World Journal of AIDS, 2012, 2, 143-158
http://dx.doi.org/10.4236/wja.2012.23020 Published Online September 2012 (http://www.SciRP.org/journal/wja) 143
Healthcare Providers’ Perceptions of the Sexual a nd
Reproductive Health Needs (Including Family Planning) of
Elderly Women from Selected Sites in Botswana
Njoku Ola Ama1, Enock Ngome2
1Department of Statistics, University of Botswana, Gaborone, Botswana; 2Department of Population Studies, University of Botswana,
Gaborone, Botswana.
Received May 3rd, 2012; revised June 28th, 2012; accepted July 7th, 2012
ABSTRACT
Much of the sexual and reproductive health services and service delivery including family planning target women of
child bearing ag es (15 - 49 years) and sometimes men. Hard ly are there programmes/intervention s that specifically tar-
get the needs of the elderly women (50 years and above), yet this group has serious sexual and reproductive health
needs as many of them are still sexually active. This cross-sectional study obtained the views of a stratified random
sample of 169 healthcare providers (doctors, nurses and pharmacists) from four selected sites, Gaborone, Selibe Phikwe,
Barolong and Kweneng East health districts in Botswana on how the healthcare system in the selected sites is meeting
the SRH/FP needs of the elderly women. The study found out that while overwhelming majority of the healthcare pro-
viders feltthat the healthcare system has no programme that specifically target the SRH/FP needs of this significant oth-
ers and their SRH/FP ne eds are not being met, less than 15% indicated that Pap smear screening as well as screening of
cervical cancer were on-going. Although there are SRH/FP services available in the healthcare system, the elderly wo men
are minimally accessing these services. Only condom, combined oral contraceptives, progestogen-only pills, treatment
of STIs, screening for HIV/AIDS and screening for cervical cancer are accessed and information is also limited to these
services. Reasons given by the healthcare providers for the non-accessibility of these services were cultural diversity
(80%), people’s sexual behavior and perceptions about sex (79%), lack of knowledge about the desired SRH/FP ser-
vices (76%), religion (73%) an d gender issues (62%). The stu dy, advocates as part of policy options to mitigate the ob-
stacles to accessing SRH/FP services, the expansion of counseling programmes, screening and treatment for breast can-
cer, public awareness campaigns, production and circulation of appropriate educational materials, effective training of
healthcare providers and the establish ment of separate clinic days for the elderly women’ SRH/FP services.
Keywords: Healthcare Providers; Elderly Women; Sexual and Reproductive Health Services; Family Planning
1. Introduction
Goal 5b of the Millennium Development Goals (MDGs),
emphasizes the universal access to reproductive health
(RH), including FP services. Yet, much of the sexual and
reproductive health (SRH) services and service delivery
including family planning (FP) target the women of child
bearing ages (15 - 49 years) and so metimes men. H ardly
are there special programmes/interventions that specifi-
cally target the needs of the elderly women (50 years and
above), including the vulnerable ones in this age group.
This group has serious sexual and reproductive health
needs. They suffer from lifelong effects of sexual bias
and low social status which can be burdensome. They
bear emotional and economic burdens which are associ-
ated with their responsibility as family caregivers, look-
ing after ageing parents, older husbands, orphans or
abandoned grandchildren [1]. The elderly women’s role
in a country such Botswana is critical as they play sig-
nificant roles in the families as caregivers in this era of
HIV/AIDS. An under standing of the challenges they face
in accessing their SRH needs including family planning
through the perspectives of the healthcare providers is
crucial to development and implementation of public
health intervention programmes that will address these
challenges and enable them have quality life. It is also
known that well over half the women over age 60 live in
developing countries [2,3].
The key primary health care providers in Botsw ana are
the doctors, nurses and pharmacists who are employed in
the hospitals and clinics throu ghou t the coun try. They are
conversant with the facilities and infrastructure for the

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
144
provision of healthcare to the inhabitants of the country,
including patients who make use of these facilities. The
perceptions of these healthcare providers reflect the true
reproductive health attitudes of the elderly women and
the extent of availability and accessibility of these ser-
vices to them. In addition, the opinions of the healthcare
providers can help inform policies aimed at improving
healthcare delivery in Botswan a.
Healthcare providers provide screening and treatment
of gynaecological disorders including reproductive and
urinary tract infections, uterine prolapse, and fistulas.
The screening and treatment of precancerous cervical
lesions is a clear need in many developing countries,
particularly in sub-Saharan Africa, Latin America, and
South Asia [4]. The screening for breast cancer and
treatment is also important for the good health of the
elderly women. As most of the elderly women in Bot-
swana are involved in caregiving for orphaned, destitute
children or family members living with HIV and AIDS,
it is important to institute medical management, particu-
larly for those women at high risk of fractures and car-
diovascular disease [5].
The proportion of elderly people who remain sexually
active varies considerably with age, sex, marital status
and general health. Estimates indicate that about 55% of
married women over 60 years and up to 24% of married
women over 76 years are sexua lly active [6]. In Australia,
12.4% of the population in 2001 was aged over 65 year s,
a proportion that is projected to rise to 21.3% by 2031 [7].
Studies in developing countries have shown that women
go through gynecological problems throughout their re-
productive years and beyond, in part due to the limited
medical care they receive during labour and delivery,
combined with high parity [8,9]. As they move towards
menopause and beyond, they are at risk from symptoms
associated with hormonal changes, heart disease, gyne-
cological malignancies and various genitourinary condi-
tions [1,10]. Their health at this time depends to a large
extent on the state of their health before menopause.
They can still be pregna nt as most of them are still sexu-
ally active, although pregnancy at this time is usually
neither desired nor desirable.
Sexual and reproductive health (SRH) services in-
cluding family planning services that protect the elderly
women from unwanted pregnancies, especially with short
intervals, and sexually transmitted diseases (STIs) add
very much on how well their premenopausal and post-
menopausal health will be. The women need the protec-
tion that condoms provide against sexually transmitted
diseases including HIV/AIDS. As women reach meno-
pause they need help to manage symptoms. After meno-
pause, women face new long term health risks, including
hormonal changes that contribute to an increased risk of
cardiovascular disease and osteoporosis and which con-
tribute to reduced sexual desires [11].
Despite the clear need to fo cus resources on women of
reproductive age, the public health services also need to
ensure that the health needs of older women, including
their sexual and reproductive health needs, are ade-
quately addressed. [10] revealed that about 31.4% of
postmenopausal women suffered from obstetric-related
gynecological diseases. In most cases there is hardly in-
formation on the SRH needs of the elderly women. For
instance, in Sri Lanka, the routine MCH/FP information
system of the Ministry of Health, Sri Lanka monitored by
the Family Health Bureau at present, do not collect data
with special reference to elderly women. The Sri Lanka
Demographic and Health Survey 2000 only collected
information on fertility, family planning and other se-
lected reproductive health issues of the ever-married
women aged 15 - 49 years. Researchers, therefore, rely
mostly on clinical impressions and experiences about the
elderly w omen’s hea lth profi le [12].
Botswana has made significant progress economically
since independence in 1966. She has relatively good
roads, solid communications network, and 24-hour hos-
pitals that are fairly well distributed th roughout the coun -
try, yet Botswana has serious barriers to comprehensive
sexual and reproductive health care including family
planning [13]. While th e government requires that sexu al
and reproductive health (SRH) services, including family
planning, prenatal care, delivery, post-abortion care, and
STI services are provided at no cost by maternity care
providers, hospitals and government clinics, indicators
such as maternal mortality, feminization of HIV, and
contraceptive prevalence do not reflect a system that
meets the needs of its population [13]. Contraceptive
prevalence in Botswana still remains at 48% [14].
About 90% of people in Botswana are known to live
within 15 kilometers of a health centre, yet use of these
centers for SRH services is very low, especially among
young people. The availability of sexual and reproduc-
tive health services do not necessarily translate to acces-
sibility, particularly for young people. The young people
indicate that they are kept away by inconvenient hours,
poor information about services, and unwelcoming atti-
tudes toward youth among service providers [15]. The
elderly women might be going through the same experi-
ences as the young people. There are no literature so far
on programmes or interventions targeting the elderly
women or are there data on elderly women’s sexual and
reproductive healthcare including family planning. There
are relatively limited information on the physical, psy-
chological and social problems of the elderly women.
The women themselves hardly seek care, often because
they accept their physical discomfort associated with gy-

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana 145
necological problems, menopause, and ageing as natural
[9,16]. A study in Botswana on older population and
health system (the case of chronic disease-hypertension)
showed that 48% of the elderly could not access health-
care because they were far. Transport availability was
also raised as an issue as 62% of them said they walked
[17] (Older Population and Health System: A profile of
Botswana).
This study documented the views of the healthcare
providers, from the selected sites for the study, on the
perceived sexual and reproductive health needs (includ-
ing family planning services) of elderly women, avail-
ability and accessibility of sexual and reproductive
healthcare services (including family planning services),
sources of information for SRH/FP needs, factors which
influenced the accessibility of reproductive health ser-
vices to the elderly women, interventions and policy
changes to improve access to SRH/FP needs of the eld-
erly women. The availability of sexual and reproductive
health services in this study was measured by the physi-
cal presence of the desired services and the presence of
qualified, nondiscriminatory healthcare providers at the
service points. This information from this study will be
necessary for policy makers, the government of Bot-
swana and the private sector to shape intervention meas-
ures to assist elderly women to seek and access the de-
sired sexual and reproductive health services.
This paper follows from a larger study between Feb-
ruary and October, 2011 [18] and relies on information
provided by the sampled healthcare providers serving in
hospitals and clinics from the study sites.
2. Methodology
The main study from which this paper has emanated was
a cross-sectional study conducted between February and
October 2011 and was supported by funding from the
Office of Research and Development, University of
Botswana. The study was on sexual and reproductive
health of elderly women from the following selected sites
in Botswana: Gaborone, Selibe Phikwe (2 urban health
districts), Kweneng East and Barolong (2 rural health
districts). The selection of the districts for the study was
informed by closeness to Gaborone (the capital of coun-
try) and to reduce cost of the study since it was a case
study that could lead to a national study. The choice of
equal number of urban and rural health districts was to
assist comparison of urban and rural women’s experi-
ences on sexual and reproductive health issues.
[19] showed that for a population of 5657 healthcare
providers in Botswana [20], a statistically adequate na-
tional sample size for the study is 360 healthcare provid-
ers. Sixty per cent of this statistically determined sample
size (n = 216) was allocated to the four selected districts
using probability proportional to size (PPS), where the
size represents the population of healthcare providers
working in each health district. This allocated number (n
= 216) is about three and a half times the expected sam-
ple size that would have been allocated to the selected
sites but this was don e to ensure that enough informatio n
was collected to facilitate appropriate analysis and inter-
pretation of the results. At the end of the studies, 169
healthcare providers (123 nurses, 40 medical doctors and
six pharmacists) were successfully interviewed, giving a
response rate of 78.2% which is very much higher than
[21].
Only one instrument, questionnaire, was used for the
study. Questionnaires were administered to the health-
care providers by trained research assistants, who ex-
plained the purpose of the study and obtained informed
consent. The questionnaires were coded to ensure the
anonymity of the respondents. Most questionnaires were
completed in the presence of the research assistants,
while some were completed by participants at a more
convenient time (self-administered) and returned to the
research assistants within one to three days. The ques-
tionnaire contained questions about the healthcare pro-
viders’ demographic characteristics, their opinions on the
reproductive health needs of the elderly women, avail-
ability and accessibility of reproductiv e health services to
elderly women, sources of information on sexual and
reproductive health services available in th e public health
system in Botswana and factors that influence the acces-
sibility of these services to the elderly women. Some of
the questions were open-ended so that the healthcare
providers could further provide information to clarify
their responses on the perceived experiences of the eld-
erly women in accessing reproductive healthcare services,
including family planning.
The questionnaire was reviewed by experts in public
health and ageing for quality, clarity and content in ad-
dressing the objectives of the study. It was latter ap-
proved by the University of Botswana Institutional Re-
view Board (IRB) and the Ministry of Health Research
and Ethical Committee before being used. A two-day
training workshop for the research assistants was organ-
ized and the contents of questionnaire were explained to
them. Permission to conduct the study was also obtained
from the District Health Management Teams in each of
the selected health districts.
Data were captured using the Statistical Package for
the Social Sciences (SPSS) computer programme. All
variables, including the responses to the open-ended
questions, were coded before being captured using the
programme. Data were analyzed using descriptive meas-
ures, such as percentages, means, standard deviation,
correlation analysis and inferential statistics, such as the

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
146
t-test. The t-test was used to determine if there were sig-
nificant differences in opinions of the doctors and nurses were married while 40.8% were single (never married) and 6.5% were cohabiting, divorced or widowed. The
sample was skewed towards nurses as an overwhelming
majority (72.8%) belonged to that professional class
while 23.7% were medical doctors and 3.5% were phar-
macist (Figure 1). This skewed distribution of the heal th-
care providers in the studied sample is reflective of the
population of healthcare providers in Botswana where
over 89% are nurses [20].
on the elderly women’s accessibility and availability of
SRH services, including family planning. Graphical rep-
resentations helped to further illustrate the results ob-
tained. The results of the study were disse minated th r ou g h
departmental seminars.
3. Results
3.1. Demographic Characteristics of the
Healthcare Providers 3.2. Meeting the SRH/FP Needs of the
Elderly Women
The analysis of the data from th e study shows that 55.6 %
(n = 94) of the healthcare providers were female while
44.4% (n = 75) were male; 24.9% were between 20 and
29 years old, 33.7% between 30 and 39 years; 27.8%,
between 40 and 49 years and 13.6% were 50 years and
over. More than half of the health care providers (55%)
had diploma certificate while 37.3% had university de-
gree; 3.6% had attempted degree and 4.1% had profes-
sional certificate. A little over a half of them (52.7%)
The healthcare providers were asked to indicate whether
in their opinions the SRH/FP needs of the elderly women
were met from the hospitals and clinics in the selected
sites. The responses which were classified as 1 = Yes, 2=
No, and 3 = Don’t know, are shown in Figure 2. The
figure shows that majority of the healthcare providers
(42%) said the needs are not met while 38% were on the
affirmative. The percentages of medical doctors, nurses
44.4
55.6
24.9
33.7
27.8
10
3.6
55.0
3.6
37.3
4.1
40.8
1.7
52.7
2.4
2.4
23.7
72.8
3.5
0 1020304050607080
Male
Female
20‐29
30‐39
40‐49
50‐59
60‐69
Diplomacertificate
Degreeattempted
Uni v e r s ityDegree
ProfessionalCertificate
Nevermarried(Single)
Cohabiting
Married
Divorced
Widowed
MedicalDoctor
Nurse
Pharmacist
Gender
Ageofhealth
providers
Educational
qualification Maritalstatus
Employment
status
Percent
Figure 1. Demographic characteristics of the healthcare providers.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana 147
35%
38%
50%
38%
48%
42%
17%
42%
18% 20%
33%
20%
0%
10%
20%
30%
40%
50%
60%
MedicalDoctor(n=40) Nurse(n=123) Pharmacist(n=6) Total
Yes No Don'tknow
Figure 2. Healthcare providers’ opinion on whether SRH/FP needs of elderly women are met.
and pharmacists that were in the affirmative were 35%,
38% and 50 %, re spectively, w hile 42%, 48% and 17 % of
the doctors, nurses and pharmacists, respectively said the
needs are not being met.
3.3. Programme Targeting SRH/FP Needs of the
Elderly Women
An open-ended question was posed to the healthcare
providers to pin point any pr ogramme in Botswana pub lic
health system that targets the elderly women’s sexual and
reproductive health needs, including family planning.
The results are displayed in Figure 3. The figure shows
that all the pharmacists, 71% of the nurses and 67% of
the medical doctors agree that there is no programme that
specifically targets the SRH/FP needs of the elderly
women in Botswana. However, 14% of the doctors and
9% of the nurses were of the view that Pap smear
screening was on-going for the elderly women, as well as
screening of cervical cancer (6%, doctors; 5%, nurses).
3.4. Sexual and Reproductive Health/Family
Planning Services Available in the Public
Health System
Although the study has shown that there are no specific
programmes that target the SRH/FP needs of the elderly
women, there are family planning services that any de-
siring elderly women can access. The healthcare provid-
ers were, therefore, asked to specify the sexual and re-
productive health/family planning services that were
available in the healthcare system. The results are shown
in Table 1. Condom (all the doctors, 93% of nurses and
80% of pharmacists), combined oral contraceptives (all
the pharmacists, 89% of doctors and 84% of nurses),
intrauterine device ( IUD ) (78% of doctors, 75% of nurses
and 20% of pharmacists) and progestogen-only pills (all
the pharmacists, 72% of doctors and 65% of nurses) are
the top four services that are available.
Treatment for STIs, screening for HIV/AIDS, screen-
ing for cervical cancer and prevention of mother-to-child
transmission services (PMTCT) were the top four SRH
services most available in the healthcare system. In addi-
tion to these, over 90% of the doctors also identified an-
tenatal care services, screening for STIs and treatments
for HIV/AIDS as being very much available in the
healthcare system (Figure 4).
3.5. Sexual and Reproductive Health/Family
Planning Services Accessible to the Elderly
Women
When asked whether these services were accessible to
the elderly women in the terms of proximity to the ser-
vice points, cost of services and availability of qualified
healthcare providers to administer these services, the
healthcare providers enumerated those services that were
accessible to th e desiring elder ly women. These are shown
in Figure 5. Condom, combined oral contraceptives and
progestogen-only pills were the top three services accessi-
ble to the elderly women. However, all the pharmacists
acknowledged the accessibility of combined injectable
contraceptives, barrier methods and emergency co ntr ac ep-
tion. Breastfeeding was also highly rated by the nurses

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
148
3% 3% 3% 3% 3% 6% 6%8% 14%
67%
4%4% 4%4% 5% 5%8%11% 8% 9%
71%
100%
0%
20%
40%
60%
80%
100%
120%
Provisionofcondoms
Screeningofbreastcancer
Postnatalclinic
Counselling
ANCcare
Hivtesting/RHTAIDSscreening
Screeningofcervicalcancer
Familyplanningclini c
PMTCT
PAPsmearscreening
None
Progr ammetargettingSRHneedsofelderlywomen(includingfamilyplanning)
MedicalDoctor(n=38) Nurse(n=121) Pharmacist(n=3)
Figure 3. Identified programmes that target SRH/FP needs of elderly women.
84%
92%
82%
92%
87%
92%
87%
97%
100%
97%
86%
82%
89%
89%
89%
92%
93%
91%
90%
92%
60%
80%
20%
60%
20%
40%
20%
40%
80%
0%20% 40% 60% 80%100%120%
Supplyofcontraceptives
TreatmentofHIV/AIDS
Postnatalcare
ScreeningforSTI’s
Familyplanning
Antenatalcare
PreventionofmothertochildtransmissionofHIV
Screeningforcervicalcancer
ScreeningforHIV/AIDS
TreatmentofSTI’s
ToptenSRHservicesavailabletoelderlywomen
Pharmacist(n=5) Nurse(n=117) MedicalDoctor(n=38)
Figure 4. SRH services available in healthcare system in Botswana.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana 149
32% 23% 36% 29% 36% 45%
58%
71%
81% 94%
17% 21%
26% 40%
58% 56% 62% 63%
75%
94%
50%
100% 100%
50%
100%100% 100%
50%
0%
20%
40%
60%
80%
100%
120%
Femalesterilisation
Emergencycontraception
Barriermethods
Abstinence
Breastfeeding
Combinedinjectable
contraceptives
Intrauterinedevice (IUD)
Progestogen‐onlypills
Combinedoralcontr a cept ives
Condom
MedicalDoctor(n=36) Nurse(n=116) Pharmacist(n=5)
Figure 5. Top ten family planning serv ices accessible to the elderly women.
Table 1. Opinion of healthcare providers on family planning services that are available in the healthcare system.
Family planning services available Medical doctor (n = 36) Nurse (n = 116) Pharmacist (n = 5)
Condom 100% 93% 80%
Intrauterin e device (IUD) 78% 75% 20%
Combined oral contraceptives 89% 84% 100%
Progestogen-only pills 72% 65% 100%
Combined injectable contraceptives 53% 65% 80%
Female sterilisation 36% 35% 20%
Breastfeeding 42% 66% 0%
Spermicides 19% 15% 20%
Barrier methods 33% 31% 40%
Sterilization 44% 22% 0%
Emergency contraception 44% 23% 80%
Diaphragm 44% 20% 0%
Vasectomy 39% 23% 20%
Norplant 36% 12% 0%
Abstinence 44% 62% 80%
Withdrawal 25% 35% 60%
Observation of safe periods 36% 38% 20%

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
150
(58%) in terms of accessibility to the elderly women. taboo issues related to sex and the use of male and fe-
male condoms. They were able to break down cultural
barriers and paved the way for open discussions on re-
productive health issues. The program also had a sig-
nificant impact on men, who began calling in seeking
advice on behalf of their wives [22,23].
The treatment for STIs, screening for HIV/AIDS and
screening for cervical cancer were the top SRH services
that were accessible to the elderly women. In addition,
90% of the doctors indicated that screening for STIs and
treatment for HIV/AIDS were also very much accessible
to the elderly women (Figure 6). The healthcare providers were asked to indicate if in-
formation on available SRH/FP services in the healthcare
system were made available to the elderly women and in
what forms. Figures 7, 8 and Table 2 show the family
planning services, sexual and reproductive health ser-
vices that the elderly women have information on, and
the sources of those information, respectively.
3.6. Information Availability on the Accessible
SRH/FP Services
One of the strategies for increasing access to SRH/FP is
the dissemination of information about sexual and re-
productive health/family planning and available services.
Public media can serve this function if the outreach is
targeted toward marginalized and vulnerable popula-
tions [22]. Using radio as a tool for advocacy and
awareness on reproductive and sexual health can also be
another powerful tool. Fo r example, the women’s youth
organization YWCA in Papua New Guinea has been a
pioneer in using radio as a tool for advocacy and
awareness on reproductive and sexual health. On the
Tokstret Radio Project, a call-in program that provided
a forum for discussion of reproductive and sexual health
issues, women took the lead in talking about highly
Figure 7 reveals that information is mostly available
on condom (91% of doctors, 88% of nurses and 80% of
pharmacists), combined oral contraceptives, progesto-
gen-only pills, and breastfeeding.
Table 2 shows that information on sexual and repro-
ductive health services are mostly available on the fol-
lowing: services for screening for HIV/AIDS, PMTCT,
screening for cervical cancer and treatment for STIs. All
the pharmacists strongly feel that information on supply
of contraceptives and family planning are very much
available.
77%
84%
90%
84%
90%
84%
87%
94%
97%
97%
82%
84%
81%
87%
85%
90%
91%
87%
89%
87%
40%
20%
60%
40%
40%
20%
20%
40%
20%
100%
0%20% 40% 60% 80%100%120
%
Phar macis t (n=5) Nurse(n=79) MedicalDoctor(n=31)
Supplyofcontraceptives
Postnatalcare
TreatmentofHIV/AIDS
Familyplanning
ScreeningforSTI’s
Antenatalcare
Preventionof mothertochildtransmi ssi onofHIV
Screeningforcervicalcancer
ScreeningforHIV/AID S
TreatmentofSTI’s
Topte nSRHservicesaccessibletoelderlywomen
Figure 6. Sexual and reproductive services accessible to the elderly women.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
151
47%
68% 68% 65% 62%
74% 74%
91%
52%
64% 65% 66% 69% 73% 74%
88%
20%20% 20%20%
40%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Femalesterilisation
Intrauterinedevice(IUD)
Combinedinjectable
contraceptives
Abstinence
Breastfeeding
Progestogen‐onlypills
Combinedoralcontraceptives
Condom
Topeightfamilyplanningservicesthatelderlywomenhaveaccesstoinformationon
MedicalDoctor(n=34) Nurse(n=108) Pharmacist(n=5)
Figure 7. Top family planning services that elderly women have information on.
Table 2. Health providers’ perception on SRH whose information is accessible to elderly women.
Employment status
Information on SRH services available to elderly women Medical d o c t o r (n = 36) Nurse (n = 113) Pharmacist (n = 3 )
Abortion (where legal) 44% 25% 33%
ALL SRH SERVICES 25% 34% 33%
Post abortion care 47% 51% 0%
Treatment of cervical cancer 64% 57% 33%
Services for victims of sexual vi olence 56% 65% 33%
Emergency obstetric care 64% 68% 33%
Safe delivery 78% 83% 67%
Supply of contraceptives 86% 86% 100%
Antenatal care 83% 90% 67%
Postnatal care 83% 90% 67%
Treatment of HIV/AIDS 89% 92% 33%
Family planning 86% 93% 100%
Screening for STI’s 92% 94% 33%
Treatment of STI’s 94% 93% 67%
Screening for cervical cancer 92% 96% 33%
Prevention of mother to child transmission of HIV 89% 97% 33%
Screening for HIV/AIDS 94% 99% 33%

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
152
Figure 8 shows that nurses (50%) and medical doctors
(16%) were the main sources through which the elderly
women got information on SRH/FP services that were
available in the health care system in Botswana. Other
sources included radio/television and relatives.
Analysis of the differences in the opinions of the
healthcare providers using analysis of variance showed
that there were no significant differences in the percent-
ages of respondents sharing a particular opinion (p >
0.05). A further analysis on the differences in the opin-
ions of the doctors and nurses (Table 3) showed that on
all the variables studied, there were no significant differ-
ences in their views (p > 0.05). The correlation coeffi-
cient between the doctors’ and nurses’ opinions were
very high, showing very close association the the views
of the doctors and nurses. The study further showed that
the information on both the sexual and reproductive
health including family planning services are mostly
provided in the form of printed materials (82%), during
the elderly women’s consultation with doctors (65%),
during separate sessions for the women (41%) or some-
times during sessions for both men and women (40%)
(Figure 9). Dissemination of information through use
of such informative sessions as drama, film shows (14%)
or separate sessions for men (16%) rarely occur. The
results have implications on interventions to reach eld-
erly women on their SRH/FP needs using printed mate-
rials and information provided by medical doctors dur-
ing consultations. The institution of education sessions
for women is also recommended.
Table 3. Test of the difference in the opinions of the doctors and nurses on some variables studied.
Opinion of doctors and nurses d.f Difference in
proportion p-value Decision Correlation coefficient, r
Family planning services available 16 0.0433 0.1179 n.s 0.8295
Family planning services accessible 16 0.0163 0.2660 n.s 0.9197
SRH services accessible 16 0.0336 0.0850 n.s 0.9313
Access to information 16 0.0166 0.1988 n.s 0.9306
n.s = not si gnificant at 5% level of signifi cance.
Figure 8. Main sources of information on SRH/FP services to the elderly women.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
153
3.7. Identified Obstacles to Elderly Women
Accessing Their SRH/FP Needs
The key obstacles to the elderly women accessing their
sexual and reproductive health needs including family
planning identified by the healthcare providers are cul-
tural diversity (80%), people’s sexual behavior and per-
ceptions about sex (79%), lack of knowledge about the
desired SRH/FP services (76%), religion (73%) gender
issues (62%) and husband-wife relations/role (60%)
(Figure 10).
3.8. Suggested Interventions to Mitigate the
Obstacles to Accessing SRH/FP Needs and
Policy Changes
When asked, in an open-ended question, what measures
could be adopted to improve the SRH/FP seeking behav-
ior of the elderly women, the healthcare provid ers identi-
fied a number of such measures which include the top ten
shown in Figure 11. An overwhelming majority of the
healthcare providers (89% and over) identified counsel-
ing (95%), screening for breast cancer and treatment
(95%), routine screening for breast cancer (93%), public
awareness campaigns on the utility of family planning
(92%), production and circulation of appropriate educa-
tion materials explaining the utility of SRH/FP care
(92%), effective training for healthcare providers and
programme managers on how to meet the elderly women
SRH/FP health seeking needs (92%) as interventions to
boost the elderly women’s SRH/FP care (Figure 11).
On policy changes to be effected to improve access to
SRH/FP services by the elderly women, the healthcare
providers recommended the establishment of separate
clinic for the elderly women (22%) and that separate
clinics days be set aside to attend to the elderly women
(9%). Public awareness campaigns on SRH issues (15%)
need to be intensified and the number of service pro-
viders like doctors, nurses, and midwives be increased,
while those on the ground should be trained (6%) (Fig-
ure 12).
4. Discussion
This paper’s main focus is to obtain the views of the
healthcare providers (medical doctors, nurses and phar-
macists) on how the sexual and reproductive health needs
including family planning of the elderly women are met
at the healthcare systems in the selected sites in Bot-
swana. The study was cross-sectional and interviewed
169 healthcare providers (40 doctors, 123 nurses and 6
pharmacist) randomly selected from the four selected
sites (Gaborone, Selibe Phikwe, Barolong and Kweneng
East).
The study has shown, based on the opinions of all the
pharmacists, 71% of the nurses and 67% of the doctors,
that the healthcare system has no programmes that spe-
cifically target the sexual and reproductive health in-
cluding family planning of this significant others and
their SRH/FP needs are not met. It is well known that the
elderly women have sexual and reproductive health
problems which are carried over from the child-bearing
ages [8-10]. The women are very relevant to the country
as caregivers in their families in the current national
HIV/AIDS programme and a substantial proportion of
them are still sexually active. The authors, [18], have
shown that 45% of the elderly women ag ed 50 - 59, 31%
of those aged 60 - 69 years and 11% of those aged 70 -
79 years still enjoy sex with their partners, a result which
is in line with [6,7,24]. It is important that a programme
that targets the SRH/FP needs of the elderly women be
put in place since their level of sexual activity could re-
sult in pregnancy.
The findings from the study revealed that availability
of SRH/FP services in the healthcare system does not
always translate into accessibility. Thus, although sexual
and reproductive health services including family plan-
ning are very much available in the healthcare system,
the elderly women are only able to access mostly con-
dom, combined oral contraceptives, progestogen-only
pills, combined injectable contraceptives, treatment for
STIs, screening for HIV/AIDS, and screening for cervi-
cal cancer. The reasons given by the healthcare providers
for the elderly women’s inability to access SRH/FP ser-
vices are cultural diversity (80%), people’s sexual be-
havior and perceptions about sex (79%), lack of knowl-
edge about the desired SRH/FP services (76%), religion
(73%) and gender issues (62%). These findings are in
line with [25]. In the traditional Botswana society, sex
and sexuality are mere social co nstructs. Both the family
and societal norms are very much in place to socialize,
regulate and control the sexual behavior of members. For
instance, grandmothers start engaging in sexual conver-
sations with girls from the age of 15 years while grand-
fathers do the same with boys. The discussions usually
center on areas such as potential sex partners, sex and
health issues, and prep aration for sex in terms of what to
expect from the male partner, how to handle the opposite
sex partner, and when to say no to sex [26]. Culturally
breastfeeding is done for two years and during this time
the lactating mother is not supposed to engage in sex
with the husband. If for some reason the woman is not
able to breast-feed for two years then they both drink
traditional medicine to prevent pr egnancy. In this culture,
women have no power when it comes to sexual decision
matters. Not only that most men in this culture do not
believe in using condoms, they say they develop rash
around the male organs whenthey use condoms [26,27].

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
154
14% 16%
20% 25%
40% 41%
65%
82%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Informative
sessions e.g.
drama
Separate
sessions fo r
men
Audio‐visual
materiale.g.
radio,CD
Separate
sessionsfor
adolescent s
Sessio n sfo r
bothmen
andwomen
Separate
sessionsfor
women
When
consulting
themedical
officer
Prin t e d
material
Forminwhichinfor ma tio nisavailable
Figure 9. Form in which the information is made available.
41% 41%
54% 56% 60% 62%
73% 76% 79% 80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Mistrust
Sexofhealthcarestaff
Roleofmalepartner
Language
Husb an d–wiferelation/role
Genderiss ues
Religion
Lackofknowledge
Sexualbeh a v io u randperceptions
aboutsex
Culturaldiversity
ToptenobstaclestoelderlywomenaccessingSRH/FPneedsidentif i edbyhealthcareproviders
Figure 10. Identified obstacles by the health providers to the elderly women accessing SRH/FP.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana 155
89% 89%89%
91%91%
92% 92%92%
93%
95% 95%
85%
86%
87%
88%
89%
90%
91%
92%
93%
94%
95%
96%
Medicalmanagementofwomen with
cardiovasculardisease
Spec ialsuppliesandequipmentto
healthproviders
Communitybasedactivities,including
suppo rtgroupsandvolunteerhealth
promoters
Supp or tservicesforwomencaringfor
familymem b e rslivingwithHIVand
AIDSandorphanedgrandchildren
Promotingofactiveandhealthy
lifestyles
Effectivetrainingforhea lt hproviders
andprogrammemanagers
Appropriateeducationalmate r i als
Publicawarenesscampaigns
Routinescreeningforbreastcancer
Scre e n ingfor breastcancerand
treatment
Counselling
Topten recommendedinterventionmeasurestoimproveSRH/FPseekingbehaviourofelderlywomen
Figure 11. Top ten intervention measures identified by healthcare providers to improve SRH/FP.
6%
9%
15% 15%
17%
22%
0%
5%
10%
15%
20%
25%
Morehealth
practitioners
Elderlywomen
shoul dbe
attendedto
differentlyfrom
theyounger
women
Public
awarenesson
SRHissues
Notsureofthe
existingpolicies
Nochangeof
policybec aus e
theelderly
womenare
cateredfor
Haveasepar ate
clinicforelderly
women
Polic
y
chan
g
esrecommended
Figure 12. Recommended policy changes by the healthcare providers to improve the elderly women’s SRH/FP access.

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
156
There is the likelihood that the non-utilization of the
SRH/FP services may have been influenced by the cul-
tural environment of the elderly women thereby changing
the perceptions and attitude of this cohort of elderly
women towards sexual and reproductive health services
including family planning.
Similar scenarios are found in the Nigerian society
where sex and sexuality issues are taboos. As a result of
perceived stigma and embarrassment, people are reluc-
tant to discuss and address sexual health issues. As [28]
puts it “Men are perceived as macho and women as pas-
sive. This gender role makes women and especially
transgender people vulnerable in different ways to SRH
problems, and inhibiting access to SRH services. For
instance, men may associate masculinity with taking
risks in their sexual relations which expose them to HIV
and STIs, and may be reluctant or too embarrassed to
seek out appropriate health information and care”. When
women are financially, materially or socially dependent
on men, their ability to exercise control in relationships,
such as negotiating the use of condoms during sex, de-
termining when and how to have sex, become limited if
not totally eroded. Social expectations about how women
should behave sometimes place women in subordinate
roles and increase their risk of being sexually assaulted,
contracting STIs and having unwanted pregnancies, and
also limit their access to SRH services [28].
Religion also plays a great role in access to SRH in
Botswana as in many other countries. Certain religious
faith have their reservation in the use contraception and
use of condom and this affect access to family planning
services.
Information is an important tool in influencing access
to SRH services including family plann ing. A lot of peo-
ple don’t have access to information to know such a ser-
vice exists in hospitals. Information needs to be shared
on the availability of SRH services, so that prospective
clients will access such services [25,26,28]. In the study,
information on available SRH/FP services to be accessed by
the elderly women was limited mostly to condom, com-
bined oral contraceptives, progestogen-only pills, screening
for HIV/AIDS, prevention of mother-to-child transmission
(PMTCT), and screening for cervical cancer out of a lot
many av ailable serv ices. This depr ived informati on invari a-
bly delimits the choice of alternative SRH/FP services that
the elderly women could use. In addition, the information
existed mainly in printed materials, could be obtained dur-
ing consultations with doctors or during separate sessions.
For women of this age group who are mostly unemployed,
with poor health conditions as most of them suffer from
arthritis and the general body aches associated with age-
ing [18], accessing this information will be difficult. This
view is further supported by the results of an earlier
study on “Older Populatio n and Health System: A profile
of Botswana” which found out that women 50 years and
over had difficulty in using the health services because
the health facilities were far and transpor t was difficult to
get [17]. There is need to address these obstacles to ac-
cess if the elderly women are to visit the hospitals and
clinics for their SRH/FP needs. Public awareness cam-
paigns can help the healthcare system overcome some of
these issues, while also promoting active and healthy
lifestyles of the elderly women.
The healthcare providers, however, recommended as
part of policy option s to mitigate the obstacles to th e eld-
erly women accessing SRH/FP services, the following
interventions: an expansion of counseling programmes,
screening and treatment for breast cancer, public aware-
ness campaigns, production and circulation of appropri-
ate educational materials, effective training of healthcare
providers and the establishment of separate clinic days
for the elderly women’ SRH/FP services. The healthcare
providers need training that enables them to be better
equipped to address the healthcare requirements of the
elderly women. Such a training should result in attitudi-
nal change so that they can value the elderly women and
be able to educate the women on appropriate measures to
take to improve the quality of their life as they age. Re-
productive health programmes, which already served the
women during their childbearing years, can be good for
caring for women as they approach menopause and be-
yond. Healthcare providers can help ensure that the eld-
erly women have access to appropriate contraceptive
methods. Depending on available resources it might be
necessary to include other services for elderly women
such as counselling about menopause and its symptoms
as well as information on how to maintain a healthy life-
style through dieting and exercise [5]. The counseling
services can be integrated into existing SRH/FP pro-
grammes. The Botswana Health Statistics Report (Health
Statistics Reports, 1980-1998) shows an increasing trend
in the incidence and prevalence of non-communicable
diseases such as cancer, hypertension and diabetes, some
of the diseases that the elderly women suffer from. Use
of Community based activities, including support groups
and volunteer health promoters, hold special promise
since they can maximise the interest and resources of the
elderly women themselves as well as the wider commu-
nity. Retired nurses can be used for this purpose to cut
down costs while ensuring efficient execution of the as-
signment. Mobile health services that will target the eld-
erly can be strengthened as the elderly women may not
be able to travel long distances.
5. Acknowledgements
The authors wish to thank the Office of Research and

Healthcare Providers’ Perceptions of the Sexual and Reproductive Health Needs (Including Family Planning)
of Elderly Women from Selected Sites in Botswana
157
Development, University of Botswana for providing the
fund for this study.
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