Perceptions of peer contraceptive use and its influence on contraceptive method use and choice among young women and men in Kenya: a quantitative cross-sectional study

Development of a community-based peer-support intervention to improve contraceptive agency and diffuse self-injectable contraception in Uganda: Application of the human-centered design approach

BACKGROUND

The low use of self-injectable contraception, coupled with the recognition that many individuals need support beyond training to use self-care technologies successfully, suggests the need for innovative programming. We describe the participatory human-centered design process we used in two districts of Uganda to develop a community-based peer support intervention to improve women's agency to make and act on contraceptive decisions and help diffuse self-injectable contraception.

METHODS

The design team included multi-disciplinary researchers from Uganda and the United States, representatives of local community-based organizations and village health teams, and local women of reproductive age. The research group conducted 21 in-depth interviews, 12 observations, and six focus group discussions to understand women's social support needs, contraceptive-seeking experiences, and communication channels. From these data, the design team derived insights into needs and opportunities to improve contraceptive agency and support self-injection use among interested women, spurring a creative idea-generation process to develop a large set of potential solutions. We collectively prioritized the most promising ideas into an integrated, theoretically informed intervention and subsequently prototyped, tested, and refined the intervention.

RESULTS

Design insights included: women value information from experienced peers and want support to navigate uneven partner dynamics, conflicting contraceptive information, concerns about contraceptive-related side effects, and unreliable contraception services. The final intervention-called I-CAN (English), Nsobola (Lusoga), An Atwero (Langi)-engages experienced self-injection users as 'mentors' to support other women ('mentees') they recruit in community-based settings. Mentors provide informational, instrumental, appraisal, and emotional support tailored to the individual needs of mentees. This support is designed to improve mentees' knowledge, consciousness of their rights related to contraception, self-efficacy, and perceived control related to contraceptive decision-making, self-injection self-efficacy, contraceptive access, and ability to act on preferences.

CONCLUSIONS

Our iterative human-centered design process incorporated diverse, lived experiences and scientific expertise and resulted in a peer support intervention with the potential to fill an important gap in contraception service delivery in Uganda. Our approach demonstrates that creating complex interventions to prioritize support for women's agency related to contraception in line with a human rights-based approach and to spread new contraceptive methods is feasible.

Determinants of family planning services uptake among women within the reproductive age in the Yendi municipality in Northern Ghana

The study investigated the prevalence and determinants of family planning services uptake among women of reproductive age (15 to 49 years) in the Yendi municipality in the northern region of Ghana. A health facility-based cross-sectional study was conducted among 396 reproductive-aged women, sampled from 6 randomly selected health facilities in the Yendi municipality. The child welfare clinic (CWC) served as the point for the sampling of study respondents. Data was collected with questionnaires adapted from previously validated tools. Data was analysed using SPSS v27 in descriptive and inferential statistics. More than half of the respondents (54.3%) said they had ever used a family planning method and almost half of them said they were still using a family planning method. The desire to control pregnancy was a key factor for wanting family planning (79.3%). Most respondents (80.6%) had high knowledge of family planning services and injectables (37.1%) and condoms (24.7%) were the preferred family planning methods. The significant sociodemographic determinants of family planning uptake were religion (Christians (aOR: 7.51; 95%CI: 1.48-38.00:; p = 0.015), traditionalist (aOR: 12.1; 95%CI: 1.90-78.36; p = 0.009)), education (secondary education (aOR: 84.99; 95%CI: 20.02-360.84:; p = 0.000), tertiary education (aOR: 158.74; 95%CI: 33.71-747.52; p = 0.000), no formal education (aOR: 11.83; 95%CI: 2.10-46.76:; p = 0.000)), occupation (farmers (aOR: 12.30; 95%CI: 3.21-47.03; p = 0.000)), and marital status (married (aOR: 0.13; 95%CI: 0.03-0.57; p = 0.007)). Factors that made women less likely to use family planning were unfriendly service providers (aOR: 2.33; 95%CI: 1.28-4.21; p = 0.005), fear of side effects (aOR: 2.19; 95%CI: 1.19-4.05; p = 0.012), and lack of knowledge about available FP services (aOR: 0.45; 95%CI: 0.26-0.77; p = 0.004). Though the knowledge of family planning was high, current uptake of family planning services was modest and there are still sociodemographic and health-related barriers to family planning utilization. Highlighting the need for training programs and policy interventions to improve uptake, reduce financial barriers, and foster a supportive environment.

Inter-generational impact: Exploring the influence of older sister-in-law's contraceptive choices on her peer contraception adoption in India

OBJECTIVE

Social network-based reproductive decisions are critical. This study compares the effect of an older peer contraceptionuse on her younger peer's use, as they share the closest social network within the household, and tend to influence one another for reproductive decisions. In this study we considered peers as two sister-in-law living in the same household.

METHODS

We used data from the fifth round of National Family Health Survey which was conducted between the year 2019 and 2021. We deployed multinomial multivariable logistic regression to find the association between older women contraception use on her younger peer. Also, an attempt has been made to determine contraceptive clustering within households in India and select states.

RESULTS

The multinomial analysis found that all the women in the household used the similar method, but still relied only on the female sterilization as the sole method for their family planning. The multinomial multivariable method found that younger peers were 3.42 time odds more likely to use permanent method if her older peer had used it previously. Also, it was found 11% increase in any modern contraception use of younger peer if all her older peer will use any modern contraceptives in India. For all the states, the contraception clustering within household ranged from 5% to 14%, with highest in Himachal (14%).

CONCLUSION

Empowering older women as peer educators in contraception workshops can foster informed discussions, dispel myths, and promote the use of modern contraceptive methods among younger peers. Integrating such initiatives into government existing policies like Mission Parivar Vikas is crucial for improving contraceptive uptake, with ASHA workers and community health volunteers playing a pivotal role in delivering targeted education within households.

"I will find the best method that will work for me": navigating contraceptive journeys amongst South African adolescent girls and young women

BACKGROUND

Given that South Africa has one of the highest rates of pregnancy amongst adolescent girls and young women (AGYW) globally, the provision of contraceptives to this group has been a key focus in recent years. Pregnancy prevention involves an on-going continuum of decision-making around contraceptive method choice, uptake, use, experience, continuation, and discontinuation.

METHODS

This paper presents analysis of data from a cross-sectional survey with 2376 AGYW, as well as qualitative in-depth interviews (IDIs) with 54 AGYW, inclusive of contraceptive journey narratives. We examine the preferences, valued characteristics, choices, beliefs, understandings and experiences of choosing and using contraceptives amongst AGYW in two South African communities characterised by high rates of pregnancy.

RESULTS

These findings shed light on the preferences towards, beliefs about, and experiences of choosing, using and discontinuing contraceptive methods amongst this population, with survey data suggesting that the most popular methods were the injection, followed by the implant, and then the oral pill. Findings illustrate the complexity and dynamic nature of contraceptive decision-making and the varied embodied and lived experiences of contraceptive use, and how these are impacted by contraception service provision.

CONCLUSIONS

Our findings show that contraception experiences of each individual are cumulative, and comprise a continuum of method initiation, use, discontinuation, method switching and on-going circular decision-making influenced by multiple social, structural, contextual and interpersonal factors, combined with shifting preferences, values and needs. To maximise the use of contraceptives amongst South African AGYW, it is necessary to provide responsive contraception service provision to reflect the changing contexts and preferences of users, in order to ensure that pregnancy prevention needs are catered for throughout their reproductive life course.

Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial

BACKGROUND

Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women.

METHODS

The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost.

DISCUSSION

Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.

Development of a Peer-Based Intervention Educating Teenagers about Long-Acting Reversible Contraception (LARC)

OBJECTIVE

Despite a decrease in teenage pregnancy rates in the U.S. in the past decades, teen pregnancy continues to be a considerable health issue. In this paper, we outline the development of our novel peer-based intervention, appropriately named Get It?, that aims to increase awareness of and self-efficacy to use long-active reversible contraceptives (LARCs) among teenagers.

METHODS

Peer narrative videos were created from audio-recording semi-structured, one-on-one interviews with teenage LARC users. Focus groups of young women 19 years old and younger were conducted to choose the most audience-appropriate videos to be included in the final intervention. Using a thematic content analysis approach, transcripts of the audio-recorded focus groups were reviewed and manually coded.

RESULTS

The final layout of Get It? included 4 videos that were chosen by participants of the focus groups, as well as supplemental activities that included a basic description of the LARC devices, the ability to anonymously post personal stories about LARC that can be shared with others, and the opportunity to email the primary investigator questions about LARC. Thematic analysis of the focus group discussions revealed when it came to narrative videos, participants desired: (1) an authentic narrator, (2) more information on the narrator, (3) narrators displaying ample emotions.

CONCLUSION

Peer narratives play a vital role in influencing a teenager's perspective on their health status, therefore understanding what constitutes reliable narration from an online format was critical in the development of a peer-based electronic intervention that informs teenagers of the most effective contraceptive available to them.

Motivators and Influencers of Adolescent Girls' Decision Making Regarding Contraceptive Use in Four Districts of Zambia

Low contraceptive use in sub-Saharan Africa, and Zambia specifically, negates the potential benefits of contraception in preventing unwanted and early pregnancies. This study aimed to explore and understand the motivators and influencers of adolescent girls' contraceptive decision making. Using thematic analysis, we analysed qualitative data from seven focus group discussions and three key informant interviews with adolescent girls aged 15 to 19 years in four Zambian districts. The data were managed and organised using NVivo version 12 pro (QSR International). Fear of pregnancy, fear of diseases, fear of having more children, and spacing of children (especially among married adolescents) were key motivators for adolescents' contraceptive use. Friends and peers motivated them to use contraceptives while fear of side effects and fear of infertility drove non-use. Peer pressure and fear of mocking by their friends were important deterrents to contraceptive use. Parents, peers and friends, family members, partners, churches, and religious groups influenced adolescent girls' contraceptive decisions. Mixed messages from these influencers, with some in favour and others against contraceptives, make adolescents' decisions to use contraceptives complex. Therefore, interventions targeting increased contraceptive use should be all-inclusive, incorporating multiple influencers, including at institutional and policy levels, to empower adolescents and give them autonomy to make contraceptive decisions.

Providers' views on hormonal family planning methods for young women: a qualitative study from Dosso, Niger

Background: Family planning (FP) providers play an important role in ensuring that clients are offered a full range of FP methods. This qualitative study explores providers' views on three hormonal FP methods and why they think young women may choose these methods in Niger.                                                     Methods: In-depth interviews were conducted with 24 FP providers in 24 government health centers in Dosso region, Niger between February-March 2020. Providers were asked about the suitability of different FP methods for women, including unmarried adolescents and young married women with children. The interviews were translated and transcribed from Hausa and Zarma into French, thematically coded, and qualitatively analyzed. Results: Many providers believed discretion to be the most important method attribute for women. Providers report preferring implants for young clients because of the more rapid return to fertility. They disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and ease of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it, or switching from another method, and less likely to believe local myths. Providers believed that women find pills to be indiscreet. Conclusions: The findings highlight that while providers have perspectives on suitable methods for certain women, they also recognize that clients have their own preferences, such as how discreet the method is. As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered.

Contraceptive method use trajectories among young women in Kenya: A qualitative study

Background

Many young women experience important key life transitions during adolescence and early adulthood, such as initiation of sexual activity, first use of contraceptives, marriage, and childbirth. For young women to be able to plan and manage their lives, it is critical to understand how these life events intersect and shape their contraceptive decision-making. This study aims to explore young women's contraceptive method use trajectories, including the factors that influence contraceptive decision-making throughout adolescence and youth.

Methodology

In 2019, the Full Access, Full Choice project (FAFC), implemented by the University of North Carolina at Chapel Hill and the African Institute for Development Policy, conducted 30 in-depth interviews with young women aged 18-24 years in three counties in Kenya (Nairobi, Mombasa and Migori). Eligible respondents had used two or more modern contraceptive methods. Interview guides utilized a modified life history approach to capture details about respondents' contraceptive use and life experiences from the time they first used contraception until the time of interview.

Results

We identified five separate contraceptive use trajectories based on the occurrence and timing of marriage, childbirth, and contraceptive method choice as well as various influences on contraceptive decision-making. The majority of respondents began their contraceptive journey by using male condoms or emergency contraception, but subsequent contraceptive decisions were varied across trajectories and influenced by different factors. For many women, the initiation of a non-coitally dependent method occurred after the birth of a child; for some, this was the first method used. Once women transitioned to using a non-coitally dependent method such as injectables or implants, many cycled through different methods to find one that had fewer side effects or provided the desired duration of protection.

Discussion

This study highlights the nuanced needs of young women throughout their adolescent and youth years in Kenya. This suggests that programs and policies need to encompass young women's diversity of experiences and motivations to best serve them.

Providers' views on hormonal family planning methods: a qualitative study from Dosso, Niger

Background: Family planning (FP) providers play an important role in ensuring that clients are offered a full range of FP methods. This qualitative study explores providers' views on three hormonal FP methods and why they think women may choose these methods in Niger.                                                    Methods: In-depth interviews were conducted with 24 FP providers in 24 government health centers in Dosso region, Niger between February-March 2020. Providers were asked about the suitability of different FP methods for women, including adolescents and married women with children. The interviews were translated and transcribed from Hausa and Zarma into French, thematically coded, and qualitatively analyzed. Results: Many providers believed discretion to be the most important method attribute for women. Providers report preferring implants for young clients because of the more rapid return to fertility. They disagreed on whether implants or injectables are more discrete for clients. That said, providers felt that clients appreciate the implant's discretion, effectiveness, long-acting nature, and simplicity of use.  Providers perceived that the majority of women choose injectables due to familiarity with the method, the fact that it is "invisible" to an outsider, and a lack of awareness of implants. Providers stated that while women may not initially choose the implant, when given more information about it, they were more open to adopting it, or switching from another method, and less likely to believe local myths. Providers believed that women find pills to be indiscreet. Conclusions: The findings highlight that while providers have perspectives on suitable methods for certain women, they also recognize that clients have their own preferences, such as how discreet the method is. As programs continue to expand method choice and new contraceptive technologies undergo research and development, highly desirable features such as discretion need to be considered.

Family planning demand generation in Rwanda: Government efforts at the national and community level impact interpersonal communication and family norms

Between 2005 and 2020, total contraceptive use among married women in Rwanda increased from 17% to 64%. The aim of this study is to better understand how the Rwandan government’s mobilization and demand generation efforts have impacted community norms and interpersonal discourse surrounding family planning. Eight focus group discussions with family planning providers and 32 in-depth interviews with experienced modern contraceptive users were conducted in 2018 in the two Rwandan districts with the highest and the lowest contraceptive prevalence rates. Results suggest that outspoken government support, mass media, and community meetings were valuable sources of information about family planning. Information received through these channels generated interpersonal dialogue about contraceptives through both conversation and observation; however, rumors and misinformation remained a significant barrier to use. A once taboo subject is now normative among married couples. Continuing to address common fears and misinformation through communication channels such as mass media and community meetings may help to further increase contraceptive uptake in Rwanda.