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  • Using the Whose Shoes? approach to involve men in maternity care in Uganda - interview with Dr Alice Ladur

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    In this interview, Dr Alice Ladur talks about her experience of using the Whose Shoes? approach to increase male partners’ involvement in maternity care in Uganda. Whose Shoes? is a co-production tool that uses a board game to help participants share experiences and reflect on their experiences of services. Alice describes the importance and impact of involving partners and families in antenatal care and highlights the value of adapting interventions to specific cultures and locations.

    About the Author

    Dr Alice Ladur is a researcher with an interest in global maternal health. She carried out her PhD in maternal health at Bournemouth University, where she won the Vice Chancellor's Postgraduate Research Prize for her project engaging men in maternity care in rural Uganda.

    Questions & Answers

    Where did you first come across the Whose Shoes? board game?

    I first took part in a Whose Shoes? maternity workshop at University College London Hospitals in 2017. As professionals from different roles and backgrounds, we used the scenarios and poems to hold conversations with women and families, and looked together at how to improve certain aspects of maternity services locally and nationally in the UK. I learned so much from my colleagues that day, as the game gave us opportunities to pause and reflect on how, as citizens, we interact with health services and how that affects outcomes.

    The workshop made me think about maternity care in Uganda. Perhaps it would help men to engage in their partner’s care if they had an opportunity to come together in a safe space? It would give them a new opportunity to reflect on their own actions, community expectations and the broader structures that lead to inequalities within the Ugandan community.

    When did you first become interested in male involvement in maternity care?

    My interests in male involvement in maternal health started back in 2006, when I was working with post-conflict communities in northern Uganda to provide HIV/AIDS prevention services. We were running health education sessions for men using discussion, role play and drama, which resulted in an observed decrease in domestic violence. I was able to see first-hand the importance of involving a woman's immediate family in improving her health. This motivated me to carry on looking at how to work with families to improve health outcomes.

    It is important to note that when we are discussing male involvement, this should never take away from women's choices. Male involvement is always dependent on whether the woman wants to involve her partner and immediate family, or not, and these interventions may not work for all women.

    Can you explain some of the issues surrounding maternal care in Uganda?

    Although there has been a steady decline over the past few years, Uganda still has a high maternal mortality rate. Antenatal care presents a unique opportunity for women and their families to learn about risks associated with pregnancy and to plan for delivery, but there are cultural barriers that mean many Ugandan men do not engage with their partner’s antenatal care.

    In Uganda, pregnancy and childbirth hold very significant meanings, one in which women find their identity and social status. That means there is a lot of pressure placed on women to produce children and extend the family lineage, with a special preference for male children. The pressure to give birth often comes from the pregnant woman's in-laws, husband and community, so it is important for us as researchers and professionals to understand the importance of family structures. We need to consider how to integrate family members in interventions to improve maternal safety. In Uganda men have considerable control over resources and decision making, and because of this, we need to work with both men and women to improve maternal health.

    In addition, there is a cultural focus on communalism in Uganda, which means that individuals are subordinated to a group, and this has a direct impact on how people seek healthcare.

    How did you adapt the game for use in rural Uganda?

    We designed a pilot study which we ran with Ugandan men based in London. It was important to test the idea, as I didn’t know whether a game format would be acceptable. Once the table was set with the board game and the little shoes, the men were captivated; everyone wanted to look at the shoes! They immediately started throwing the dice and picking up cards. Without any formal introductions, I let them carry on playing the game, and they really got involved.

    I learned a lot from the pilot study, for example, that I would need to make the messages more specific and hard-hitting. This was particularly true around addressing cultural ideas that affect women during pregnancy and create barriers to accessing health services.

    We also realised we would need to translate all the Whose Shoes? materials so that the game was immediately accessible to users in the rural Ugandan communities where we were going to use it.

    Where and how did you run the Whose Shoes? Sessions in Uganda?

    We ran the sessions from a primary healthcare facility in rural Uganda, a long way from the capital city. The community healthcare setting made it more accessible for the women and their partners. We had to get ethical approval and approval from several community structures to run the sessions.

    We asked pregnant women accessing the healthcare facility whether they would be interested in their partners taking part, and were careful to promote each woman's choice in allowing her partner to be part of the project. We then invited the partners of women who consented, to come and take part.

    There was some political unrest around the country at the time of the fieldwork and this came out in the sessions, when the colours on the board game took on political meanings for participants. Uganda was then divided along colour lines - yellow and red - and these groups disliked each other. When playing Whose Shoes?, those that loved red were leaning towards everything red in the game and detesting everything yellow, and vice versa. I had to spend home time reintroducing the colours in the context of the game and explaining the purpose of the study. Although it was a challenge, it gave us an opportunity to reinforce the fact that maternal death knows no colour divide or political affiliation.

    I engaged a male facilitator to run the sessions, due to the cultural dynamics of the setting. He was very skilled and humorous - there was always a lot of laughter at the sessions! It was great having a male facilitator who had first-hand experience of maternity services; he had been at the birth of both of his babies, so his presence really reinforced the idea that it is possible for men to be part of their partners’ maternal care.

    What response did you get from the men who took part?

    Despite the political unrest and the tensions, the sessions went really well. Some of the more tragic scenarios had a real impact and helped to drive the message home about the importance of antenatal care.

    Many of the men were able to open up and share some of their fears. One participant said, “The game gives room for everyone to share their mind and encourages participation, you think better as you are talking. And I think I learned from my colleagues here." The feedback we received really reinforced the idea that Whose Shoes? creates safe spaces to reflect, share experiences and learn from each other.

    The sessions also revealed issues we did not know about before, such as a perception among the men that antenatal care clinics were spaces where women went to ‘report’ them, and that's why they took so long at the clinic. We were able to allay these fears and explain that the real reason that antenatal appointments took so long was a shortage of staff and high demand for services. It allowed us to widen the discussion and reinforce the reasons why antenatal care is so important, because there is a prevailing perception that you should only seek health care when you're physically sick.

    For me, the highlight of the whole project was seeing pregnant women coming back to access antenatal care services a lot happier and more relaxed. When I spoke to them, they attributed this to the men knowing about the importance of antenatal care.

    What did you learn about factors that can make coproduction more effective?

    I learnt that it's important to adapt health messages to suit local context. For instance, during antenatal sessions, women are encouraged to think about improving their nutrition by eating more green leafy vegetables and animal products. But I observed that in response to this, women tended to grumble or whisper to each other that making these diet changes was impossible because of the dynamics at home. In their community, it is generally men who make decisions around buying food and what dishes appear on the table. So it was important to integrate messages about healthy eating during the board game sessions. I observed that after the sessions, some of the men were going to the market and buying animal products and green leafy vegetables. This was really exciting as it showed that the messages were being taken seriously by the men after engaging in Whose Shoes? board game.

    Some of the feedback from the participants reinforced the importance of adapting interventions to each specific cultural setting. One man said, "The people who thought about this game, really thought so well."

    Do you have any plans to expand the project, or use your findings in other areas?

    For me, the next step is to complete the write up of a paper on the Ugandan study and then share the results widely. I think there is also an opportunity to explore the long-term behavioural impact of Whose Shoes? in maternity care.

    Further reading

    Podcast: Using Whose Shoes in PhD work with men in Uganda to improve maternity outcomes (12 December 2021)
    Safe maternal and newborn care: World Patient Safety Day 2021
    Maternal care and safety in low- and middle-income countries
    NHS - Experience of care: Creative Coproduction using Whose Shoes? (10 November 2021)
    Whose Shoes: Keeping the conversations alive during the pandemic to build the future of health and social care

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