Table 4.

Overview of major themes on the intervention’s effects on hypothesized intermediate outcomes, with select representative quotations, by level of the social ecological model with interactions across levels highlighted

Individual

Improved knowledge of modern contraceptives included its positive influence on relationship, economic, and physical health and reduced misinformation about side effects, resulting in more positive attitudes towards and intentions to use family planning. Individual-level change positively interacted with relationship strengthening content to influence relationship-level change (e.g., communication with partner). • “I got to understand that when you produce so many children, your income is affected and developing yourself may not be easy. It is good to give birth to the children whom we can plan for and educate well. I learned that, with many children, your relationship at home is negatively affected” (Interview, Man). • “Many of us were scared of family planning. We thought it causes cancer, loss of sexual appetite, and so many other things. When the doctor and midwife told us the truth about family planning, this also made it easy for us to discuss with our spouses. The fear of using family planning went away” (Men’s Focus Group Discussion).

Changes in personal endorsement of gender inequitable attitudes was apparent through qualitative narratives and resulted in changed relationship dynamics (see interpersonal-level) • “Before the program, I didn’t know that a man can also listen to a woman’s decisions. I had this saying in me: ‘Omukazi tansalirawo’ [translation: a woman cannot make a decision for me]” (Men’s Focus Group Discussion). Shifts in rigid gender roles allowed for more acceptance of men’s involvement in learning about and participating in sexual and reproductive health care and family planning, moving men away from the idea that family planning is for women only. • “We men would feel shy to escort a woman to the hospital. We would find it awkward that you go together for family planning. But after being taught, I personally found it necessary to go together since this issue concerns both of us and it is for our wellbeing” (Men’s Focus Group Discussion).

Interpersonal

The effect of reduced gender inequitable attitudes was evident in relationship dynamics, with positive changes spanning communication, shared decision-making, more equitable division of labor, reduced intimate partner violence, and less reproductive coercion (women being forced to stop contraceptive use), having positive effects on men and women’s communication about family planning and shared decision-making. • Equitable communication and decision-making: “I want to talk about our culture. There is a saying in our language of the Baganda [tribe], ‘Omusajja tadibwaamu’ [translation: When a man is rebuking you, a woman, you are supposed to only submit and don’t dare to answer back]. But after the program, our men learned with us about good communication skills that help us to achieve a successful family. [Our husbands] now allow us to talk back and even listen to us. My husband these day listens to me, which was not the case before” (Women’s Focus Group Discussion). • Division of labor/gender roles: “I used to struggle with whom to leave my baby, whenever I was to go distribute the evening foods and teas at our trading center. Yet, it would earn us some money. Sometimes I would fail to go, because there was no one to leave my baby with. After the study, I now see a change. Whenever my husband is free, he takes care of our baby. It worked for us” (Women’s Focus Group Discussion). • Division of labor/gender roles: “Before the program came, I never wanted my wife to work. I listened carefully to the program’s teachings, and realized that, single-handedly, I cannot manage to sustain my family. I got some money, and got a place for my wife to sell charcoal and she is doing well. It helped me to improve the well-being of my home. Sometimes, I even borrow money from her business, when things are not working very well in my business and, later, I return it” (Men’s Focus Group Discussion). • Violence: “I never used to mind about what or how my wife feels. If she is pregnant, I could not escort her to the health center. If she is not interested in having sex, that is not my problem; she has to do it. But the midwife pointed out some of these issues are the source of violence in homes. When there is violence in a home, family planning [broad program definition of planning for one’s future] is hindered since there is no agreement and no good communication” (Men’s Focus Group Discussion). Beyond the relationship effects achieved through changed gender attitudes, the intervention had direct effects on improved communication skills overall and the ability to make joint-decisions on family planning together, attributed to communication skill building content and the “Family Action Plan” (couple goal setting). • “The fact that [my spouse and I] sit and dialogue together, I no longer dictate to her and even we decide together. This is to say that the good communication we have provides a conducive atmosphere for any discussion, even inclusive of family planning” (Interview, Man). • “You taught us how to set our goals with our spouses. We had to agree on the number of children to have, but also to know, which intervals we are to have them” (Women’s Focus Group Discussion).

Community

The group dialogues aimed to reshape specific community norms that reinforce large family size and gender inequity, and were counter to using family planning. The following excerpt shows select examples of community beliefs that were the subject of community dialogues (beliefs underlined) that were reshaped through dialogues to align with the program’s definition of family success. This particular excerpt demonstrates the effectiveness of examining these norms in the broader context of poverty and changing economic conditions. • “Participant: I come from an extended family, where my ancestors and immediate relatives believe in big family size. All those things you talked about in our culture are still being valued and practiced. About men being decision makers on everything, men looked at to have as many wives and as many children as their fathers, a man with many children considered to be with honor, and that, the more children you have, the more the chances of getting some of them with special blessings. My mind set was also in sync with those beliefs, before the sessions on community norms.   Moderator: So how effective or ineffective was the discussion on this aspect?   Participant: After the sessions on it, I did not remain the same. We are living in another era, where so many things, as you taught us, have changed. The land is smaller, the resources are limited, the cost of living has gone up, and I noticed that I don’t have the capacity any more to afford a large family size. I noticed that I cannot afford to fulfill what religion demands” (Men’s Focus Group Discussion). The group dialogues also aimed to redefine definitions of a “successful family” to be one that includes planning for the future, inclusive of family planning. • “Before this program came, for me I had decided to have as many children as I wished, but when they taught us about family planning and its benefits, I realized that, that’s not the best way to manage the family” (Men’s Focus Group Discussion).