Health New Media Res > Volume 4(1); 2020 > Article
Kyomuhendo and Semujju: "I fear to use family planning": how communication campaigns reinforce family planning misconceptions in Uganda

Abstract

This paper analyzes the intersubjective audience interpretations of health communication campaign messages promoting modern family planning. Based on the encoding and decoding theory, the authors used focus group discussions and in-depth interviews to examine how women, men, and couples in Uganda decoded three radio and seven poster campaign messages. A thematic analysis of the data reveals how the respondents’ negotiated or oppositional decoding of the key campaign messages was due to the fear of side effects, partner disapproval, and socio-cultural norms. The authors conclude that despite near-universal awareness about family planning, the country’s low contraceptive prevalence is exacerbated by information transmission approaches that are not responsive to the audience’s fears and information needs.

Introduction

Family planning communication interventions have existed in Uganda for over six decades (Mukasa, 2009; Namasivayam, Lovell, Namutamba, & Schluter, 2019). Currently, knowledge of modern methods of family planning1 is nearly universal in the country with 99% of both women and men being aware of at least one method of contraception (Uganda Bureau of Statistics and ICF, 2018). Despite this, the uptake of contraceptives among married women remains low at 36.3 percent and their unmet need for modern family planning is high at 26 percent (PMA 2020, 2018). As such, it is estimated that a woman in Uganda would have an average of 5.4 children by the end of her child-bearing years if she bore children. This rate is higher than the total fertility rate worldwide estimated at 2.4 children per woman (Population Reference Bureau, 2019). Consequently, Uganda’s rapid population growth is driven by a high fertility rate. While this situation is partly attributed to inadequate information on family planning in Uganda (Ministry of Health, 2014; Nuwasiima et al., 2019), this paper argues that the focus on routine information transmission which ignores the audience’s information needs is curtailing the uptake of modern family planning in Uganda. In order to present the above argument, this paper draws from the encoding and decoding theory and uses qualitative research methods to examine how women, men and couples interpret campaign messages on modern family planning. Many studies on family planning interventions targeting different audiences generally use basic measures of contraceptive awareness that quantify if audiences “have heard” or been exposed to any family planning information about specific methods (Alege, Matovu, Ssensalire, & Nabiwemba, 2016; Uganda Bureau of Statistics (UBOS) and ICF, 2012; Uganda Bureau of Statistics and ICF, 2018). However, there is limited qualitative research on how audiences make sense of family planning information. Such research could give better insights on their perceptions and quality of knowledge that can impact their decision to use or not to use contraceptives. As such, there is need for qualitative exploration of how audiences decode family planning information as well as establish the socio-cultural foundations that may influence how audiences respond to messages promoting modern family planning.
The paper is divided into five parts. The first part reviews the literature and presents the theoretical framework in which the findings will be contextualized. The second part is the method, which informs the reader how the data were collected, and the methods that were employed during data collection. This is followed by the section which presents data and another one which discusses the findings and conclusion.

Literature Review

The Government of Uganda’s ambitious national development plans, Vision 2040 and Family Planning Costed Implementation Plan, 2015-2020, commit to reducing the unmet need for family planning to 10 percent and increasing the modern contraceptive prevalence rate by married women to 50 percent by 2020 (Ministry of Health, 2014). Fundamental to this plan is the use of health communication campaigns to improve acceptance and continued use of modern family planning by both women and men of reproductive age.
Uganda’s focus on health communication is informed by the fact that such campaigns are a recognized means of publicizing family planning information in developing countries (Safieh, Schuster, McKinnon, Booth, & Bergevin, 2019). Such campaigns aim to influence cognitive effects such as knowledge, attitudes, and social norms and change behaviors through the use of communication interventions (Measure Evaluation, 2018). Health communication campaigns usually place messages in the media that reach large audiences typically through radio, television, and new technologies including internet and mobile phones, print media such as newspapers, magazines, flyers and outdoor media such as billboards and posters (Wakefield, Loken, & Hornik, 2010). These communication platforms serve as major tools to promote awareness, motivate attitude change and increase service and product utilization of modern family planning among the target audience (Measure Evaluation, 2018; Safieh et al., 2019). Health communication campaigns tend to rely on linear transmission of information that positions the health communicator as an agent of positive change and the audience as a passive recipient of information (Seale, 2002; Waisbord & Obregon, 2012). Pointing out the unidirectional nature of communication campaigns, Waisbord and Obregon (2012) contend that such campaigns are not communication but rather an instance of massive distribution of information by certain powerful actors who carefully assess how target audiences may respond to messages. Critical assessments have argued that the centralized production of health communication campaigns make them impersonal, highly prescriptive and without cultural references for different audience segments (Vasconcellos & Araujo, 2013). They maintain that because of this unidirectional approach, health communication campaigns fail to adequately recognize the agency of the audience as active participants in the communication process who ascribe to varied message interpretations (Bourrier, 2018; Seale, 2002). Other researchers have emphasized that health communication campaigns instead should underscore the process and environment in which audiences make sense of health-related information (Mahmud, Olander, Eriksén, & Haglund, 2013; Waisbord & Obregon, 2012). The notion of audiences making sense of health-related information underpins the process of encoding and decoding of messages (Hall, 2002).
According to Rimal and Lapinski (2009) the features of a message and the way audience members respond to a message have the greatest impact on the success of communication campaigns. This view is primarily explained in this paper using Stuart Hall’s theory of encoding and decoding (Fourie, 2009; Hall, 2002) that provides a cultural explanation of how media messages are produced, circulated, consumed and reproduced.
Hall argued that researchers should pay attention towards the analysis of the social and political context in which content is produced (encode) and the consumption of media content (decode) in everyday life (McQuail, 2010). This theory provides a critical approach to analyzing the effectiveness of health communication messages since it takes cognizance of the social-power relations underpinning the construction and interpretation of meaning. Hall (2002) stresses that an audience member does not passively accept the meaning of a text but rather can read and interpret texts encoded by a producer, in one of three ways: the dominant code in which a message recipient simply accepts the meaning as produced in a text; the negotiated code in which the recipient partially accepts the meaning of the text but also applies his or her own views and interpretation influenced by factors such as their age, gender, knowledge, culture and social background; and the oppositional code in which the recipient understands the intended meaning but completely disagrees with the message because it is either controversial or they do not understand it in the same sense, or is neither applicable to them nor their society. In other words, the message encoded by the communicator is not necessarily the message that will be decoded by the audience except under the dominant code.
Hall’s perspective changed the way communicators think about audiences since it empowered them as key determinants to enabling effective communication. With the rise of new media technologies audiences are not becoming just active participants but also creators of media content and are empowered to take control of messages directed at them (Harrison, 2013; Turow, 2017). Therefore it is important for the communicator to think about his or her audience and how they will interpret a given message. In the same vein, Viswanath & Randolph (2004) contend that for campaigns to be successful there should be effective manipulation of the information environment so that the audience has sufficient exposure to the campaign message and themes.
Studies on the efficacy of health communication campaigns in increasing modern contraceptive use in developing countries have revealed mixed results (Safieh et al., 2019; Sood, Shefner-Rogers, & Skinner, 2014) suggesting that communication interventions mainly achieve modest rather than strong impacts. Most of the literature that associates the audience exposure to media campaign messages with the positive influence of people’s knowledge, attitudes and contraceptive use in Africa and other developing countries are from quantitative studies (Ajaero, Odimegwu, Ajaero, & Nwachukwu, 2016; Babalola, Figueroa, & Krenn, 2017; Mwejuma, Mosha, & Msuya, 2017; Okigbo, Speizer, Corroon, & Gueye, 2015; Sileo, Wanyenze, Lule, & Kiene, 2015; Snyder, Badiane, Kalnova, & Diop-Sidibe, 2003). In contrast, several qualitative studies undertaken in Africa have found that limited knowledge among men and women about contraceptives (Dougherty et al., 2018; Kabagenyi et al., 2014; Kabagenyi, Reid, Ntozi, & Atuyambe, 2016; Kriel et al., 2019) majorly contributes to negotiated and oppositional decoding of information promoting family planning uptake. Whereas there is general consensus among scholars (Babalola et al., 2017; Bertrand, Babalola, & Skinner, 2012) that health communication campaigns can address the aforementioned barriers, Wakefield et al. (2010) caution that such campaigns often fail to achieve their behavior change goals due to unmet audience expectations. Moreover, given the enormous amount of funds, time and effort dedicated to health communication programmes promoting modern family planning methods, the three decoding positions of Stuart Hall can help to inform the interpretation of the messages that the data reveals because the notion of an active audience (Hall, 2002; Katz, 2001) cannot be neglected any longer as the earlier communication theories had professed (Noelle-Neumann, 1973).
Therefore, campaigns targeting health-related behavior change must consider the audience’s ideas, needs, and values (Encyclopedia of Communication and Information, 2020) as opposed to mere dissemination of routine information promoting different types of contraceptives. This is the part that interests this paper. By analyzing how audiences decode family planning messages, the paper seeks to establish the implications of the information transmission approach employed by health communication campaigns in Uganda.

Methods

Study Design

A qualitative study was conducted using focus group discussions with women and men aged 18-45 and in-depth interviews with married couples aged 18-45 residing in Kabarole district, Uganda. These participants represented the audience segment targeted by the family planning communication campaigns in this paper. The research methods were adopted to ensure data validity from source triangulation. They also catered for the inclusion of the different audience segments targeted by the communication campaigns examined in this paper. The encoding and decoding theory further facilitated the use of qualitative methods to probe into how the study participants interpreted media content based on their beliefs, predispositions and social contexts. This was a departure from most audience studies in health communication that tend to use quantitative methods to examine media effects on audience members. However, the quantitative approach does not provide a comprehensive understanding of the various reasons audiences respond the way they do to health communication messages. This is a gap this paper addresses.
Three radio and seven poster messages promoting modern family planning methods were used to examine the respondents’ interpretation of family planning campaign messages. The messages were part of two family planning communication campaigns disseminated by the Ministry of Health and Uganda Health Marketing group between 2014 and 2015.

The Communication Campaigns

Uganda Health Marketing Group in collaboration with the Ministry of Health implemented the Smart Choices campaign for smaller families in 2014. It was a nationwide, multichannel campaign promoting the uptake of long term (intrauterine devices and implants) and short-term contraceptives (pills, condoms, and injectable contraceptives). The campaign targeted women, men and couples aged 18-45. It employed communication tools comprising print, radio and television commercials as well as community communication tools such as posters, wall charts, handbooks, t-shirts, and aprons promoting family planning products.
The Ministry of Health also executed a national family planning campaign in 2015 as part of the Uganda Health Systems Strengthening Project designed to improve access to and quality of maternal health, newborn and family planning services. The campaign targeted men and women, that are married or cohabiting, through radio messages and community dialogue. The campaign aimed to increase the uptake of modern family planning services and products at health facilities by driving demand for men and women to consult health workers for family planning services.

Description of the Campaign Messages

Radio Spot One: The message positioned good health as a desired goal attainable by men, women or couples using intrauterine devices, condoms, implants, pills or contraceptive injections. Condoms were described as being cheap, easy to use, avoiding unplanned pregnancies and protecting a man’s health. Intrauterine devices and contraceptive injections were said to be administered every five years and three months respectively, so as to protect women from unwanted pregnancies and facilitate their career growth. Similarly, couples who used pills and intrauterine devices were described as being happy and able to save money, plan for their retirement, build a home and comfortably meet their children’s basic needs, especially quality education. The audience was encouraged to consult a health worker about modern methods of family planning.
Radio Spot Two: The message informed the audience that the Ministry of Health had availed different modern methods of family planning in small and big health facilities. It described the methods as reliable, efficient and free of charge. The radio spot modeled couple communication and male involvement in family planning as well as health-service seeking by couples. It featured a couple discussing the possibility of seeking guidance on modern methods of family planning from a health worker. The husband alludes to two children as an ideal number although the wife believes she should have more to compensate the bride price he paid for her at marriage. However, the husband re-affirms the need to consult a health worker on how to space child birth saying that couples who love each other wait for two years. The wife is eventually convinced on the need for spacing so as to accord their two children a good life before getting another child.
Radio Spot Three: The message features a rural setting in which a woman narrates how growing up with four brothers and five sisters was difficult. There was hardly enough food and good education since they were poor. With the advice of a health worker, the narrator opts to use an injectable as her smart choice now that she has one child. She believes that using modern family planning will enable her have a loving relationship with her child and ensure good health and a good life for them both.
Poster Messages: The poster messages addressed the specific well-being/good life needs of young and middle-aged couples as well as women and men. These messages portrayed that using a modern family planning method enabled couples space their pregnancies, ensured women’s economic prosperity and career growth, facilitated men’s future investment and guaranteed happiness, good health and general well-being for couples and their children. The ideal family size was shown as two children, a boy and girl on one of the posters. All the messages encouraged women, men and couples to seek additional guidance on modern family planning from a health worker.

Study Location

Uganda is located in the eastern African region. The country’s total fertility (5.4) and teenage pregnancy rates (25%) remain among the highest globally (Family Planning 2020, 2018). Its population is currently estimated at 39 million and is projected to grow at an annual rate of 3 percent (Uganda Bureau of Statistics, 2018). The country’s population is young with more than 50% under the age of 15, implying that the country has a high fertility and low life expectancy (Uganda Bureau of Statistics, 2018). The country’s population is characterized by a high dependency percentage ratio (95.5%) and a large proportion of unemployed people (58%) (Uganda Bureau of Statistics, 2016). Population pressure in Uganda constrains the quality of education, health services and retards economic growth and infrastructure development (National Population Council, 2018).
The study was conducted in Kabarole district in the western Uganda located 300 kilometers from the capital city, Kampala. The district that covers a total land area of 200,523 square kilometers has a population of 469,236 inhabitants of which 52.8% are below 18 years (Uganda Bureau of Statistcs, 2017). The district has one of the highest total fertility rates in the country at 5.4 children per woman, which is higher than Kampala district where the total fertility rate is lowest at 3.6 children per woman (Uganda Bureau of Statistics and ICF, 2018). In Kabarole, 30% of women aged 15-19 have begun child bearing, registering the third highest percentage in the country (Uganda Bureau of Statistics and ICF, 2018). Early marriages are prevalent with 42.9% of young people aged 10-17 being married. The desire for big families is common among married men and women who consider the ideal number of children as 6.0 and 5.1 respectively, while the unmarried men and women consider 5.4 and 4.8 as a suitable number of children to have respectively.
Knowledge of modern methods of family planning is high in Kabarole, with 99.6 % of women and 100% of men having heard of at least one method (Uganda Bureau of Statistics and ICF, 2018). However, only 37.4% of married women are using contraceptives. Yet the need for modern family planning exists among married women (69.2%) and sexually active unmarried women (55.4%) with an unmet demand for contraceptives (Uganda Bureau of Statistics and ICF, 2018). Most households (74.2%) own a radio set and exposure to family planning messages among women (66.7%) and men (67.6%) is mostly through radio. The majority of the male (63.9%) and female population (53.5%) aged above 18 own a mobile phone. However, only a few women (2.6%) and men (6.2%) received family planning messages via the mobile phone (Uganda Bureau of Statistcs, 2017; Uganda Bureau of Statistics and ICF, 2018).

Participant Selection

We used purposive sampling to select study participants that were knowledgeable about at least one modern method of family planning and consented to participate in the focus group discussions. These groups were stratified by age, marital status, religion and level of education. Participants were recruited from health facilities, churches and local markets with the assistance of village health team members and local council leaders. Snowball sampling was used to recruit married couples that participated in the in-depth interviews. Participants for both interviews and focus group discussions were selected from both rural (Kyaitamba, Nsororo, Kabende) and peri-urban (Fort Portal, Buhinga, Kijura) settings comprising ethnically mixed populations of Batooro, Bakiga and Banyarwanda.

Data Collection

Data was collected from 16 focus group discussions, eight female and eight male groups, as well as 12 in-depth interviews with married couples. This accounted for 187 participants, 96 women and 91 men respectively. Females and males were interviewed separately in the focus group discussions while interviews with each couple were held jointly. The participants were exposed to either the three radio messages or the seven poster campaign messages, before embarking on the interviews and discussion, so as to avoid recall bias. Open-ended, semi-structured interview guides were used to explore how the respondents interpreted campaign messages on family planning. Open-ended interviews enabled us to collect data in the participants own words. The interviews and discussions were conducted in the local language, Rutooro until saturation was reached with no new information emerging. Data gathering was undertaken by two trained and experienced research assistants. All interviews were recorded with the participants’ permission and field notes taken. The lead author supervised all data collection to ensure quality control. All respondents were encouraged to participate in the discussion and interviews.

Data Analysis

All the discussions and interviews recorded were transcribed verbatim in Rutooro. The transcripts were verified for accuracy before being translated into English. Analysis of data which involved frequentative steps was undertaken by the lead author. Using thematic analysis, transcripts were read several times until groups of words, phrases and ideas were categorized into codes. A master-code list was then created capturing the themes emerging from the data. Thematic saturation was reached when no new codes emerged. Direct quotations from the study participants are presented in italics to underscore whether the study participants decoded the messages in a dominant, negotiated or oppositional position.

Ethical Consideration

The study received ethical approval from the Uganda National Council of Science and Technology. Informed consent was also obtained from each study participant prior to data collection. Participants who could not write were assisted by the research assistants witnessed by other participants in the respective groups.

Results

Four key themes were identified as ways in which women, men and couples interpreted campaign messages on family planning. These included: messages are informative, fear of side effects, fear of partner disapproval, and fear of sociocultural norms. The study participants recognized that the campaign messages clearly informed them of different types and benefits of modern methods of family planning which signifies a dominant decoding position. However, a recurring narrative among the subsequent themes was that of “fear’’ being aroused in the audience’s interpretation of the messages. Yet according to the participants, none of the campaign messages addressed their fears. This resulted in extensive negotiated or oppositional decoding of the campaign messages.

Messages on Family Planning are Informative

There was general unanimity among respondents that the campaign messages were informative since they showed and mentioned the different types of modern family planning methods that women, men and couples can use to avoid unwanted pregnancy. This dominant decoding of the messages was voiced by the participants who mentioned that contraceptives such as pills, intrauterine devices, condoms, injectable contraceptives and implants could be used by women, men and couples to plan for their families by spacing and limiting birth for either two or five years. Commenting on the poster messages, a male respondent explained that:
What I have got from these messages is that we should be using things like condoms, pills and injections…when we use these methods, we will be able to look after our child and be well. We will feed her so that she grows well. By the time we produce another one, she will be old enough (Male, Focus Group Discussion Participant, Kabende).
Another dominant position discourse among the participants was through their narration of how the messages informed couples to bear children they could comfortably take care of, explained to couples how to avoid frequent childbirth, and advised couples to seek guidance on contraceptives from health workers. A couple explained their interpretation of the poster messages as such:
Wife: The messages are talking about family planning.
Husband: Mostly they are showing happy families because they have few children.
Wife: There is another message which shows this woman with one child, they are together very happy and she is carrying the baby on the back. It shows that producing few children does not burden the parents in taking care of them.
Husband: Another thing, I can see the messages are showing the different methods to use in order to get few children. So if you aren’t sure of a method, you can go and ask a health worker (Couple, In-depth Interview Participants, Nsororo).
Most respondents also stressed that the key messages informed them of the benefits of couples using modern family planning methods. The cross-cutting themes that emerged from respondent groups on the benefits were that it facilitates happy and peaceful families, ensures quality education for children, averts poverty in families and enables couples to nurture healthy children. In contrast, they observed the dangers of not using modern methods of family planning as inadequate food supply, failure to educate their children and persistent poverty in families.
Women tended to report about how the messages promoted joint-couple decision making on modern family planning. They also relayed how the messages encouraged them to space their childbirth since it would be good for women’s health, ensure good nutrition for the family and safeguard the country from crime. As one of them noted:
What I have learnt from the message is to work with the man. If you have a husband, you work together and agree together to plan your family…so that we can produce children we can easily take care of. We can also agree on the number of years to stop producing babies (Female, Focus Group Discussion, Buhinga).
On the contrary, the appeals exclusive to men in their dominant decoding position presented an economic perspective since they mentioned that the messages informed them of how modern family planning enables men to secure their children’s future and generate income for their families. As one man puts it:
The radio message teaches us to produce few children and plan to secure their future. It teaches us to plan our resources for a good life. If I space my children they will grow up well and I will not be financially burdened in the home. I will spend less and the children will grow well (Male, Focus Group Discussion Participant, Nsororo).
A lone negotiated decoding position pronounced by one of the male respondents was that the messages targeted men with multiple sexual partners and encouraged them to use condoms if so as to avoid sexually transmitted infections. However, none of the messages relayed this.
What I have learnt from the messages is that we should be careful…because the truth is that as men…we usually move out there…If I go out there I will definitely need a condom so as to not fall sick (Male, In-depth Interview Participant, Kyaitamba).

Fear of Family Planning Side-Effects

The most dominant negotiated decoding position manifested in the narratives among the participants who reported that the messages were silent on the side effects of modern contraception. However many of their fears about contraceptive side effects stemmed from either their personal experiences or rumors among peers and the community. The major fears cited based on hearsay were that contraceptives caused cervical cancer, fibroids, secondary infertility or bareness. As one woman puts it:
They say that family planning has caused cancer of the cervix. That for all women having cervical and uterine cancer it might have been caused by the injectable contraceptive. But the information on radio has not said anything about cancer. That is our problem. (Female, Focus Group Discussion Participant, Kyaitamba).
Similar sentiments were expressed by men who reported how the campaign messages did not address stories in the community about the side effects of contraceptives and yet they did not know whether to believe them or not. This resulted in their oppositional decoding positions.
These messages which we hear on radio and in health facilities, they are meant for us, the people. But how do they assist us? My wife used an injection but when she went in her menstrual periods, she bled a lot and the blood could not stop flowing. We went back to the health center and saw the doctor and he counseled her and they fixed the intrauterine device in her. We have spent two months and a half with it but we are getting information from people who are not doctors that intrauterine devices cause cancer. We do not know the truth whether it causes cancer or not. That is why I want her to remove it (Male, Focus Group Discussion Participant, Buhinga).
Other respondents also exhibited oppositional decoding of the messages since they reported that they have experienced side effects such as amenorrhea and excessive and prolonged menstrual bleeding that affected their sexual desires. Prolonged bleeding and vaginal dryness were also said to affect couples’ sexual intimacy. Others experienced general body malaise that affected their ability to work. A male participant narrated his wife’s ordeal:
When my wife uses the injection, in the afternoon she has to cover her feet with a scarf saying that they are freezing. She gets headaches, this or that. We decided IUD, she failed to use it. She failed to use most methods. So I decided…to move to another bedroom…I abstain and that’s our family planning. I see her as a missed call (Male, Focus Group Discussion Participant, Kabende).
Men’s negotiated decoding of the messages also manifested in their fears about rumors related to concerns that the intrauterine device could disappear in a woman’s body and cause her to produce deformed children. Men also associated condoms with pain, irritation, limited sexual pleasure and feared that the lubricant in condoms could cause cancer. A male respondent expressed his fear about radio messages promoting condoms and yet word of mouth suggested otherwise:
They tell us about the fluid in condoms…that any man who wears a condom can get infected with cancer. Even the woman he sleeps with will get cancer. In fact that’s why many women are getting cancer. Condoms are not safe. But the messages only tell us the good things about family planning (Male, Focus Group Discussion Participant, Kabende).

Fear of Partner Disapproval

Despite the campaign messages encouraging couple communication, joint-couple decision making and uptake of contraceptives to control their fertility, a number of female respondents reported negotiated decoding of the messages. This they attributed to lack of spousal support due to apathy and sexual jealousy. Others described their partners’ negative attitudes toward modern contraception. A female respondent narrated her experience with the husband:
For most men, when you join family planning and…you leave your husband at home, he will think you are going to other men. He wants you to carry a baby or a pregnancy all the time. He thinks, that way, nobody will get attracted to you…I have experienced this with my husband. When I say I want to go on family planning, it does not please him. He says those on family planning are prostitutes. So I fear due to uncertainty (Female, Focus Group Discussion Participant, Kabende).
In light of this, some male participants expressed their oppositional decoding positions by questioning why the campaign messages contradicted God’s choice of natural family planning. A number of men in the focus group discussions agreed with the subsequent views:
R1: Yes, this method in the message is good, but there is a question. God did not create us to use contraceptives. He created man to be with his woman. What method did he create to limit child birth? That is the one we should use.
R4: God is the one who takes care of children (Male, Focus Group Discussion Participants, Nsororo).
Due to the aforementioned attitudes, some women expressed negotiated positions since they reported discreet use of contraception in spite of the campaign messages encouraging joint couple decision making on family planning. Justifying the discreet use of family planning, a female respondent intimated:
The man might say you shall not use contraceptives. But you have to make a personal decision because it is you to look after your children. You suffer with them, you take them to hospital. There is when your husband does not support you and you do not feel good. So you decide to use family planning quietly (Female, Focus Group Discussion Participant, Kabende).
Some male respondents also reported that their partners’ disapproval of contraceptives undermined the campaign key messages. They mainly cited women’s fear of their spouses having children from extramarital affairs which resulted in some women being disagreeable to contraceptive use. As one respondent explained:
The message has taught us how happy we shall be when we use contraceptives. However, there is when a man tells the wife to use family planning and she refuses because she thinks you want her to stop having children while you are planning to go out there and produce more children with a mistress (Male, Focus Group Discussion Participant, Kyaitamba).

Fear of Sociocultural Norms

Gendered stereotypes manifested in the participants’ negotiated or oppositional interpretation of campaign messages. Women expressed fear that whereas the messages encouraged them to use modern family planning, those who used contraceptives risked being stigmatized as “barren” and “prostitutes”. Describing the stigmatizing attitudes of society, a participant said:
A couple can decide to have like three children…but you will find the parents of the husband saying, does this woman think she has delivered…they will call the woman barren, yet she has children. So she fears to use family planning (Female, In-depth Interview Participant, Nsororo).
Respondents further observed that the key campaign messages promoting small families did not take cognizance of some cultural norms that delight in huge families as a means of ensuring the permanence and wealth of a clan. Women singled out mothers-in-law as pressurizing them to bear many children. Like a respondent elucidated:
There are also mothers-in-law that say to the woman, you do not want to produce children. You only came to eat and fill the toilet…they want you to produce until all the children are finished from the womb. So it becomes difficult to use family planning (Female, In-depth Interview Participant, Kyaitamba).
Other cultural norms manifested in the search for a particular gender, especially the boy-child. In fact, one of the campaign poster messages portrayed the ideal nuclear family as comprising a father, mother, son and daughter. Explaining the prevailing community beliefs, a male respondent noted:
We can see on that message the couple has two children, a boy and girl. They look nice. But for some you find if the woman has not produced a boy and has maybe produced girls only, the husband will tell her to continue producing children looking for a boy. So they will not use contraceptives (Male, Focus Group Discussion Participant, Kyaitamba).
Other negotiated decoding was a result of the campaign messages seen to be clashing with some of the participants’ religious beliefs. Some religious leaders were said to promote only natural family planning methods and yet the messages promoted only modern contraceptives including intrauterine devices, implants, pills, injectable contraceptives and condoms. Whereas some religious leaders endorsed modern methods of family planning, many reportedly forbade their congregations from using modern contraceptives. As such, the respondents’ feared religious retribution since some spiritual teachings equated the use of modern family planning to committing murder. A female participant’s view on why people fear to use contraceptives was that:
For us Catholics, we are told that God’s commandments instruct us not to kill…But the Priest/Father says we kill, kill, kill every day, when we get a contraceptive injection or swallow contraceptive pills… they say it is written that you produce until all the eggs are finished…the Priest says women who use contraceptives cannot be delivered from sin, since no such woman has not committed murder (Female, In-depth Interview Participant, Kyaitamba).
The sternness with which such religious leaders condemned the use of contraceptives resulted into the fear that competed with the campaign key messages encouraging the uptake of modern contraception. A conversation between the moderator and male respondents in a focus group discussion illustrated this:
R3: Religion does not allow family planning. They say we should produce and multiply. That is why they tell us to use natural family planning
M: Which religion specifically?
R3: That is how it is written in the Bible.
R5: All religions do not accept it because you are killing.
R5: The priest taught us that the one who teaches people about family planning is a killer. And if someone gives you a method and you use it, you have both killed -laughter (Males, Focus Group Discussion Participants, Nsororo).
Women also reportedly feared to go against the teachings of a religious cult that promoted polygamy and prohibited its followers from using contraceptives. A respondent recounted a community member’s experience in this regard:
Bisaka’s cult for Abahereza does not believe in family planning…there is a woman who said their leader Owobusobozi had stopped them since family planning is against their law…they believe in polygamy and having as many children as one wants (Woman, Focus Group Discussion Participant, Kabende).

Discussion

This study examined how women, men, and couples interpreted campaign messages promoting modern family planning. It gives in-depth perspectives on how unintended communication effects at an individual, interpersonal, and community level resulted into a boomerang effect (Hyunyi & Salmon, 2007) whereby the audiences’ interpretation of the campaign messages was different from the expected response to the persuasive messages promoting modern family planning.
The campaigns’ heavy focus on informing the audience about the types and benefits of modern family planning methods did not fully address the target audiences’ need for comprehensive information about the side effects and efficacy of the different contraceptives. While the linearity of information predicted by the earlier propaganda models (Lasswell, 1948) still explains how audiences are influenced by top-down information transmission, similar to what Hall (2006) calls the dominant position of decoding information, the negotiated and oppositional decoding instead eclipsed the campaigns’ key messages promoting contraceptive uptake. Hence, although the study participants understood the importance of modern family planning as communicated in the messages, the dominant outcome of fear negated the messages call to action especially because the participants experienced a dissonance effect (Cho & Salmon, 2007) yet they did not have complete knowledge to enable them overcome their fears. This disempowered their choice to adopt or use modern contraception consistently. Models of behavior change (Freijy & Kothe, 2013; Guttman & Zimmerman, 2000) postulate that a dissonance effect can be avoided if individuals have the necessary environmental support, such as adequate information, for behavior change to happen. Related findings in Rwanda, Kenya, Nigeria and Senegal attest that awareness of modern methods of family planning does not equate to appropriate knowledge that would enable couples to make informed choices of what contraceptives to use (Farmer et al., 2015; Okigbo et al., 2015). The implication herein is that for health communication campaigns to be effective, appropriate theoretical perspectives of formative research and audience analysis should be factored in campaign planning, so as to cater for the diverse information needs of different audience segments (Wakefield et al., 2010). That way, campaign messages could promote optimum levels of behaviour change and possibly mitigate the factors that cause negotiated and oppositional decoding of messages by the audience. Explaining the importance of theory in a previous family planning communication campaign, Witte (2005, p. 349) posits that, campaign designers should “systematically develop theoretically based campaign messages that promote adaptive actions and avoid unintended effects from campaigns that might inadvertently promote fear-control actions that inhibit protective action.” In promoting adaptive actions, family planning communication would therefore integrate the various manifestations of fear that men, women and couples have about contraceptives.
Our findings emphasize the necessity for health communication campaigns to consider the sociocultural context in which messages are decoded as articulated by Hall (2002). By showing how social networks propagated misinformation about contraceptives, we confirm the need for future health communication campaigns to look beyond individuals and couples to broader social networks as primary audiences to be targeted. Social networks are an important medium through which since they can influence the information, attitude, and behavior of women, men, and couples (Kagurusi, 2013; Ochako et al., 2015), especially because they are part of the social ecology in which the primary target audiences exist. Findings in Nigeria confirmed that the type of people with whom respondents discussed family planning had a significant effect on their use of contraception. Those that discussed family planning with their spouse, friends and health workers were more likely to use contraception (Ankomah, Anyanti, & Oladosu, 2011).
Thus, it is important that future family planning communication campaigns look beyond individuals and couples, and include members of social networks as primary audiences. Campaign designers would then identify context-relevant audiences, as informed by formative research, to target with personalized and comprehensive information about modern family planning. An opportunity to reach the audience with personalized information from trustworthy sources lies in harnessing new media platforms such as the mobile phone to augment other communication channels. Previous research in Kenya on engaging men in a mobile health approach to support family planning confirmed that men who engaged in SMS dialogues with a nurse had reduced misconceptions about contraceptives and this stimulated couple communication about family planning (Harrington et al., 2019). Global research also suggests that providing family planning information via mobile phones is appealing to men and women of reproductive age and can positively influence their knowledge, attitude and utilization of family planning services (Dev et al., 2019; Ippoliti & L’Engle, 2017).
Another dimension to the significance of the sociocultural context is demonstrated by how negotiated and oppositional interpretation of the campaign messages by the participants was inspired by fear of religious and cultural beliefs, as well as traditional understanding of gender roles, in which men are instrumental in determining the use or non-use of contraceptives. Typologies of the unintended effects of health communication remind us that campaigns can reinforce social distribution of knowledge, attitudes and behavior rather than reform (Cho & Salmon, 2007). The participants in this study echoed this notion as they voiced their fear of cultural stigma and religious retribution. This makes it difficult for the dominant decoding position to entrench through such fears for a significant communication impact. Ironically, one of the campaign messages augmented cultural norms that prefer a particular gender, by depicting the ideal nuclear family as comprising a father, mother, son, and daughter. Thus, campaign designers should be mindful of conveying such misleading stereotypes in their communication that intensify fear of sociocultural norms. Scholars in the field of health communication advise that campaign effects tend to have a greater influence on knowledge than behaviors due to the complexity in requiring audiences to adopt new behavior in place of strongly rooted cultural and religious norms (Ankomah, Anyanti, & Oladosu, 2011; Mayne, Wissing, Knight, & Miziniak, 2018; Okigbo et al., 2015). Such social norms should thus be addressed as focal themes in future family planning campaign messages.
The nexus between gender norms and campaign messages encouraging couple communication and joint-decision making on contraceptive use propagated negotiated or oppositional interpretations of the messages. A dominant discourse among women was that the fear of partner disapproval of modern family planning affected their ability to respond positively to the messages. We find it pertinent that subsequent framing of campaign messages on modern family planning continues to reinforce the benefits of equitable joint couple decision-making, couple communication and male involvement in family planning so as to overcome the fear of partner disapproval. Also important is for health communication campaigns to target men as primary users of contraceptives in their own right so as to overcome the deeply entrenched norm that family planning is a women’s domain (Hardee, Croce-Galis, & Gay, 2017; Kriel et al., 2019). Related findings indicate how these aforementioned factors enabled improved contraceptive uptake and continuation in Togo and Ethiopia (Koffi et al., 2018; Tilahun, Coene, Temmerman, & Degomme, 2015). Campaigns to empower both men and women with appropriate information on modern family planning could benefit from the use of multiple communication platforms. Mobile technologies could be integrated in multichannel communication campaigns so as to link both men and women to family planning information and services. Our views are consistent with current research which points out that mobile health is highly appropriate for people in low to middle income countries since it is cost-effective and efficient. Furthermore, it is suitable for engaging people on reproductive health issues given that it allows for privacy, convenience and access to comprehensive information (Ippoliti & L’Engle, 2017). Although the majority of women and men in our study setting own mobile phones, our paper shows that they hardly received messages about family planning via their phones. This is a missed opportunity. With the expansion of mobile devices in resources limited settings, future family planning communication campaigns should endeavor to meet different audience segments at their level of technology use. As evidenced by a recent study of seven African countries comprising Ghana, Kenya, Nigeria, Senegal, South Africa, Tanzania and Uganda, mobile phone communication of sexual and reproductive health issues was substantially more popular among people aged 18 - 34 years. Using mobile health to target such audience segments that are in the reproductive age bracket is potentially beneficial for family planning promotion (Pew Research Center, 2015).

Conclusion

By examining how audiences interpret campaign messages promoting modern family planning, this paper has advanced previous discussions in the literature which have predominantly focused on the quantitative effect of campaigns on audiences’ family planning knowledge, attitude and behaviour and not how audiences make sense of such messages. It contributes to qualitative literature explaining how audiences decode health campaign messages which could inform message design in future health campaigns.
The paper further confirms previous research of how audiences can decode messages differently from what the communicator intended. It establishes how such miscommunication gives rise to “fear’ as an unintended campaign effect. In demonstrating the multifaceted manifestations of fear in the audience narratives, it introduces different ways in which fear can be perceived and presented in theorizing communication about family planning in an African context. This is distinct from the ordinary understanding of fear appeals in health communication literature. This has implications for future family planning communication interventions that must address the information needs of different audience segments with regard to the fear of side effects, spousal disapproval, and sociocultural norms. The authors also suggest that future messages should be framed to promote positive gender and sociocultural norms that endorse an empowering discourse.
Whilst arguing for reframing of messages, we also suggest that for family planning communication campaigns to be effective, they should not only focus on information transmission by the campaign designers but be responsive to emerging audience information needs. In highlighting audience information needs, the paper makes a case for the integration of mobile technologies as a trending multichannel platform that should be integrated in health communication campaigns. In so doing, the risk of negotiated and oppositional decoding of messages by the audience could be mitigated. Ultimately, this should contribute to the country’s national and Sustainable Development Goal targets that aim at ensuring universal access to modern family planning services by 2030.

Limitations

Although our findings are of theoretical and programmatic relevance to the fields of health communication, family planning and public health, further research is needed to examine the extent to which they are generalizable to other health disciplines, populations and contexts. Secondly, out of the scope of this study are people with cultural and religious influences yet they have adopted a dominant decoding of messages promoting modern family planning and are current contraceptive users. Future studies should help to understand what dissipates their fears or how they deal with their fears to enable their use of contraceptives.

Notes

Funding Details

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Wellcome Trust (UK) (Grant No: 087547/Z/08/Z), the Department for International Development (DfID) under the Development Partnerships in Higher Education (DelPHE), the Carnegie Corporation of New York (Grant No:B 8606), the Ford Foundation (Grant No: 1100-0399), Google. Org (Grant No:191994), Sida (Grant No: 54100029) and MacArthur Foundation Grant No: 10-95915-000-INP. The funders did not in any way contribute to the design of the study and collection, analysis, and interpretation of data.

Data Availability Statement

The empirical data, that informed this paper, is in the possession of the corresponding author. The data is derived from data collected for a doctoral research study being undertaken by the corresponding author.

Notes

1Modern methods of family planning include short and long term contraceptives such as contraceptive pills, implants, injectable hormonal contraceptives, intrauterine devices, male and female condoms, tubal litigation, and vasectomy (World Health Organization, 2018).

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