Methods of Research – DRAFT

Research Title:

IMPLEMENTATION OF REPRODUCTIVE HEALTH LAW: AWARENESS ON FAMILY PLANNING PRACTICE AND STRATEGIES OF IMPROVING HEALTH AMONG SELECTED COUPLES OF BARANGAY BANAOANG, STA. BARBARA

Genaro C. Reyes III, RN
2014

Chapter I

INTRODUCTION

Rationale

The earth does not contain enough resources to indefinitely sustain the current enormous population growth. For instance, there is a limited area of arable land and living space. China, home to 1.2 billion people or 1/5 the world's population, is an excellent example of the kinds of problems that arise in an increasingly crowded society (Hanson,ND).

The Philippines is having a large population that results to low quality of life of women and children, health and family welfare. Population is admittedly one of the many causes of poverty since the government had difficulty in addressing the needs of its people.

In addition to, the Philippines is the 39th most densely populated country, with a density over 335 per squared kilometer, and the population growth rate is 1.9% (2010 Census), 1.957% (2010 est. by CIA World Factbook), or 1.85% (2005–2010 high variant estimate by the UN Population Division, World Population Prospects: The 2008 Revision) coming from 3.1 in 1960.
The 2013 total fertility rate (TFR) is 3.20 births per woman, from a TFR of 7 in 1960.
In addition, the total fertility rate for the richest quintile of the population is 2.0, which is about one third the TFR of the poorest quintile (5.9 children per woman). The TFR for women with college education is 2.3, about half that of women with only an elementary education (4.5 children per woman).

Congressman Lagman states that the bill "recognizes the verifiable link between a huge population and poverty. Unbridled population growth stunts socioeconomic development and aggravates poverty". In Population and Poverty, Aniceto Orbeta, Jr., showed that poverty incidence is higher among big families: 57.3% of Filipino families with seven children are in poverty while only 23.8% of families who have two children live below the poverty threshold.

Proponents argue that smaller families and wider birth intervals resulting from the use of contraceptives allow families to invest more in each child’s education, health, nutrition and eventually reduce poverty and hunger at the household level. At the national level, fertility reduction cuts the cost of social services with fewer people attending school or seeking medical care and as demand eases for housing, transportation, jobs, water, food, and other natural resources. The Asian Development Bank in 2004 also listed a large population as one of the major causes of poverty in the country, together with weak macroeconomic management, employment issues, an underperforming agricultural sector and an unfinished land reform agenda, governance issues including corruption.
(http://en.wikipedia.org/wiki/Responsible_Parenthood_and_Reproductive_Health_Act_of_2012)

So the government of the Philippines has decided to pass the Reproductive Health Bill which is now known as RH LAW. This law is aiming to guarantee universal access to methods and information on maternal care and birth control. The said law also stressed the need to enhance the status of women, which was crucial for achieving sustainable development. To realize this goal, women must have equal access to education and equal participation in social, economic, cultural and political life.
(http://www.studymode.com/essays/Rh-Bill-In-The-Philippines-763659.html)

The bill mandates the government to “promote, without bias, all effective natural and modern methods of family planning that are medically safe and legal”.
Although abortion is recognized as illegal and punishable by law, the bill states that “the government shall ensure that all women needing care for post-abortion complications shall be treated and counseled in a humane, non-judgmental and compassionate manner”.
The bill calls for a “multi-dimensional approach” integrates a component of family planning and responsible parenthood into all government anti-poverty programs. Age-appropriate reproductive health and sexuality education is required from grade five to fourth year high school using “life-skills and other approaches”.
(http://en.wikipedia.org/wiki/Responsible_Parenthood_and_Reproductive_Health_Act_of_2012)

However, some other people are still against in this law, especially the Catholic Church. They believe that the issue in overpopulation was the first reason why RH Law was made is nothing else but a LIE. They believe that poverty in millions of Filipino is not caused by overpopulation but rather they believe it is caused by corruption of the government officials.
This belief results to ignorance of the implemented programs on birth control measures like the sex education which is supposed to be learned by a responsible citizen at the right age.

Among the benefits of family planning often cited by contraceptive users are improvements in women's health and the family's economic status. In research conducted in Western Visayas, the Philippines, women said family planning allowed them more freedom to participate in the work force and more time to participate in community activities. Women who used family planning were generally more satisfied with their lives and more likely to share in household decision-making (David and Chin, 2007).

Some individuals or couples on the other hand, select a contraceptive method and continue using it throughout their reproductive lives. Others will change methods several times. This is because, they may want greater effectiveness. Or, they may be dissatisfied with side effects, have problems getting a method, or have previously followed poor advice from clinic staff. Some may simply wish to experiment, if various contraceptive options are available (Alejo et al., 2008). Decisions regarding the allocation of limited resources should, whenever possible, be based upon scientifically supported evidence. Evidence applicable to such decision-making is very limited and what does exist is not effectively disseminated to the decision makers.

Theoretical Framework
The primary concerns of this research focuses on the application, testing, and refinement of an appropriate conceptual or theoretical model, with attention devoted to the problem of measurement of the key variables of that model. The Health Belief Model is a model which has been shown to have application in the areas of preventive health behavior and compliance with medical regimens. This Model integrates several aspects of health decision making. The Health Belief Model (Katatsky Me, 2009) is suggested as a potentially useful conceptual framework for family planning research for a number of reasons. First, the Model is based firmly on social psychological theory and depends heavily on motivational and cognitive factors. Second, by taking an expectancy theory approach to health behavior, the Model derives considerable conceptual strength. Third, there is also a growing body of research to support the Model's explanatory capability.
According to Bandura's theory on self-efficacy (Pajares, retrieved 20:53, 30 August 2006 (MEST)), people with high self-efficacy, that is, those who believe they can perform well, are more likely to view difficult tasks as something to be mastered rather than something to be avoided.
People will be more inclined to take on a task if they believe they can succeed. People generally avoid tasks where their self-efficacy is low, but will engage in tasks where their self-efficacy is high. People with a self-efficacy significantly beyond their actual ability often overestimate their ability to complete tasks, which can lead to difficulties. On the other hand, people with a self-efficacy significantly lower than their ability are unlikely to grow and expand their skills. Research shows that the ‘optimum’ level of self-efficacy is a little above ability, which encourages people to tackle challenging tasks and gain valuable experience.
For Bandura, the capability that is most "distinctly human" (p. 21) is that of self-reflection, hence it is a prominent feature of social cognitive theory. Through self-reflection, people make sense of their experiences, explore their own cognitions and self-beliefs, engage in self-evaluation, and alter their thinking and behavior accordingly. Of all the thoughts that affect human functioning, and standing at the very core of social cognitive theory, are self-efficacy beliefs, "people's judgments of their capabilities to organize and execute courses of action required to attain designated types of performances" (p. 391). Self-efficacy beliefs provide the foundation for human motivation, well-being, and personal accomplishment. This is because unless people believe that their actions can produce the outcomes they desire, they have little incentive to act or to persevere in the face of difficulties” (Pajares, retrieved 20:53, 30 August 2006 (MEST)).
Another model describes the role of social interaction (or diffusion) in reproductive change. Montgomery and Casterline (1996) drew attention to the two fundamental components of diffusion: social learning and social influence. According to them, social learning refers to the acquisition of information from others, which in the case of fertility control may include information on the types of contraceptive methods available, the health side effects of the methods and the cost of the methods. At the inter-personal level, social learning takes place when the other actors provide information that shapes an individual’s subjective beliefs about prices, qualities, advantages and health risks of family planning methods. Social influence, on the other hand, refers to the power that individuals exercise over each other through authority, deference, and social conformity pressures. It is noted that individuals, faced with the need to make decisions in constantly changing environments characterized by ambiguities and uncertainties, rely on information drawn from African Population Studies (Feyisetan, et al.,2000).

Statement of the Problem
This study was conducted to determine the awareness on family planning practice and strategies of improving health among selected couples of Barangay Banaoang, Sta. Barbara

Specifically, the study aimed to answer the following questions: 1. What are the socio-demographic profile of couples in terms of the following: a. age, b. gender, c. educational attainment, d. religion e. family income 2. What are the level of awareness of couples on contraceptive knowledge and practice by method of couples in the target population? 3. What are the strategies to be adapted by couples to improve their health and family services? 4. Are there significant associations on the levels of awareness of couples on their contraceptive knowledge and practice by method to their demographic profile? 5. Are there significant associations on the level of awareness of couples on their strategies to improve family health and planning services to their demographic profile?

Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the professional literature and related studies reviewed for discovering facts about the topic under study. These related studies and literature offered evaluation and enhancement in the conduct of this research work
Related Literature
DOH (2006) revealed that birth spacing enables women to recover their health improves women's potential to be more productive and to realize their personal aspirations and allows more time to care for children and spouse/husband, and informed choice that is upholding and ensuring the rights of couples to determine the number and spacing of their children according to their life's aspirations and reminding couples that planning size of their families have a direct bearing on the quality of their children's and their own lives.
However, the use of modern methods according to NEDA (2009) is below 50. In terms of new acceptors and current users, family planning performance has not exhibited a sustained growth. This could be attributed to: (1) inadequate knowledge on population and family planning; (2) lack of family planning service centers and service providers; and (3) commodity support. NEDA (2009) affirmed that demographic effects on growth demonstrate that excess population may have some effect on the rate of productivity gains. The faster the growth of population of working ages, for example leads to a much larger labor force. It may also have some adverse impact on child health, nutrition and educational performance. These in turn have a future impact on the quality of human resources.
As cited by USAID (2009) family planning assistance saves lives, improves health, contributes to healthier children, and prevents abortion. When couples can choose the number, timing and spacing of their children, they are better able to adequately feed and educate their children, potentially ending the cycle of poverty. Communities thrive, and in turn, countries fare better. Today the greatest deficits in access to health services can be found in the poorest segments of the population. By channeling resources to family planning, nations can save lives, stabilize population growth, reduce poverty and improve women’s position in society.
USAID (2009) also suggests that all countries should assess the extent of national unmet need for good-quality family-planning services and its integration in the reproductive health context, paying particular attention to the most vulnerable and underserved groups in the population, should take steps to meet the family-planning needs of their populations as soon as possible and should seek to provide universal access to a full range of safe and reliable family-planning methods and to related reproductive health services which are not against the law.
Moreover, USAID (2009) noted that couples should be informed on the methods that can assist them in determining the number and timing of their children’s births as a way of improving family health and economic well-being. As fertility rates decrease, poverty rates are also expected to decline. As more women and men learn about reproductive health and family planning, families will become healthier and stronger, and enjoy greater equality of life (USAID, 2009).
Previous research on contraceptive behavior demonstrates the importance of factors associated with resource constraints and cultural preferences in determining desired family size and contraceptive use (Alejo et al., 2008). Women's age, parity, marital status, poverty, education, religious affiliation, race and ethnicity, immigration status and region of residence are strong correlates of fertility behavior. The existing literature argues that women with limited resources (financial or otherwise) and a low preference for additional children are less likely than others to have additional births (Park et al., 2003).
Moreover, when people stop using a certain contraceptive, it may not be because they are dissatisfied with their method. People who stop a method after long-term use usually do so because their reproductive needs or intentions have changed. Such change is to be expected and does not necessarily imply problems with the original choice of method. Rather, people are making a choice that better reflects their needs (USAID, 2001).
Moos et al. (2003) confirms that knowledge of correct contraceptive method use is positively associated with appropriate use; however, other factors, such as reservations about the method itself, lack of partner cooperation, and the woman’s beliefs about her fertility may attenuate the effect of knowledge. Several personal characteristics appear to influence correct and consistent contraceptive use. Among them are age, race or ethnicity, religion and income level. However, Khan et al. (2002) emphasized that the impact of these factors and the direction of their effect on compliance with method rules are not consistent across populations or cultures.

Related Studies

Biddlecom, Casterline and Perez (2009) conducted study on husbands’ and wives' attitudes about contraception at the couple and aggregate level in the Philippines. Their findings revealed that among 780 matched couples and currently married women 25-44 years old from urban and rural barangays in Munoz in Nueva Ecija province and in Manila, 75% of men and women strongly approved of contraception. Men were slightly less approving and less likely to perceive that their friends and relatives strongly approved. 50-66% of couples shared the same view. About 33% of spouses did not accurately perceive their partner's approval. The highest proportion of both men and women considered prevention of pregnancy as a very important attribute of contraception. Women tended to rank spouse's and others' approval, the effect of contraception on the marriage, and contraceptive accessibility as "more important" more often than did men.
Moreover, Biddlecom, Casterline and Perez (2009) noted that under 66% of couples ranked a specific attribute of contraception as "very" important. Couple agreement on a "very" important attribute ranged from 31% of couples' agreement on financial cost to 65% on effectiveness. Women tended to rate each method more negatively than men did. Men and women viewed the pill and the IUD more negatively than withdrawal and rhythm. Gender differences did not vary by type of method. Moderate to low levels of agreement on the pill, the IUD, the condom, and rhythm exceeded what would be expected by chance alone. Agreement did not relate to spousal discussion of contraception or joint decision making. When couples both approved of contraception, 81% agreed on intended use in the future, and 78% were current users.
Biddlecom, Casterline and Perez (2009) suggest that views on contraception have an impact on contraceptive use.
Similarly, a study conducted by Laing (1997 as cited by Alejo et al., 2008) on the differentials in contraceptive use-effectiveness in the Philippines, out of 1865 women who accepted family planning at the clinics in Philippines showed that: 1) after 1 year about 30% of the acceptors stopped practicing contraception; and 2) 22% became pregnant. 7 variables were measured: desire for additional children, educational attainment, religious affiliation, place of residence, distance from the clinic, cost of supplies, and husband's behavior. Only the contraceptive method first accepted had a strong effect on the likelihood of continuation of contraception or pregnancy. The IUD proved to have the highest continuation rate and the lowest pregnancy rate of all methods.
Among 418 women who participated in the study conducted by FHI (2007) had a method preference. Ninety-three percent of the women (390) received their preferred method. The method preferences were for injectables (51.9%), female sterilization (19.9%), implants (14.4%), male sterilization (7.7%), the intrauterine device or IUD (4.3%), oral contraceptives or OCs (1.7%), and condoms (0.2%).
Thirty clients (7.2 percent) did not receive their preferred method. Of these clients, 10 (33%) received no method at all, leaving these women unprotected against unwanted pregnancy. The reasons given by providers for not providing a method to these 10 clients was that pregnancy was suspected (70%) or the woman was not menstruating (30%).
Twenty clients received a method different from their choice. The main reasons given by providers were that the client changed her mind during the visit (55%), there were medical contraindications (20%), or the client was not menstruating (15%).
The fact that about 70% of contracepting couples rely on a female method (United Nations, 1994 as cited by Alejo, 2008) may be due in part to the limited contraceptive choices that men have. A number of surveys have shown that the majority of men believe they should be jointly responsible for birth control with their wives, and have expressed willingness to use methods that are as yet hypothetical, such as a pill for men. Male partners of women experiencing side effects may, especially, want to share responsibility for contraception.
Nearly all sexually active women knew about contraceptives, Barrett and Buckley (2007) study revealed that the respondents participated in their study reported that they had ever used the IUD (71%) or any modern method (77%). In both surveys, women with higher levels of wealth (odds ratios, 2.2–3.1) and education (1.9–2.5) were more likely than other women to know about contraceptive methods other than the IUD. The ability to choose among multiple methods is central to the decision to practice contraception, because individuals' and couples' contraceptive needs differ according to their motivations for pregnancy prevention (delaying, spacing or stopping), their concerns about STIs and the cultural acceptability of available methods.

Questionnaire

A. SOCIO- DEMOGRAPHIC PROFILE 1. Name (Optional): __________________________________________ 2. Age : a. 18-25 [ ] b. 26-32 [ ] c. 33-39 [ ] d. 40-49 [ ]

3. Gender: a. Male [ ] b. Female [ ]

3. Educational Attainment: a. Elementary Graduate [ ] b. High School Graduate [ ] c. College Graduate [ ]

4. Religion a. Roman Catholic [ ] b. Jehova’s Witness [ ] c. 7th Day Adventist [ ] d. Iglesia ni Kristo [ ] e. Baptist [ ] f. Born-again Christian [ ] g. Methodist [ ] h. Mormons [ ] i. Others [ ]

5. Family Income Status:
a. 7,000.00 – 10,000.00 [ ]
b. 10,001.00 – 20,000.00 [ ]
c. 20,001 and above [ ]

5. Contraceptive method used by the couples [ ] a. Rhythm method/Periodic abstinence [ ] b. Basal body temperature method [ ] c. Cervical mucus method [ ] d. IUD [ ] e. Condom [ ] f. Depo-Provera (injection) [ ] g. Spermicides [ ]

B. LEVELS OF KNOWLEDGE ON CONTRACEPTIVE METHOD

Directions: Put a check (/) mark in the space provided after each item in which your answer corresponds. The following scale of 1 to 3 signifies the level of contraceptive knowledge and practice by method.

1 – Not oriented

2 – Oriented

3 – Well Oriented

Your answer in this questionnaire serves as our data in assessing and understanding your perceptions with regards to your level of knowledge on contraceptive and practice by method. Your response will be highly appreciated and confidentially observed.

C. STRATEGIES FOR IMPROVING HEALTH AND FAMILY PLANNING SERVICES

Directions: Put a check (/) mark in the space provided after each item in which your answer corresponds. The following scale of 1 to 3 signifies the degree of awareness of respondents regarding strategies to improve family planning services.

1 – Not Aware (NA)

2 – Partially Aware (PA)

3 – Fully Aware (FA)