraceptive methods|| || || || || || || || || |
|Attitudes|| || || || || || || || || |
|Wants no more children|| || || || || || || || || |
|Ideal number of children (median)|| || || || || || || || || |
|People who said ‘Couples should decide together about their number of children’|| || || || || || || || || |
|People who had said ‘Yes, I want sterilisation after I have enough children’|| || || || || || || || || |
Table 5. Behaviour of currently married women and their husbands before and after family planning education (FPE). Values are given as %, unless otherwise stated.
|Women and men who had spoken with their partner about the number of children they would have|| || || || || || || || || |
|Women and men who had obtained their FP knowledge from health personnel|| || || || || || || || || |
|The proportion of effective contraceptive method users among women who are currently using a contraceptive method||62.5||80.0||17.5*||27.0||47.2||20.2*||64.3||87.1||22.8†|
|Women using a contraceptive method proposed by a health personnel among all current users||50.0||30.0||−20.0||27.7||30.5||2.8||35.7||61.2||25.5†|
|Women using a contraceptive method provided by a primary health service among all current users (except withdrawal)||50.0||66.6||16.6||37.5||88.8||51.3†||83.3||60.7||−22.6*|
|Women using a contraceptive method by self purchase among all currently users (except withdrawal)||50.0||44.4||−5.6||50.0||27.7||−22.3*||16.6||32.1||15.5|
|Reasons for not using any contraceptive method among current nonusers of contraceptive methods|| || || || || || || || || |
| Wanting more children||41.1||47.6||6.5||32.5||37.3||4.8||40.7||61.5||20.8|
| Husband opposed||4.0||11.6||7.6*||8.9||14.6||5.7||7.8||3.8||−4.0|
|Lack of knowledge about contraception||23.3||6.9||−16.4†||13.4||0.0||−13.4†||18.4||10.2||−8.2*|
|Women who did not want their last pregnancy||30.1||48.9||18.8†||47.9||51.0||3.1||47.9||36.1||−11.8*|
|Reasons for not using contraceptive methods among nonusers before their last pregnancy:|| || || || || || || || || |
| Wanting children||55.1||46.6||8.5||41.1||54.9||13.8||39.2||66.2||27.0|
| Husband opposed||5.1||6.6||1.5||13.3||8.4||−4.9||13.9||3.7||−10.2|
| Lack of knowledge about contraception||20.6||14.6||6.0||20.0||4.2||−15.8†||20.2||20.0||−0.2|
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Our data on family planning awareness in the villages we studied, for example, age of first pregnancy, age of first marriage, and number of children, were similar to the data for rural Turkey in 19937. Thus, the present information may be considered valid for similar rural areas.
A survey of available literature4,5,8–20 reveal several attempts to determine which gender would benefit most from family planning education. These studies reported that providing family planning education to men was usually neglected and that involving men in family planning education would be very useful.
When the findings were analysed for this study, three important outcomes were noted: it was observed that levels of knowledge about family planning increased significantly in all intervention groups; attitudes on family planning were not changed; and the behaviour of women with respect to family planning were improved during the second survey applied two years later.
By the end of the study there was a significant decrease in the proportion of women without knowledge about any contraceptive methods in all intervention groups, especially in the group where family planning education was given only to women. The proportion of husbands who did not have any knowledge about any contraceptive methods also decreased significantly in the group where family planning education was given only to their wives, but not in the other groups.
In all groups there was a significant decrease in the proportion of women giving the answer ‘I do not know how I can prevent pregnancy’ among currently married women who were not using any contraceptive method. The highest decrease in those without knowledge about contraception was in the group where family planning education was given only to women (from 23.3% to 6.9%).
The rate of any contraceptive usage among women was not changed in all intervention groups, but the rate of effective contraceptive usage among women using any one of the contraceptive methods was significantly increased in all intervention groups, especially the group where family planning education was given to both sexes. Usage of the withdrawal method was decreased and usage of the intrauterine device increased. In a study7 performed in the suburb regions of Izmir, Turkey, similar findings were obtained.
During the base-line survey, 8.3% of women who were not using any contraceptive methods said that they were not using them because of breastfeeding. During the second survey the percentage of these women decreased significantly in all intervention groups (to 2.5% on the whole). This improvement was higher in the group where family planning education was given only to women when compared with the other groups. This finding showed that family planning education was effective and that certain beliefs and practices, such as not using any contraceptive methods during breastfeeding period, may be corrected.
Knowledge about contraceptive methods from the health staff increased significantly among women and their husbands in the group where family planning education was given only to currently married women aged between 15–49. This may be due to a lower rate of previous knowledge related to family planning among women and their husbands living in this village. Also, the proportion of women who began to use the contraceptive method which they were currently using on the recommendation of health staff increased in the group where family planning education was given to both sexes (in Yamaçoba).
The instruction of family planning education created many positive changes among women and their husbands. According to our results, however, it was difficult to determine in which intervention group family planning education was more effective. The wide range of answers given to a lot of questions may be due to some confounding factors, such as routine health care, routine family planning education provided by province health officers or routine family planning education available through the media.
For this reason, in each group, the directions of change taking place between the base-line survey and second survey in areas of knowledge about contraceptives, contraceptive attitudes and contraceptive behaviour which were statistically significant were cumulated and evaluated. According to these evaluations, the level of knowledge with respect to family planning among women in the group where family planning education was given to both sexes showed highest increase, compared to the other groups. The attitudes to family planning among both women and their husbands in the group where family planning education was given only to currently married women aged between 15–49 showed highest positive increase compared with others.
Family planning behaviour among women in the group where education was given only to husbands showed a slightly higher increase than the others. So, it is not wrong to think that family planning education should also be provided directly to men. Women's knowledge of family planning may be reflected in their behaviour more effectively by involving their husbands in family planning education, which is supported by the evidence from other research4,5,9,10,17,20.
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In this study we determined that significant positive differences exist between the data of the base-line survey and the second survey in all intervention groups, with no important advantage of one intervention group over the others. As the reason of this finding, it is believed that an effective family planning education programme provided to one member of the couple may easily affect the other. In a report reviewing the studies performed in this field, similar results were recorded11. Our study showed that providing consistent, systematic education on family planning, which is difficult to improve in populations with a low level of literacy, such as exists in rural areas, is more important than selecting any specific gender group as the target population.
We would like to thank Dr B. Uckun and Dr S. Summak for the English editing of this paper.