Table 1.
Themes that emerged from thematic analysis of patient interviews in Sudan.
| Themes | Description of theme | Illustrative quotes | |
|---|---|---|---|
| A | Themes addressing Aim 1 | ||
| 1 | Desire for fertility information | Fertility information that was desired and if it was generated or endorsed | ID5: ‘yes, I’m currently searching [for information]’ |
| 2 | State of fertility knowledge in this sample
|
Current fertility knowledge, gaps in knowledge, and misconceptions or myths about fertility | ID20: ‘yes after 35 the chance is weak, very weak’ ID13: ‘I would say a year is good’ ID1: ‘I feel I have little information’ ID17: ‘no I didn’t know, especially the specific age I didn’t know that’ ID13: ‘cleanliness and things like that’ [referring to causes of infertility]’ ID16: ‘[ovarian] cysts always’ [referring to causes of infertility] |
| 3 | Benefits of fertility education
|
Potential benefits of implementation of the tool to the participants (self), to people in Sudan generally (other), and the potential uses of the tool | ID2: ‘yes I would look at it, I would find it beneficial’ ID17: ‘our society is in need of lots of raised awareness, A LOT!!’ ID13: ‘to see where there are gaps and to fill them’ |
| B | Themes addressing Aim 2 | Illustrative quotes | |
| 1 | Specific suggestions for the tool
|
Specific comments/suggestions about aspects of the tool and its implementation | ID19: ‘maybe in the olden days maybe, but now it’s ‘aadee’ [normal] (…) if you introduce yourself properly in the beginning and they see you are a doctor, a professional [then they would be more willing to accept these taboo topics]’ ID19: ‘something printed the boys will not read it (…) if its lectures or seminars (…) they will accept it, they will listen, because a boy by nature wants to hear not to read’ ID13: ‘I imagine the home to be the best context, I mean the most important role, one sees their father and their mother and how they are, it’s better that they show them’ ID10: ‘your mother, older sister at home’ ID19: ‘the real difference lies in whether the information was given by a specialist, not man or woman’ ID12: ‘it could be specifically for women, a seminar just for women so they can ask’ ID18: ‘I think at puberty they should be made aware of these things’ ID19: ‘when they are in the engagement period, approaching marriage’ ID16: ‘from early on is better so I can avoid things like drinking too much coffee and tea and things like that’ ID15: ‘every girl MUST go and get checked out before she gets married’ |
| 2 | Factors influencing implementation
|
Factors affecting tool implementation endorsed by the participantsFactors affecting implementation generated by the participants | ID1: ‘it’s choices, you don’t like the page, you turn it’ ID1: ‘clear and direct questions so that the answer is clear and direct, you benefit and I benefit’ ID14: ‘if it [FertiSTAT] is distributed right’ RRB: so, you’re saying even if they say they don’t accept it, we should give it anyway? ID14: ‘I told you, he will calculate it [risk level] in his head. He might think maybe this is right, he will do it himself [fill out FertiSTAT]’ |
| 3 | Challenges and barriers to implementation
|
Challenges and barriers to successful implementation of the tool | When asked if she would accept the materials: ID5: ‘yes acceptable’ [but when asked if others would accept it, her response was different] ‘some people will consider it and others will not’ ID4: ‘people may not accept these subjects’ ID1: ‘cons, there are no cons for me, the topic is normal’ RRB: ‘do you think people will respond authentically?’ ID1: ‘no (…) from the beginning, you will get a sense of whether this person is willing to accept things, or not accept, for example, this sex question, most people will say “enough I don’t want to (continue)”’ ID11: ‘(…) you will face difficulties, you will face unacceptance of the idea itself. I’ve done village work, acceptance of things like this was problematic for people. To communicate to them about family planning and to prevent circumcision of females and things like that, we faced problems, our problem is our customs’ ID14: ‘it will depend on their level of understanding, they may not accept it. Not everyone will accept, everyone has a different level of understanding’ ID1: ‘the religious one, in a religious way (…) God has forbidden certain things because they (the forbidden actions) can harm us’ ID13: ‘it seems that it’s always the case that if you trust the source [person] that the information is coming from, that’s better. But if it comes from someone I don’t trust, I will just leave him and go’ |
| 4 | Self-disclosure | Factors that affect self-disclosure, e.g. social norms, social desirability, demographics.How issues of self-disclosure were resolved internally: self–other as a resolution for internal conflict of modern–traditional, cultures in transition, pull between modern versus traditional values.When is self-disclosure important (practice versus research) | RRB: ‘is there anything else you could add that you think would help us?’ ID1: ‘no, your way is nice’ ID19 (graduate level education): ‘OK you really have to write this [more research on varicocele] in the recommendations!!’ RRB: ‘so it’s not a problem, for example we say ‘this area, people should not talk about’?’ ID8 (62-year-old man): ‘it’s WRONG not to talk about it!!’ |
| 5 | Understanding of being at risk | Aspects that affect our understanding of being at risk, e.g. demographics, previous knowledge and experience, culture (social norms, religion) | ID7: ‘everyone knows what can harm them and can help them, and they are still doing the [behaviour that is] wrong, like, for example, sex, they know it can transmit diseases but they still do it. They use protection and say ‘I won’t get a disease’. They know everything but they try in different ways to do things, but this thing [premarital sex] is haram [forbidden by Islam] and wrong’ ID1: ‘before marriage (…) I felt like I didn’t want to educate myself’ ID14: ‘They should show this to the men too, so they don’t say it’s just from the woman [the fertility problem], they have to, they have to know it, this thing especially, boys will be boys, so you know boys can have relations [sex] as much as he wants before marriage and stuff, and then he comes and then, I mean after marriage he will have repented to God [no longer engages in sex with anyone other than his wife] and they have no problem [no extramarital affairs]’ RRB: ‘was the information beneficial? And was there any information you were not aware of before?’ ID6: ‘yes, useful, I’ve seen it before’ ID15: ‘every girl MUST go and get checked out before she gets married, to get herself checked, I had problems with my period, and I was not bothered with it’ ID1: ‘God has forbidden certain things because they can harm us’ ID13: ‘So, knowing about this, awareness about such things especially here in Sudan, here the girl won’t go to the doctor no matter what. For example, if her period is late she should find out, if her period she could have a problem, go to the doctor’ |
| 6 | Compatibility with worldview | Compatibility of information with worldviews, social norms, beliefs and values that affect the acceptability and feasibly of using the tool in Sudan and the issues related to self-disclosure and understanding risk | ID5: ‘this is a type of education and [education] is not wrong’ ID1: ‘sex outside marriage is haram [forbidden by Islam], God has forbidden certain things because they can harm us’ ID7: ‘And I tell you something, in this day and age, they all know, they know wrong from right. And they are doing the wrong (regardless). Everyone knows what can harm them and can help them. And they are still doing the wrong, how, like, for example, sex, they know it can transmit diseases but they still do it. They use protection and say ‘I won’t get a disease’. They know everything but they try in different ways to do things, but this thing [premarital sex] is haram [forbidden by Islam] and wrong’ ID13: ‘yes, early is 1 year, some people wait 4 or 5 years to get tested, no I mean you have just wasted time like this. It’s better that they find out, so that even if God did not will it [meaning you can’t have babies], you can separate. Sometimes there are people that God gives them [a baby] with someone else, it was not meant to be here [in the first marriage]’ |
| 7 | Cultural tailoring | How the tool could be tailored to fit the culture, i.e. according to gender, age, level of education or understanding and religiosity | ID14: ‘(…) printed materials, posters, pamphlets that can reach the mum or the aunt at home, they read it. People who can’t read [illiterate] can get it at the mosque, you give the information to the imam [priest] and tell him to convey. This way the people at the mosque will know something and the mums will get the printed material’ ID1: ‘the religious one, in a religious way, that sex outside marriage is haram [forbidden by Islam], God has forbidden certain things because they can harm us’ ID10: ‘it’s better from a woman of course! (…) a man, for example, I can’t ask him questions, but you are a woman like me so I can ask you questions’ ID1: ‘you reach her at her level of understanding, each person at their level of understanding’ |
ID, participant identification number; RRB, Rasha R. Bayoumi (interviewer); tool, Fertility Awareness Tool (FertiSTAT).