2. Materials and Methods
Purposive quota sampling was used to recruit 27 Samburu men. Nine semi-structured interviews (SSIs) and three focus group discussions (FGDs) were then conducted with these men in May 2016. The SSIs included men who were not involved in the FGDs. Assisting with data collection was a research assistant (a 22-year-old Samburu man from a different part of the County) and two women who work as FPCORPs (Family Planning Community-Own Resource Persons) with CHAT assisting by mobilising men in the community to participate in this research. Being from the local community, these women were trusted, and without their presence the research would not have been possible.
A flexible topic guide (see Supplementary Materials) was used to focus on participants’ thoughts on family planning, family size, and the environment. Broad introductory questions engaged participants with the topics before using more specific questions and probes to gain further insight into their thoughts. FGDs were appropriate for this study because they allow for an exploration of social consensus and the opportunity to debate controversial issues through discussion. Furthermore, while family size and fertility can be argued as a couple/family level issue, the use and sharing of resources (including livestock) is often a community decision and therefore it was important to use focus groups to explore this. All SSIs and FGDs were conducted in the local Samburu language “Maa”.
2.1. Study Setting
The research took place in five Samburu pastoral communities in the East of the County. The Samburu face several major barriers to accessing health services. The first is remoteness: villages included in this study were located between 15 and 50 km to the nearest health facility, and the Samburu travel across difficult terrain to access it. Some health services also cost money, and some families were too poor to afford them. To address these barriers, CHAT staff travel by whatever means necessary to deliver health and FP services to these underserved communities, including by car, camelback, or foot. CHAT delivers its FP strategy through the employment of FPCORPs, who help to ensure community acceptance of the programme, considering the existence of traditional and familial opposition to FP.
2.2. Study Participants
Twenty-seven men (all previously engaged with CHAT’s PHE programme) were recruited from the Lodungokwe, Lengei, and Lolua communities and the livestock markets at Lengusaka and Lolkuniani. Participants were stratified across three age groups (Table 1
) to ensure a wide age range was represented and because during FGDs, men (particularly those aged 18–30) would be more comfortable discussing issues within their own peer group. Had discussions included a mixture of generations, there might have been a risk of younger men’s opinions being strongly influenced by dominating elders. Men age 18–30 represented the “Moran”, the warrior generation that begins at circumcision and lasts for approximately 15 years. During this time, a Moran is unable to marry and often lives away from home, carrying out important security and livestock management duties for his community. Men age 30–45 represented the younger generation of elders who had completed their time as Moran and had married, returning to their homes. The final age category was 45 and over, representing the older generation of elders.
2.3. Ethical Considerations
Ethical approval was received from the University College London (UCL) ethics committee (Project ID: 8323/001) and the Kenyan National Commission for Science and Technology (who granted the researcher with a permit to complete this project) and were affiliated with the Kenyan Medical Research Institute. Any personal health concerns of participants would have been passed on to CHAT and the most appropriate health facility, however, no such issues were raised. Data collected were anonymised during transcription and stored on a password-protected computer; all recordings were deleted following transcription.
2.4. Participant Recruitment
Upon arrival in Samburu, the lead researcher met with a research assistant and the FPCORPs to discuss participant recruitment. One FPCORP informed men of my research project, mobilising them in advance. A major challenge in recruiting Samburu men was that they were often out grazing their herds of livestock, and therefore unable to take part in potentially time-consuming qualitative research. Therefore, all study sites were purposively chosen according to when men of the required age group were available to take part.
The FP CORPs arranged Lodungokwe village to be the site for the FGD and interviews with men in the 18–30 group, Lolua for the 30–45 FGD, and Lengei for the 45+ FGD. SSIs with men of the 30–45 and 45+ groups were arranged at the Lengusaka and Lolkuniani livestock markets, respectively. All participants were provided with information and consent forms written in English, which were read and translated into Maa for them as necessary. For the men who could not write, consent forms were signed using a thumbprint.
2.5. Data Collection
The FGDs at Lodungokwe, Lengei, and Lolua, and the SSIs at Lolkuniani and Lodungokwe took place at a time and place of the participants’ choosing. Because the lead researcher is not fluent in Maa, a research assistant facilitated all SSIs and FGDs. He was selected for this role because he was fluent in English, Maa, and Swahili, had previous research experience, and because being a Samburu himself, he was familiar with the context and issues discussed, and understood the important cultural and emotional meanings in men’s answers. Time was spent discussing the topic guide and how it would be translated with him before commencing data collection; specific emphasis was placed on keeping the questions open, allowing the participants to answer in the same manner. SSI responses were simultaneously translated so that the researcher was able to probe specific areas and make detailed notes. Also present at the SSIs and FGDs were the two FPCORPs. Without their presence, as trusted members of the community, the researcher would not have been able to conduct data collection. Through experience, the Samburu are fearful of exploitation and will not engage with research projects unless there is transparency about the intended outcomes. Because the lead researcher was linked to CHAT, the strong relationship that the NGO has with the communities was fundamental to their willingness to discuss and voice their opinions. Due to a lack of time, back-translation of transcripts was not completed, which would have verified the accuracy of translations.
After translation and manual transcription of the data, the transcripts were uploaded onto the qualitative analysis software package NVivo 11. Thematic analysis [30
] was used, due to its flexibility as a method. The data was read frequently and carried out progressive low-level coding, which produced 46 codes related the topics investigated. Further thematic analysis generated key themes (Figure 1
); a concerted effort was made to check for men who had different opinions to the rest of the cohort, and to place them within the greater framework of themes being developed.
Bremner et al. argue that there has been an overly simplistic portrayal of the interrelationships between poverty, population growth, and environmental degradation, and that context must be considered to understand what the barriers and facilitators are to successful and community acceptable PHE programmes [31
All men interviewed in this study were supportive of the environmentally sensitised approach of CHAT’s FP programme, and they wished that they visited more often. In agreement with other literature on PHE programmes [1
], relating family size to resource availability is a compelling strategy to increase FP uptake considering the dependence that the Samburu have on key resources such as water and trees. Along with provision of contraceptives, the educational aspect of the programme fits well with the participants’ universal support for education in their communities.
Importantly, following the African Development and Health Research Centre’s (ADHRC) (2016) recommendations for increased sensitisation of Samburu men to FP in order to improve uptake, CHATs PHE programme presents an example of how this can be achieved. This sensitisation is particularly important in patriarchal Samburu families, where men were against their wives using contraceptives without their approval, seeing themselves as the key decision makers on family size.
All men outlined that the Samburu traditional pastoral livelihood is entirely dependent on natural resources, and almost universally acknowledged the environmental and livelihood benefits of having smaller families. Eight of the nine elders older than 45 (of whom six had more than five children), highlighted that because today ‘life is hard’ it is difficult to provide for large families. A key finding was that although most men ultimately favoured large families, they believed that a compromise of smaller family size should be made in the current context of limited natural resource availability; their increasingly degraded environment could not sustain large families as it had in the past. This reveals that the fertility ideals of Samburu men might be more dynamic than previous cultural assumptions. They understood that having fewer children reduced pressure on parents and ultimately allowed them to support their families with fewer livestock which they could better care for during periods of drought. Having many children and being dependent on large herds of livestock was known to make families more vulnerable during drought, since with few other options, livestock mortality majorly affects the ability of parents to ensure the health and survival of their children.
While the younger age groups of men age 18–30 and 30–45 regularly supported the rationale of smaller families and the benefits they bring, traditional aspirations for large families were still present to some degree in these cohorts. Interestingly, while voicing this opinion of compromise for the Samburu in general, some participants did not intend to practice FP in their own home. Permeating the entire age-cohort, but particularly strong among the elders, the desire to have many children was closely tied to the idea that survival of the Samburu people is dependent on pastoralism and that the land was unfit for any other use. These findings agree with Kaye-Zwiebel and King who found varying perceptions among the Samburu on the adequacy of their grazing land, the economic sufficiency of livestock, and the benefits of conservation [32
]. Men described the division of labour within large families for livestock management as a rational decision in the Samburu context. This mirrors Mavanza and Grossman’s findings in Tanzania that were related to fishing rather than pastoral labour [33
]: they found that people desired large families to help catch fish, which were their most important source of income and food. As highlighted by eight individuals, the traditional Samburu association of large families and livestock herds with wealth and pride remained a compelling reason to have many children regardless of environmental conditions. This rationale remains a challenge for PHE initiatives, as it is difficult to elicit change in Samburu family desires while men view expansive livestock management as their most fundamental tradition and aspiration. While most participants age 45+ did support family planning to some extent, it is worth considering that these individuals had already fathered multiple children which may have influenced these supportive views. The fact that the younger generation were largely in support of family planning despite (in most cases) not having had any children is an important consideration and may reflect a different perspective on family size compared to elders in the community. Further study is necessary to measure whether fertility ideals such as these among the younger age cohort lead to any changes in family planning outcomes in the near future.
Men also aspired to protect their environment for economic reasons. Through the sale of natural resources and livestock, the environment provides income for the Samburu. Despite occasionally creating conflict through restricting access to traditional grazing land, wildlife conservation was stated to have created economic benefits for the community through employment and tourism, along with the provision of grants for children’s education. However, while large family groups migrate with numerous livestock, conflict with wildlife undermines any economic benefits from conservation. These findings support those of Kitzanides’ (2010) study: when men understand the economic and social value that a healthy environment brings to the community when it is not degraded from overpopulation, they become more supportive of FP [10
In line with Canning and Schultz’s Bangladeshi study [34
], smaller family size and access to education was seen to allow women to take on economic enterprises outside their traditional domestic role. Ahmed et al. argued that FP could reduce MMR [35
]; although this particular assertion is impossible to verify in this qualitative study, men described how maternal death had reduced after access to FP, and that greater birth spacing made women visibly healthier. Men also thought that child health had improved, since mothers did not have to feed and care for several young children at once. The new income streams provided by healthy women that start up small businesses marks an evolution of Samburu family dynamics. However, men in all age-groups saw themselves as the key decision makers on family size, a belief which was said to lead to marital problems when women chose to act on their different fertility desires and take contraceptives against their husband’s wishes. Therefore, despite an indication that Samburu women are becoming more empowered to make their own fertility decisions, a husband’s approval may still play a crucial role in determining whether a couple has a smaller family.
Faced with both environmental and economic pressures, men indicated the tribes’ transition towards a more fragmented livelihood, combining traditional livestock management with income generated from conservation, employment following attainment of education, and the aforementioned development of businesses by women. This supports research which argues that the Samburu were transitioning to a more diversified economic strategy including agro-pastoralism, mixed rangeland and wildlife conservation, and urban migration for salaried-labour in order to cope in an increasingly market based economy [32
] Because family size is closely linked with all of these factors (children are often required for livestock management, large families may lead to wildlife conflict (due to greater probabilty of contact), education is more attainable for children of smaller families, and women can enter into the economy if they are not burdened with several children), most men recognised that having smaller families was an appropriate strategy. This supports Kidanu et al.’s Ethiopian findings, where communities encouraged the use of FP because having fewer children, although against traditional aspirations, was a more sustainable strategy in their economic and environmental context [38
Because CHAT’s PHE initiative is uniquely sensitised to the Samburu livelihood, it plays an important role in educating the community about the relationship between family size and the environment in a region that is experiencing frequent environmental stress. A challenge remains in reaching the remote family groups in Samburu who have not yet been reached by the PHE programme. Men described these communities as holding on to traditional desires for large families and substantial herds of livestock, driving environmental degradation through a resource exhaustion-migration cycle.
Since they are seen as major beneficiaries of this intervention, future research would benefit from qualitative studies that included Samburu women.
This study only included men that had already been exposed to CHAT’s programme, and it remains possible that men developed their given opinions irrespective of the programme or that their thoughts do not translate into any action on family planning uptake. Therefore, to evaluate the impact of CHAT’s PHE programme on FP, maternal health and environmental health, quantitative studies that compare key indicators between PHE and non-PHE control groups that have not been exposed to CHATs programme would be of benefit.
Despite conscientious and detailed Maa to English interpretation by my research assistant, some cultural nuances may have been lost during transcription of the FGDs. Furthermore, due to time and resource constraints, we were not able to verify the accuracy of transcripts with another Maa-speaker.
Although the lead researcher made it clear that he was working independently, the fact that two FPCORPs who work for CHAT accompanied me during data collection created the possibility of social desirability bias: men could have given responses that they believed would please CHAT and lead the mobile clinic to visit more frequently. However, upon reflection on the data collected, we do not believe this to be the case, since men gave a range of rich individual opinions related to family size and the environment, most, but not all of which, supported family planning. This suggested that men felt able to express their views relatively openly. Furthermore, without accompaniment by the trusted FPCORPs, access to the community would not have been granted.
Since the sample size in this study was small and the men included were only those who have been exposed to CHAT’s PHE programme, findings cannot be generalized to communities not exposed to the FP programme. However, they do give an indication as to how men would potentially receive it should expansion continue. Furthermore, the exploratory nature of this study was to investigate and understand perceptions among Samburu men on the links between family size, family planning, and the environment; it will stand as a precursor for further expanded research in the region that includes a larger sample size and a more experimental design.
The lead researcher’s interpretations were regularly discussed with my research assistant to develop both complementary and divergent understandings of the data collected. The researcher was attentive to discrepant cases, where men offered opinions that were considerably different to the other responses. The researcher endeavoured to remain as objective as possible when designing the topic guide and conducting SSIs and FGDs with Samburu men, but the lead researcher cannot discount supportive predispositions that he may have towards CHAT’s PHE programme.
Because this study lacked a control group who had not been exposed to the PHE intervention, results cannot be objectively extrapolated to the wider Samburu community. However, it can serve as a useful indication as to how men may respond should they participate in similar PHE programmes in the future. This study shows that the unique PHE approach, which relates to the Samburu tribes’ close relationship with the natural environment, may be used as a tool to improve acceptance of FP among men in the Samburu community. The majority of participants highlighted that large families and herds of livestock can lead to wildlife loss, environmental degradation, and unsustainable natural resource use. Because of this, and in combination with frequent and prolonged drought (which some believed was being driven by deforestation by migrating family groups), men found it increasingly difficult to provide for their families. Because of these current circumstances, most men agreed that a compromise of smaller families should be made. However, despite voicing agreement towards reductions in family size in order to ensure sustainable use of natural resources, a small proportion of men did not intend to practice FP in their own homes. This finding highlights the challenges that remain for PHE programmes in translating men’s verbal support for FP into practice.
Economics is a fundamental reason behind recognition of the benefits of smaller families. Men understood their environment to have monetary value, either through conservation for wildlife tourism and related educational grants, or in the maintenance of livestock value. This finding supports previous studies that revealed economic incentives as an important driver of support for FP among men. The economic empowerment and improved health of women that were not burdened with many children was discussed as a major benefit of FP. These economic benefits of FP along with the environmental pressures highlighted by men may reflect a shift towards a more fragmented Samburu livelihood that is less dependent on pastoralism than in the past.
CHAT should continue to expand its mobile clinic and PHE approach, ensuring equitable distribution of services that will ultimately benefit human and environmental health. Furthermore, due to the access to and support from men delivered by the programme, Kenyan FP policy should consider integrating community-based PHE strategies among underserved pastoral groups living in fragile ecosystems.