Quantitative results

A total of 705 responses were analyzed from Akonolinga, 885 from Ayos, 1,747 from Tiko, and 656 from Bangem (see Table 4). Female respondents were surveyed more in Tiko and Bangem, and mostly male respondents in Akonolinga. Ayos represented a more balanced gender response rate for men and women. Most of the respondents across the four districts were married followed by single respondents with a mean age range of 34–42 (Table 5). The highest education level of the majority of the respondents across the districts was secondary school. Most household respondents across the four districts reported farming as the main activity, and more respondents from Tiko reported to be self-employed. Most reported religious status was Catholic followed by Presbyterian.

Table 4 Socio-demographic characteristics of respondents for the household surveyTable 5 Mean age and characteristics of household respondentsSocio-demographic characteristics of respondentsUsing the health belief model to understand family planning knowledge, gaps and unmet needs Survey results

Employing the Health Belief Model, where we aimed to comprehend knowledge gaps and unmet needs regarding family planning among participants. The household survey results revealed intriguing insights into participants’ perceptions, experiences, and preferences related to family planning.

Perceived benefit and knowledge

A majority of participants in the survey from each district (over 80%) acknowledged the benefits of family planning, with a considerable portion of women having utilized family planning methods before (over 60%) (Table 6). Notably, respondents from all districts primarily received family planning messages from health facilities, followed by community health workers in Tiko, Ayos, and Bangem. Akonolinga stood out, reporting radio and television as the second most common sources (see Fig. 4). Overall, 95% of household respondents had prior knowledge of family planning, underscoring the prevalence of awareness across the study areas.

Fig. 4

Number of households that responded on their sources of family planning information

Media preferences for family planning messages

Media preferences varied across districts, with over 80% of respondents in Ayos and Bangem expressing a willingness to receive family planning messages via mobile phones. In contrast, Tiko and Akonolinga exhibited different patterns, with 55% and 15%, respectively, showing interest in this mode. Understanding these preferences is crucial for tailoring communication strategies to effectively reach diverse communities see Table 6 below.

Table 6 Perceptions and gaps in family planning based on responses from the household survey Perceived severity

Some participants reported experiencing some side effects and this was more in Akonolinga (see Table 6 above). These side effects were further explored in the FGD and discussed in detailed in the subsequent section.

Cues to action

Majority of participants expressed a preference for receiving family planning messages on a weekly basis (Fig. 5). Tiko emerged as the district with the highest demand for weekly messages, underscoring the desire for consistent and regular information dissemination. Following Tiko, Ayos, Bangem, and Akonolinga showed decreasing levels of preference for weekly messages. The desire for daily family planning messages was also evident, albeit with a lower frequency compared to weekly preferences. While most preferred more frequent updates, a notable proportion expressed a preference for monthly FP messages. Also, respondents’ preference on language used for communicating FP messages varied according to the language that is most spoken in the district and/or household (Fig. 6). This suggests the need for a diverse messaging schedule to cater to varying preferences and the language use in communicating the message. Very few participants indicated a preference for yearly messages. Additionally, a substantial number did not specify any particular frequency, suggesting an openness to various communication schedules. The diverse preferences observed across districts emphasize the importance of flexibility in communication strategies. While a majority favors weekly messages, acknowledging the demand for daily, monthly, and less frequent updates is crucial. Tailoring family planning messages to meet these varied preferences ensures a more inclusive and effective outreach. Recognizing the district-specific nuances revealed in this study provides valuable insights for crafting nuanced communication plans that resonate with the diverse preferences of participants in Cameroon.

Fig. 5

Household responses based on frequency of listening to family messages from a mobile phone distributed over time

Fig. 6

Number of household responses on preferred language for family planning

Participants listed a variety of methods that they have used with male condoms being the most used in the last two years followed by implant and injectable (see Fig. 7). Interesting the natural method was reported more in Tiko.

Fig. 7

Number of household responses on the method of family planning used in the last 2-years

Results of the focus group discussion

A total of 12 FGDs were organized, three from each district. One for women, one for men, and one for CHW. Each FGD composed of 6 to maximum of 12 respondents (see Table 7). The responses are grouped according to themes from health belief model as described below with identification of the gaps and areas of intervention based on participants responses as illustrated in Table 7. The results below present the patterns that emerged from participants responses in line with categories from the HBM and informed the process of identifying the gaps (also presented in Table 1) and identification of the interventional messages.

Table 7 Individual distribution of respondents for FGD by district including demographics characteristics Perceived benefits

Participants from all four-district believed that family planning is good and necessary and provided additional explanation in relation to benefits of family planning in relation to the use of contraceptives to prevent pregnancy, promote health and well-being, financial control and minimizes stress, and can protect against other sexually transmitted diseases. Participants provided additional explanation as described below and this is also highlighted in Table 1.

My partner/ husband, decided to be using condoms so that it will help me take better care of the baby but also prevent unwanted pregnancy for my health and the health of the baby. So, he uses condoms. At times if he wants to go without, he uses the withdrawal method. But he’s very conscious of it.

[FGD women Tiko/Bangem]

“As he earlier said, family planning is good because I realized that when you control your bed, you control your finances, and you control your headache. Controlling your headache in the sense that, if you were supposed to have 2 kids, and you were just fooling around anyhow without knowing about family planning. You will have a third one when you are not prepared. The first one may be in class 1 and the second one is in nursery 1. The third one you did not prepare for will come and the financial issues will increase, the headache will also increase. Because you will be paying fees for class 1, nursery 1 then start thinking of buying food for the one the mother is carrying on the back. As I earlier, I will go in for the condom method”. (FGD, men /Tiko, Ayos).

I think it is a good thing because even in school, we were thought that family planning is a good thing because it permits to reduce the birth rate between some people. For example, a guy and a girl decide to make a child. The two will first talk to see if it is possible or not with their means. I think that family planning is a good thing. Others think that it is a bad thing because they find it useless and is a wastage of time. Its helps reduce some diseases and permits a good development. That is what I wanted to say. [FGD men Akonolinga/Tiko].

Perceived barriers

Some men reported challenges in communication with women and some reported conflicting interests amongst young adolescent group and the men in their understanding of potential side effects. Some men believed the side effects reported by women in relation to weight gain may hamper the use of family planning. Some of them thinks that it causes infertility and believe that their participation in the discussion was a perfect avenue for them to gain better understanding around miss information and myth in relation to aspects of infertility. See additional information in Table 1.

“It is necessary that people think of another education on condom because as he have just said, you come across a girl you love and to whom you can’t refuse anything, and she says that she wants something, men are fragile and vulnerable in front of such situations. I think we should complete education on condom because you see there are people who have never seen the female condom which exists since 6 to 7 years. My son told me to leave him alone with this stuff. That the gel is the solution to all these things. I asked him, the action period is how long. He told me to stop disturbing him”. [FGD Men Tiko/Akonolinga]

it’s true because at times when you use the condom violently, she tells you how you’re cheating on her. It’s good to talk about it to agree on a method. [FGD Tiko Men/Akonolinga]

There are other women in different places that birth to at least 2 children and look for a nurse or a doctor for family planning. They may implant it under her skin or inject it, but when their partner finds out about it, it is a big problem. The one you implant is put in such a way that it can cause damage, we see this at times. [FGD Tiko Men]

I am a user of family planning, I started with oral, but when I realized that it causes people to gain weight I moved to implanting and this is my season 2 in implanting. The first 5 years went through, then I went to the second 5 years which is ongoing. Where I live, I generally hear women say it causes ‘internal heat’ some discourage the idea by saying it causes infertility. When I say I’m delighted to be in this discussion or meeting today is that at the end of it all, I should really know the truth about family planning. Whether it causes internal heat or it causes infertility, I need justifications on that one. [FGD Tiko men]

Perceived susceptibility

Some participants reported the vulnerable nature of adolescent girls who are sometimes hesitant to use condom with the notion that it does not provide the pleasure that is deserved. Some men believed this act exposes them to become more vulnerable as they aim to satisfy the girls. This was mostly reported by men who highlighted the need to educate youths and adolescent whom they see as the most vulnerable. On another note, some men reported the need to be caution in the way they use condom and to understand their wives’ menstrual cycle to avoid unintended consequences.

“Nowadays, what we notice is that most youngsters don’t use condoms. Maybe the boy will want to use the condom, but the girl will refuse saying that the condom reduces the pleasure. So, when the girl says that, you the guy must obey because you want to satisfy your partner. They usually say, “we don’t eat bananas with its skin”. So, to eat a banana you must remove the skin. If you insist, she will refuse. And that is how we go on for it”. [ Tiko FGD Men].

“I talk with mine because to be honest, calculating the menstrual cycle is not easy, to this day I cannot say I’ve mastered it. The method I have confidence in is condoms, but we were using a different method, the one for 3 months. She had some issues; she was no longer bleeding so she stopped. After having stopped the side effects creeped up. we saw a doctor who prescribed and proposed some drugs so that her system would return to normal. From there on, her cycle went back to normal, and we are using condoms and practicing abstinence for a year and a half to be certain that her cycle was back to normal” [FGD Men Akonolinga].

“Through the course of the process be careful how you carry yourself. If your wife doesn’t shave and you are putting all the pressure, there will be friction and an accident will occur. Or if you don’t understand that your wife shaved 2 days ago there is a likelihood of some ‘shoot out’ you just want to jump on her in excitement immediately it touches a blade it is bound to go off even at the level of wearing it. At times we wear it completely when we are supposed to leave some air at the tip so that it can help in its own way. When you wear it completely, the last thing that touches it, the least friction causes the same accident. Most of these are the modes of how we use condoms”. [FGD Men Akonolinga/Tiko].

Perceived severity

Participants from all four districts expressed their experiences with some of the side effects with the use of family planning methods from both the men and women. Some had doubts and needed additional clarification to get a better understanding due to limited knowledge. Others were more concerned about additional knowledge to motivate them to commence family planning and what method is best.

“I learned that my girlfriend, has the pill, injection. She experienced some side effects, she was bleeding a lot so because of that we adopted the morning-after pill”. [FGD men Ayos].

“My wife took Jadelle for 5 years, and after one year, she started feeling uneasy and had a lot of dizziness, she was getting small illnesses regularly, so we forced to remove it and now we are using condoms, male condoms”. [FGD Men Tiko].

“just like me, we started the 3-month injection, but the side effects didn’t permit us to continue so we reverted to male condoms. Tried one that is said to last 5 years. It didn’t work because she was complaining too much, small illnesses weight loss etc. so we were forced to…. Now I prefer condoms. I too work at the hospital so when they removed it, they proposed she try another one and she refused”. [FGD men and women Bangem/Tiko].

An interesting discussion on condoms ranged from the mode of utilization, cost, quality, availability, and ignorance. Some men are of the opinion that though pharmacies may be selling low-quality condoms, it is easier to detect the quality of the condom from the cost. An interesting paradox, as some men estimated the severity of the consequences of using a low-quality condom, others saw it as an equity issue based on affordability because some men are unable to afford a good condom if the quality is determined by price as explained below and in Table 1.

“Because when you decide to go to the shop for 200cfa. For example, a condom costs 200cfa. Those who are not financially capable, will go for the one for 100cfa”. [Tiko FGD men].

“For someone like me who is a local, if we hear rumours that pharmacies are also dealing with local drugs what can I do? Because pharmacies are also looking for cheaper options to make a profit. I, as a local person cannot distinguish good condoms from bad condoms, I just buy them, those are also my worries”. [FGD men Bangem/Tiko].

“When they talk about family planning, condoms are part of it, I just want to say that a condom is not supposed to burst. That’s my worry. For the other ones that you implant, the women using them will gain weight. When you use the method then think about the effects, it is concerning”. [Tiko FGD men]

Self-efficacy

Some women think some men are also vulnerable and not trustworthy so important to always use condoms:

“You could have a stable partner, but if he strays you can still use it, it’s not only to avoid pregnancy. There’re men in the town hall who are married, and they stray, the women can be faithful. When he comes back you don’t know what he has done outside so use the condom, that’s how you’ll avoid illnesses. I don’t joke with that. I have a husband, but I use it”. [Women Akonolonga FGD].

Cues to action

Participants presented various approaches to stimulate the use of family planning which ranges from listening to messages in local languages, educating adolescent and households, dialogue with partners and listening to messages frequently was reported as a motivating factor, especially in a local language.

“I’m interested, particularly on the part of choice, since there are many side effects there may be a method that suits your wife. It seems many women have that issue so you may need another method but which?” [FGD men Akonolinga].

“Since we’re here we have local people around, and all of us are agreeing that you should put messages in the local language, which is pidgin. The way he speaks is different from the way I speak, so when we go back to our communities many people there still have limited education. So pidgin English is good. Therefore, those who can speak English can continue to sensitize in English and those in Pidgin will sensitize in Pidgin”. [FGD Women Tiko].

“Because those young ones outside, if they have applications, which help them, she will talk of it to a friend and at the end they will understand the necessity of this application.The beginning will be difficult. When you don’t understand you feel like it is difficult. But it is an ideal idea”. [FGD men Akonolinga, /Tiko].

Respondents believed that using a digital platform like BornFyne to educate families and households on family planning directly from their phones is an innovative approach. In their opinion, it would help even if the woman or man does not know how to use the mobile phone their children can always train them. They see it as a way of empowering household and not just an individual benefit. In addition to using such platform, they suggest the importance of parent educating their children at home on FP aspects.

“We understand that an application of this type can educate a mass of people. Because with Android, the phones you can’t buy, which you don’t know of this phone, your daughter can teach you and it understood easily”[FGD Women Ayos/Akonolinga/Bangem].

“If the application is limited at the level of education, and what is to be avoided is that I have seen in certain applications where we propose that parents should really emphasize the education of their children, especially young girls. They are vulnerable. We should prompt parents to discuss with their children, boy or girl, we don’t know where the problem can come from”. [ FGD Men Tiko.

Education

Some participants emphasized the need for more education on abstinence and the importance of parents talking with their children at home. One participant listed three key elements in defining contraceptive methods and that the first contraceptive method is education between parents and the child, the second is abstinence which can only be practice with prior education, and the third is the use of condom for protection against sexually transmitted diseases in the event of any risk or unforeseen exposure. CHW reported the need for more education on FP targeted to the men, this was based on their experiences during home visits. They reported that most of the time, FP messages are directed to women during clinic visits and some men are not exposed to this information and sometimes perceived FP as a myth and think that some FP methods can cause infertility.

“The first contraceptive method is education, parent–child. The second contraceptive is abstinence, and we can’t practice abstinence if we have not been educated. In case of major risk, there is a condom at the third level which is a barrier, especially for STD/STI. It is the first great barrier. There are other contraceptive methods, but a condom is the first barrier”. [FGD Men Akonolinga/Tiko].

“In our local areas, we noticed that some people have partners at home and have given birth to more than 2 children, and we suggest they should do something about it, like taking a break. Some women refuse and demand sex”. [FGD Tiko Men].

“First, for some people nowadays it’s still a myth, recently during my visits I was talking to a girl who told me that she couldn’t take a method because it would make her not give birth anymore. So, there are some people who don’t even know what family planning is, especially men because in hospitals they talk to only women about it. So, when the woman talks to her husband about it, he’ll even get angry, and it causes problems for the couple. So, it’s difficult to reach a consensus or to agree that we should either take pills or injections. In nearly 300 households that I surveyed, I found about 15 couples who made arrangements together to go to family planning. The second point is that some people want children, and they don’t want to hear things like that because there are families where he’ll tell you that he was with his brother and he’s dead. So, he doesn’t want to hear about family planning”. [CHW Ayos FGD].

Equity concerns in the sensitization of male versus female condoms

Participants expressed an important observation in relation to the use of female condoms. Most men reported that they have never seen a female condom and they do not have an idea what it looks like and how it can be used. They believed that there has been limited sensitization on female condoms and more promotion for male condoms. Some men also reported on the cost of male condoms and the quality of the condoms and their experiences.

“Another aspect is that we are used to the male condom. Firstly, the male condom is 150 FRS while for females it is not the case. I myself have never seen a female condom. I was surprised that we were talking about it. Even on TV, I have never heard of it. I just hear people talking. We are used to the male condom”. [FGD Tiko Men].

Silo decision making

Most men reported that some women make the decision all by themselves without consulting their partners. In addition, they reported that women go behind and discuss with doctors/nurses and when the side effect becomes serious, then they disclose it to the husband, and sometimes it would be the husband that will observe the effect, as reported below.

“Some women go behind their partner’s back to see the doctor. Fortunately, some doctors notice this and ask them where their partner is. This is also a challenge in our local community. Some doctors tell the women to rest after giving birth and also insist that the man should rest (stop sexual intercourse). If you force a woman, then that is a different situation. Both men and women need to discuss when they should be sexually active”.[FGD men Akonoliga/Tiko].

Cultural aspects

Other participants provided cultural aspects and practices that they are engaged with and expressed some doubts. One participant reported several encounters with women seeking traditional and herbal treatment to stimulate return to fertility. As a result, participants are curious to understand if the injectable method has an effect on the woman especially during child labor.

“I know about herbal medicine that can be used to assist most girls. most girls who inject family planning are between 19 and 20 years. At times they come back to me, telling me they have missed their period unsure if it’s because of the injection, because they don’t understand. At times I give them some herbs so that their period comes. I want to know whether it’s the family planning that makes them stop menstruating”. [FGD Men Tiko/Akonolinga].

“Second thing, if they inject the one for 5 years and after 5 years they get pregnant, giving birth is an issue. They called me to come during labour. I didn’t reach the hospital, but I have a ‘stick’ I give to women who are in labour and between 10 and 15 min that child will be born. After this time, it will only be operation. I don’t really know whether that injection affects you after expiring if you get pregnant it will cause issues during delivery. Most girls in my area call me on the phone asking me to see them/come to the hospital. I help them the way my father showed me, I just don’t know whether those 2 things, the injection they take makes them skip menstruation and the time it has expired, and you are in labour. It disturbs them” [FGD Men Tiko/Ayos].

Generally, the men were very pleased with the focus group discussion and the topic of the discussion, and this was reported across all four districts.

“My comment is that I am happy about this discussion and all my seniors and juniors are happy about this meeting. We don’t want this meeting to stop today because everyone is happy. It is 23 years since we haven’t had such a meeting. We are heirs in this village, born, grown, aged, look at the class of men we already have. So, this meeting is hearted. The day you need us we can include more people for us to be more numerous. The elders asked me to talk as such”. [Men Akonolinga FGD].

Identifying the family planning messages to address gaps and unmet needs from participants’ responses

Table 1 presents the identified knowledge gaps based on participants' responses as described in the analysis section above. These knowledge gaps range from their need to understand when to use a family planning method as described in the excerpts above, and when to remove it before and or after giving birth and including post-partum. Most importantly, what type of family planning is best and how to go about it especially removing or deciding to stop. Participants need to understand the potential short- and long-term side effects of family planning methods. They expressed the need to break communication barriers and encourage education and family-oriented discussions, especially targeting youth and adolescent girls and boys. We categorized these knowledge gaps and identified intervention messages that aligns with the gaps from various sources [26,27,28,29,30,31,32,33,34,35,36,37] (https://www.doctissimo.fr/html/sante/mag_2001/mag0427/sa_3940_nexplanon.htm#comment-se-passe-le-retrait-de-l-implant) and presented in Table 2. Table 2 list the identified gaps from the participant’s responses and the patterns that emerged from the data, including excerpts from participants that align to the identified gap. The last column presents sample messages from the literature that aligns with identified gaps. Thus, the next step present how the sample messages were further contextualized with the community, and validated, to be uploaded into the platform.

Other aspects considered in the identification process of the gaps are listed below.

1.

Are there existing guidelines for FP within each district or health facility?

2.

language used in communicating family planning messages in each district.

3.

The person communicating the message.

4.

Channel of communication.

Contextualizing family planning messages for the BornFyne-PNMS version 2.0

The evaluation of messages across diverse literacy levels and gender groups in all four districts revealed distinct patterns. Among women unable to read and write, 48% found the messages challenging, while 52% understood the messages well. In contrast to that, women with reading and writing skills displayed a higher understanding, with 56% deeming the messages well or perfectly understandable. Similar trends were observed among men, where 46% of those unable to read or write struggled, didn't understood the messages well. Men with literacy skills exhibited an 80% understanding rate, emphasizing the positive impact of literacy on message comprehension. These results underscore the importance of tailoring communication strategies based on literacy levels and gender differences for more effective outreach.

Of the 50 messages that were tested, 24 messages were revised as shown in Table 8 and Supplemental Table 1. The final messages uploaded into the BornFyne platform are presented in Table 8 and supplemental table 1. The final messages were also submitted to the Department of Family Health for final review and validation. The messages are translated into French, pidgin English and Beti languages. The French version of the Supplemental Table 1 is available upon request. Generally, men presented a better understanding of the content of the messages compared to women. However, the messages were understood by the participants, but some key words used was a concern from participants and they proposed the importance of changing the wordings with common word or synonym as shown in Table 8 and Supplemental Table 1. Words underlined in the messages signify terms identified during the FGD testing that required rephrasing. The community members proposed replacements for these underlined words to better align with their understanding and that of their community.

Table 8 Contextualizing family planning messages for the BornFyne-PNMS version 2.0