J. biosoc. Sci. (1978) 10, 59-79

ATTITUDES TOWARDS FAMILY SIZE AND FAMILY PLANNING IN RURAL GHANA-DANFA

PROJECT: 1972 SURVEY FINDINGS

D. W. BELCHER*, A. K. NEUMANNt, S. OFOSU-AMAAHt, D. D. NICHOLASt AND S. N. BLUMENFELD t

* School of Medicine, University of Wasington, Seattle, USA, t School of Public Health,UniversityofCalifornia,Los Angeles, USA, andt DepartmentofCommunity

Health, University ofGhanaMedicalSchoot, Accra, Ghana

(Received 5th May 1977)

Summary. This report describes a family planning KAP survey conducted in 2000 households in rural Ghana between April and October, 1972, as one of the Danfa Project's baseline studies. Subsequent re-surveys were done in 1975 and 1977 to assess changes related to project health education and family planning programmes.

Reported knowledge about family planning was three times that reportedin previous studies in rural Ghana. About 70 Yo of the respondents approveof family planning, but most want a large family, with over six children. At all ages, males wanted two or three more children than did women.

The current 3 Yo population growth rate in Ghana may increase due to continued early age of marriage, the rising size of the reproductive age groupand improved pregnancy outcome.

Although the expected relationships between knowledge and use offamilyplanning and age and education were present, these differentials were typically only 10-15 Yo. In the project area it appears that women will be most important in making the decision to practise family planning, althoughmotivation of males is being stressed.

Most villagers hear about family planning through informal, word-of­mouth channels with relatively little use of news media, family planningworkers or clinic health personnel. To improve the practice of family plan­ning, village-based health educators are working with volunteers includingtraditional birth attendants, community leaders, teachers and church groups.

Introduction Demographic surveys conducted in Ghana before 1970 reported that knowledgeand approval of family planning were particularly low in rural areas (Caldwell,1968a; Pool, 1967; Gaisie et al., 1970). During the 1960s the government of Ghana held an official pronatalist stance; advice about family planning was unavailable

59

60 D. W. Belcher et al.

and contraceptive sales were restricted (Caldwell, 1968a). The government position shifted in 1969 when it adopted a national family planning policy which led in 1971 to nationwide propaganda activities and a network of urban clinics. One major effort to affect rural areas as well was begun in 1970, when th- Ministry of Health, University of Ghana Medical School and the School of Public Health, University of California at Los Angeles initiated the Danfa Comprehensive Rural Health and Family Planning Project (Danfa Project). The Danfa Project was established to investigate the effectiveness of alternative comprehensive health and family plan­ning delivery systems for a rural population of 50,000 persons in southern Ghana (Neumann, Sai & Dodu, 1974; Neumann et al., 1976a) and it is scheduled to operate for a period of 9 years.

In order to measure results of the alternative delivety systems, the project undertook a seriez- of baseline studies, including a family planning KAP (Know­ledge, Attitudes and Practice) survey conducted in 2000 households from April to October, 1972. The initial survey was designed to provide benchmark information for comparison to repeat surveys in the same households in 1975 and 1977. Pre­programme attitudes and practices reported in the baseline survey will be compared to re-survey responses obtained during and following project health education and family planning programmes. The KAP data from the baseline studies, reported below, suggest that knowledge about and a favourable attitude towards family planning is now widespread in rural southern Ghana.

Setting of the KAP survey

The Danfa Project is located in a zone 10 to 50 miles north ofAccra, largely on the Accra plains but rising to a hilly range on the northern border. The coastal savannah is covered with extensive bush but few trees. Inadequate transport and long dist­ances to existing health facilities are major barriers to utilization of services in the project area. Transport by commercial vehicles is irregular and relatively costly. During the period of heavy rains (April-June), attendance at health clinics falls, due to seasonal farming activities and worsened road conditions.

The Danfa Project is divided into four areas with approximately 12,000 per­sons in each. Different combinations of health programmes are being delivered and analysed in each area. In Area I, family planning is integrated with comprehensive health care offered by a health centre and satellite clinics. In Area II, mobile family planning clinics are supported by a vigorous health education programme. In Area III, the family planning mobile clinics operate alone. Area IV is used as a reference population or control area to learn how much family planning takes place in the absence of Danfa Project health and family planning programmes.

The 1972 Danfa Project household census enumerated 50,127 persons who lived in the 250 square mile study area; this population density of 200 persons per square mile is about twice the average density in Ghana. The project area's birth rat- is 47 per 1000 persons and its death rate is 17 per 1000, resulting in a natural gr 3wth rate of 3%per year. It isa young population: 47.5 %were below 15 years of al~e and the median age was 17 years. Females aged 15-44 years constitute 20% of tLe project. The major health problems are related to communicable diseases and

61 Family size andfamily planningin Ghana

undernutrition, which contribute to an infant mortality rate of about 100/1000live births. At the current fertility rate and an expected modest decline in mortality,the population will double in about 2L years.

Four-fifths of the adult males are working as farmers and/or labourers. Two­thirds of the adults are uneducated although literacy fates in younger age groups are rapidly rising because of expanded education facilities during the past 15 years.There are 310 villages and hamlets in the project area. The majority of residents live in villages with 100-400 persons. None of the communities is larger than 2000 persons.

This profile information about a predominantly agricultural population,characterized by high fertility, low educational level, and difficult access to health services, was important in the planning and implementation of the project's familyplanning mobile clinics and village-based health education activities.

Method Multi-purposehouseholdsurvey

The family planning knowledge, attitudes and practice (KAP) survey was partof a multi-purpose household interview survey conducted in 2000 households from April to October, 1972. Five questionnaires were used to obtain baseline informa­tion about fertility, maternal and child health practices, illness within the preceding2-week period and family planning KAP.

Sampling design The primary target group for research in the Danfa Project is that of pre­

school children and their mothers and the survey concentrated on this group. The sampling frame consisted of all project households which contained one or more females aged 15-44 years during the 1971-72 census. The definition used for house­hold was that of the 1970 Ghana enumeration survey:. 'a group of persons livingtogether and eating from the same cooking pot;' 10,000 such households exist in the project area. The sample was stratified into four groups by village size (largevillages had 60 or more households) and household size (large households had seven or more members.) A sample of 500 households was randomly selected from each of the four areas. The number of households used in each stratum was pro­portionate to the stratum's households compa ed to the area's households. The large sample size was necessary because of anticipated attrition during the 5-yearstudy period. For example, of the original 2000 household sample selected by the computer, 40% had to be replaced for the following reasons: 20% had moved away; I I %were temporarily absent; and 9%were no longer eligible (the requiredfemale was not available, or the household size category had changed). Replace­ment of a missing or ineligible household was carried out from a listing of randomlyselected substitute households for each stratum.

The final interviewed sample of 4718 persons contained 2745 females aged15-44 years (married and unmarried) and 1973 males aged 15-64 years. Older males were interviewed because of their frequent remarriage and production of offspring through younger wives.

62 D. W. Belcher et al.

Interviewers Twenty full-time project interviewers (eighteen males, two females) were trained

to administer the survey questionnaires. These were secondary school leavers with a GCE at O-level. They were fluent in at least two of the three local languages (Ga, Ewe, Twi). Interviewers were given a 10-day training course on techniques of conducting the interview. Approximately half of the training time was spent in mock classroom interviews or in field interviews done in non-project villages. During the actual survey, completed questionnaire forms were edited each day in the field to ensure close supervision and continuing interviewer education. Inter­viewers lived in tht survey conmunities during the study.

Interview procedures A registration of all current household members, by updating previous census

information, was carried out in each sample household. Adults were individually interviewed. Almost all the interviews were done in private. Up to three interview follow-ups were made, when necessary, to complete an interview.

Questionnaire content The KAP interview schedule contained 30 questions and required about 40

minutes to administer. Ouestions were asked about respondent characteristics: age, sex, residence, number of live births, number of living children, education, religion, marital status, age at first marriage and desired family size. Questions were also asked to determine the respondents' family planning knowledge, approval and practice of contraception and the source of their family planning information. For the information about attitudes, this statement was read: 'Many couples do something to postpone pregnancy so that they can have just the number of children they want and can have them when they want them. flow do you feel about this? Would you say that you approve, disapprove or feel uncertain about this?' Know­ledge about individual contraception methods was initially obtained by eliciting spontaneous responses. Probing was then conducted by reading aloud a list of methods with appropriate Ghanaian descriptive wording. A separate fertility schedule covered pregnancy and birth history, outcome of pregnancy, surviving children, birth intervals, age at menarche and first birth and sub-fertility.

Table 1. Distribution of respondents by sex and age

Age (years) Mean

All 15-19 20-24 25-29 30-34 35-39 40-44 45+ age

Females No. 2745 623 532 510 427 345 308 27.5 % 100.1 22.7 19"4 18'6 15'6 12'6 11.2

Males No. 1973 394 214 196 254 212 222 481 34.1

% 100.0 20.0 10.8 9,9 12.9 10,7 11.3 24.4

63 Family size andfamily planningin Ghana Table 2. Mean values for selected variables by sex and age

Age (years)

Variable <30 30+ All

Age at first marriage Females 17.8 19.2 18.5 Males 21.8 26.0 25.3

No. of living children Females 2.2 4.6 3.4 Males 2.1 5.0 4.6

Desired family size Females 6.1 7.2 6.6 Males 7.5 10.4 9.8

Live births 2.7 6.2 4.4

Question items were selected by consultants in Ghana and drew upon informa­tion from previous Ghanaian surveys (Caldwell, 1968a, b; Gaisie et al., 1970; Pool, 1967). The initial drafts were translated into Ga, Ewe and Twi and were extensively pre-tested in the field by eight experienced interviewers. Th, niajorityof items were pre-coded so that responses were simply circled or checked as indi­cated. Interviewers were trained to probe when responses were indefinite (e.g. 'I don't know' or 'it's up to God'), using methods described elsewhere (PopulationCouncil, 1970). Non-sampling error was reduced by the extensive questionnaire,pre-testing, intensive interviewer training, and daily editing and supervision in the field.

Characteristics of the sample group Information about age and sex, marriage and fertility experience, desired familysize, education, religion and ethnic group is helpful for understanding the study group. These variables are used in subsequent analysis to attempt to explain differences in knowledge and attitude.

The picture of the average respondent is shown in Tables 1,2 and Text-fig. 1. The mean age of female respondents was 27.5 years, and of males, 34.1 years(Table 1). Males first married in their mid-twenties, about 7 years later than their wives (Table 2). The .,,e gap between spouses was larger for the older remarried males, since they man :'considerably younger women. The typical female respon­dent reported 4.4 live I: ths, of which 3.4 had survived up to the time of interview, so that 22.7 Yo had died. Males at all ages desired larger families than comparable females, averaging about three more children than the women.

Text-figure 1 shows the educational level attained by the respondents. The effect of increased schooling opportunities in recent years is clearly shown: older respondents reported less education. In Cl age groups males have received more

64 D. W. Belcher et al. Females

100i

75- None

50

r2 5 Y4sqWnda mar

Males E ary25 con .

75Nune

0o,

0110 Middlef

0- A- 0 15- 20- 30- 40- 45+

Age (years)

Text-fig. 1. Percentage distribution of education level by age and sex.

education. The smallest sex differential for education exists for respondents below women wereage 20. In the main female reproduct've years (age 20-39), nine

uneducated for every five men with no schooling. (Prot-Religious affiliations involved three major groups: Christians, 51.1 Y%

estant, 33.3 %; Catholic, 5.1 Y.; Apostolic, 5.9 %; others, 6.8 Y.); traditional reli­

gions, 43.7 %;and Muslims, 5.3 %. The sample's ethnic composition reflects the three major groups in south­

eastern Ghana: 35'4% were Ga; Ewe, 214%; Akan, 22'4% (Akwapim, Ashanti-

Brong, other Akan); other Ghanaian, 5.1 Y0 (e.g. Fanti, northern); and non-Ghana­

ian, 15.6% (predominantly Togolese immigrants). The Ga and Akan respondents

have resided in the study ara for the longest time and have had greater access to

education than more recent immigrants.

Findings

Fertilityand desiredfanily size

Ghanaians have traditionally desired large families, as reflected by one of the

highest fertility rates in the world. In some tribal groups, the mother who produces

ten children is given recognition (Gaisie, 1972). The large family norm is still

widely held. The average desired number of children for males was 9.8, with females

wanting an average of 6.6 children. Marriage practices and age at first marriage are

impottant influences of fertility. The four marriage categories reported by KAP

respondents ,re shown in Table 3. Marriagehistory. Marriage in the survey area is a fluid relationship with stages

of mutual consent and marriage by customary rites. Cohabitation by mutual

consent is generally the initial marital state, and isnormally followed within a few

years by customary rites. Under 2% of marriages in this rural population were

formalized by civil registration or church services.

65 Family size andfamily planningin Ghana

Table 3. Percentage distribution of marital relation­ships by respondents' sex

Females Males Both Marriage form (N=2168) (N=1351) (N=3519)

Mutual consent 20.6 8.1 15.8 Customary rites 75.9 86.3 79.9 Registration

or church 1.3 2.1 1.9 Other 2.2 3.5 2.4

Remarriage rates were high among women during their repoductive years and among men at all ages. For ever-married respondents, 49 % of men and 40 % of women had been married two or more times with the average number of marriages 17 and 13, respectively.

Almost all Ghanaian women marry at some time. By age 25, over 90Y are married, and by age 40, 992 % of female project residents have been married (1971 project census data). If the survey had shown a rise in median age at first marriage over time (by comparing younger to elder age cohorts), a smaller com­pleted family size could be expected, since women who marry at older ages are at risk of conception for a shorter portion of their fecund life.

The survey showed that the percentage of women marrying before age 20 is not t iling. In fact, early marriage was reported more frequently in the age groupbelow 30 years. About two-thirds (65.7%) of ever-married women below age 30 were married by age 20, compared to three-fifths (56.7 %) of older respondents. It is not surprising that the recent increase in educational opportunities for rural females has not affected age of marriage in the study population; since women generally attain only low levels of schooling. Role expectations and employmentopportunities for rural women have changed little. Furthermore, being pregnant or nursing children does not cause a loss of income from work typically done byrural women (farming, petty trading and preparation of food for sale). In addition, there may be increased opportunities for early marriage at this time. This could occur as a result of more males becoming married at younger ages, or a migration of single males into the area.

Pregnancy is desired immediately after becoming married. The average female reported menarche at 15.6 years, was married at 18.5 and had the onset of her first pregnancy at 18.7 years. Pregnancy occurred at a fairly constant rate thrc ugh­out the reproductive period, with little fall off in older women. The median number of pregnancies reported for different age groups was: under-20, 1; 20-24, 2; 25-29,3; 30-34, 5; 35-39, 6; and 40-44, 7. No reduction in the rate of fertility occurred despite the instability of marriage.

Fanilysize. Several other factors will affect the completed family size, currentlybetween six and seven children in rural Ghana. First of all, nutritional status is improving and more rural health services are becoming available, so rural women

66 D. W.Belcher et al.

can be expected to have v longer and healthier fecund period. A recent study of

privileged Ghanaian girls at secondary school revealed their average age at menarche

12.9 years, about 2 years lower than reported for rural girls (Ofosu-Amaah,was 1969), including those ir the Danfa Project area. The younger age of menarche is

presumably related to better nutrition (Editorial, 1974). Expanding antenatal and

clinics for the children aged under 5years should improve the outcome of pregnancy

and the proportion of children who survive. Second, fertility rates will be influenced by the shift from polygamous to mono­

gamous unions among younger couples. In traditional marriage, the nursing

mother was expected to abstain from sexual relations until her child was weaned.

Sanctions existed against resuming sexual relations during this period. The mono­

gamous wife may have an increased risk of conception and could have pregnancies

at closer intervals. Age differences among spouses presumably affect the wife's child-bearing role,

communications about family size (Caldwell, 1968a, b) and marital decisions in

general. This survey's finding of an average age gap of 7 years at first marriage is

widened further in many unions where older men have remarried much younger

women. Such males wanted large numbers of children. Sirce they tend to be more

established farmers with better economic situations, there is less need for supple­

mentary income from the wife than might be the case for younger couples. There­

fore a large marital age differential may act to enhance the wife's child-bearing

role. Selected variables related to desiredfamily size. Motivation for the couple to

practise family planning is influenced by th.eir desired family size, their expectations as child-bearer (Easterlin, 1973).about children's survival and the woman's role

T'he desire for additional children in this survey is more closely related to the the number of pregnancies. Additionalnumber of surviving children than to

children were wanted by 61 % of women with parity seven or eight, compared to

about 41 %of women with seven or eight surviving children. In order to determine possible relationships between the desire for additional

children and age, number of pregnaiicies, number of living children and number into, Kendall ronk correlation was performed. The desireof marriages entered

for additional children is inversely related to age (-0.360), number of pregnancies of living children (-0.451). Since the intracorrelations(-0.420) and number

between these three variables are fairly strong a series of partial correlations was

run to isolate the correlations two at a time. When number of pregnancies is re­

moved as a factor, the correlation between number of additional children desired When number ofand number of living children changes from -0.451 to -0.198.

living children is removed as a factor, the correlation between number of additional

children desired and number of pregnancies changes from -- 400 to -0.084.

These data support the conclusion drawn above: the number of additional children

desired is more influenced by the number of living children than by the nu.nber factors reinforce one another in determiningof pregnancies although the two

number of additional children desired. The desired family size (defined in this study as the current number of living

children plus number of additional children wanted) had a significant sex differen­

---

67 Family size andfamily planning in Ghana 100

/V80 - A' 2­

~40 ' o0

20

0 . 9 1-4 5-6 7-8 9+

No. of living children

Text-fig. 2. Desire for additional children by respondents' sex and number of livir g children. Males: e-0, no more children; A---A, 3 or more children. Female,: o-o, no more children; a---z, 3 or more children.

5 ­

-

0

0

1

0 1-4 5-6 7-8 9+

No. of living children

Text-fig. 3. Average number of additional children wanted by respondents' sex and number of living children: 0, males; a, females.

tial: the average male desired a family of 9.8 children, while females wanted an average of 6.6 children (Table 2). Text-figure 2 shows that for all levels of number of living children about twice as many females as males wanted no more children. It also shows that males were less responsive to large numbers of living children: almost half of the males who reported having seven or more living children wanted three or more additional children. Some of these, however, were from previous marriages. Younger male respondents expressed a desire for smaller family size (Table 2). Text-figure 3 shows that the average number of additional children wanted falls steadily for females as the number of their surviving children increases;

68 D. M.Belcher et al.

for males with seven or more living children, a plateau of about three additional children is reached.

Table 4 shows the relationship of education and religion to the average number of children desired. With increasing levels of education, smaller numbers ofchildren were desired. Christians were more likely to want smaller families. To some extent, education and Christianity are inter-related in Ghana, since chur'ches have provided much of the education available. Previous urban studies in Ghana have found a similar association of higher education and Christianity with smaller family norms (Caldwell, 1968b).

Table 4. Average number of children desired* related to sex, age, education level

and religion of respondent

Education Religion

Sex and age Middle and (years) None Primary secondary Christian Muslim Traditional

Females <30 6.4 5.3 4.6 5.1 6.0 6,5 30+ 6"9 6"3 5'8 6"5 6'6 7.1

Males <30 8.1 5.9 6.0 6.5 5.8t 8.9 30+ 10.2 9.2 7.3 8.0 8.6 10.7

* Obtained by adding present living children to additional children wanted; respondents with no living children were excluded.

t Small number (12) in cell.

Over 40% of ever-married respondents in this study had been married two or more times. Kendall rank correlation was performed to examine possible relation­ships between multiple marriage and the number of children both fathered and desired by men. The analysis does not distinguish between men who claim multiple marriages as a result of having been married more than once insequential fashion and those who might be simultaneously married to more than one woman (poly­gamy), a possibility in Ghana.

There is only a weak (though statistically significant) correlation (0.192) between number of children desired and number of marriages. Since the number of children desired is a statement of intent rather than fact, this variable is subject to some uncertainty. On the other hand, the statement of number of living children a respon­dent has is entirely factual, and this variable shows a strong correlation (0.673) with number of marriages.

Since the zero order matrix shows a strong correlation of both number of marriages (0.601) and number of living children (0.660) with age, the apparent relationship between these two variables might be spurious, since they share a

69 Family size and family planningin Ghana

common and predictable correlation with the age factor. To examine this possi­bility, the first order correlation between number of living children and number of marriages was obtained with age removed as a factor. The resultant correlation coefficient of 0.400 is evidence that a substantial relationship does exist and that multiple marriage does play a role in increasing the number of children a man has.

The moderately strong correlation (0.393) between number of living children and number of additional children desired is of interest because one might expect that the more children a man already has, the fewer additional ones he would want. The explanation lies largely in the influence exerted by the number of marriages on both of these variables. When the number of marriages is controlled for, the partial correlation coefficient drops to 0.118. This streigthens the hypothesis that number of marriages is a key factor in determining the number of children a man has.

This finding did not hold true for women. The zero order correlation matrix shows a very weak correlation (0.078) between number of children desired and number of marriages, and a modest negative correlation (-0"183) between number of additional children desired and number of marriages. When age is removed as a factor in these two sets of variables, the partial correlations beconie 0.015 and -0.080, respectively. Thus, among our women respondents, number of marriages plays little role in determining tile number of children a woman either has or says she wants. One possible explanation for this difference in behaviour may lie in this matter of age. Men who remary tend to marry younger women, with a probable expectation of having their wives produce children, or perhaps yielding to the self-expectations of these younger women for children to come of the marriage. On the other hand, women who remarry would be older than women marrying for the first time, and are likely already to have borne some children and have less interest in bearing more. This hypothesis is supported by the s:rong negative correlation between the number of additional children desired and age (-0.360) and between additional children desired and the number of living children (-0.451).

Survey respondents showed a clear preference for boys in their additional children. Both mate and female respondents expressed a preference for more boys than girls, and on the average wanted about 50 %more boys. Until the desired sex proportions are reached, such a sex preference might act to motivate additional pregnancies.

Attitudes towardfnidlyplanning Each respondent was asked if he approved, disapproved or felt uncertain about

family planning, after listening to a definition read by the interviewer (see Method). Most respondents (70.1 %) reported approval, including 67.4% of males and 72.1 %of females; 26.7% of the sample disapproved and 3.7Y were uncertain. The relationships of selected factors-age and sex, pregnancy, Ciucation level and religion--to approval are shown in Tables 5 and 6.

Table 5 shows that approval is greatest in respondents below age 30 and that females in most age groups approved more than comparable males. Female respon­dents' approval of family planning was fairly uniform irrespective of the number of pregnancies. Women with only 0-2 pregnancies reported above average approval rates. This probably reflects an interest in spacing, rather than limitation, since

70 D. W. Belcher et al.

Table 5. Percentage distribution of approval of family planning by sex

and age

Age Females Males (years) (N = 2743) (N = 1969)

15-19 74.5 72.3 20-24 76.9 74.3 25-29 71"7 76'5 30-34 69'3 64.4 35-39 68"1 68.2 40-44 67.2 60.8

45+ 60.8 All 72.1 67.4

this group (chiefly below age 25) expressed a desire for about six children on the average.

One method for analysing subjective fertility pressure is to relate approval of family planning to the number of additional children desired (Dow, 1971). In both sexes, an expressed desire for up to six additional children was associated

Table 6. Percentage distribution of approval of family planning

by education level, religion, sex and age

Education

Sex and Middle and age (years) None Primary higher All

Females <30 70.7 717 81.2 74.3 30+ 66'6 76.9 83-3 68.5

Males <30 65.3 66.2 78.6 73.7 30+ 60.7 60.9 69.8 62'8

Religion

Christian Muslim Traditional, Other

Females 7.8 63-3 67.9 Males 71 9 57.0 63.9

71 Familysize andfamily planningin Ghana

with above average rates of approval of family planning. Those desiring seven or more additional children had significantly lower rates of approval of family plan­ning.

Table 6 shows that there was little rise in the percentage approving of family planning until at least middle school education was attained. Most rural middle schools are situated in larger communities, where residents have greater mobility. It is unclear whether increased rural educational opportunities will affect future attitudes about limitation of family size because the more highly educated young adults may migrate to urban areas.

Christians had the highest approval percentage, (74.7 %)of the various religious groups. There was little difference among different Christian groups. Seventy-six percent of Protestants (1193 of 1569), 73.9 %of Catholics (176 of 238) and 71.5 % of other Christian denominations (424 of 593) approved of family planning. In urban areas this has been attributed to higher education levels among Christians (Cald­well, 1968b) and more recently the support of family planning by the Church Council of Ghana.

Knowledge and use offamily limitation

Respondents were first asked for spontaneous information about family planning knowledge; a list of contraceptive methods, using familiar Ghanaian descriptive terms, was then read by the intel viewer. After each method was read, the respondent was asked ifhe had heard ofit. The marked difference in spontaneous information compared to prompted recall is shown in Table 7.

Table 7. Percentage distribution of knowledge about family planning elicited spontaneously or

with prompting by sex and age

Knowledge

Sex and age (years) Alleged* Recognizedt

Females <30 26.1 90.4 30+ 29.2 92"9 All 27.3 91-4

Males <30 30.3 89.7 30+ 35.2 96.7 All 33.2 93.9

All respondents 29.8 92.4

* Spontaneous recall.

t Aided recall.

72 D. W. Belcher et al.

Over 90 % of respondents reported knowledge about family planning when contraception definitions were read. Srwh information was diffused uniformly throughout different age, sex and educational groupings. The use of aided recall resulted in a rise in male knowledge of 60.7 %and for females 64.1 Y., above the level reported for spontaneous knowledge. The marked increase in alleged know­ledge after hearing definitions read was noted during questionnaire pre-testing, when interviewers felt that the use of read definitions tended to make the question less sensitive and more matter-of-fact. It is possible that some respondents answered in the affirmative, when, in fact, they had not known about the method. However, there was no pressure to respond either way. The spontaneous question asked the respondent to list all of the methods he knew. If rural, predominantly illiterate respondents are less prepared to give complete and well-organized responses, it

8­

7 ­

6 6 0-_0 -0

M 00 0

15- 20- 25- 30- 35- 40- 45+

Age (years)

Text-fig. 4. Average number of contraceptive methods known by respondents' age and sex: e-, males; o---o, females.

is not surprising that questions using definitions might produce more valid infor­mation. In addition, the interviewers were quite familiar with the community setting where they worked. Villagers may have responded more openly to inter­viewers in this study because they already knew them from previous Danfa house­hold censuses.

Knowledge about family planning was found to be widely diffused among all age and sex groups. Text-figure 4 shows that (except for respondents below 20 years old) the average respondent reported knowing about six methods.

Prompted knowledge and reported use of selected traditional and modern contraception methods are listed in Table 8. Only 7 % reported use of vbstinence, and 4 % had practised the rhythm method to postpone pregnancy. Interviews conducted during pre-testing disclosed that the majority of respondents who knew about rhythm had an erroneous concept of when it was effective: most stated that the week after menstruation was when conception took place.

Table 8 shows that there was no sex differential in knowledge about specific modern contraception methods, except that more rmen knew non-prescriptive

73 Familysize andfamily planningin Ghana

Table 8. Percentage distribution of knowledge about contra­ception methods compared to use of contraception by method

and respondents' sex

Females Males (N= 1973) (N = 2742)

Contraceptive method Knowledge Use Knowledge Use

Traditional Abstinence 84.4 5.7 82.9 8.9 Rhythm 76.1 3.2 75.9 5 6 Withdrawal 48.0 2.7 59.0 4.3 Breast-feeding 51.3 0.5 47.8 0.8

Modem Condom 57.4 2.7 70.5 4.2 Foam, Jelly 28.7 1.5 30.0 1.8 Pill 63.1 3.6 61.5 3.2 IUD 55"7 0'3 51'4 0"2 Female sterilization 79.4 0.3 73.5 0.5

methods, especially the condom. A high degree of information about female sterilization was found. Sterilization for medical reasons has been available for many years in large urban hcspitals in Ghana. Hysterectomy may also have been confused with this question. Since large numbers of relatives and friends accom­pany and visit hospital patients, iZis possible that information about even in­frequent operations might become widespread.

Table 8 also relates knowledge to use of contraception. Males reported more use of all methods except the pill and IUD. For the mote commonly used modem methods, about one in twenty persons who knew of them had used them. In the first 3 years of Danfa Project family planning clinics, the most accepted methods have been foam, condom and pill. The IUD has had a much lower acceptance rate, because of considerable fear and concern about alleged serious side-effects, including migration of the loop into other areas of the body.

Table 9 shows the relationship of age, sex and level of education to use of several categories of contraception. Higher education levels were clearly associated with increased use of modern contraceptive methods. At the time of the baseline survey the only outlets for contraceptive materials were located in large towns or cities outside the project area. The more mobile educated person could obtain supplies during visits to urban areas. Younger educated males used modern contra­ceptives as much as, or more than, older men, who tended to rely more on tra­ditional methods. Women over 30 years generally used both traditional and modern methods moye than younger women.

Previous use of contraception was also analysed by ethnic group. For the four largest groups, Ga, Akan, Ewe and non-Ghanaian (mostly Togolese), there was no ethnic differential for males. For women below 30, however, Ewe and non-Ghanaian

74 D. W. Belcher et al.

Table 9. Percentage distribution of contraception users* by sex, age, education and contraceptive method

Sex, age and education group

Females No education

<30 30+

Primary <30 30+

Middle <30 30+

Secondary + <30 30+

Males No education

<30 30+

Primary <30 30+

Middle <30 30+

Secondary + <30 30+

Total Females Males

* Persons who

Traditional

8.1 10.6

9.3 13.9

10.2 11.3

6.7 42'9t

6.4 19.2

6.8 20.7

7.8 20.9

11.4 23.9

9.9 14.9

reported no

Methods usedt

Non-prescription Clinic

1.0 1.7 0.7 1.3

3.3 3.7 2"8 9"2

11.8 8.1 11.3 1?"9

13.3 11.1 28'6t 28.6t

0.6 1.2 0.5 1.0

6.8 4.5 2.9 3.4

9.3 4"6 9.4 4.7

31.4 17.1 23.9 12.7

3.7 3.8 5.5 3.4

knowledge were excluded from

question about use of known methods. t Traditional: abstinence; prolonged breast-feeding; withdrawal;

rhythm. Non-prescription: condem; jelly/foam. Clinic: pill, IUD. * Small number (14) in cell.

75 Familysize andfamily planning in Ghana

women reported use of contraception only half as often as Ga and Akan women. The Ga and Akan groups are the area's original inhabitants, and the more recent arrivals, chiefly engaged in farming, have more traditional attitudes. These groups will require special educational efforts to influence their receptivity towards family planning.

Sources of informationaboutfamilj planning The initial source of information for people who had heard of family planning

is shown in Table 10. Three-quarters of all respondents had heard through informal channels consisting offriends and relatives. Formal channels (which are used by the National Family Planning Programme), such as family planning field workers, clinic staff and news media, reached another one-fifth. Other sources were reported by just under one-tenth of respondents. Of particular interest during KAP re­surveys will be any increase in contact with field family planning workers related to the Danfa Project.

Table 10. Percentage distribution of source of family

planning information

Source Females Males Both

Friends or relatives 72.2 72.6 72.4 Health personnel

Family planning 6.3 5'5 6.0 Clinic staff 7.0 4'1 5.7

News media 5.9 10.2 7.7 Teachers 0.6 0.6 0'6 Other persons 1.4 1.5 1.4 Cannot recall source 6.7 5'5 6.2

Most sources of information were reported equally by both men and women. Males used news media sources almost twice as frequently as females (10.2% of males compared to 5.8% of women). This is probably related to their higher literacy rate and greater access to radios and newspapers. In the project area, studies have shown that women attend clinics about twice as frequently as men. Seven percent of women reported clinics to be their source of information, com­pared to 4Y of men. Family planning workers were reported about equally by men (5.5 o) and women (6.3 ). The group having greatest contact with these workers were the 30-44-year-old women, while respondents below age 20 seldom used them.

There is a striking geographical variation in the source of information used. Text-figure 5 shows the sources of family planning information for each of the four project study areas. Areas I and It have the best access to health services and reporte,d the greatest use of clinic and family planning sources for information. These areas, with good roads to large urban areas and market towns, reported that

76 D. W. Belcher eta.. 60

50

40 [

30­

20

10 M

II III IV

Area

Text-fig. 5. Percentage distribution of source of information about family planning by project area: 0, villager; 0l, townsman; M,clinic; ::, news media; M,FP worker.

townspeople were information sources ahnost as often as villagers. In Areas III and IV, other villagers were the primary source of information used.

Respondents from Area III, the most isolated region, reported the least use of formal channels for family planning information and the highest use of villagers.Area IV is a higher income area because of better farming conditions and more cash crops than in the other three areas. Previous socio-economic studies have shown Area IV to have twice as many radios as the other areas, consistent with its higher reported use of news media.

Although the numbers reached by formal networks of communication in the baseline survey were small, these findings suggest that a greater ro!e for clinic-based information to reach women and news media to inform men might be attempted.Improved communications to more isolated areas, such as Area II, which lack both a clinic infrastructure and the economic base to receive news media, will probably depend on contact by field workers.

Discussion Caution should be used in applying the findings of this study to other rural areas in Africa. The findings relate to the Danfa Project study population rather than a representative sample of rural Ghana. Because it is located in the south near Accra, greater exposure to modern influences, similar to those described in southern Nigeria (Caldwell, 1970), can be expected. Furthermore, because of different definitions, sample design, and interview procedures, results cannot be compareddirectly to those of previous family planning KAP surveys in Ghana (Caldwell,1968a, b; Pool, 1967) or West Africa (Dow, 1967, 1971; Caldwell, 1970).

Reported knowledge about family planning in this survey was three times that

77 Familysize andfamily planningin Ghana of previous KAPs done in rural Ghana. Several factors have produced this increase. First of all, nation-wide publicity about family planning began in 1971. While most educational efforts have been concentrated in urban areas, the topic of family planning has become acceptable and discussions about birth control measures are more open than in the past. Part of the increase in knowledge was due to the way the questions were asked, as there was such a great increase with prompted queries.

The picture that emerges is that, while there is widespread knowledge and approval of family planning, a desire for a large family with over six children continues and there is relatively little practice of family limitation. Males at all ages were particularly interested in large families, and wanted two or three more children than did women. Men who remarried were strongly inclined to have additional children. The prospects for a decrease in fertility are not encouraging.During the past 20 years there has not been any rise in the age at first marriage for women. Though marriages are rather unstable, pregnancy continues to occur at a steady rate throughout women's reproductive years. Child-bearing remains the dominant female role, and even younger educated women want large numbers of children. Other factors may affect future fertility rates. The 15-19-year-old cohort was 17 '/ larger than the 20-24 cohort, so that with improving health services and better pregnancy outcomes, birth rates may be expected to rise.

The groups most likely to be receptive to family planning on the basis of this study were females (especially those with two-six children), Christians, those with middle school education or above, and those below 30 years of age. While these groups were more receptive than others, the differentials are typically 10-15 %,not high enough to provide the basis for prediction of acceptance of family planningand selection of likely target groups.

Established family planning education methods are based on the assumptionof a long-lasting monogamous marriage where the partners are mutually concerned with the mother's health and the economic costs involved in raising and educatingtheir children. In the project area, marriage does not seem to have this permanence.Men and women frequently remarry. Women often support themselves and their children. In spite of their higher educational levels and mobility, men approveless of family planning, want larger numbers of children, remarry more frequently,and accept less responsibility for long-term support of their children. For these reasons they may not be very receptive to a family planning rationale about future educational costs or long-term maternal health. In the social setting in rural Ghana, women are the key to family planning efforts. They have the greatest health risk, often bear the large part of the financial burden of raising children, and are able to make independent decisions.

The information gained by this study about previous channels used for familyplanning information is of significance. Three-quarters of respondents reportedhearing about family planning by word-of-mouth from friends and relatives. Little information was acquired during visits to clinics, although earlier studies in Ghana found clinics to be the most important source of information about familyplanning (Gaisie et al., 1970). Teachers were rarely sources of information, and other community workers, such as agriculture extension workers, were not re­

78 D. W. Belcher et al.

ported. Family planning workers were cited as sources of information by 6 o of in Accra at one of thethe respondents. Such contacts would have had to occv.

National Family Planning Programme clinics. There were no family planning field

workers stationed in the project area until after the baseline survey. No respon­

dents reported hearing about family planning from traditional practitioners or

social and 'hurch organizations. Radios were reported as the source of information twice as frequently in one area (Text-fig. 5). With the increasing ownership of

transistor radios in rural areas, public communications may become increasingly

valuable for maintaining awareness of family planning. These findings provided guidelines for project educational activities. Danfa

Project health education assistants, who are middle-level workers living in project

villages, stress face-to-face discussions about family welfare and community development (Neumann et al., 1976b). They are making special efforts to contact

and motivate males. The importance of such personal communications in helping

decision to accept family planning has been described inthe individual reach a previous studies about communication in family planning (Schramm, i971). Such

contacts take place at clinic visits, at home, and in group discussions. Information that these channels were being under-utilized.from this baseline study showed

To improve contact and widen the base of social support for family planning, the to identify, recruit, train and co­village-based health educator has been trained

ordinate several village volunteers in family planning. These include traditional

birth attendants, community leaders, teachers and church groups.

The challenge for family planning in the project population will be to modify the

family size desired and to close the gap which currently exists between a high level of projectof approval and a low level of persons who take any action. The success

efforts to convert the favourable attitudes about family planning into current

practice will be measured in subsequent KAP surveys.

Acknowledgment

The help and encouragement in planning and conducting the baseline KAP survey

by the following persons is gratefully acknowleged by the authors: Dr J. W. Nis­

wonger, Dr J. Cannon-Wolinsky, Miss 0. G. Johnson, Mrs L. Knutson, Mr K.

Kwabia, Mr K. Abedi-Boafo, Mr T. K. Nsiah and Mrs R. Konauh.

Computing assistance was obtained from the Health Sciences Computing Facility, UCLA, supported by NIH Special Research Resources Grant RR-3.

The Danfa Project is financed in part by the USAID Contract AID/CM/afr­IDA-73-14.

References

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CALDWELL, J.C. (1 968b) Population Growth and Family Change in Africa. The New Urban Elite in

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CALDWELL, J.C. (1970) Ante-natal knowledgu and practice in Nigeria. Popul. Stud. 24, 21.

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