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Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

ABSTRACT: BACKGROUND:More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper presents a study protocol that intends to evaluate the dynamics of contraceptive use, discontinuation, and switching among women of reproductive age initiating use of a contraceptive method. METHODS:This longitudinal mixed-methods study is being conducted in Migori and Kitui counties, Kenya. A formative assessment using Interviews with adolescents, older women, heterosexual couples, health care workers, and community health volunteers explored barriers to contraceptive continuation and perspectives on discontinuation utilizing a qualitative cross sectional study design. Following the formative assessment, a client-centered intervention focusing on improving quality of family planning services, including counseling, will be implemented in 10 health facilities. A 24-month prospective cohort study among women of reproductive age initiating contraception with follow-up at 3, 6, 12, and 24?months will then be undertaken to assess the discontinuation rates, examine the dynamics of contraceptive use, discontinuation and switching, and further explore barriers and enablers for contraceptive continuation and switching among the study population. DISCUSSION:In sub-Saharan Africa, contraceptive discontinuation studies have mainly been based on survey data that is collected retrospectively. By implementing a longitudinal mixed-methods study, we gain deeper insights into the contraceptive dynamics influencing the decision to continue, discontinue, and even switch following implementation of a client-centered intervention that enhances quality of care. Additionally, the study will shed more light on the profile of women discontinuing contractive use and further explore individual and couple-level dynamics influencing decision-making on continuation and discontinuation. The findings of this study will provide information that can be used to develop and implement human-centered interventions that focus on improving quality of family planning services and consequently improved continuation rates and overall satisfaction with method. TRIAL REGISTRATION:The study is registered with the Clinical Trials Registry, NCT03973593 .

SUBMITTER: Ontiri S

PROVIDER: S-EPMC6727395 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

Ontiri Susan S Mutea Lilian L Muganda Maxwell M Mutanda Peter P Ajema Carolyne C Okoth Stephen S Orero Solomon S Odhiambo Ruth R Biesma Regien R Stekelenburg Jelle J Kabue Mark M

Reproductive health 20190905 1

<h4>Background</h4>More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper pr ...[more]

PMID: 31488170

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Project description:IntroductionTransgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women.MethodsUsing a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings.Results21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk.ConclusionsPrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.

Project description:BackgroundNearly half of women will switch or discontinue using their selected contraceptive method in the first year. Research on early switching or discontinuation provides important clinical and public health insights, although few studies have assessed associated factors, particularly among longitudinal cohorts.ObjectiveThe current study explores attributes associated with early contraceptive method switching or discontinuation (<6 months of initiation) among participants enrolled in the intervention cohorts of the Highly Effective Reversible Contraceptive Initiative Salt Lake Contraceptive Initiative (Utah, United States).Materials and methodsHighly Effective Reversible Contraceptive Initiative Salt Lake participants have access to no-cost contraception for 3 years. This includes both the initial selection and the ability to switch or to discontinue methods without cost. Methods available included the following: nonhormonal behavioral methods (male/female condoms, withdrawal, diaphragms, cervical caps, and fertility awareness); short-acting methods (pill, patch, ring, and injectable); and long-acting methods (intrauterine devices and contraceptive implants). Participants completed surveys at baseline and at 1, 3, and 6 months. We collected data on participant demographics, contraceptive continuation, switching, and discontinuation, as well as factors associated with these changes, including established measures of pregnancy intention and ambivalence and reasons for switching or discontinuing. We conducted descriptive statistics, univariable, and multivariable Poisson regression analyses to assess predictors of both discontinuation and switching. We also conducted χ2 analyses to compare reported reasons for stopping between switchers and discontinuers.ResultsAt 6 months, 2,583 women (70.0%) reported continuation of their baseline method, 367 (10%) reported at least 1 period of discontinuation, 459 (12.4%) reported switching to a different method, and 279 (7.6%) did not provide 6-month follow-up. Factors associated with discontinuation included selection of a short-acting method (incidence rate ratio [IRR], 2.49; 95% confidence interval [CI], 1.97, 3.12), report of Hispanic ethnicity (IRR, 1.45; 95% CI, 1.12, 1.89) and nonwhite race (IRR, 1.48; 95% CI, 1.08, 2.02), and having any future pregnancy plans, even years out. Participants with some college education were less likely to report discontinuation (IRR, 0.73; 95% CI, 0.57, 0.94). Selecting a short-acting method at baseline was also associated with increased likelihood of method switching (IRR, 2.29, 95% CI, 1.87, 2.80), as was having 2 or more children (IRR, 1.37; 95% CI, 1.08, 1.74). Women were less likely to switch if they were on their parents' insurance (IRR, 0.74; 95% CI, 0.56, 0.99). Among participants who switched methods, 36.9% switched to a long-acting reversible method, 31.7% switched to a short-acting hormonal method, and 31.1% switched to a nonhormonal behavioral method, such as condom use. Of participants providing a reason for stopping, 454 women (73.2%) reported side effects as 1 reason for switching or discontinuing their initial method.ConclusionEarly contraceptive method switching and discontinuation are frequent outcomes of contraceptive use. These changes are common even with removal of contraceptive access barriers.

Project description:BACKGROUNDMissing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants).METHODSIn each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study.RESULTSWhile current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower.CONCLUSIONSHigh levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Project description:BACKGROUND:In Kenya, unsafe abortion is the leading cause of maternal deaths in adolescent girls aged 15-19 years, and a majority did not use a modern contraceptive before becoming pregnant. The aim of this study was to explore attitudes related to abortion and contraceptive use among secondary school teachers and student peer-counsellors in a low-resource setting in western Kenya. METHODS:A mixed methods design, combining a questionnaire-survey and focus group discussions (FGDs), was utilised to explore attitudes to abortion and contraceptive use among teachers (n = 15) and student peer-counsellors (n = 21) at a secondary school in Kisumu, Kenya. First, two Likert scale questionnaires were used: a modified version of the Stigmatising Attitudes, Beliefs and Actions (SABA) scale and the Contraceptive Use Stigma (CUS) scale. Secondly, four FGDs were conducted. Descriptive statistics and Abductive Thematic Network Analysis (ATNA) were used to analyse the data. RESULTS:Overall, Social judgments on abortion and contraceptive use were found among teachers and student peer-counsellors, with similar patterns between sexes. Christian and cultural values; A majority, 28/36 considered abortion a sin, and chastity and purity before marriage were highly valued feminine ideals. Discrimination and isolation; 18/36 believed that a girl who has had an abortion might be a bad influence on other girls, and 13/35 stated that an adolescent girl cannot decide for herself if to use a contraceptive method. Conflicting views on abortion and contraceptives; A third (11/34) believed that contraceptives may cause infertility, and its use was related to promiscuity. Girls associated with abortion and contraceptive use were considered immoral, lacking parental guidance, and were used to represent bad examples in school. Although conflicting views were present, sexuality was considered a taboo topic, which left adolescents ignorant on contraceptive use. CONCLUSIONS:Adolescent girls associated with abortion and contraceptive use are at risk for social judgements and discrimination, by both peers and teachers. Sexual and reproductive health training needs to be implemented in teacher education to increase knowledge on adolescent sexuality, abortion and contraceptive use to improve adolescents' sexual health and decrease the stigma. TRIAL REGISTRATION:This was a prestudy nested in a cluster randomised intervention study, registered on February 28, 2017, at ClinicalTrials.gov (NCT03065842).

Project description:BackgroundAddressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives.MethodsQualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach.ResultsUse of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods.ConclusionThis study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

Project description:BackgroundUnderstanding contraceptive use dynamics is critical to addressing unmet need for contraception. Despite evidence that male partners may influence contraceptive decision-making, few studies have prospectively examined the supportive ways that men influence women's contraceptive use and continuation.ObjectiveThis study sought to understand the predictive effect of partner influence, defined as partner's fertility intentions and support for contraception, and discussions about avoiding pregnancy prior to contraceptive use, on contraceptive use dynamics (continuation, discontinuation, switching, adoption) over a one-year period.MethodsThis study uses nationally representative longitudinal data of Ugandan women aged 15-49 collected in 2018-2019 (n = 4,288 women baseline; n = 2,755 women one-year follow-up). Two analytic sub-samples of women in union and in need of contraception at baseline were used (n = 618 contraceptive users at baseline for discontinuation/switching analysis; n = 687 contraceptive non-users at baseline for adoption analysis). Primary dependent variables encompassed contraceptive use dynamics (continuation, discontinuation, switching, and adoption); three independent variables assessed partner influence. For each sub-sample, bivariate associations explored differences in sociodemographic and partner influences by contraceptive dynamics. Multinomial regression models were used to examine discontinuation and switching for contraceptive users at baseline; logistic regression identified predictors of contraceptive adoption among non-users at baseline.ResultsAmong users at baseline, 26.3% of women switched methods and 31.5% discontinued contraceptive use by follow-up. Multinomial logistic regression, adjusting for women's characteristics, indicated the relative risk of contraceptive discontinuation doubled when women did not discuss pregnancy avoidance with their partner prior to contraceptive use. Partner influence was not related to method switching. Among non-users at baseline, partner support for future contraceptive use was associated with nearly three-fold increased odds of contraceptive adoption.SignificanceThese results highlight the potentially supportive role of male partners in contraceptive adoption. Future research is encouraged to elucidate the complex pathways between couple-based decision-making and contraceptive dynamics through further prospective studies.

Project description:ObjectivesThis study aimed to examine patterns and determinants of modern contraceptive discontinuation among women in Kenya.MethodsSecondary analysis was conducted using national representative Kenya Demographic and Health Surveys of 2003, 2008/9, and 2014. These household cross-sectional surveys targeted women of reproductive age from 15 to 49 years who had experienced an episode of modern contraceptive use within five years preceding the surveys from 2003 (n = 2686), 2008/9 (n = 2992), and 2014 (5919). The contraceptive discontinuation rate was defined as the number of episodes discontinued divided by the total number of episodes. Weighted descriptive statistics, multivariable logistic regression analysis, and Cox proportional hazards analysis were used to examine the determinants of contraceptive discontinuation.ResultsThe 12-month contraceptive discontinuation rate for all methods declined from 37.5% in 2003 and 36.7% in 2008/9 to 30.5% in 2014. Consistently across the three surveys, intrauterine devices had the lowest 12-month discontinuation rate (6.4% in 2014) followed by implants (8.0%, in 2014). In 2014, higher rates were seen for pills (44.9%) and male condoms (42.9%). The determinants of contraceptive discontinuation among women of reproductive age in the 2003 survey included users of short-term contraception methods, specifically for those who used male condoms (hazard ratio [HR] = 3.30, 95% confidence interval [CI] = 2.13-5.11) and pills (HR = 2.68; 95CI = 1.79-4.00); and younger women aged 15-19 year (HR = 2.07; 95% CI = 1.49-2.87) and 20-24 years (HR = 1.94; 95% CI = 1.61-2.35). The trends in the most common reasons for discontinuation from 2003 to 2014 revealed an increase among those reporting side effects (p = 0.0002) and those wanting a more effective method (p<0.0001). A decrease was noted among those indicating method failure (p<0.0001) and husband disapproval (p<0.0001).ConclusionsFamily planning programs should focus on improving service quality to strengthen the continuation of contraceptive use among those in need. Women should be informed about potential side effects and reassured on health concerns, including being provided options for method switching. The health system should avail a wider range of contraceptive methods and ensure a constant supply of commodities for women to choose from. Short-term contraceptive method users and younger women may need greater support for continued use.

Dataset Information

Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

Publications

Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

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