Qualitative Study for Understanding Knowledge, Attitudes and Behaviors of Communities for

Reproductive, Maternal, Newborn and Child Health in Rural Afghanistan

Introduction and BackgroundWith the population of 30 million people, Afghanistan is among the least developed countries of the world. As per the United Nations statistics, life expectancy at birth of just 44 years in Afghanistan is worst in Asia and eighth worst in the world. Similarly, the rate of mortality of nearly 20 deaths per 1,000 inhabitants is the fourth worst in the world after Sierra Leon, Swaziland and Angola. Decades of armed conflict and political uncertainty in Afghanistan have aggravated public health challenges to formidable levels as every year a large number of deaths occur due to mostly preventable and curable causes. The Global Burden of Disease Study conducted in 2010 found that the largest share (almost 50%) burden of disease in Afghanistan is due to maternal, neonatal and nutritional causes of death. The Table 1 provides a glimpse of key Reproductive, Maternal, Newborn and Child Health (RMNCH) Indicators of Afghanistan.

Table 1: Key RMNCH Indicators Status

IndicatorStatus (% or number) Source

Maternal Newborn and Child Health IndicatorsTotal fertility Rate 5.1 Afghanistan Mortality Survey 2010Maternal Mortality Ratio (per 100,000 live births) 327 Afghanistan Mortality Survey 2010Infant Mortality Rate (per 1,000 live births) 74 MICS 2011Under - 5 Mortality Rate (per 1,000 live births) 102 MICS 2011Neo-natal Mortality Rate (per 1,000 live births) 36

United Nations Inter-agency Group for Child Mortality Estimation 2012

At least once ANC by skilled personnel 48.1 National Nutrition Survey 2013At least four times ANC by skilled personnel 16.4 National Nutrition Survey 2013Content of antenatal care (BP measure, Urine and blood sample taken) 7.4 National Nutrition Survey 2013Skilled attendant at delivery 45.5 National Nutrition Survey 2013Contraceptive Prevalence Rate (%) 21 MICS 2011

Pregnant Women Receiving at least 2 Doses of Tetanus Toxoid 23.8 Afghanistan Mortality Survey 2010Delivery in a Health Facility 32.9 MICS 2011Caesarian Section 3.6 MICS 2011Postnatal Care Less than 4 hours 1 in 5 women Afghanistan Mortality Survey 2010Pregnant women anemia prevalence 16.3 National Nutrition Survey 2013

Tuberculosis immunization coverage 64.2 National Nutrition Survey 2013Polio immunization coverage 48 National Nutrition Survey 2013Immunization coverage for diphtheria, pertussis and tetanus (DPT) 40.2 National Nutrition Survey 2013Neonatal tetanus protection 40.8 National Nutrition Survey 2013

One of the key interventions for improving preventive and promotive aspects of reproductive, maternal, newborn and child health as well as for improving health-seeking behavior, promoting client-centered approaches and building demand for knowledge and services in general is the comprehensive use of social mobilization and communication strategies. The strategy development requires identification of key barriers which need to be overcome through communication and mobilization interventions. There exists some knowledge on the knowledge, attitudes and practices with respect to RMNCH in Afghanistan however there is a need to have more in-depth understanding of the underlying causes of the different problems and to substantiate what has already been documented through existing literature.

ObjectivesThe study in hand is a component of the overall activity of development of Comprehensive Social Mobilization and Communication Strategic Plan for Reproductive, Maternal, Newborn and Child Health, Afghanistan. It aims to improve understanding of different knowledge, attitude and practice barriers that will be focused through communication for improving household level practices and well as health care seeking especially from Afghan public sector health system.

The specific objectives are:

To explore the feelings of rural Afghan mothers and fathers at the time of pregnancy, child birth and child illnesses.

To identify key health care practices at household level in rural areas of Afghanistan related to pregnancy, child birth and child illnesses

To identify key decision makers, gatekeepers and influencers at household and community levels for decisions about health care seeking outside home in rural Afghan areas.

To know communities’ sources of information about RMNCH behaviors and health care seeking practices in rural Afghan areas.

MethodologyThis was a qualitative study. The primary sources of data were fathers, mothers and community health workers in rural Afghan communities. Data was collected through Focus Group Discussions (FGDs) using a semi-structured guideline to conduct the FGDs. The FGDs were conducted with fathers and mothers who have at least one child. Besides, community health workers who have been involved in delivering any of key RMNCH services were also included in the study. Separate FGDs guides were developed for each group of respondents. FGDs were conducted in 4 districts i.e. Sorobi, Dehsabs, Bagrami and Qarabagh.

Purposive sampling technique was employed to identify the respondents of the study. The FGDs participants were identified through the community leaders at each site. They were explained the purpose of study and requested to identify the participants and assemble them on a given date and time at an agreed place.

Trained researchers who possessed experience in conducting FGDs were employed for conducting the FGDs in local language. A facilitator and a note taker conducted each FGD. Female researchers conducted female FGDs and male researchers conducted the male FGDs. The field data collectors were trained on conducting FGDs on the guides prepared for data collection. They were introduced to the purpose and objectives of study, the FGD guides and Dos and Don’ts of the FGDs and obtaining informed consent.

The study participants were informed about the purpose of the study before the onset of the discussion. They were informed about their right to not to participate in the study or leave at any time they would like to leave or refuse any information without any question being asked. A form was used to obtain the consent of participants. The verbatim were transcribed into written notes for analysis purposes. The data was sifted under the various themes defined in the guide and entered into excel sheet for analysis purposes.

FindingsGeneral Characteristics of ParticipantsA total of 97 individuals (50 females and 47 males) participated in the FGDs with an average of almost 12 participants per FGD. The lowest number was 9 in the male FGDs in village Baghalam of District Qarabagh. The number of community health workers (CHWs) who participated in the FGDs was 37 (13 Female CHWs and 24 male CHWs). The average age of the participants was 39 years with almost negligible difference amongst males’ and females’ average ages i.e. 40 years and 39 years respectively. All female participants except Female CHWs i.e. 37 were housewives. The male participants including Male CHWs had different occupational backgrounds. The most mentioned i.e. by 9 males was private business. The other important categories included farmers by 6 males and shopkeepers by 4 participants. The other less mentioned occupation included teacher, well digger, watchman, driver and malak. With respect to literacy, 64 participants were illiterate i.e. did not possess the ability to read and write and 33 were literate. A higher number of females i.e. 43 out of 50 females as compared to 20 out of 50 males were illiterate.

Feelings during PregnancyFeelings of the audience is an important factor to marry the offerings through communication messages with the audience interest. Effort was made to explore the feelings of mothers and fathers during the 3 important stages of childbirth i.e. during pregnancy, around delivery and during post-partum period. The observations about feelings during pregnancy are as follows:

The feeling of happiness was the most predominant feeling mentioned by almost all female respondents. It was mentioned as the only feeling as well as in combination with other feelings. Out of 36 mothers, majority i.e. 24 mothers mentioned their feelings of only happiness on becoming pregnant. Ten women expressed mixed feelings such as tension, depression, fear, illness feeling along with the feeling of happiness. Only 2 participants mentioned their feelings of sadness.

Different reasons were quoted for being happy on the onset of pregnancy. The most mentioned reason i.e. by 15 mothers was “becoming mother”. The second most quoted reason was the “honor” i.e. by 4 mothers. The other reasons mentioned in less number were late pregnancy, son preference, new earning hand and new person to the family.

The negative feelings such as depression, fear, sadness appeared to be primarily driven by the inaccessibility of maternity services (4 mothers), earlier own experience and observation of others poor outcomes of pregnancy (3 mothers) and existing physiological problems (3 mothers). The

inaccessibility of maternity services was underpinned by non-availability of husband, unwillingness of husband and family problems.

When Female Community Health Workers (FCHWs) were asked about their observation of women when they became pregnant, almost all FCHWs (10 out of 12) endorsed the feeling of happiness being the overwhelming feeling of the women on becoming pregnant. Two FCHWs observed the feeling of sadness owing to repeated pregnancy and financial issues. It is however interesting to note that none of these 2 reasons were mentioned by any female for any of their negative feelings during pregnancy.

As in the case of the mothers, pregnancy is a matter of happiness for fathers as well. All male participants of the FGDs mentioned the feeling of happiness on having pregnancy. The most mentioned underlying reasons for happiness was “becoming father” that was expressed by 17 out of 23 fathers. Out of these 17 respondents, 11 mentioned becoming father as the only reason for their happiness while others mentioned it along with other reasons. The other reasons mentioned included honor (3 fathers), addition to family (2), addition to Muslim population (2), have someone to play with (2), addition to country’s population (1).

Interesting to note here is that in contrast to mothers, fathers did not mention any feelings of worry around pregnancy. This may be due to their lack of involvement with the pregnancy owing to social taboos confounded by their lack of lack of knowledge about pregnancy matters. Besides, it is mothers who primarily undergo the physiological and psychological experiences during pregnancy and thus can anticipate the negative outcomes on their health and understand their needs whereas fathers might lack in the understanding of the needs of mothers during pregnancy.

The observations reported by Male Community Health Workers (MCHWs) appeared to reinforce the findings from the FGDs with Fathers. Happiness was mentioned by all MCHWs (21), and the primary reason mentioned was the feeling of “becoming a father” mentioned by 18 MCHWs. The other reasons of happiness included support to fathers (5), increase in family (5), honor (4) and manhood (1). Interesting to note here is that support to fathers was not mentioned by any father in father FGDs.

Feelings around DeliveryThe overwhelming feelings of happiness during pregnancy appears to gradually fade away when the time of delivery comes which is understandable given the seriousness of the delivery stage. Mixed feelings were expressed by the participants. Depression (7), tension (6) and fear (6) were the most mentioned feelings at the time preceding and during delivery. Besides, 2 participants mentioned the feeling of sadness and 1 mentioned the feeling of pain in this regard.

What caused depression? The respondents who mentioned depression feelings mentioned the lack of permission from husband/family for having delivery in the clinic that resulted into the loss of child (3), abortions (2) and non-availability of anyone to take the mother to hospital at the time of delivery (1) as the causes of the depression.

The feeling of tension was underpinned by the perceptions about labor (3), not having permission to go to clinic (1), having anemia (1) and not having a healthy baby (1). The feeling of fear was driven by perceptions of labour pain (4), losing the baby (1) and not having first baby healthy due to anemia (1).

With respect to positive feelings, 7 participants mentioned the feeling of happiness, 2 participants mentioned the feeling of honor and 1 participant mentioned the excitement feelings. Interesting to

note is that the feeling of happiness was predominantly related with having hospital delivery (7) followed by mother and child being normal/healthy.

The feelings reported by the female community health workers however contrasted with the feeling mentioned by mothers themselves. Out of 12 FCHWs, 9 mentioned the feelings of happiness and 2 mentioned the feelings of sadness owing to the inability to go to the clinic and repeated deliveries. It is though not clear as why FCHWs mentioned the feeling of happiness one can postulate that being health workers they had access to health facility and therefore they themselves were happy because one of the reason for being sad was inability to deliver in health facility and other was repeated pregnancy. The contrast in the two type feelings again underscore the gaps in understanding of the health workers of the mothers feelings.

Whereas the males tend to not exhibit any feelings of tension during pregnancy, the feeling of tension becomes predominant feeling of fathers around delivery time. Tension around the time of delivery was reported by 19 out of 23 fathers. The feelings of tension were related to the fear of loss of wife and child (17), to loss of money (1), clinic being far away (1) and complications of labor (1). This reflects that males do attach a lot of value to the life of wife and neonate, however, the realization of this value comes at a later stage. The responses from Male Community Health Workers also reinforced the overwhelming presence of feelings of tension at the time of delivery (15 out of 21). Fear was mentioned by 4 MCHWs and 2 mentioned having feelings of hope. The tension feelings were predominantly related with the loss of wife and the child by 13 respondents, health facility being far and lack of transport by 4 respondents.

Feelings after DeliveryThe feelings after delivery appeared to be deeply connected with the outcomes of the delivery. Out of 36 mothers, half i.e. 18 mentioned having good feelings. Apart from successful birth outcomes, the good feelings were related with having good food (4), substantial rest (4), healthy baby and mother (1). Negative feelings were expressed by rest of the mothers (18). These included bad feelings (5), fear (2), depression (4), tension (3) and sadness (3).

What were the determinants of the aforementioned negative feelings that were exhibited by half of the respondents? Lack of access to medical services (6), non-availability of food (5), lack of rest (5) and bad behaviors of the mother in law (1) and husband (1) were mentioned as the underlying reasons of negative feelings. These findings appear to resonate with the Post Partum Hemorrhage (PPH) being the leading cause of maternal deaths. PPH requires medical intervention and women failing to get the medical services in postpartum thus become more vulnerable to death due to PPH.

Majority of the Female Community Health Workers i.e. 10 out of 12 mentioned that their pregnancy lasted well. This may be due their being health workers themselves and having the required agency to manage their birth outcomes because of their knowledge about health issues and their management and access to health facilities.

Interestingly, fathers predominantly mentioned the feelings of happiness (13 out of 23) in post-delivery stage, followed by 6 fathers who mentioned the feeling of tension and 4 fathers who mentioned the feeling of being relaxed. Fear and sadness were expressed by 1 father each. The perceptions for being happy included good end (5), wife was healthy (2), problem solved (2) and becoming father (1). The contrasting feeling of tension emerged from wife not becoming healthy after delivery (5). It is also interesting to note that whereas happiness and relaxation feeling prevailed amongst fathers in post delivery times, the bad feelings, fear, depressions, tension prevailed amongst the mothers during post delivery times. This may be attributable to the fact that

it is the woman who is undergoing the post delivery implications occurring in her body and psychology and men do not interact with women during post partum period and thus may neither have the knowledge of the issues nor could appreciate the problems of the mothers which may translate into the lack of care by males in post partum time. In MCHWs FGDs, 18 out of 21 participants mentioned the feelings of happiness and relaxation. They attributed these feelings to the end of the “dangerous stage” and having good birth outcomes.

Ways and Means to Express the FeelingsEffort was made to explore the ways and means through which Afghan mothers and fathers express their feelings during pregnancy, childbirth and birth outcomes. Not very many traditions or customs were mentioned around pregnancy. Only 2 respondents from Male CHWs mentioned saying prayers and recitation of Quran on the occasion of knowing their pregnancy. Not mentioning the ways and means of expression of feelings during pregnancy could have different explanations. First, the respondents did not understand the question which may not hold true because 2 respondents did answer the question and one respondent did mention not knowing. Secondly, lack of the comprehension and resultantly not having answer could also be a function of inexistence of any such practices due to the social taboos around pregnancy whereby this is not openly discussed, cheered and mentioned in the family, community and society. Interestingly, the number of men who mentioned “praying” increases to 12 for the delivery stage. These men are however only from the category of MCHWs. This may be a function of their knowledge of the dangers associated with the delivery and labor stage by virtue of their being health workers.

Whereas, there did not appear the existence of customs and traditions of open expression during pregnancy and labor for both males and females, several customs and traditions of rejoice were mentioned by only males in post-delivery times (understandably as females are not physiologically fit in that time). Recitation of Holy Quran, arranging party for friends, distribution of sweet and candies, giving foods to poor, calling friends, video party were mentioned as practices of welcoming the newborn. The 6th Day after birth was the most mentioned day for celebrations.

Sharing of the FeelingsWho are the feelings shared with? It is an important question for identification of those who can affect the change process. For mothers it appeared that husband and mother in law are the closest associates whom the news of pregnancy is shared with. Out of 36 mothers, 27 mentioned sharing their pregnancy related feelings with husbands and 24 mothers mentioned sharing the feelings with their Mother in Laws. The other less significant members of family with which women shared their feelings around pregnancy included wife of brother in law (7), woman’s mother (5), husband’s sister (4), sister (2) and grandmother (1). Similar findings were observed in the FGDs with FCHWs, whereby husbands and MILs were the key resorts of the pregnancy related feelings sharing by females.

Now whereas, husbands are the primary recipient of the news of pregnancy, who do they talk about pregnancy? Interestingly, the mother of husband i.e. MIL of the woman also happens to be the primary member of family for pregnancy related feelings sharing through husband. Sixteen out of 23 fathers in male FGDs mentioned sharing of the pregnancy related feelings with their mothers. The second big category with whom males shared their feelings around the pregnancy was their friends (13) followed by MCHWs (9), males’ MILs (9), aunt (7), sister (7) and doctor (7) and father (4). Almost similar were the findings from the FGD with the MCHWs except that brother was also mentioned by 3 respondents.

The comparison of the male and female FGDs provide some interesting insights. Firstly, MIL (mother of the husband) turns out to be the most contacted person for sharing the feelings of pregnancy.

This may be due to fact that she is perceived to be the most experienced person in family regarding the pregnancy issues and primary custodian of the family growth within the premises of the household and thus is the potential channel to influence both mother and father. Besides, probably in coherence with the Afghan culture the women tend to not share the news of pregnancy outside of family as nowhere was mentioned any peer in female FGDs whereas in case of males the friends/peers are a big stakeholder in pregnancy news sharing. Interesting to also note here is that whereas females did not mention any health worker, the male health workers were mentioned by male FGDs participants to be contacted about during pregnancy. It reflects that firstly males do take interest in pregnancy matters but they have a limited choice to seek advice and guidance on that. They only resort to MCHWs in this regard for the reason that they probably belong to same gender and are accessible.

Postpartum period is an important stage in women’s lives and considered as opportunity for convincing women on different maternal, neonatal, child health behaviors, family planning and nutrition. Mother in Laws were mentioned the most (by 23 mothers) as the person with whom they shared their feelings and discussed during post-partum followed by husbands (11). The findings were similar in FCHWs FGDs except that they did mention CHWs with whom women shared their feelings which were not mentioned at all in mother FGDs.

It appears that in contrast to pregnancy when husband was most talked about by women, in postpartum MILs are the most contacted family member by the females. It may be due to the factors that postpartum issues being more medical are easier to discuss about with females (MILs), whereas pregnancy is dominated by social aspects such as happiness etc and women like to communicate this to husbands being their intimate partners and biggest shareholders of happiness. Family in general was also mentioned by 8 respondents whereas this was not mentioned for the stage of pregnancy which indicates that pregnancy is probably dealt as a more private matters as compared to postpartum stage of child birth. Important here is also to note that none of the health workers was mentioned to have been talked with in postpartum by the mothers. This is consistent with the fact that post natal care visits prevalence is extremely low which is a point of pondering because neonatal deaths can be averted through timely PNC visits and similarly postpartum deaths of mothers can also be averted by timely seeking of services of a health worker. The CHWs were mentioned in FCHWS FGDs which may be due to the fact that respondents themselves for CHWs.

In male FGDs, Mothers (Mother in Law of woman) was mentioned the most (by 22) as the person with whom fathers shared their feelings and talked about in postpartum stage of child birth. The second most mentioned category was community health workers (16) followed by mother in laws (mothers of wives) by 12 respondents. These findings are consistent with the findings around pregnancy discussions. Mothers remain the primary member of family with whom husbands interact. Friends were however not mentioned about postpartum discussions. However, CHWs appear to be significantly contacted by husbands in postpartum period. The other important category mentioned by husbands was sisters (8). Similar were the findings from the FGDs with male CHWs.

Health Care SeekingHealth care seeking from qualified health workers is an important behavioral determinant of the health status of communities. Out of 36 mothers, most i.e. 21 did not seek any health care in pregnancy from a qualified health worker, 6 participants mentioned seeking one time care and 2 mentioned twice seeking health care and one respondent in each category mentioned seeking health care 3 and 4 times. Almost similar trend was mentioned in the male FGDs with fathers. Nine

out of 21 males mentioned not seeking any care for their wives during pregnancy, 3 mentioned single time and 6 respondents mentioned 3 times care seeking, twice and four times seeking care was mentioned by one respondent and 2 respondents mentioned seeking care more than four times. Important here is also to note that the health care seeking where undertaken appeared to be prompted by some reasons and was mostly not routine health care seeking. The reasons mentioned for health care seeking included vaccination, absence of fetal movement, problem during pregnancy, jaundice. This appears to be consistent with the low ANC seeking in Afghan communities i.e. One ANC visit (48%) dipping down to 16% for 4 ANC visits. With respect to delivery services seeking, out of 36 women most of the mothers (20) mentioned having delivery at home and 16 women mentioned hospital delivery which is also consistent with the national figures of 45% skilled birth attendance.

When inquired about the health care seeking in Post-Partum period, most i.e. 30 out of 36 women mentioned not seeking any care after delivery. The findings from the health workers FGDs highlighted that the care seeking in postpartum period appears to be overwhelmingly driven by surfacing of any problem such as illness of the child, bleeding or due to pain, anemia and need for child vaccination otherwise communities do not tend to seek PNC.

Decision Makers for Health Care SeekingHealth care seeking involves a certain degree of decision making at household level. Who are the key decision makers regarding health services seeking for mothers and children in the phases of child birth and later on for child illnesses? Mother in Law (MIL) was mentioned the most (by 27 respondents), followed by husbands (by 21) and Father in Law (FIL) (by 17). Only one respondent mentioned herself as taking the decision. Important here is to note a few things. Firstly, the decisions are usually taken jointly by MIL, FIL and Husband. Secondly, whereas FIL appears to be a key decision maker, he does not appear to be interacted with both by mother and husband in sharing of the pregnancy related feelings and information. MIL however continues to be important stakeholder of the decision making as well as pregnancy information sharing and thus appears to be instrumental in brokering/influencing the decision to seek health care.

The Female Community Health Workers FGDs also partially reinforced the findings from female FGDs with respect to decision makers of health care seeking in pregnancy. Firstly, all FCHWs (13) mentioned husbands as decision makers along with MILs. Besides, all of them also mentioned Community Health Worker (CHW) as the decision maker with husbands and MILs who was not mentioned in the female FGDs with mothers. However, none of them mentioned Father in Laws to be the decision maker for health care seeking during pregnancy in contrast to female FGDs participants’ observations. Besides, all of the FCHWs also mentioned themselves as the decision makers which may be due to their being the health worker.

With a slight variation, the findings from female FGDs were reinforced in male FGDs as well. All participants of male FGDs mentioned themselves (husbands) as being the key decision makers along with family elders. Eleven mentioned fathers, 8 mentioned mothers and 14 mentioned family elders as the co-decision makers. Same categories were mentioned in the male community health workers FGDs as well.

No major variation was observed with respect to different phases of child birth i.e. pregnancy, delivery and Post-Partum phase. The findings bring forth the stark aspect that mothers themselves are not decision makers at any level and whereas the decisions are about their body, life, health but they do not take decisions for themselves.

Decision InfluencersWhereas, decision makers are important in their own regard, decision influencers also play an important role in happening of the decisions by affecting the decision makers. Effort was made to identify the key decision influencers at the household level. The respondents were asked about the people whose advice was valued while undertaking decisions regarding health care seeking in pregnancy. In female FGDs, Mother in Law (MIL) was mentioned the most (27 respondents) followed by husbands (by 25 respondents) and women themselves (12 respondents) and Community Health Workers (7). The findings from the FGD with Female Community Health Workers also reinforced these findings. Husbands, MILs, CHW and elders of the family were mentioned to influence the decision of seeking health care by all participants (13).

Similar findings emerged from the FGDs with males as well. Mother of the husband (MIL of wife) was mentioned the most (all 21 respondents) followed by mentioning mothers in law of husband (12 respondents). The male participants however also mentioned doctors (11 respondents) advice being held important which was not mentioned in any of the female FGDs. Fathers and home elders were also mentioned by 8 respondents. The FGDs with Male Community Health Workers (MCHWs) also identified the mother of the husband (MIL of wife) as an important decision influencer (12 out of 24 respondents). A majority of MCHWs (21 out of 24) however mentioned health workers (doctors, midwife, CHW, nurses) whose advice was given value in decision to seek care from health facility. No difference was observed with respect to categories of influencers in pregnancy, around delivery and in postpartum care seeking.

Reasons for not using the Health FacilitiesEffort was made to explore the reasons for non-utilization of the health facilities. The most mentioned reason by the females (8) was clinic located at far distance followed by the factor of ill-treatment by 6 respondents that also included poor manners and lack of attention to the patient. The other reasons mentioned included lack of privacy, asking for money, lack of medicine.

Given the culture of Afghan and the earlier findings we understand husbands are key decision makers for seeking health care from health facility. FGDs with them identified several interesting reasons of their dissatisfaction which might be underlying their negative attitude towards seeking health care from health facilities. The most mentioned reasons included absence of waiting areas (15), no permission to attendant to accompany wife (15), no facilities such as toilet for the attendant (15), bad conditions of food in hospital (15). The other less mentioned reasons included high prices of canteen (6), unreadable prescriptions (5). A few respondents also mentioned lack of medicine, difficulty in finding blood and medicine, bad advice of prescribing formula milk as inhibiting factors.

The FGDs with male Community Health Workers also provided some insights into the reasons for not using the health facilities. The most mentioned reason was ill-treatment (12), followed by long waiting time (8), asking for money (7), clinic being located at far distances (7), non-availability of doctor most of the time (7), no equipment (7), low quality medicine (7), no diagnosis facility (7) and bad attitude of providers (5).

Perceptions of Needs of Mothers and NewbornsEffort was made to explore the perceptions of the respondents about the needs of mothers during child birth stages and of newborns. The needs mentioned the in female FGDs with mothers were food (35/36) and rest (34/36). The other needs mentioned were medicines (12) and family support (10). With respect to newborns the biggest need identified was clothes (33), good hygiene (20) and warm place (12). Same needs were identified in the FGDs with the female CHWs except that they also mentioned colostrum as the need for the neonate. Food, rest, medication for women were

underscored in the male FGDs however, besides these chicken, meat and cow ghee was also predominantly mentioned in the male FGDs as needs of mothers.

With respect to neonates’ needs, vaccine was mentioned the most (9 respondents). The other needs identified included breastfeeding (3), cool temperature (3), clothes and medicines 92) and circumcision (1). Food and rest were also the needs identified by most of the participants (12 and 11 respectively) in male Community Health Workers FGDs. Fruits, vegetables, apples, fluids and fruits were the other mentioned needs by 2 participants. With respect to newborn needs, vaccine was identified as the need by most of the respondents, followed by clothes (9), Breast Feeding (8), complementary foods (8) and milk (8).

The perceptions of the needs by communities provide some interesting insights. One can see that the proven interventions such as ANC check ups, PNC check ups, skilled birth attendance are not perceived as the needs of mothers and newborns. Some of the nutrition interventions such as feeding of colostrum to newborns, breastfeeding and need for iron for pregnant mothers have also got some currency in the Afghan culture, however, these interventions may also not bring the harvest unless the health care seeking is considered by communities as the need of mothers and newborns because through active health care seeking can communities benefit from the other positive behaviors through reinforcement and access to correct information and other complementary interventions. This is also necessary that some of the wrong practices appear to be prevailing amongst the communities such as the need to keep neonate in cool temperature, giving milk and complimentary food to neonates (expressed in male FGDs).

Causes of Children DiseasesMost of the respondents were aware of the leading common diseases of childhood. In female FGDs, diarrhea and pneumonia was mentioned by majority of the respondents i.e. 26 and 25 respectively, followed by allergy by 9 and malaria by 4. There was no visible difference amongst the male, female and health workers FGDs. Diarrhea and pneumonia were mentioned the most in all groups of participants. As we know that most of causes of diarrhea and pneumonia are same, so respondents were asked about the causes of diarrhea in children. The most mentioned cause by respondents in female FGDs was unclean water (34), followed by bad hygiene (27), open sources of water (13), bad sanitation (12), dirty hands (11) and dirty food (10) which reflect that women had a good awareness of the causes of diarrhea in children. The causes mentioned most by male FGDs respondent were dirty hands (6), dirty clothes (6), unclean water (7) and dirty food (7). Some of the respondents also mentioned environmental hygiene including garbage, dirty area, and open defecation as causes of diseases in children.

Sources of InformationThe respondents were further probed for their sources of knowledge regarding the different causes of diarrhea in children. Multiple sources of information were mentioned by respondents. Majority 28 out of 36 female FGDs participants mentioned self-experience and an equal number identified health personnel as sources of information. Besides, 22 female respondents mentioned TV as their source of information followed by radio by 14 respondents, clinic (7) and father (7). Almost same sources of information were identified in male FGDs. Life experience was the most mentioned source of information (13), followed by CHWs (11), TV (9), radio (3) and doctor (2).

Household Practices for DiarrheaThe respondents were inquired about the household practices about diarrhea of children and when did they take the child to clinic for health care seeking. A number of things were identified by respondents which they used to give to children with Diarrhea. Out of 24 women in mother FGDs

who responded, majority i.e. 9 women mentioned youghart, jawani badyani (salt water), followed by 8 mentioning Esapghol and boiled water and 7 mentioned ORS. Bartang, banana, white rice, red and yellow capsules, medicines from pharmacy were mentioned by 6 respondents each. Bean soup, rice water, floor serum, pameerak and halela were mentioned by 5 respondents each. Almost similar things were mentioned in the male FGDs. Youghart with salt was mentioned by the most (8), followed by ORS, boiled water, boiled water with salt, soft food, rice water, rice and yougart by 6 respondents in each category. Esapghol was mentioned by only 2 respondents.

When did they take to clinic, was the next probe. Majority of mothers in female FGDs (21 out of 24) mentioned fever and non-responsiveness to home remedies as the symptoms when they would take the child to clinic. The other responses included inability of the child to drink or eat and drowsiness by 7 respondents, followed by vomiting by 2 respondents. The perceptions of males however appeared little different in this regard. Majority of the male respondents considered inability to eat (13), vomiting and blood dysentery (12 each) and fever (8) as decision points.

Interesting here is to note that sunken eyes and skin turgor are the most important measures of dehydration in diarrhea that mandates immediate/emergency care seeking were not mentioned by any of the respondent in both male and female FGDs as the decision points. Besides, it appears that use of salt is emphasized more in communities but use of sugar does not appear to be the practice whereas the alternative fluids for ORS are usually made by combination of sugar and salt. A number of local things have also been mentioned which needs to be looked at for their suitability and accordingly encouraged or discouraged. The use of ORS appears to be low which shall be promoted in any case which can address the use of other local things and be positioned as good and easy alternative.

Childhood ImmunizationPerceptions of BenefitsEffort was made to understand community’s perceptions about childhood immunization. All respondents in female FGDs mentioned the general response of prevention from childhood illnesses. Whereas in male FGDs, respondents could also identify names of some diseases that in their view were prevented by immunization. Out of 22 male respondents, paralysis and measles were identified by most of the participants (10 each) followed by Lashmania and Whooping Cough (by 8 each) and prevention of general diseases (6).

Reasons for not getting children immunizedThe reasons were explored from the female respondents (9) who mentioned not having their children vaccinated. Not knowing the benefits by 5 respondents and side effects such as fever by 4 respondents were mentioned as the major reasons. Causes sterility in children, causes paralysis and don’t trust the vaccines were mentioned by 1 respondent each. When asked from males, the major reason mentioned for not getting children immunized was that it causes weaknesses (12) and not knowing the benefits of vaccination (12).

Reasons for non-Immunization of Pregnant WomenImportant here is to mention a few causes that were mentioned in female CHWs FGDs for not getting pregnant women immunized. These included reasons such as girls who are vaccinated will give birth only to girls, vaccines weaken the ova, and vaccines cause sterility. The other reasons mentioned included husbands and MILs not allowing them to get vaccinated.

Family PlanningPerception Benefits and Reasons for not using itFamily planning is an important intervention for improving reproductive, maternal, newborn and child health. FGD participants were probed for their perceptions of benefits of the family planning. Interestingly almost all female participants (24) perceived FP as helpful intervention for their own and child health. Majority of the respondents (11) could also relate it to spacing between pregnancies. When probed for barriers to use, amongst those who mentioned not doing family planning (12), majority (9) mentioned not using contraceptives due to side effects and one mentioned husband not permitting to use.

When males were asked about their perception of benefits of family planning, out of total 24 respondents, most (10) saw it as a help to mother for taking care of children. Helping mother to get ready for next baby, prevention of mother’s weakness, prevention of mental disorders of mother and prevention of repeated pregnancies were mentioned by 8 respondents each. Five respondents also related with the well growth of the child. One respondent refuted any benefit mentioning it as not part of the Afghan culture and one mentioned it having no benefits. When probed for the reasons of not using contraceptives, most of the respondents (12) mentioned it as a sin and prohibited in Islam, followed by it being the cause of diseases (9), and cause of weight gain (8).

Sources of Information for Communities on MNCHThe respondents were asked about their sources of information about Reproductive, Maternal, Newborn and Child Health (RMNCH). Television (TV) was mentioned by the most of participants in female FGDs (30) as their source of information followed by Radio (25) and doctor (21). The other major sources of information mentioned by mothers included clinic (15) and self-experience (6) and midwife (5). Interestingly in male FGDs with fathers, Radio was the most mentioned sources of information (10), followed by doctor (9), self-experience (7) and health personnel (7). Mullah was also mentioned by 6 male respondents as their source of information. TV was mentioned by a lesser number of males (5). Besides, books/magazines were also mentioned by 4 and CHWs by 3 respondents.

From the above findings it evident that electronic media is coming in a big way in the lives of the Afghan people. Females have more exposure to TV for the reason that they stay more at home while males listen more to radio which probably could be a function of the portability of radio currently in the form of mobile FMs. The health workers of all cadre though continue to play an important role as the sources of information. In contrast to females, males do also get information from mullahs.

Conclusions and DiscussionThis is a small qualitative study that employed only FGDs as method of data collection. Whereas, the findings of the study could not be generalized in its own regard, yet these findings serve the purpose of augmenting and validating the existing knowledge. The study provides some interesting insights into the lives of Afghan people with respect to different RMNCH communication perspectives.

Whereas the feeling of happiness is the predominant feeling for both males and females at the time of pregnancy, the mothers do have feelings of tension, fear, illness, depression owing to the issues such labour pains, accessibility to health facilities etc. In contrast to women, husbands only exhibit the feeling of happiness at the time of pregnancy. The feelings of tension and fear surface for males at the time of delivery when they are concerned with the life of wife and the newborns. The feelings

of happiness are underpinned by motherhood and honor for women and for men it’s about social and economic support.

In post delivery times, whereas happiness and relaxation feeling prevailed amongst fathers in post delivery times, the bad feelings, fear, depressions, tension prevailed amongst the mothers during post delivery times. This may be attributable to the fact that it is the woman who is undergoing the post delivery implications occurring in her body and psychology and men do not interact with women during post partum period and thus may neither have the knowledge of the issues nor could appreciate the problems of the mothers which may translate into the lack of care by males in post partum time.

There did not appear the existence of customs and traditions of open expression during pregnancy and labor for both males and females, several customs and traditions of rejoice were mentioned by only males in post-delivery times (understandably as females are not physiologically fit in that time). Recitation of Holy Quran, arranging party for friends, distribution of sweet and candies, giving foods to poor, calling friends, video party were mentioned as practices of welcoming the newborn. The 6th Day after birth was the most mentioned day for celebrations.

Mother in Laws (MIL) appears to be the most important person with respect to different aspects of child birth. She is the most contacted person by husbands for sharing the feelings of pregnancy. This may be due to fact that she is perceived to be the most experienced person in family regarding the pregnancy issues and primary custodian of the family growth within the premises of the household. In contrast to pregnancy when husband are most talked with by women, in postpartum MILs are the most contacted family member by the females. It may be due to the factors that postpartum issues being more medical are easier to discuss about with females (MILs), whereas pregnancy is dominated by social aspects such as happiness etc and women like to communicate this to husbands being their intimate partners and biggest shareholders of happiness.

Interesting to also note is that whereas females do not tend to contact any health worker, the male health workers were contacted by husbands about during pregnancy. It reflects that firstly males do take interest in pregnancy matters but they have a limited choice to seek advice and guidance on that. They only resort to Male Community Health Workers (MCHWs) in this regard for the reason that they probably belong to same gender and are accessible.

Health care seeking unless promoted by any cause appears to be abysmally low with respect to maternal, newborn and child health issues. Mother in Law, husband and fathers of husbands appear to be key decision makers in matters of pregnancy, delivery and postpartum. Whereas, primary decisions may rest with the males due to the financial strings with them, MIL however continues to be important stakeholder of the decision making as well as pregnancy information sharing and thus appears to be instrumental in brokering/influencing the decision to seek health care. Interestingly, whereas Father in Law is involved in key decision of health care seeking at the time of delivery, he does not appear to be contacted by any member of family in earlier stages. The findings also bring forth the stark aspect that mothers themselves are not decision makers at any level and whereas the decisions are about their body, life, health but they do not take decisions for themselves.

The decision makers and decision influencers tend to overlap. MIL, husbands, FIL continue to be important decision influencers as well. For males, though male community health workers also appear to influence the decision.

Food and rest were the most identified need for women during different stages of child birth whereas for newborns, clothes, good hygiene and warm place were the identified needs. The

perceptions of the needs by communities provide some interesting insights. One can see that the proven interventions such as ANC check ups, PNC check ups, skilled birth attendance are not perceived as the needs of mothers and newborns. Some of the nutrition interventions such as feeding of colostrum to newborns, breastfeeding and need for iron for pregnant mothers have also got some currency in the Afghan culture, however, these interventions may also not bring the harvest unless the health care seeking is considered by communities as the need of mothers and newborns because through active health care seeking can communities benefit from the other positive behaviors through reinforcement and access to correct information and other complementary interventions. This is also necessary that some of the wrong practices appear to be prevailing amongst the communities such as the need to keep neonate in cool temperature, giving milk and complimentary food to neonates that can be rectified through active health care seeking.

Diarrhea, pneumonia are well known to be the diseases of children. It is encouraging to note that communities could trace the causes to hygiene issues including washing of hands, dirty foods, environmental and personal hygiene, open defecation etc. The existence of this knowledge is an opportunity to capitalize on this knowledge and reinforce these to the level that these turn into practices of the communities.

While health care seeking remains low, what are community’s remedies for managing childhood illness especially diarrhea. A number of things have been identified that communities practice for managing childhood diarrhea. However, it appears that use of salt is emphasized more in communities but use of sugar does not appear to be the practice whereas the alternative fluids for ORS are usually made by combination of sugar and salt. A number of local things have also been mentioned which needs to be looked at for their suitability and accordingly encouraged or discouraged. The use of ORS appears to be low which shall be promoted in any case which can address the use of other local things and be positioned as good and easy alternative. While investigating the decision point, interesting is to note that sunken eyes and skin turgor are the most important measures of dehydration in diarrhea that mandates immediate/emergency care seeking but these were not mentioned by any of the respondent in both male and female FGDs.

Certain myths and misconceptions seem to prevail in communities around immunization which may be adversely affecting the use of vaccines. Vaccines are related with weakness, sterility, girl child etc. Family planning is mostly perceived as helpful intervention by both males and females, however, it is also seen as a sin by men which can adversely affect its use.

Electronic media is coming in a big way in the lives of the Afghan people. Females have more exposure to TV for the reason that they stay more at home while males listen more to radio which probably could be a function of the portability of radio currently in the form of mobile FMs. The health workers of all cadre though continue to play an important role as the sources of information. In contrast to females, males do also get information from mullahs.

Recommendations There is need for developing a sense of responsibility amongst males for all stages of child

birth especially around delivery and in postpartum. The feelings of happiness in pregnancy can be linked with responsibility at the later stage.

MIL, Husbands and FIL appear to be the key audience who needs to be focused with respect to different knowledge gaps and behaviors.

Mothers need to be positioned as the primary stakeholder of the decisions about their life.

There is inconsistency between the understanding of the community health workers of the needs of the issues of mothers and fathers and what mothers and fathers themselves think which can result into loss of effect of messages delivered by CHWs. The CHWs understanding needs to be improved.

Male CHWs provide a big opportunity to transform male behaviors whereas FCHWS are not usually contacted by females.

Health care seeking needs to be repositioned from problem based to active care seeking. It may be anchored around financial, religious, honor paradigms and also married with the existing care attitude of males for their wives and child and also with the fear of loss of their wife and child.

Active information relay on symptoms of diarrhea need to be undertaken for improving the knowledge of communities on danger signs that can come handy in triggering early health care seeking response.

The perception of FP being a helpful health intervention needs to be strengthened through bringing in religious sanctity to it.

Aggressive use of mass media both TV and Radio is recommended to reach out to masses for promoting positive behaviors and improving knowledge.